Clinical course. 10/22 Admission 10/23 Chest CT 10/24 Bone scan 10/25 CT guide biopsy Discharged for second opinion to 和 信 醫 院, then lost follow up

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1 Case introduction 陳 先 生, 71y/0 96/10/9, Received TURP for BPH at 仁 愛 醫 院, pre-surgery CXR showed an abnormal mass over LUL. 96/10/19 TMUH, He went to Dr. 鍾 OPD for help Abnormal CXR finding Arrange chest CT and admission at 10/22

2 History 70y/o Cigarette 1.5 PPD/day for > 50years, quit for 2 weeks No chemical substance exposure history Denied s/s of cough, sputum, dyspnea, DOE, body weight loss, chest pain, or chest tightness Past history of :Type II DM (for unknown years), BPH s/p TURP Denied any of malignant family history

3 Clinical course 10/22 Admission 10/23 Chest CT 10/24 Bone scan 10/25 CT guide biopsy Discharged for second opinion to 和 信 醫 院, then lost follow up

4 Lab data CBC/DC: BCS: Bl. T. INR APTT PT Baso Eos Mono Lym Neu WBC PLT RDW MCH MCV HCT Hb Ca K Na Alb Bili T GPT GOT Cr BUN

5 CXR 96/10/19 A well-defined patch in the left lung, near the hilum, no central necrosis seen. No bone metastasis seen.

6 CT without contrast A lobulated border, heterogenous mass 4.5x3.8 cm in dimension, at the posterior segment of LUL of lung with focal pleuralitail and hilar attachment.

7 CT with contrast Few of enlarged mediastinal lymphadenopathy at pre-aortic and retrocavalparatracheal regions.

8 D/D of whitish patch in CXR Lung collapse Pleural effusion Consolidation Fibrosis Cavitating lesion Mesothelioma Lung neoplasm

9 Lung collapse Lung area size change Homogenous patch, no lung marking in it Organ deviation, ex: trachea, heart, diaphragm, mediastinum, lung fissure Ribs retraction No definite heart border (if near heart) Lat view

10 Lung collapse

11 Pleural effusion Homogenous Crescent-like Lung fissure Underline disease: Transudate or Exudate, ex: CHF, cirrhosis, TB, malignancy

12 Consolidation Heterogenous Irregular border Air bronchogram Clinical s/s

13 Fibrosis Old film Reticulonodular, honey comb Smaller lung In bilateral base more like lung edema Mediastinum deviation

14 Cavitating lesion Malignancy thick wall, >5mm Lung abscess thin wall, air-fluid level, history Aspergilloma ball in the hole Pulmonary embolism

15 Mesothelioma Irregular border, lobulated, pleural Pain, cough

16 Lung neoplasm The coin lesion Irregular, lobulated border Rare calcification Look for metastasis Old film

17 Pathological report Patho report: Microscopically, it shows a picture of adenocarcinoma arranged in solid nests and infiltrative pattern. The carcinoma cells have pleomorphic nuclei, prominent nucleoli, and eosinophilic cytoplasm.

18 Final diagnosis Left lung, upper lobe, NSCLC, ct3n2m0, stage IIIA

19 Discussion of lung cancer The most common cause of cancer mortality worldwide for both men and women. The term lung cancer, or bronchogenic carcinoma: refers to malignancies that originate in the airways or pulmonary parenchyma.

20 Risk factor Smoking account for 90% cause, 1PPD/ day for 40 years folds than other people, the rate will increase accompanied with asbestos approach. Radiation RT for breast cancer or lymphoma Environmental toxins: second-hand smoke, asbestos, radon, metals (arsenic, chromium, and nickel), ionizing radiation, and polycyclic aromatic hydrocarbons

21 Risk factor Pulmonary fibrosis 7 folds Other factors HIV infection, genetic factors, dietary factors No screening test (chest radiography, sputum cytology, or CT) has been shown to reduce mortality from lung cancer. -- except early CT for selected high-risk patient, it can detect stage I lesion (2007)

22 Classification Adenocarcinoma 38%, peripheral Squamous carcinoma 20% Large cell carcinoma 5% Small cell carcinoma 14%, respond to C/T Other non-small cell carcinomas, which cannot be further classified 18% Other 6%

23 Symptoms Cough: 45-74% Weight loss: 46-68% Dyspnea: 37-58% Chest pain: 27-49% Hemoptysis: 27-29% Bone pain: 20-21% Hoarseness: 8-18%

24 Effect Superior vena cava syndrome (SCLC) Pancoast s syndrome (NSCLC) Paraneoplastic phenomena Hypercalcemia (PTH,SCC), SIADH(SCLC), Cushing s syndrome(acth,sclc) Metastasis: Liver LFT, AKP, CT Bone PET, Bone scan, AKP (SCLC) Adrenal gland CT, rarely symptomatic Brain CT

25 Lab Need to check: complete blood count, serum electrolytes, calcium, alkaline phosphatase, albumin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and creatinine

26 Diagnostic image (NSCLC) The imaging modalities most commonly used in the staging of lung cancer include CXR, CT, PET, MRI, Bone scan Tumor character: -- Tumor size, -- Presence or absence of satellite nodules, -- Presence, absence, and extent of atelectasis, -- Invasion of adjacent structures

27 Diagnostic image--cxr Prior radiographs can be extremely important as baselines for comparison. Although most lung cancers are visible on chest radiographs, detection of mediastinal lymph node metastases, invasion of the chest wall, and invasion of mediastinal structures cannot be accurately determined

28 Diagnostic image -- CT Should be performed in all patient. The CT should survey an area from base of the neck to below the adrenal glands Intravenous contrast material can be helpful in distinguishing mediastinal structures and assessing potential vascular invasion. Detect metastases of brain, liver, adrenal gland CT is far less helpful in detecting bone metastases.

