1. NON SMALL CELLLUNGE CANCERDR…OMARHASHIM

2. Most common noncutaneous cancer in the world . The 2nd common cancer In us . The lunge cancer is the most frequent cause of cancer death. Etiology ;- 80—90 % of cases due to smoking . Is related to the number of cigarettes … number of yrs …. Type of cigarette Asbestos . previous radiotherapy to the chest . Inhalation of radon gas , polycyclic aromatic hydrocarbon , nickel ,chromate Inorganic arsenical . Types of NSCLC ;- Adenocarcinoma Bronchioalveolar carcinoma . Squamous cell carcinoma . Large cell carcinoma

3. Pathogenesis Two theories were proposed to explain lung cancer: Multicellular model: considering small cell carcinoma of neural crest (neuroectodermal) origin and other carcinomas of endodermal origin Unicellular model: considering that all types of carcinomas arise from a single multipotent stem cell capable of variety of phenotypes Carcinogenesis is a multistep process including activation of proto oncogenes and loss of tumor suppressor genes

5. Workup ;- H &P ………. Performance status , wt los , smoking status ... Labs CBC…. BUN …. Cr … LFT …. Alkline phosphate . Imaging ;- CT chest & abd ;- size &site of 1ry tumor …. Relationship to Lunge fissure , mediastinum , chest wall ….. Mediastinal or other l ns Metastatic disease (lunge ,, liver ,, adrenal ,, bone ) CT brain &bone scan if clinical suspicion PET scan for more sensitivity and specificity for pathological confir - than CT MRI brain for LNs + non squ and all stage 3 & 4 MRI ;-of the thoracic inlet for superior sulcus tumors to assess vertebral Body & brachial plexus invasion . Pathology ;-- thoracentesis for pleural effusion . For central lesions . Perform bronchoscope CT guided biopsy for peripheral lesion , perform Ct guided biopsy . Mediastinoscopy or bronchoscopic biopsy

6. Staging ;- T1 ;-tumor 3cm or less in diameter , surrounded by lunge or visceral pleura Distal to the main bronchus . ……………………………………………………………………………… T2 ;- tumour > 3cm diameter , involving main bronchus 2cm or more distal To the carina , or invading visceral pleura , or associated with atelectasis Which extends to the hilum but not involve the whole lunge . ………………………………………………………………………………………. T3 ;-tumour invading chest wall , diaphragm . Mediastinal pleura ,or peri – Cardium ,or tumour in main bronchus < 2cm distal to carina or atelectasis Of the whole lunge . ……………………………………………………………………………… T4 ;- tumour invading , mediastinum , heart , great vessels , trachea , oesophagus Vertebra , or carina , or intralober tumour , or malignant pleura effusion .

7. N0 ;-… no regional node metastases …………………………………………………………… N1 ;- Ipsilateral peribronchial or hilar node involvement ……………………………………………………… N2 ;- Ipsilateral mediastinal or sub carinal nodes . ………………………………………………… N3;- contra- lateral mediatinal nodes or supraclavicular nodes . ……………………………………………………………………………………………………………………….. Staging grouping ;- T1 -2 N0 . T1-2N1 or T3 N0 . a ]T1-2N2 , or T3 N1-2 b ] T 4 any N M0 , or any N3 M0 . Any M1

9. Outcome ;- 5 yrs os N1 50 %

10. ……………………………………………………………………………………………… Stage 1,2 ;- inoperable ;- definitive RT to 1ry & LN Conventional fractionation is 2gy /fx to 66 Gy

12. Outcome ;- 5 yrs os 20 – 25 % , MS . 16 -17 months inducation chemo –RT pcR rate 15- 20% post- op RT possible 5 – 10 % os benefit for N2 ……………………………………………………………………………………………. Stage 3 ( inoperable ) ;- Concurrent chemo –RT ( 63 Gy ) -> aduj chemo . If unacceptable risk of Pneumonitis with upfront RT , consider inducation chemo for down staging ->concurent chemo –RT to ( to postchemo volume ) . If no progression . Outcome ;- 5 yrs osandMS concurrent chemo- RT 20 -25 % , 16 – 17 months . Sequential chemo –RT 20% , 13 -15 months , RT alone <10 % , 10 -12 months …………………………………………………………………………………………………………… Stage 3 b ( no pleural effusion ) ;- Concurrent chemo –RT ( 61-63 ) , IF unacceptable risk of pneumonitis with Upfront RT, consider induction chemo for down- staging -> concurrent Chemo-RT (to postchemo volume ) if no progression . If T4 N0 may treated with surgery -> chemo ± RT ( if residual or ± SM ) or Chemo ±RT -> surgery -> chemo

13. Typical chemo;- postsurgery ;- Cisplatin 100mg/mxm d1 & etoposide 100mg/m xm d1-3 every 4 week x 4Cycle . Other combinations with vinorelbine , vinblastine , gemcitabine & docetaxel May be consider . Alternatives ;- if not able to tolerate cisplatin ; carboplatin , paclitaxel every 3week for 4 cycles . Concurrent with RT ; Cisplatin 50mg/mxm d1 , 8 , 29 & 36 and etoposide 50mg/mxm d1 -5 & 29-33 . Alternative ; cisplatin week 1 & 4 vinblastine weekly , or carboplatin &pacli- Taxel weekly . Sequential chemo – RT Cisplatin 100 mg/ mxm d1 , 29 & vinblastine 5mg/ mxm weekly x 5 week Alternative carboplatin & paclitaxel every 3week x2 cycles . Consolidation chemo after chemo –RT ;- Carboplatin & paclitaxel every 3 week x 2 cycles . Local treatment as necessary (E.G pleurodesis ) & treat as stage 4 .

14. Stage 4 ;- Platinum – based chemo ± bevacizumab ± palliative RT . Frist line chemo uses 2agents with response assessment after each cycle , for up to 4-6 Cycles or until progression .