LUNG CANCER MANAGEMENT IN LOW RESOURCE SETTINGS

1. DR KANHU CHARAN PATRO
M.D,D.N.B[RT],FAROI[USA],MBA,PDCR,CEPC
7/21/2018 1
LUNG CANCER MANAGEMENT
IN LOW RESOURCE SETTING

6. LIMITED RESOURCE
1. SET-UP
2. EQUIPMENT
3. MAN POWER
4. MONEY
5. MANAGEMENT
6. AVAILABILITY

7. SOURCE
1. GOVT.
2. NGO
3. NCCP
4. DONATIONS
5. VOLUNTEERS
6. HIRING OR PURCHASING
7. OUT SOURCING
8. GENERIC MEDICINES

12. Statistics
>9.7 million cases are detected each
year
6.7 million people will die from cancer
Every day, around 1700 Americans
die of the disease
20.4 million people living with cancer
in the world today
1 in 3 people will be diagnosed with
cancer in the UK and 1 in 4 will die
from their disease

13. 13

15. EPIDEMIOLOGY
In the world lung cancer accounts for 13% of total
cases and 18% cancer related deaths.
Lung cancer is the second most common cancer and
most common cause of cancer related death among
American men and women.
 Lung cancer is rare below age 40, with rates
increasing until age 80, after which the rate tapers off.
Overall 5 years survival rate is approx 16%.

16. 1
6
Epidemiology
●
●
●
●
Most common & Deadliest worldwide.
Survival at 5 years in USA is 15%.
Primary risk factor- SMOKING (~90%)
Adenocarcinoma more than Small/Squamous.
(Filtered cigarette, fine particles reach periphery)

17. LUNG CANCER IN INDIA
Non-small-cell lung cancer constitutes 75 - 80% of lung cancers.
More than 70 % of them are in Stages III and IV, thus
curative surgery can not be done in these cases.
Small-cell lung carcinoma constitute 20% of all lung cancers .
Extensive stage in 70% of patients at the time of diagnosis.
While in many Western countries adenocarcinoma has become the
commonest lung cancer.
In India it is still squamous cell carcinoma in both males and
females

18. Lung Cancer Facts

19. Lung Cancer Risk

20. • Lung Cancer Risk

25. Stage IV NSCLC
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<1% = 5 year OS
80% of Lung Cancers Diagnosed after the
Cancer has Spread When Chance of Cure Small

26. Other than smoking, what else can cause lung
cancer?
- Secondhand exposure to smoke
- Radon
- Having had smoking related cancer
- Family History
- Environmental pollutants (pollution, dust,
asbestos)
- COPD or Pulmonary Fibrosis
Lung Cancer Risk

27. ? ?
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31. Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
HistopathologistMolecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

32. ONCOLOGY TEAM-LUNG CANCER
1. Surgical oncologist-thoracic surgeon
2. Radiation -oncologist
3. Medical Oncologist
4. Pulmonolgist
5. Counsellor
32

33. LUNG Cancer Progression
A B C D
Primary TumorLocal
Invasion
Atypical
Hyperplasia
In situNormal
Time
Time Points:
A. Overt non invasive carcinoma
B. Onset of local invasion
C. Onset of metastatic dissemination

34. CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness

35. Nagging cough or hoarseness
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36. Staging
T1:
3 cm or less, completely covered
by pleura, does not involve main
bronchus

37. Staging
T2:
> 3cm size.
Visceral pleura involved.
Main bronchus invasion but > 2cm
from carina.
Atelectasis / obstructive
pneumonitis that extends to the
hilar region but does not involve
the entire lung.