29 Diagnostic image -- PET FDG-PET improves the detection rate of malignancy compared to conventional diagnostic studies such as CT or radionuclide bone scan, which frequently alters diagnostic management and treatment decisions PET is not suited to the detection of brain metastases due to high glucose uptake

30 Diagnostic image -- MRI MRI may be more accurate than CT in delineating mediastinal or chest wall invasion. MRI may more readily identify tumors involving the superior sulcus or abutting the diaphragm because of its ability to directly visualize the lung apices and diaphragmatic surfaces in the sagittal or coronal planes MRI is the most effective modality for detecting brain metastases. It is also useful in the evaluation of adrenal lesions

31 Diagnostic image Bone scan Increasingly widespread use of PET imaging has virtually replaced bone scans in asymptomatic patients. Advantages of the bone scan include: less time-consuming, wider field of view, and less likely to have false-negative results associated with osteoblastic lesions

32 AJCC TNM Staging system

33 AJCC TNM Staging system

34 AJCC TNM Staging system

35 SCLC staging The two stage system originally introduced by the Veterans' Affairs Lung Study Group (VALSG) is widely utilized in staging of SCLC -- Limited disease is defined as disease confined to the ipsilateral hemithorax and within a single radiotherapy port (corresponding in part to TNM stages I through IIIB).(30~40%) -- Extensive disease is defined as evident metastatic disease outside the ipsilateral hemithorax. (60~70%)

36 SCLC tumor markers Eight SCLC antigen clusters have been identified by segregation analysis, and divided into three groups: neural, epithelial, and neuroendocrine. Because of their epithelial cellular origin, virtually all SCLCs are immunoreactive for keratin and epithelial membrane antigen. Expression of dopa decarboxylase, calcitonin, neuronspecific enolase, chromogranin A, CD56 (neural cell adhesion molecule [NCAM], gastrin releasing peptide (GRP), and insulin-like growth factor-i (IGF-I), also a number of polypeptide hormones, including ACTH and vasopressin

37 Treatment Initial evaluation: Whether a lung cancer is a NSCLC or an SCLC is critical for treatment planning, and a tissue diagnosis is necessary. Staging for NSCLC with TNM system. Staging of SCLC with Veterans Administration Lung Study Group designations

38 Treatment of NSCLC Patients with stage I or II NSCLC should be treated with complete surgical resection whenever possible. Postoperative adjuvant chemotherapy has been shown to improve survival in patients with pathologic stage II disease and may have a role for patients with stage IB NSCLC. Not surgical candidates: R/T may be useful

39 Treatment of NSCLC For patients with pathologically proven stage III disease prior to definitive therapy, a combined modality approach using concurrent chemotherapy is generally preferred. Surgery following CT/RT may also retain a role for carefully selected patients with T3 or T4 lesions and negative mediastinal lymph nodes.

40 Treatment of NSCLC Patients with stage IV disease are generally treated with systemic therapy or a symptombased palliative approach. In appropriately selected patients, chemotherapy and/or molecularly targeted therapy may prolong survival without sacrificing quality of life. Radiation therapy and surgery may also be useful for symptom palliation in some patients.

41 Prognosis (NSCLC) Stage IA IB IIA IIB IIIA IIIB IV Five-year survival

42 Treatment of SCLC Patients with limited stage disease are primarily treated with a combination of chemotherapy and radiation therapy. Surgery is not used except in the rare patient who presents with a solitary pulmonary nodule without metastases or regional lymph node involvement.

43 Treatment of SCLC For patients with extensive stage SCLC, chemotherapy alone is used as the initial therapy. Prophylactic radiation has been shown to decrease the incidence of brain metastases and prolong survival in patients with both limited and extensive stage SCLC who respond to their initial treatment

44 Prognosis of SCLC Patients with limited stage disease: Median survivals: 15~20 months Five-year survival rate: 10~13% Patients with extensive stage SCLC: Median survival: 8~13 months Five-year survival rate: 1~2%

45 Reference Robbins Pathologic Basis of Disease 6/e Chest X-ray made easy 2/e UpToDate: 1. Overview of the risk factors, pathology, and clinical manifestations of lung cancer. 2. Diagnosis and staging of non-small cell lung cancer. 3. Pathobiology and staging of small cell carcinoma of the lung. 4. Overview of the initial evaluation, treatment and prognosis of lung cancer. Images came from Google.

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