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I-ELCAP • 213000 new case of lung cancer , 5 years survival just only 15%\ • Past few decade is static • Because 50% case was advance cancer when they come to Dr • In the past decade increase interest in the role of low dose spiral CT • CXR missed 70-80% of lung cancer detect by the CT • CT screening trials have report higher rate of early lung cancer 70-80%(stage Ia) • Average size of CT :1.5cm • Average size of CXR : 3cm • SEER new diagnosed lung cancer stage I ONLY 25% • SURVIVAL < 2cM IS BETTER THAN > 2- 3CM • Can increase 10x of operation • But not all screen detect cancer are curable some were stage III at the time of diagnosis • Interval lung cancer (cancer that develop between annual screening CT scan) rapid growth and frequently small cell lung cancer • Most controversial is cost effect www.I-ELCAP.org • From 1993 ELCAP..I-ELCAP • CT screen for lung cancer • 15% has positive result • 6% has repeat positive result Definition of Positive result? • At least I solid pr part solid noncalcified nodule 5mm or more in diameter • Or at least one nonsolid noncalcified nodule 8mm or more in diameter • If there is noncalcified nodule but too small ,…semipositive ..calling for repeat one year later. Repeat screening; positive? • Growth in size • Growth in consistency • Growth in soilid componant in semi- solid or previois non solid nodule The I-ELCAP regimen provides recommendation for the work up • Follow their protocol 90% of biopsy result in malignancy • Recommendation turned out to be quite successful • None of biopsy without recommendation was cancer • 85% of the screen–diagnosis is stage I • Also found the tumor size in this stage I cancer is more smaller • The % of stage I lung cancer were much higher than SEER data(surveillance,epidermiology, and end result )program. • Long term F/U10 years survival rate regardless of stage and tx was 80% • Clinical stage I 10 years survival was 92 % Pathology of lung adenocarcinoma and CT screening specimens • Major subtype of adenocarcinoma • 2004 WHO major subtype : mixed subtype,acinar, papillary, BAC (mucinous nonmucinous, mix) • Some subtype is more invasive and some are sensitive to iressa • EGFR and K ras mutation • CT screening 94% was adenocarcinoma Molecular pathways to lung adenocarcinoma • Adenocarcinoam is more and or esp in women and young patient and nonsmoker • Microarray expression studies demonstrate that gene expression is very different in smoker and nonsmoker • Smoking activation to RAS signaling • Non-smoking associated activation of EGFR signaling Limited resection for small peripheral carcinoma • Systematic nodal dissection could improved stage-specific survival and may improved overall survival. So lobectomy and SND still is standard choice • <1cm tumor has 10 % node metastasis • 2cm tumor has 20-40% has node metastasis and 2/3 is N2 • But due to CT screening: the tumor is more smaller so limited resection could we try in select case? • GGA( Ground glass attenuation )>50% of the total tumor size have a similary good prognosis (Noguchi classification)sublobar resection may be appropriate in selected case, but can cure? Wary . Pre-invasive lesion (patho) • 1999: squamous dysplasia and carcnoma in situs • 2004: atypical adenomatous hyperplasia, diffuse idiopathic pulmonary neuroendocrine cell hyperplasia • May be multicentri Iatrogenic contribution to thoracic neoplasm • Given continuing advances od early detection and supportive care and therapy : cancer survivor in USA is 3x since 1971 and increasing by 2% each year • Cancer survivor is about 3.5% of US population • We will meet second primary or late sequelae or treatment relate problem • Treatment-associated lung tumor: such as R/T and C/T Lung cancer staging: intrathoracic nodal assessment • 1982 a landmark paper by Dr pearson: mediastinal nodal metastasis could elude pre-op staging even in CT become routine and in which mediastinoscopy was well established • 38% of case were upstaged at thoracotomy..Unexpect n2 disease • N2 has only 20% 5 years survival • Correct staging may improve survival • Radical or en block to describe nodal dissection technique. • 1996 workshop: SND • Definition: number or node and at lease three mediastinal nodal station, and include one subcarina region • Review SND . Find 18% unexpect n2, no rescue • SND : better staging and find more ln deposit . • But early concern is add the morbility of surgery. • N0 survival was related to the number of node excised at thoracotomy Definition of complete resection • Lns specimens should include at lease six lymph node, three removed from intrapulmonary or hilar status and three removed from mediastinal station,one of which must be the subcarina station. • Other suggest: more extensive sectioning and immunohistochemical stain will find more subtle nodal deposit PET CT • 18-FDG • Phosphorylate • 18-FDG-6-phosphate • Inside the tumor cell could not degrade and trapped in cell and accumulated • For SPN or lung mass 0.7cm -4cm can confirmed the maliganant • Sensitivity 92-94% • Specificity 86-90% • Duke : only 5% stage Ia is negative False positive and negative • False positive:TB or other grnulomatous disease; such as histoplasmosis coccidiomycosis or inflammatory process ;rheumatoid nodule, sarcoidosis or cryptogenic organizing pneumonia ,BOOP • False negative: carcinoid tumor BAC well differential adenocarcinoma or metastatic tumor from renal cell ca of testicular ca( most carcinoid are positive) • <1cm may not be detect • Limit is 7-8mm • Serum glucose result in decrease intracellular FDG uptake • At Mayo clinic do not perform PET scan unless blood glucose <150mg/dl PET in staging or node or metas • CT sensitivity 61% ,specificity 79% • PET 80% 90% • Due to false positive, if there are no documented distal metastasis , must be biopsy before patient be judge as unresectable • 10-15% false positive , so if identified distal metas, esp one site metas, we would perform biopsy to get the potential curative thoracotomy PET vs isotope bone scan • Isotope bone scan have larger bone scan • If we already have PET scan , we have no reason obtaining a bone scan • But except brain . MRI or brain scan is better.
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