38. Staging
T3:
Chest wall
Diaphragm
Mediastinal pleura
Pericardium
Main bronchus <2cm to carina
Complete atelectasis / obstructive
pneumonitis of entire lung

39. Staging
T4:
Carina
Vertebrae
Great Vessel
Esophagus
Heart
Separate tumour nodule in same
lobe
MALIGNANT pleural / pericardial
effusion

40. Staging
N0:
No regional LN metastases
N1:
LN mets in ipsilateral peribronchial
and/or intrapulmonary (Levels 10, 11,
12, 13, 14)
N2:
Ipsilateral mediastinal or subcarinal
N3:
Contralateral mediastinal /hilar
Ipsilateral or contralateral
supraclavicular/ scalene nodes

41. Staging
Stage I: no lymph node involvement
Stage II: lymph nodes involved or tumor invading
into chest wall
Stage III: mediastinal nodal involvement or bad
tumour factors
Stage IV: metastatic disease

42. 7

44. LUNG CANCER METASTASIS
Adrenals - ~50% of cancers
Liver – 30-50%
Brain – 20%
Bone – 20%

45. 4
5
Workup
● History:
– Smoking, Weight loss, Performance status
●
●
Examination
Imaging:
–
–
–
CECT incl. adrenals, PET-CT preferred.(50% staging changed)
CECT (sens 75%, spec 66%) vs PET-CT (91%, 86%)
EBUS
● Tissue:
– FNAC, TBFNA, Mediastinoscopy, VATS

46. C
A
U
S
E
47

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49. • Lung Cancer Symptoms

50. Clinical Presentation
Majority are symptomatic at presentation (>85%)
Symptoms are broadly classified as
1. Due to lung lesion
2. Due to intra-thoracic spread
3. Due to distant metastasis
4. Due to paraneoplastic syndrome

51. SIGNS AND SYMPTOMS
1. Dyspnea (shortness of breath)
2. Hemoptysis (coughing up blood)
3. Chronic coughing or change in regular coughing
pattern
4. Wheezing
5. Chest pain or pain in the abdomen
6. Cachexia (weight loss), fatigue, and loss of appetite
7. Dysphonia (hoarse voice)
8. Clubbing of the fingernails (uncommon)
9. Dysphagia (difficulty swallowing).

52. Clinical Presentation
S/S Incidence
Cough 75%
Hemoptysis 50%
Dyspnea 40%
Chest pain 35%
Hoarseness 5%
SVC syndrome 5%

53. SIADH
Cushing’s Syndrome
Carcinoid Syndrome
Gynecomastia
Cerebellar degeneration
Eaton Lambert syndrome
Autonomic neuropathy
Optic neuritis
Pure red cell aplasia
DIC
Anemia, thrombocytopenia
Acanthosis nigricans
Hyperkeratosis
Hypertrichosis
VIP induced diarrhea
Hyperamylesmia

54. Pathogenesis: Squamous type

55. Diagnosis
1. CXR – identifies nodules usually >1cm
2. CT Chest – more definitive view of lung
parenchyma and adjacent lymph nodes
3. PET scan – helpful in staging to determine
degree of metastases
4. MRI/CT brain – useful in looking at CNS
involvement
5. PFT

56. DIAGNOSTIC WORK UP
1. Complete history
2. Complete physical examination
Chest-may show signs of-
I. Partial or complete obstruction of airways
II. Pneumonia
III. Pleural Effusion
Neck Examination-Signs of Supraclavicular
lymphadenopathy
Abdominal examination-signs of hepatomegaly
Neurological examination-signs of Brain metastasis

57. Bronchoscopy
Most valuable invasive investigation as it allows:
Confirmation of diagnosis:
Biopsy and brushings 80% accurate
Low false positive rates 0.8%
Transbronchial forceps biopsy positive in 70%
Visualization of tumor done in 60% - 75%
Staging of the tumor:
Extent of bronchial and carinal involvement.
Symptom alleviation:
Stenting
Bleeding control
Importance in brachytherapy
Response assessment
Detection of preinvasive malignancy (screening):
Autoflurosecence bronchoscopy.

