Chapter 085. Neoplasms of the Lung (Part 8) ppsx

Chapter 085. Neoplasms of the Lung
(Part 8)

Small Cell Lung Cancer
A simple two-stage system is used. In this system, limited-stage disease
(seen in about 30% of all patients with SCLC) is defined as disease confined to
one hemithorax and regional lymph nodes (including mediastinal, contralateral
hilar, and usually ipsilateral supraclavicular nodes), while extensive-stage disease
(seen in about 70% of patients) is defined as disease exceeding those boundaries.
Clinical studies such as physical examination, x-rays, CT and bone scans, and
bone marrow examination are used in staging. In part, the definition of limited-
stage disease relates to whether the known tumor can be encompassed within a
tolerable radiation therapy port. Thus, contralateral supraclavicular nodes,
recurrent laryngeal nerve involvement, and superior vena caval obstruction can all
be part of limited-stage disease. However, cardiac tamponade, malignant pleural
effusion, and bilateral pulmonary parenchymal involvement generally qualify
disease as extensive-stage because the organs within a curative radiation therapy
port cannot safely tolerate curative radiation doses.
Lung Cancer Staging Procedures
(Table 85-3) All patients with lung cancer should have a complete history
and physical examination, with evaluation of all other medical problems,
determination of performance status and history of weight loss, and a CT scan of
the chest and abdomen with contrast. Positron emission tomography (PET) scans
are sensitive in detecting both intrathoracic and metastatic disease. PET is useful
in assessing the mediastinum and solitary pulmonary nodules. A standardized
uptake value (SUV) of >2.5 is highly suspicious for malignancy. False negatives
can be seen in diabetes, in slow-growing tumors such as BAC, in concurrent
infection such as tuberculosis, and in lesions <8 mm. False positives can also be
seen in infections and granulomatous disease. Thus, PET should never be used
alone to diagnose lung cancer, mediastinal involvement, or metastases. Instead, its
primary function is to help guide a mediastinal biopsy for staging purposes and to

help identify sites of metastatic disease. Fiberoptic bronchoscopy obtains material
for pathologic examination and information on tumor size, location, degree of
bronchial obstruction (i.e., assesses resectability), and recurrence.
Table 85-
3 Pretreatment Staging Procedures for Patients with Lung
Cancer

All Patients
Complete history and physical examination
Determination of performance status and weight loss
Complete blood count with platelet determination
Measurement of serum electrolytes, glucose, and calcium; renal and liver
function tests
Electrocardiogram
Skin test for tuberculosis
Chest x-ray
CT scan of chest and abdomen
CT or MRI scan of brain and radionuc
lide scan of bone if any finding
suggests the presence of tumor metastasis in these organs
Fiberoptic bronchoscopy with washings, brushings, and biopsy of
suspicious lesions unless medically contraindicated or if it would not alter therapy
(e.g., very late stage patient)
X-rays of suspicious bony lesions detected by scan or symptom
Barium swallow radiographic examination if esophageal symptoms exist
Pulmonary function studies and arterial blood gas measurements if signs or
symptoms of respiratory insufficiency are present
Biopsy of accessible lesions suspicious for cancer if a histologic diagnosis
is not yet made or if treatment or staging decisions would be based on whether or
not a lesion contained cancer

Patients with Non-small Cell Lung Cancer Who
Have No
Contraindication
a
to Curative Surgery or Radiotherapy with or without
Chemotherapy
All the above procedures, plus the following:
PET scan to evaluate mediastinum and detect metastatic disease
Pulmonary function tests and arterial blood gas measurements
Coagulation tests
CT or MRI scan of brain if symptoms suggestive
Cardiopulmonary exercise testing if performance status or pulmonary
function tests are borderline
If surgical resection is planned: surgical evaluation of the mediastinum at
mediastinoscopy or at thoracotomy
If the patient is a poor surgical risk or a candidate for curative
radiotherapy: transthoracic fine-
needle aspiration biopsy or transbronchial forceps
biopsy of peripheral lesions if material from routine fiberoptic bronchosc
opy is
negative
Patients Presenting with Small Cell or Advanced Non-
small Cell Lung
Cancer
For proven small cell lung cancer, all the procedures under "All Patients,"
plus the following:
CT or MRI scan of brain
Bone marrow aspiration and biopsy (if peripheral blood counts abnormal)
For non-
small cell lung cancer or cancer of unknown histology, all the

procedures under "All Patients," plus the following:
Fiberoptic bronchoscopy if indicated by hemoptysis, obstruction,
pneumonitis, or no histologic diagnosis of cancer
Biopsy of accessible lesions suspicious for tumor to obtain a histologic
diagnosis or if therapy would be altered by finding of tumor
Transthoracic fine-
needle aspiration biopsy or transbronchial forceps
biopsy of peripheral lesions if fi
beroptic bronchoscopy is negative and no other
material exists for a histologic diagnosis
Diagnostic and therapeutic thoracentesis if a pleural effusion is present

a
Patients with non-
small cell lung cancer and extrathoracic metastatic
disease, malignan
t pleural effusion, or intrathoracic disease beyond the bounds of
a tolerable radiotherapy port.
Note: CT, computed tomography; PET, positron emission tomography.