8. Pathological Classification
Non Small Cell Lung Cancer Small Cell Lung Cancer
(NSCLC) (SCLC)
Squamous Cell Carcinoma 25 – 30% Oat Cell Carcinoma
Adenocarcinoma 35-40% Intermediate Cell Carcinoma
Large Cell Carcinoma 10-15% Combined Cell Carcinoma
9. TNM Staging (AJC CS ERR)
Primary Tumor - T
T1 Tumor <3cm without invasion more proximal than lobar bronchus
T2 Tumor >3cm OR
of any size with any of the following
- Invades Visceral Pelura
- Atelectasis of less than entire lung
- Proximal extent of at least 2cm from carina
T3 Tumor of any size with any of the following
- Invasion of Chest Wall
- Invasion of Diaphragm, Mediastinal Pleura, Pericardium
- Atelectasis involving entire lung
- Proximal extent within 2cm of carina
T4 Tumor of any size with any of the following
- Invasion of mediastinum
- Invasion of heart or great vessels
- Invasion of vertebral body
- Presence of malignant pleural or pericardial effusion
- Satellite tumor nodes within same lobe as primary tumor
10. TNM Staging
Nodal Involvement - N
N0 No regional node involvement
N1 Involvement of ipsilateral hilar or ipsilateral peribronchial nodes
N2 Involvement of ipsilateral mediastinal or subcarinal nodes
N3 Involvement of contralateral mediastinal or hilar nodes OR
Ipsilateral or contralteral scalene or supraclavicular nodes
Metastasis - M
M0 Distant Metastasis absent
M1 Distant Metastasis present
29. Treatment Options
SURGERY
TARGETED
RADIOTHERAPY
THERAPY
CHEMOTHERAPY
30. Treatment by Stages of Cancer
Stage Description Treatment Options
Stage Ia – Ib Tumor localized in lung Surgical resection
Stage IIa – IIb Tumor spread to local lymph nodes Surgical resection
Stage IIIa Tumor spread to regional lymph Chemotherapy followed
nodes in trachea, chest above by radiation or surgery
diaphragm
Stage IIIb Tumor spread to contra lateral Combination of
lymph nodes Chemotherapy and
Radiation
Stage IV Tumor metastasis to organs outside Chemotherapy and or
chest palliative care
32. Radiation Therapy
Treatment of stage I and stage II
NSCLC, radiation therapy alone is
considered when surgical resection is
not possible.
Role of radiation therapy as surgical
adjuvant therapy after resection of the
primary tumor is controversial.
Radiation therapy reduces local failures
in completely resected (stages II and
IIIA) NSCLC but has not been shown to
improve overall survival rates.
Radiation therapy alone used as local
therapy has been associated with 5-year
survival rates of 12-16% in early-stage
NSCLC (ie, T1 and T2 disease).
No randomized trials have directly
compared radiation therapy alone with
surgery in the management of early-
stage NSCLC
33. Chemotherapy
Only 30% of patients with NSCLC become eligible for
surgical resection
50% of patients who undergo resection experience
either a local or systemic relapse of cancer
80% of patients with NSCLC end up taking some sort
of chemotherapy
Combination chemotherapy has better survival rates
than single agent chemotherapy, which has potentially
no role in curative therapy of NSCLC.
Adjuvant chemotherapy (after surgery) has failed to
elicit any benefits, however neoadjuvant chemotherapy
(given prior to surgery) has improved survival in
patients with Stage IIIa disease.
34. Chemotherapeutic Agents
Drug Mechanism of Action Toxicity
Cisplatin / Carboplatin Causes intrastrand and interstrand cross- Tinnitus, Hearing Loss,
linking of DNA, - strand breakage Toxic Neuropathy,
Myelotoxic
Vinorelbine It inhibits tubulin polymerization during G2 Granulocytopenia,
phase of cell division Constipation, Fatigue
Gemcitabine Antimetabolite that acts as inhibitor of DNA Myelosuppression, Flu
synthesis like symptoms,
Hemolytic Uremic
Syndrome, Lung
toxicity
Paclitaxel Inhibits tubulin depolymerization in spindle Myelosuppression,
during cell division neuropathy,
hypersensitivity
Pemetrexed disodium Disrupts folate-dependent metabolic Fatigue,
processes essential for cell replication. myelosuppression,
Infection, GI toxicity
Docetaxel Inhibits cancer cell growth by promoting Myelosuppression, fluid
assembly and blocking disassembly of retention, HSN rxns
microtubules
Etoposide Causes single strand breaks in DNA, inhibits Myelosuppression,
repair of DNA Transient Hypotension
36. What are “targeted therapies”?
Cytotoxic vs. Cytostatic
Primarily target malignant cells
Target molecules involved in:
◦ cell growth signal transduction
◦ angiogenesis
◦ metastasis
Generally less toxic at therapeutic doses
Many are oral agents