58. 1. Endoscopic FNA-
2. Endobronchial USG guided transbronchial
needle aspiration(EBUS-TBNA) can be done for
ultrasound suspicious lymph nodes-
1. Paratracheal-Level 2 & 4
2. Subcarinal-Level 7
3. Hilar lymph node stations-level 10
3. Thoracocentesis-
4. If on multiple taps of pleural fluid is consistently
bloody or exudative ,it should be considered
malignant.

59. 1. Thoracoscopy
2. Video assisted thoracoscopy(VAT) is used for-
1. Diagnosis
2. Staging
3. Resection of lung cancer
3. Peripheral nodules can be easily seen and excised.
4. It can also be used to reach mediastinal nodes not
accessible by standard mediastinoscopy,EBUS-
TBNA or EUS-FNA techniques.

60. Pathology
Sputum cytology: 20% to 30% sensitivity
Bronchoscopic examination: 90% positive
CT-guided Bx: 95% positive
Bx: Primary tumor lesion, scalene node

61. Bronchoscopy CT guided biopsy

62. Non Small Cell 85%
Adenocarcinoma 37%
Squamous 25%
NSCL 19%
Other 12%
Large Cell 4%
Bronchoalveolar 3%
Small Cell 15%

65. Presentation

66. Chest X ray

67. Stages and Treatments of SCLC
Limited Stage
The cancer is confined to one area of the chest
Include nearby lymph nodes
Treated with radiation therapy and chemotherapy
Extensive Stage
A tumor has spread beyond the lung
Accounts for 70% of SCLC
Treated with chemotherapy only

68. Small cell lung Ca Limited stage

69. 70
Small Cell Lung Cancer
●
●
●
●
●
Limited disease: confined to the hemithorax.
Extensive : extends beyond the hemithorax.
Most of the improvement in outcome was
attributed to more effective combination
chemotherapy regimens.
Locoregional therapy alone, either surgery or
RT, improved the short-term survival only
slightly.
Role of RT proven once distant metastasis
was controlled & local failure was apparent.

70. Small Cell Lung Cancer
●
●
●
●
●
Thoracic RT and Prophylactic Cranial
Irradiation.
TRT concurrent with chemotherapy.
Early TRT showed better outcome than late.
Accelerated hyperfractionation better than daily
fractions ( 5yr survival 28% vs 21%)
No significant difference in local tumor control or
survival with treatment between 45 Gy and 65
Gy when effective chemotherapy was given.
Murray N, Coy P, Pater JL, et al. Importance of timing for thoracic irradiation in the combined modality treatment of limited-stage small-cel5l 9lung
cancer. The National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 1993;11:336-344.

71. Prophylactic Cranial Irradiation
Brain metastases -10% atpresentation
- 80% at 2 yrs*
Irradiation of entire intracranial contents
Lower border at C2-3vertebra
Doses 24 – 30 Gy @ 3Gy/#
Increased the 3 year survival from 18% to
26%#
60
#Ann Oncol 2002;13:748-54*Cancer 1979:44;1885-1893

72. Limited Disease
CCRT (EP x 4 + 45Gy) -> CR -> PCI
Extensive Disease
Role of R/T: Palliation
Standard therapy for SCLC

73. 7
4
Overview of management in NSCLC
●
●
●
●
Surgery is the main stay for resectable and
operable non small cell lung cancer
Radiation plays a role in the definitive and
adjuvant management of NSCLC
Chemotherapy is an important adjuvant
treatment modality, often used with radiation
Radiation along with chemotherapy are useful
for palliation

74. 75
• Stage: I : Surgery the mainstay; SBRT
• Stage II: Surgery the mainstay; SBRT
• Stage III: Surgery + RT, CT + RT
• Stage IV: Palliative RT
• Prophylactic cranial irradiation*
RT in NSCLC: Stage wise

