CANCERUL BRONHO-PULMONAR

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1 CANCERUL BRONHO-PULMONAR Diagnosticul CBP a. Clinic - simptome si semne bronhopulmonare : tuse, hemoptizie, durere toracica, dispnee - simptome si semne toracice, extrapulmonare: sindromul de VCS, sindromul Pancoast- Tobias, disfagia, colectii pleurale recidivante, paralizie diafragmatica - sindroamele paraneoplazice : degete hipocratice, anemia, acanthosis nigricans, neuropatie periferica, hipoglicemia, encefalopatie, sindrom nefrotic, etc - sindroamele metastatice : creier, oase, suprarenale, ficat b. Investigatii paraclinice - investigatii neinvazive - radiografia toracica, impportanta pentru depistare, dar insuficienta - examenul CT : de rutina, date importante pentru descriptorii TNM - examenul RMN : utila in invaziile aperturilor toracice, a peretelui toracic - echografia : evaluare adenopatii mediastinale, colectii pleurale, metastaze - scintigrafia : aprecierea functionalitatii pulmonare, meta osoase - citologia sputei: rezultate bune in localizarile centrale - dozare markeri tumorali : ACTH, apfa-fetoproteina, calcitonina, antigenul carcino-embrionar - investigatii invazive : - bronhoscopia : permite o evaluare corecta a descriptorului T - punctia percutanata toracica: tumori nerezecabile, sau refuzul interventiei - toracoscopia : permite evaluuarea lezionala completa intratoracica - biopsia ganglionara supraclaviculara - mediastinotomie ssau mediastinoscopie; evaluare adenopatii mediastinale Stadializare Se face pe baza descriptorilor TNM, dupa cum urmeaza ( A 7-a Clasificare TNM a Cancerului bronho-pulmonar, 2010 ) vezi tabelele 1,2,3,4. Table 1. T descriptor changes: comparison between 6th and 7th edition of the TNM T definitions 6th ed. 7th ed. descriptor descriptor Tumors = 2 cms. T1 T1a Tumors > 2 cms and = 3 cms. T1 T1b Tumors > 3cms and = 5cms. T2 T2a Tumors > 5 cms and = 7 cms. T2 T2b Tumors > 7 cms. T2 T3 Separate nodule(s) in the primary lobe. T3 Separate nodule(s) in a different ipsilateral lobe. M1 Malignant pericardial effusion. M1a Pleural dissemination. M1a

2 Table 2. Grouping of lymph node stations into zones. Nodal Zone Lymph node station Low cervical, supraclavicular, sternal notch (1R 1L) Upper paratracheal (2R 2L) Upper zone Prevascular (3a) and retrotracheal (3p) Lower paratracheal (4R 4L) Subaortic (aortopulmonary window - 5) Aortopulmonary zone Para-aortic (ascending aorta or phrenic nerve - 6) Subcarinal zone Subcarinal (7) Paraesophageal (8) Lower zone Pulmonary ligament (9) Hilar (10) Hilar zone Interlobar superior (11s) and inferior (11i) Lobar (12) Peripheral zone Segmental (13) Subsegmental (14) Table 3. M descriptor changes: comparison between 6th and 7th edition of the TNM M factor definitions 6th ed descriptor 7th ed descriptor Metastasis cannot be assessed. MX M0 Malignant pericardial effusion. M1a Pleural dissemination (malignant pleural effusions, pleural nodules). M1a Additional nodules in the contralateral lung (same histology). M1 M1a Distant metastasis. M1 M1b Table 4. TNM staging groups changes: comparison between 6th and 7th edition of the TNM 6th ed 7th ed T/M descriptors N0 N1 N2 N3 T1 (=2cm) T1a IA IIA IIIA IIIB T1 (>2 cm =3 cm) T1b IA IIA IIIA IIIB T2 (>3 cm =5 cm) T2a IB IIA IIIA IIIB T2 (>5 cm = 7 cm) T2b IIA IIB IIIA IIIB T2 (>7 cm) IIB IIIA IIIA IIIB T3 (direct invasion) T3 IIB IIIA IIIA IIIB (same lobe nodules) IIB IIIA IIIA IIIB 2

3 (extension) IIIA IIIA IIIB IIIB M1 (ipsilateral nodules) IIIA IIIA IIIB IIIB (pleural effusion) M1a IV IV IV IV M1 (contralateral nodules) IV IV IV IV M1 (distant) M1b IV IV IV IV Tratament 1. Principii generale - tratamentul chirurgical este asociat cu chimioterapia, radioterapia, imunoterapia, terapia endobronsica (dezobstructii prin laserterapie, plasare de stenturi) - este diferit in SCLC (indicatii de exceptie), fata de NSLC, unde tratamentul chirurgical este de prima intentie in stadiile IA, IB, IIA, IIB si IIIA, in celelate stadii (IIIB si IV) avand doar un rol paliativ - tratamentul chirurgical este aplicabil doar in ¼ din cazurile diagnosticate - pentru aprecierea oportunitatii tratamentului chirurgical, trebuie sa tinem seama de o serie de criterii : extensia lezionala, functia rrespiratorie, functia cardiaca, conditia biologica generala, varsta - cele mai frecvente interventii chirurgicale practicate sunt : lobectomia, pneumonectomia, bilobectomia, mai rar rezectia atipica sau tehnicile bronhoplastice - rezectia pulmonara trebuie asociata cu tehnici de limfadenectomie mediastinala - rezultatele tardive postchirurgicale depind in primul rand de stadializarea TNM (st I supravietuire la 5 ani de 60-80%, st II de 39%, st III de 20%) 2. Tratamentul urgentelor chirurgicale in CBP Tratamentul chirurgical al cancerului bronho-pulmonar este de regula un tratament la rece, aplicat dupa o investigare completa lezionala, functionala si biologica si dupa realizarea unei stadializari TNM corecte. Totusi, in evolutia sa naturala pot surveni complicatii ce necesita un tratament chirurgical de urgenta. a. Hemoptizia masiva De regula, in cancerul bronho-pulmonar hemoptiziile sunt mici. Neglijarea acestui semn, poate duce la extensia tumorii sii agravarea hemoptiziilor. Prin instalarea unei fistule bronho-vasculare se ajunge la o hemoptizie masiva fatala, sau hemoptizii repetate in cantitati mari. Decesul se produce fie prin exsanghinare, fie prin obstructie traheo-bronsica cu insuficienta respiratiorie acuta. Alternativele terapeutice sunt: - fotocoagulare bronhoscopica - embolizarea arterei bronsice - lobectomia sau pneumonectomia - devascularizarea peribronsica b. Abcesul pulmonar Apare fie prin obstructia artborelui bronsic (supuratie retrostenotica), fie prin necroza tumorala (discrepanta intre rata de multiplicare a masei tumorale si posibilitatile sale limitate de nutritie). Tehnica chirurgicala de electie este rezectia pulmonara (lobectomia). In situatii ce nu permit efectuarea unei toracotomii, intra in discutie drenajul percutan sau dezobstructia bronsica prin laser. 3

