BRONCHOIAL TUMOURS

STAGING OF BRONCHOGENIC CANCER Small cell lung cancer is staged as; Limited , when the tumour confined to the ipsilateral hemi-thorax and supra clavicular LNs . Extended , everything else. - Non – small cell lung cancer , is commonly classified as TNM staging system, Primary tumour (T). Tx primary tumour cannot be assessed , or tumour proven by presence of malignant cell in sputum or bronchial washing, but not visualized by imaging or bronchoscopy.

T0 no evidence of primary tumour Tis carcinoma in situ T1 tumour <3 cm surrounded by lung or viceral pleura. T2 tumour >3 cm , or >2 cm from main carina, or invading viceral pleura , or associate with atelectasis or obstructive pneumonitis, that extend to the hilum. T3 tumour of any size invading chest wall , diaphragm, parietal pericardium, mediastinal pleura, or tumour in the main bronchus < 2cm from main carina. T4 tumour of any size invading, mediastinum, heart, great vessels , trachea, oesophagus, carina, vertebral body, or malignant pleural or pericardial effusion.

Regional nodes (N) Nx can’t be assessed N0 no regional LN metastasis N1 ipsilateral peribronchial and/or ipsilateral hilar nodes N2 ipsilateral mediastinal and/or subcarinal nodes. N3 contralateral mediastinal or hilar nodes , or any scalene or supra clavicular nodes. Distant metastasis (M) Mx cannot be assessed M0 no distant metastasis M1 distant metastasis present , including separate nodes in different lung lobes.

Stage TNM subset 0 Tis I A T1 M0 N0 l B T2 M0 N0 ll A T1 N1 M0 ll B T2 N1 M0 T3 N0 M0 lllA T1 N2 M0 T2 N2 M0 T3 N1-2 M0 lllB T4 N0-2 M0 T1-4 N3 M0 lV any T, any N , M1

Management of primary lung cancer 1- Non – small cell cancer A- surgery The aims of surgery for lung cancer are to completely excise the tumour and local lymphatics, with minimal removal of functioning lung parenchyma. Stage l and ll NSCLC are usually amenable to surgery if the patient is fit enough , therefore careful staging and assessment of the patient's respiratory reserve and cardiac status are essential requirement to surgery. Surgery will offer 5 year survival rates of over 75% in stage l and 55% in stage ll disease .

Contra indications to surgical resection in Lung Ca. 1- Distant Metastasis 2- Invasion of central mediastainum structures(T4) 3- Malignant pleural effusion (T4) 4- Contralateral mediastinal nodes (N3) 5-FEV1<0.8L 6- Unstable or severe cardiac or other medical conditions

B- Radiotherapy; Radical radiotherapy can offer long term survival in selected patients with localised disease in whom co-morbidity precludes surgery. The greatest value of radiotherapy is in palliation of distressing complications such as, spinal cord compression , superior vena caval obstruction, severe haemoptysis, pain caused by chest wall invasion or skeletal metastasis, or trachea or main bronchial obstruction. Now a days there is CHART radiotherapy which is ( continuous hyper fractionated radiotherapy), in which a similar dose of radical radiotherapy given in smaller and frequent fractions.

C- Chemotherapy Usually considered in patient with stage lll and lV disease and only 40% respond to it temporarily. Combination chemotherapy is usually superior to single chemotherapy and the survival gained is usually 6-7 weeks compare with best supportive care only. Adjuvant chemotherapy following surgery has been found to have significant survival advantages.

2- Small cell lung cancer A- Chemotherapy The treatment of SCLC with combination cytotoxic drug and some time in combination with radiotherapy, can increase the median survival with this highly malignant tumour from 3 months to over a year. regular cycle of chemotherapy are usually used and nausea and vomiting are the common side effects. The combined chemotherapy are either (cyclophosphamide , doxorubicin and vincristine) or (cisplatin and etoposide).

B- Radiotherapy Patient with limited disease will benefit from consolidation radiotherapy following chemotherapy ,some times palliative radiotherapy can be given in patient with extensive diseased.

Prognosis The overall prognosis in all types of lung cancer are poor , around 80% of patients die with in one year from diagnosis , less than 6% surviving 5 years following diagnosis. The best prognosis is with well differentiated Squamas cell cancer which have not metastasised and amenable to surgery.