75. Treatment Algorithm
Non-small cell lung cancer

76. Stage Description Treatment Options
Stage I Tumor of any size is found only in the lung Surgery
Stage II Tumor has spread to lymph nodes associated
with the lung
Surgery
Stage III a Tumor has spread to the lymph nodes in the
tracheal area, including chest wall and
diaphragm
Chemotherapy followed by
radiation or surgery
Stage III b Tumor has spread to the lymph nodes on the
opposite lung or in the neck
Combination of chemotherapy
and radiation
Stage IV Tumor has spread beyond the chest Chemotherapy only

78. Surgery

79. Surgery : Types
1. Radical operation:
1. Pneumonectomy.
2. Lung Conservation:
1. Lobectomy.
2. Sleeve resection.
3. Wedge resection.
4. Segmentectomy.
3. Mediastinal lymph node dissection:
1. Provides complete nodal staging.
2. Identifies patients who require adjuvant
radiotherapy.
3. Improves survival.
4. Improves local control.
5. At least nodal sampling should be
performed, if not complete
lymphadenectomy.

80. Lymph node dissection
Lobe specific mediastinal nodal
dissection in NSCLC:
Right Side:
Upper lobe (1,2,3,4,7)
Middle lobe (1,2,3,4,7)
Lower lobe (1,2,3,4,7,8,9)
Left Side:
Upper lobe (4,5,6,7)
Lower lobe (4,5,67,8,9)

81. Complete Resection
1. Free resection margins proved
microscopically
2. At least a lobe specific mediastinal nodal
dissection with complete hilar and
intrapulmonary nodal dissection.
3. At least 6 nodes should have been removed
with 3 from mediastinal nodes.
4. No extracapsular extension in the nodes.
5. Highest mediastinal node removed should be
microscopically free.

82. Criteria for inoperability
1. Tumor based criteria:
1.Cytologically positive effusions.
2.Vertebral body invasion.
3.Invasion or in casement of great vessels.
4.Extensive involvement of Carina or trachea.
5.Recurrent laryngeal nerve paralysis.
6.Extensive mediastinal lymph node metastasis.
7.Extensive N2 or any N3 disease.

83. CHEMOTHERAPY & TARGETED
THERAPY

87. Chemotherapy
Based upon the premise that 70% - 80% patients
will have micrometastasis during presentation.
Situations where CCT can be used:
Neoadjuvant CCT as an induction regimen
Adjuvant chemotherapy with or without radiation*
Palliative chemotherapy in systemic disease.
No advantage of consolidation chemotherapy
has been established.

88. Summary of CCT evidence
1. Evidence for any beneficial effect of CCT exists for patients with:
WHO performance status 0 – 2
Age < 70 yrs.
2. Platinum based regimens should be used and single agent CCT
should be avoided (except in selected PS 2 patients)
3. Adjuvant CCT after Surgery is not recommended without further
evidence of its efficacy.
4. Median prolongation of survival is approx 3.4 months in the
palliative care setting but QOL is better than with BSC.
5. Aggressive CCT regimens have failed to demonstrate a survival
advantage over conventional regimens despite the cost and toxicity.

89. Chemoradiation
Administration of chemotherapy concurrently with
radiation therapy theoretically improves local
control by sensitizing the tumor to radiation, while
simultaneously treating systemic disease, albeit
at the expense of greater local toxicity.

90. Preoperative Chemotherapy
No benefit for stage I and most stage II (T1-2N1)
Neoadjuvant for stage IIB (T3N0), IIIA(T3N1-2)
with good performance status:
minimal increased in survival

91. Postoperative Chemotherapy or
Chemoirradiation
S + PORT + C/T (cisplatin-based) Vs S + PORT:
2% absolute reduction in risk of death
(p = .46) .
P’t with minimal BWL and highly performance
status: improved survival post-OP CCRT Vs. R/T
alone. (cisplatin-based chemotherapy)

92. Sequence of Irradiation and
Chemotherapy
Most randomized trials show no benefit of thoracic irradiation
when administered after chemotherapy
CCRT > Sequential chemoradiation therapy
R/T initiation: within 6 wks or follow 2 cycles C/T
R/T is given early in the course of or concurrently with
chemotherapy.

