Lung Cancer. Management of (2006) Philippine Society of Medical Oncology. Governing Council Offi cers. Council Members.

Transcription

1 Management of Lung Cancer (2006) Philippine Society of Medical Oncology Unit 1418, 14/F, orth Tower, Cathedral Heights Bldg. St. Luke s Medical Center. E. Rodriguez Sr. Avenue Quezon City 1099, Philippines Telefax: (632) / local psmo-sec@pacifi c.net.ph Website: Governing Council Offi cers President Vice President Secretary Treasurer Ma. oemi L. Alsay Uy, M.D. Ma. Belen E. Tamayo, M.D. Ellie May D. Belarmino-Villegas, M.D. Jhade Lotus P. Peneyra, M.D. Council Members Buenaventura C. Ramos, Jr., M.D. estor L. Atienza, M.D. Marie Claire V. Soliman, M.D. Gerardo H. Cornelio, M.D. (Immediate Past President) Advisory Council Antonio H. Villalon, M.D. Priscilla B. Caguioa, M.D. Jasmin V. Reyes-Igama, M.D.

2 The following practice guidelines are the top two cancers in the Philippines: Lung Cancer, followed by Breast Cancer. These guidelines were adapted from the CC (ational Comprehensive Cancer etwork) and was written and reviewed by the following: Medical Oncology Fellows in training UP-Philippine General Hospital Dr. Jose R. Reyes Memorial Medical Center St. Luke's Medical Center Sto. Tomas University Hospital Veterans Memorial Medical Center PSMO Governing Council Medical Oncology Consultants The Philippine Society of Medical Oncology, is presently in consultation with other societies dealing with cancer management. Thus, we hope the next edition will contain a consensus of practice guidelines, agreed upon by all societies concerned, and to include all the Top Ten cancers in the Philippines. 139

3 Algorithm for the Management of Lung Cancer 1 Lung CA Suspect (A) 2 19 Chest X-ray PAL (B) 3 4 o Mass? 9 Centrally located? Peripheral location? 13 Enlarged neck nodes? Pleural effusion? 17 Highly suspect cancer? o other CT Scan CA site? (C) o mass? Manage by case. Refer Bronchoscopy with biopsy or cytology (D) Percutaneous FAB (E) 14 Biopsy Thoracentesis with cytology (F) 5 Radiotherapy 6 Go to # 9 7 Close follow up. Refer Refer Figure 1 140

4 1 2 3 o cancer? (G) Highly suspect cancer? Radiotherapy 4 Refer 5 6 SCLC? Stage (H) Go to Figure 1b T1T2 0M0? ot and/or Chemotherapy 10 Lobectomy (J) 11 Adjuvant (K) and/or Chemotherapy (L) T3T4 1-3M0? Metastatic 13 Chemotherapy ± Palliative chemotherapy and or Figure 1a 141

5 1 SCLC 2 3 Stage (I) Stage I? Surgery +margins? Stage II/III? Surgery Close follow up Chemo Resectable? Surgery Stage IV Chemo ± Single site mets? Palliative treatment Chemo ± Multiple Chemo/ 24 Palliative Treatment Figure 1b 142

