Dr. P.K. Das Dr. P.K. Das MD, DM (Medical Oncology, MD, DM (Medical Oncology, AIIMS) AIIMS) Senior Consultant Senior Consultant Indraprastha Apollo Indraprastha Apollo Hospital Hospital New Delhi New Delhi [email protected][email protected]RECENT ADVANCES IN MANAGEMENT OF LUNG CANCER
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Dr. P.K. Das Dr. P.K. Das MD, DM (Medical Oncology, AIIMS)MD, DM (Medical Oncology, AIIMS)
Senior Consultant Senior Consultant
Indraprastha Apollo HospitalIndraprastha Apollo Hospital
A cough that does not go away Chest pain, often made worse by deep breathing Shoulder pain with numbness in some fingers; with
or without droopy eyelid (HORNER’S SYNDROME) Hoarseness Weight loss and loss of appetite Bloody or rust-colored sputum Shortness of breath Fever without a known reason Recurring infections such as bronchitis and
pneumonia New onset of wheezing Headaches; change in vision or speech Seizures
Diagnostic Studies
– Imaging:
Used to visualize the interior of the body. Examples of
such studies include X-rays, Ultrasound, Computerized
Involves use of a light on a flexible fiberoptic viewing
device (endoscope) to examine lining of the passages
Lung cancer presentation
The chest x-ray shows a shadow in the left lung, which was later diagnosed as lung cancer.
A CT scan of the lung shows a mass lesion in the right lung. The mass turned out to be lung cancer on examination of the needle biopsy sample.
PET (Positron emission tomography)
Computerized image of chemical changes eg sugar metabolism that take place in tumor tissue
Patient injected with radioactive sugar (FDG PET) and then scanned
Uptake will happen in active tumor : distinguish normal from abnormal tissue
PET Image
Histologic Examination
Tissue Acquisition Bronchoscopy Biopsy Core needle Fine needle Brush cytology Incisional Excisional Other procedures
MicroscopyGrading
G1 G2 G3, G4
Tissue Acquisition
Is done through biopsy – a procedure through which tissue or fluid is removed from the body for examination.
Core needle biopsy:
– A procedure which uses a special needle to cut a core of tissue for examination
Fine needle aspiration (FNAC):
– Is a cytologic procedure in which a needle is inserted into an organ or body cavity and a small sample of fluid and cells is removed.
Brush Cytology:
– Brush cytology is a technique in which a very small brush, attached to an endoscope, is used to rub off tumor cells for examination. Often used for Pancreatic and lung cancers.
Lung Biopsy – Core needle
Lung Biopsy
CT Scan of the chest with a
biopsy needle extending into a lung
mass
The needle is oriented vertically
and goes into the mass (indicated
by red color). The lung tissue is
black and the bones are white.
The patient is prone and the heart
is the large white structure at the
lower part of the chest.
Lung Cancer Subtypes:
• 1) Small Cell Lung Cancer
• 2) Non- Small Cell Lung Cancer
• a) Squamous b) Non- a) Squamous b) Non- SquamousSquamous
• (i) (i) Adenocarcinoma Adenocarcinoma
• (ii) Large (ii) Large Cell CarcinomaCell Carcinoma
Adenocarcinoma Cancer arising out of glandular
tissues Most frequent type diagnosed in
lung cancer (30 – 40%) Common in smokers and non-
smokers More common in women than in
men Usually arise in the peripheral
areas of lung and metastasize quickly
Bronchoalveolar carcinoma (BAC) is a subtype of adenocarcinoma and is found more in women and is associated with scars of tuberculosis
Early diagnosis is rare and prognosis is poor
Large Cell
Account for approx. 15% Progonosis same as adenocarcionoma Both ( adeno and large) are known as Non-Squamous Undifferentiated large cell, can be classified as poorly differentiated.
