Tag Archives: Staging

Staging lung cancer: CONCLUSION

lung

Because resection of lung cancer is the best current treatment for localized lung cancer, a very aggressive approach should be considered, including a variety of invasive techniques, before accepting ‘indeterminate’ radiographical findings that imply unresectability. Even if staging rules out curative resection, it may allow entry into induction protocols, with later resection being possible. A systematic approach to staging allows coordination among pulmonologists, radiologists, oncologists and surgeons, and is the basis of a ‘rational’ approach to the management of lung cancer. It’s time to pay less money – just get discount Cialis Professional at the best online pharmacy.

Staging lung cancer: SUMMARY

lung

Staging lung cancer requires a physiological as well as pathological assessment. It is laborious, and many patients are unsuitable for resection. There are some ‘grey’ areas where definite recommendations cannot be made, and each centre needs to review its own results. Lymphadenopathy can be assessed by mediastinoscopy, bronchoscopy, CT-guided needle biopsy and/or thoracoscopy. There is evidence for ‘selective’ mediastinoscopy, but there is also strong support for ‘routine’ mediastinoscopy. Thoracoscopy can be viewed in the same fashion. The definition of what constitutes a ‘physiological’ high risk patient also varies between centres. Despite all of these issues, there are three basic ‘guidelines’.

Staging lung cancer: STAGING CARCINOID TUMOURS

Carcinoid tumours have been considered a tumour type in a spectrum of Kulchitsky cell or neuroendocrine neoplasms, which range from typical carcinoid through atypical carcinoid and, finally, SCLC . Typical carcinoids have low malignant potential, with less than 5% incidence of lymph node metastases and greater than 80% cure rates with surgery . Atypical carcinoids have an incidence of lymphatic me-tastases in up to 70%, with a 10-year survival of less than 50% . Clinical evidence of carcinoid syndrome implies atypical features, a large lesion or metastases, with rare exceptions . The most recent authoritative classification of neuroendocrine neoplasms adds a tumour type called large cell neuroendocrine carcinoma . This is ahigh grade carcinoma that fits in the spectrum somewhere between atypical carcinoid and SCLC, with a prognosis approaching that of SCLC.

Staging lung cancer: STAGING SCLC (2)

Lung cancer

Approach to diagnosis of adenocarcinoma: Diagnosis of adenocarcinoma, unlike other cell types that commonly arise in the lung, does not necessarily imply primary lung cancer, and on pathological examination alone it may be difficult to impossible to confirm a lung origin. One therefore needs to consider the possibility of metastatic disease, even when the lesion appears to be solitary.

Staging lung cancer: STAGING SCLC (1)

The role of surgery in SCLC is limited because chemotherapy is considered the primary treatment. Staging is mainly used for prognosis and to determine eligibility for treatment protocols . However, application of TNM staging reveals that stage I SCLC can be resected with 25% five-year survival or higher, assuming chemotherapy is also given. Frequently, stage I SCLC is diagnosed after resecting a solitary pulmonary nodule when this diagnosis was not anticipated preoperatively. Extensive staging is still required.

Staging lung cancer: INTEGRATING STAGING INTO ATREATMENT PLAN FOR NSCLC (4)

Lung cancer

Intraoperative studies may have a role in determining how well a resection can be tolerated. Initial data suggest that long term cardiac disability (but not mortality) may be predicted at the time of ‘test clamping’ of the pulmonary artery by recording a right ventricular ejection fraction (RVEF) of 35%, a pulmonary vascular resistance (PVR) of at least 200 dyne-s-cm- and/or a PVR:RVEF ratio of 5.0 . Some groups use a variety of ‘angioplastic’ and ‘bronchoplastic’ reconstructions to preserve as much functional lung as possible in patients who are identified as high risk . Patients with peripheral T1 lesions without evidence of mediastinal metastases who are not suitable for thoracotomy may be considered for thoracoscopic wedge resection, although the risk of local recurrence is increased .

Staging lung cancer: INTEGRATING STAGING INTO ATREATMENT PLAN FOR NSCLC (3)

High risk patients: It is important to consider both ‘resectability’ (ie, the tumour) and ‘operability’ (ie, the patient’s ability to tolerate surgery). A more aggressive approach to staging is justifiable in patients whose general medical condition (usually cardiopulmonary) puts them at high risk for thoracotomy. Individuals with primary cardiac limitations may require stress tests, echocardiography and possibly coronary angiography. Patients with correctable coronary disease may undergo preoperative angioplasty or bypass, or, rarely, simultaneous coronary bypass and lung resection . The major question is whether pulmonary reserves are adequate to tolerate the proposed resection . Unfortunately, no single preoperative test is sufficiently accurate in predicting the risk of surgery, but rather an integrated approach, taking into account clinical judgement and a number of physiological variables, is often needed (Figure 1) .

Staging lung cancer: INTEGRATING STAGING INTO ATREATMENT PLAN FOR NSCLC (2)

Lung cancer

Patients with adenopathy on CT should also undergo more invasive staging by one of the methods described previously. Ten per cent of patients with NSCLC and positive N2 disease have single, ipsilateral, intracapsular spread only and are still candidates for resection . The remainder may be candidates for neoadjuvant therapy. Such regimens for stages IIIA and IIIB have been described, with a subsequent complete resection rate as high as 73% .

Staging lung cancer: INTEGRATING STAGING INTO ATREATMENT PLAN FOR NSCLC (1)

Apparently operable NSCLC: It appears that T1 and T2 lesions with no evidence of mediastinal adenopathy on CT scan do not require more invasive staging. This does not appear to increase the incidence of ‘nontherapeutic’ thoracotomies or decrease the cure rate . Staging of T3 lesions without evidence of adenopathy is controversial. Survival is markedly reduced in T3N2 stage IIIA tumours, and if a particular centre plans induction regimens for these patients, biopsy of the upper mediastinal N2 nodes should be performed routinely . Other centres prefer to go straight to thoracotomy, with plans for complete mediastinal node dissection and adjuvant therapy, although there is no proven survival benefit .

Staging lung cancer: THE ROLE OF THORACOTOMY IN STAGING

Lung cancer

It is apparent from the above discussion that a proportion of patients may require thoracotomy to determine ultimately whether complete resection is possible. In addition, complete staging at thoracotomy determines both prognosis and the role of adjuvant treatments . A more difficult and controversial area is how to determine at thoracotomy that resection will not benefit a patient, especially because there is an emotional pressure ‘to do something’. Careful exploration may reveal invasion of mediastinal structures or the vertebrae that would, except in rare circumstances, preclude curative resection. Some centres perform mediastinal lymph node dissection before any resection because they feel that extensive spread precludes curative surgery. You are always welcome to visit the best and most trusted pharmacy offering to buy ventolin inhalers and giving you only most efficient medications with no rx required and fast delivery right to your doorstep.

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