6 Management of Lung Cancer The management of lung cancer must be multidisciplinary and interdisciplinary, with each discipline respecting the specialty expertise of the other, all for the benefit of the cancer patient. (A) A change in pulmonary habits is the most significant sign of lung cancer. Coughs, chest pain, rust colored-streaked sputum, hemoptysis, hoarseness, weight loss, and dyspnea are common symptoms of lung cancer (B) Postero-anterior and lateral chest films are the most valuable first tolls to establish the diagnosis when there is clinical suspicion of lung cancer. (C) Asymptomatic smaller tumors can be detected by the CT scan. For lung cancer suspect, do CT scan of chest, upper abdomen and adrenal glands. CT scan is also the most useful of all modalities for determining the characteristics of T and in the thorax and M in the brain and liver. (D) Bronchoscopy yields (+) histology only if the lung cancer is centrally located or has invaded centrally. Cytological studies include sputum and bronchial washing exams by Papaniculao technique. (E) Percutaneous needle biopsy guided by fluoroscopy or CT scan gives accurate cytologic diagnosis from peripheral lung lesions and also from liver/bone metastatic lesions. (F) Pleural fluid can undergo cytologic exam when pleural effusion is the presenting symptomatology. (G) There are 2 major histological types, whose management differ accordingly: 1) small cell anaplastic carcinoma (SCLC)- tends to be disseminated at diagnosis; rapidly growing, 2) on-small cell carcinoma (SCLC)- slow growing; with three cell types: a) epidermoid carcinoma - most common centrally located, b) adenocarcinoma - tends to be peripherally located, c) large cell anaplastic carcinoma - similar to adenocarcinoma in metastatic pattern. For both SCLC and SCLC, staging work up includes CT scan of chest, upper abdomen and adrenal glands (if not yet done in diagnostic work up), ultrasound of the liver (if upper abdomen CT scan was not done), brain and bone scans (if symptomatic). (H) SCLC Stage: 1. Limited disease - confined to lung and regional lymph nodes. 2. Extensive disease - denotes metastasis outside lung and regional lymph nodes. (I) SCLC stage by TM classification A. TM a. Tis carcinoma in situ b. T 1<3 cm tumor size not involving the visceral pleura c. T 2 >3 cm tumor size, >2 cm from the carina, (+) visceral i. pleural involvement, partial atelectasis d. T 3 tumor involves the chest wall, diaphragm, mediastinum i. pleura or parietal pericardium, <2 cm from the carina, complete atelectasis of either lung e. T 4 tumor involves the mediastinum, heart, trachea, i. carina, vertebral body; presence of malignant pleural/pericardial effusion; presence of satellite nodule/tumor f. 0 o spread to lymph nodes (L) g. 1 Spread to L within the lungs, ipsilateral hilar Ls h. 2 Spread to subcarinal or ipsilateral mediastinal Ls i. 3 Spread to cervical Ls or contralateral hilar and i. mediastinal Ls j. M 0 o distant spread k. M 1 Spread to distant organs, to other lobes of the i. lungs or to Ls further than those mentioned in stage B. STAGE a. 0 - Tis0M0 b. IA - T10M0 c. IB - T20M0 d. IIA - T11M0 e. IIB - T21M0,T30M0 f. IIIA - T1-T32M0,T31M0 g. IIIB - AnyT3M0, T4AnyM0 h. IVB - AnyT Any M1 (J) In SCLC T1-20M0 and SCLC Stage I and II, surgery is done to achieve complete tumor resection and avoid an exploratory thoracotomy or an incomplete surgical resection. The choice of surgical procedure - lobectomy, pneumonectomy, segmental or sleeve resection - depends on disease extent and patient's functional status. Here, surgery may not be done if with medical contraindications. The presence of distant metastases or extrahepatic metastasis is indicative of inoperability and a surgical procedure is an absolute contraindication. Surgical management is the responsibility of the surgical oncologist and or the thoracic surgeon. (K) Irradiation is used to achieve: 1. Definitive irradiation of localized lung cancer 2. As part of a combined treatment approach 3. Palliation of symptoms Radiotherapy can be given in combination with chemotherapy if a patient is assessed (age, ECOG performance status, co-morbidities, preference) to be able to receive combination modality of treatment. Radiotherapy is the responsibility of the Radiation Oncologist. (L) In SCLC, combination chemotherapy is the treatment of choice for all stages. In SCLC, chemotherapy is currently restricted to recurrent or metastatic disease and for palliation of inoperable symptomatic patients whose disease is beyond radiotherapy control. Recent data also suggested benefits for Stage III disease after surgery or radiotherapy. eoadjuvant chemotherapy is reported to be promising due to better staging procedures and use of cisplatin-containing regimens. Drug therapy for cancer is the responsibility of the Medical Oncologist. Initial work up prior to any treatment include baseline CBC, creatinine, serum electrolytes, LDH. 143

7 Recommended Therapeutics (Drugs Mentioned in the Treatment Guideline) The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's reference, available drugs are listed under each therapeutic class. Cytotoxic Drugs Alkylating Agents Cyclophosphamide Biomedis Cyclophosphamide Cytoxan Melphelan Alkeran Antimetabolites Capecitabine Xeloda Fluorouracil Biomedis Fluorouracil Fluracedyl Fluroblastin Uflahex Methotrexate Biomedis Methotrexate Emthexate Pfizer Methotrexate Inj Pemetrexed disodium Alimta Tegafur/Uracil UFT Platinol Platosin Erlotinib Tarceva Gemcitabine HCl Gemzar Mitoxantrone Domitrone Paclitaxel Biomedis Paclitaxel Paxus Pharmachemie Paclitaxel Taxol Others Geftinib Iressa Cytotoxic Antibiotics Doxorubicin HCl Adriblastina RD Biomedis Doxorubicin HCl Caelyx Pfizer Doxorubicin HCl Inj Pharmachemie Doxorubicin Epirubicin HCl Pharmorubicin Sandoz Epirubicin Mitomycin C Kyowa Mitomycin-C Mitotic Inhibitors Docetaxel Biomedis Docetaxel Hentaxel Taxotere Etoposide Lastet Pfizer Etoposide Posid Topresid Vepesid Vincristine sulfate Biomedis Vincristine Sulfate evexitin Pfizer Vincristine Inj Pharmachemie Vincristine Other Cytotoxics Carboplatin Biovinate Crobextin Paraplatin Pharmachemie Carboplatin Cisplatin Docistin ippon Kayaku Cisplatin Pfizer Cisplatin Inj Platamine 144