4 c. Pneumotoraxul spontan secundar Pneumotoraxul spontan secundar este o entitate rara in cancerul bronho-pulmonar. Se produce prin ruptura unor bule de emfizem din jurul tumorii, sau prin ruptura tumorii in pleura. Poate apare la un pacient la care diagnosticul de neoplasm este precizat, sau poate fi factorul ce permite stabilirea diagnosticului. Tratamentul este in functie de stadializarea neoplasmului bronho-pulmonar. Daca pneumotoraxul se instaleaza la un pacient cu cancer bronho-pulmonar depasit chirurgical, se efectueaza drenajul prin pleurotomie la care se asociaza tehnici de pleurodeza, iar daca pneumotoraxul este persistent se recurge la un drenaj valvular a la long. Daca meoplasmul este operabil, se va efectua rezectia pulmonara impusa de situatia lezionala. d. Sindromul de vena cava superioara Se realizeaza prin comprimarea sau invazia venei cave superioare prin tumora pulmonara sau prin adenopatiile tumorale mediastinale. Prezenta adenopatiilor mediastinale extensive contraindica interventia chirurgicala. In aceste situatii se indica radioterapie de decomprimare. Atunci cand sindromul este realizat prin extensia tumorii pulmonare s-au propus tehnici de rezectie laterala de perete venos (invazie limitata), sau rezectie circumferentiala cu reconstructie cu proteze vasculare (PTFE). e. Pleurezia masiva recidivanta Pacientul este internat in insuficienta respiratorie severa. Examenul radiologic releva o opacifiere cu caracter lichidian a unui hemitorace, uneori cu deplasarea controlaterala a mediastinului. Primul gest terapeutic este punctia pleurala ce permite ameliorarea starii generale a pacientului. Practic ne confruntam cu doua situatii: a. Pleurezie masiva recidivanta de etiologie necunoscuta, în prezenta unei tumori pulmonare cunoscute preoperator. Tumora pulmonara este evidenta. Întrebarea este daca suntem în fata unei pleurezii neoplazice sau atelectatice. b. Pleurezie masiva recidivanta neoplazica (cu multiple punctii pleurale in antecedente si diagnostic histopatologic precizat prin analiza lichidului sau prin biopsie pleurala) In aceste situatii, se recurge fie la chirurgia toracoscopica, fie la practicarea unei minitoracotomii, cu efectuarea biopsiei pleurale si a pleurectomiei parietale partiale si drenaj pleural. Se injecteaza citostatice sau se face pudraj cu talc, pentru obtinerea unei bune simfize. f. Pericardita recidivanta Se asociaza de regula cu pleurezia recidivanta. Pacientul se interneaza de urgenta cu un sindrom hipodiastolic relevat clinic si prin investigatiile paraclinice (radiografie toracica, EKG, echocardiografie sau examen CT). O data diagnosticul strabilit primul gest terapeutic consta in evacuarea lichidului pericardic, prin punctie pericardica. In cazurile recidivante se recomanda interventia chirurgicala: fereastra pleuropericardica (realizata prin chirurgie toracoscopica sau prin minitoracotomie), sau fereastra pericardo-peritoneala (realizata prin laparotomie sau laparoscopie). Fereastra pleuro-pericardica toracoscopica este interventia recomandata, fiind miniinvaziva, cu rezolvarea definitiva a colectiei pericardice. g. Invazia extinsa a peretelui toracic Produce dureri insuportabile. Atunci cand extensia tumorala, sau conditia functionala si biologica a pacientului contraindica o rezectie curativa, in limite oncologice, de regula se 4

5 tenteaza cuparea sindromului algic prin iradiere externa sau rizotomie. O alternativa o constituie rezectia paliativa de perete toracic (rezectie costala si de parti moi, neurectomie intercostala) la care se poate asocia brahiterapia. h. Obstructia proximala a arborelui traheobronsic cu insuficienta respiratorie In situatiile in care interventia chirurgicala este contraindicata (infiltratia extensiva a traheei, sau a ambelor bronhii primitive), se recomanda interventii de bronhologie interventionala: foraje transtumorale prin crioterapie, laserterapie (laser CO2, Nd YAG) si plasarea de stenturi. 5

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