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SWOG
ONCOLOGY RESEARCH PROFESSIONAL (ORP) MANUAL
VOLUME II
LUNG
CHAPTER 8
REVISED: OCTOBER 2014
Disease Information
The mucosal lining of the bronchus is the most common site of origin for lung carcinoma. The
trachea, which lies in the anterior mediastinum, divides into the right and left lungs, and then
divides into lobar bronchi for the upper, middle and lower lobes on the right and the upper and
lower lobes on the left. The lungs are encased in a membrane called the visceral pleura; a
similar membrane called the parietal pleura lines the chest cavity. The potential space between
these two membranes is the pleural space.
Lung Histopathology
There are two major histologic types of tumors: small cell (some types of small cell are referred
to as oat cell), and non-small cell. Small cell anaplastic carcinoma tends to be disseminated at
the time of diagnosis. This is an aggressive and rapidly growing neoplasm. Disease is limited
to the thorax at presentation in only 25% of patients. Metastases will be found in regional
glands, bone, the central nervous system, and the bone marrow.
Non-small cell lung cancer is a less aggressive disease, but still metastasizes frequently to sites
including opposite lung, liver, bone, kidney, mediastinal nodes, pleura, adrenals, and the central
nervous system.
Prognostic Factors
Cell type and stage of disease at presentation are important prognostic factors. Additionally,
age, sex, albumin and LDH levels, recent weight loss, and performance status at initial
presentation have prognostic value in most types of lung cancer.
Treatment
Non-small cell lung cancer
Initial treatment for NSCLC depends upon the stage or resectability of the tumor. Treatment for
stage I-II, resectable disease is typically surgery. Patients with stage IIIA disease often receive
combined modality therapy (i.e. chemotherapy plus surgery or chemotherapy plus radiation
therapy) or radiation alone.
Patients with more advanced disease typically receive
chemotherapy.
Small cell lung cancer
Patients with extensive disease are treated with chemotherapy. Patients with limited disease
are often treated with a combination of chemotherapy and radiation therapy. Responses are
common in small cell carcinoma, but survival benefit is limited.
Chapter 8 - Page 1
ORP Manual, Volume II
Version 1.0
SWOG
ONCOLOGY RESEARCH PROFESSIONAL (ORP) MANUAL
VOLUME II
LUNG
CHAPTER 8
REVISED: OCTOBER 2014
Staging
Non-small cell lung cancer
Most SWOG lung cancer protocols in non-small cell lung cancer (NSCLC) utilize the TNM
classification scheme and stage groupings as defined in the American Joint Committee on
Cancer staging. Note that staging and eligibility sections of the protocol must always be
consulted when determining eligibility and staging for a particular SWOG study. A protocol may
have been developed when an earlier version of AJCC staging was in place and that version
would be used for the duration of the study. Recently developed lung protocols and protocols
currently under development utilize AJCC Version 7.
AJCC Version 7 Staging Primary Tumor (T)
TX
Primary tumor cannot be assessed, or tumor proven by presence of malignant
cells in sputum or bronchial washings but not visualized by imaging or
bronchoscopy.
T0
No evidence of primary tumor.
Tis
Carcinoma in situ.
T1
Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura,
without bronchoscopic evidence of invasion moreproximal than the lobar
bronchus* (i.e., not in main bronchus).
T1a
Tumor ≤ 2 cm in greatest dimension.
T1b
Tumor > 2 cm but ≤ 3 cm in greatest dimension.
T2
Tumor > 3 cm but ≤7 cm or tumor with any of the following features (T2 tumors
with these features are classified T2a if ≤ 5 cm)
•
Involves main bronchus, 2 cm or more distal to the carina
•
Invades the visceral pleura (PL1 or PL2)
•
Associated with atelectasis or obstructive pneumonitis that extends to the
hilar region but does not involve the entire lung
T2a
Tumor > 3 cm but ≤ 5 cm in greatest dimension.