Squamous Cell Accounts for 30% of lung
cancers
Strongly associated with smoking
Tend to be more centrally located
Forms necrotic cavities, that can be seen on X-rays
Cell doubling rate is slow and surgical resection leads to a 30% 5 year survival rate
5 year survival rate of all SCC is 5 – 7%
Small Cell Lung Cancer (SCLC)
– Comprises 15-20% of all lung cancers
– Spreads more aggressively than NSCLC
– Is more responsive to chemotherapy
– Frequently found in smokers or former
smokers
Small Cell Lung Cancer (SCLC)
Two stages: As per Veterans Administration
Lung Cancer study group (VALCG)
Limited stage
Extensive stage
TNM staging is Now the standard after 7th
Edition 2009
Small Cell Lung Cancer (SCLC) : Sites of
metastases
SITE PERCENT
Liver 30
Bone 25
Bone marrow 20
Brain 10
Extrathoracic LN 5
Subcutaneous mass 5
Small Cell Lung Cancer (SCLC) : Paraneoplastic syndromes
More common than in NSCLC
SIADH (syndrome of inappropriate antidiuretic
hormone) : 15% of cases
Hyponatremia (low serum sodium)
Cushing’s syndrome
Neurological syndrome
Peripheral neuropathy
Eaton lambert syndrome (proximal muscle weakness)
Step by Step Approach – Advanced and Metastatic NSCLC Advanced and Metastatic NSCLC
Metanalysis BMJ 1995Pujol 2006
NSCLC: Strategies to overcome chemotherapy‘s plateau
Landmark Lilly Trial (Scagliotti et al) for the first time demonstrated a survival advantage of treatment (Pemetrexed) by histology effect
NSCLC distribution by stage and associated survival rates
NSCLCStage Distribution1
NSCLC Stage
1-Year Survival
25-Year
Survival3
I 13%–24%IA
IB
91%
72%
50%
43%
II 5%–10%IIA
IIB
79%
59%
36%
25%
III 31%–44% IIIA
IIIB
50%
37%
32%
19%
7%
IV 32%–39% IV 20% 2%
1. Bulzebruck H, et al. Cancer. 1992;70:1102-1110. 2.Mountain CF. Chest. 1997:111;1710-1717. 3. Goldstraw P. Presented at the 12th World Conference on Lung Cancer; September 5, 2007; Seoul, Korea.
Importance of Adjuvant Therapy Three randomized phase III trials and the Lung
Adjuvant Cisplatin Evaluation meta-analysis have shown a significant survival benefit for adjuvant cisplatin-based chemotherapy for selected patients with completely resected stage II and IIIA NSCLC
Postoperative adjuvant cisplatin based chemotherapy now represents the standard of care for the management of stage II to IIIA NSCLC
Adjuvant cisplatin-based chemotherapy significantly improves survival for patients with resected stage II and IIIA NSCLC
CONVENTIONAL RADIATION THERAPY
XRT, is the medical use of ionizing radiation as part of cancer treatment to control malignant cells and also for some benign ds.
The treatment by radiation is when the tumour is treated along with margin of safety with conventional dose, fractionation regimen.
Devising precise methods of delineating targets– MULTI-MODALITY IMAGING
Target Localization for verification by on-board imaging (OBI) & changing the set up accordingly
Minimizing the uncertainty due to intra-treatment motion (4D RT- Respiratory Gating)
DYNAMIC ADAPTIVE RADIOTHERAPY Two components:
Adapt to tumor motion (IGRT) Adapt to tumor / organ deformation and volume change.
3D CRT, IMRT & IGRT
3D-CRT & IMRT: Treatment Delivery & Verification
3D CRT, IMRT & IGRT
6. Match with DRRs in EPID software
5. Take Portal images
7. Final Treatment Execution
High Tech Radiotherapy MachinesHelical Tomotherapy Gamma Knife
Cyber KnifeNovalis Tx
PRECISION-A Way ForwardState Of Art Technology-NOVALIS TX
3D CRT, IMRT & IGRT
NOVALIS Tx- Precision Radiotherapy and Radiosurgery
Novalis Tx, Newest generation LINAC
Novalis Tx machine utilizes X-rays that are targeted at the tumor to destroy the growth of cell without pain and discomfort.
The Novalis TX offers the advanced definition of “multileaf collimator” (HDMLC 120). Precision 2.5 mm
3D CRT, IMRT & IGRT
The Novalis TX linear accelerator can deliver radiation in many ways
Image Guided Radiation Therapy (IGRT)
Intensity Modulated Radiation Therapy (IMRT)
EXAC TRAC Adaptive Gating
Frameless Stereotactic Radiosurgery using High definition micro MLC (HDMLC)
Stereotactic Whole body radiation ( SBRT)
3D CRT, IMRT & IGRT
NOVALIS- Respiratory Gating Method where on-off status of treatment beam is controlled by
signals produced whenever breathing signal falls in the preset gating window
Instead of enlarging PTV to encompass the range of motion, treatment delivered only during part of the respiratory cycle.
3D CRT, IMRT & IGRT
Novalis Tx- Rapid Arc The Powerful Treatment with Novalis Tx –
Platform can deliver it quickly with the rapid arc Technology, so that patients spend little time immobilized on the treatment table. Fast treatments are easier and accurate.
3D CRT, IMRT & IGRT
NOVALIS Tx
For treatment precision – sharp, precise beams
Beam Shaper: 2.5 mm HD120® high-definition beam shaper
Gantry Precision: Mechanical accuracy throughout with 0.5 mm isocentric precision