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95
TABLET FORMS

98. GOALS
High dose to tumor tissue-Tumor control
Normal tissue sparing
Minimize long and short term toxicities
Better Quality of life
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100. Evolution of Treatment
Techniques
CONVENTIONAL RT
Collimator shapes Beam
Rectangular Treatment Field
Shaped Treatment Field
1970s and earlier
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103. 10
4

104. MULTI LEAF COLLIMATOR

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108. 109
Breathing motion
Systematic Inter-fractional Treatment preparation
Random Intra-fractional Treatment execution
Movie by
John Wolfgang
“ ”

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110. 111

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112. 113

113. 114
Breath hold techniques
• Voluntary breath hold
• Rosenzweig KE et al. The deep inspiration breath-hold technique in the treatment of inoperable
non-small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2000;48:81-7
• Active Breathing Control (ABC)
• Wong JW et al. The use of active breathing control (ABC) to reduce margin for breathing motion.
Int J Radiat Oncol Biol Phys. 1999;44:911-9
• Abdominal press
– Negoro Y et al. The effectiveness of an immobilization device in conformal radiotherapy for lung
tumor: reduction of respiratory tumor movement and evaluation of the daily setup accuracy. Int J
Radiat Oncol Biol Phys. 2001;50:889-98

114. Postoperative Radiation Therapy
Postoperative irradiation:
1.positive or close surgical margins (T3)
2.positive hilar or mediastinal lymph
nodes

115. Postoperative Radiation Therapy
Postoperative irradiation: positive or
close surgical margins or positive hilar or
mediastinal lymph nodes.
Tumor doses of 60 to 70 Gy in 2-Gy fractions are
usually recommended.

119. Technique of Radiation Therapy
for locally advanced NSCLC
2-Yrs S.V
CHART(54Gy) 30%
Conventional Tx (60Gy) 20%

120. SEQUELAE OF THERAPY
Late Sequelae
Pneumonitis (10% grade 2 and 4.6% grade 3)
Pulmonary fibrosis (20% grade 2 and 8% grade 3
or greater)
Esophageal stricture
Cardiac sequelae (pericardial effusion, constrictive
pericarditis, cardiomyopathy)
Spinal cord myelopathy
Brachial plexopathy.

129. Stage IV: Metastatic Breast Cancer

130. METASTASIS
-please do not watch crying
131

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132. METASTASIS- give a smiling death
133

133. Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

134. Spinal metastasis
135

135. 136

136. Brain metastasis
137

137. 138

138. Whole brain radiotherapy
139

139. Choroidal metastasis
140

140. Superscan-extensive bone mets
141

141. Hemibody radiation
142

142. Prophylactic radiation
143

143. svco
144

145. Prevention-passive smoking

146. Calculation
One cigar-5 rupees
10 cigars/day-50 rupees
1500 rupees per month
Around RS -15000per year
Around RS -1.5L per 10 year
Around 4.5 lakhs per 30 year
If cancer developes-no

147. Spent on smoking

150. Smoking is The Breath Blocker
Chronic Obstructive Pulmonary Disease (COPD)
Smoking causes most
cases of COPD.
There is NO CURE for COPD

151. Smoking is the Heart Stopper
•Smoking causes cells lining veins and arteries to swell.
•Narrower arteries mean
reduced blood flow to the
heart, brain, and organs.
•Clots can block narrowed
arteries, causing heart attack,
stroke, and even sudden
death.
•Even occasional smoking
damages blood vessels.

152. I have cancer
but
No money for treatment

153. All specialities under one roof
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LOTS OF BLOOD REQUIRE

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156. Nicotine replacement
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157. Nicotine patches
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158. What can I do for society
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159. SELF –I will not smoke
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160. HOME
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161. I will not a victim of passive smoking
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162. I will not sell tobacco
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163. • Why You Should Care

165. Wayne McLaren as the Marlboro man (1976) Dying from Lung Cancer (1992)

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