T2b
Tumor > 5 cm but ≤ 7 cm in greatest dimension.
Chapter 8 - Page 2
ORP Manual, Volume II
Version 1.0
SWOG
ONCOLOGY RESEARCH PROFESSIONAL (ORP) MANUAL
VOLUME II
LUNG
CHAPTER 8
REVISED: OCTOBER 2014
T3
Tumor > 7 cm that directly invades any of the following: parietal pleura (PL3),
chest wall (including superior sulcus tumors), diaphragm, phrenic nerve,
mediastinal pleura, parietal pericardium; or tumor in the main bronchus less than
2 cm distal to the carina but without involvement of the carina; or associated
atelectasis or obstructive pneumonitis of the entire lung or separate tumor
nodule(s) in the same lobe.
T4
Tumor of any size that invades any of the following: mediastinum, heart, great
vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina;
separate tumor nodule(s) in a different ipsilateral lobe.
*The uncommon superficial tumor of any size with its invasive component limited to the bronchial wall,
which may extend proximal to the main bronchus, is also classified as T1.
Regional Lymph Nodes (N)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and
intrapulmonary nodes involved by direct extension of the primary tumor
N2
Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s)
N3
Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or
contralateral scalene or supraclavicular lymph node(s)
(See the version 7 of the AJCC Staging Manual for information on regional nodal
stations for staging)
Distant Metastasis
MX
Presence of distant metastasis cannot be assessed.
M0
No distant metastasis.
M1
Distant metastasis
M1a
Separate tumor nodule(s) in a contralateral lobe; tumor with pleural nodules or
malignant pleural (or pericardial) effusion**
M1b
Distant metastasis
**Most pleural effusions associated with lung cancer are due to tumor. However, there are a few patients
in whom multiple cytopathologic examinations of pleural fluid are negative for tumor. In these cases, fluid
Chapter 8 - Page 3
ORP Manual, Volume II
Version 1.0
SWOG
ONCOLOGY RESEARCH PROFESSIONAL (ORP) MANUAL
VOLUME II
LUNG
CHAPTER 8
REVISED: OCTOBER 2014
is nonbloody and is not an exudate. When these elements and clinical judgment dictate that the effusion
is not related to the tumor, the effusion should be excluded as a staging element.
Stage Grouping
GROUP
T
N
M
Occult
TX
N0
M0
0
Tis
N0
M0
IA
T1a
N0
M0
T1b
N0
M0
IB
T2a
N0
M0
IIA
T2b
N0
M0
T1a
N1
M0
T1b
N1
M0
T2a
N1
M0
T2b
N1
M0
T3
N0
M0
T1a
N2
M0
T1b
N2
M0
T2a
N2
M0
T2b
N2
M0
T3
N1
M0
T3
N2
M0
T4
N0
M0
T4
N1
M0
T1a
N3
M0
T1b
N3
M0
T2a
N3
M0
T2b
N3
M0
T3
N3
M0
T4
N2
M0
T4
N3
M0
IIB
IIIA
IIIB
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ORP Manual, Volume II
Version 1.0
SWOG
ONCOLOGY RESEARCH PROFESSIONAL (ORP) MANUAL
VOLUME II
LUNG
IV
CHAPTER 8
Any T
Any N
M1a
Any T
Any N
M1b
REVISED: OCTOBER 2014
Small cell lung cancer
SWOG protocols in small cell lung cancer typically use extent of disease (limited versus
extensive) to define stage groupings. These groupings are defined as follows:
Limited disease is confined to the single hemithorax, ipsilateral hilar lymph nodes, mediastinum,
and/or ipsilateral supraclavicular lymph nodes. In addition, the patient's disease must be
encompassable in a single radiation port.
Extensive disease is disease spread beyond the areas defined for limited disease. A patient
with malignant pleural effusions is classified as having extensive disease.
Chapter 8 - Page 5
ORP Manual, Volume II
Version 1.0