Lung Cancer

Understanding the disease Treatment options Side effects of treatment

Three lobes on the right and two on the left

Three lobes on the right and two on the left

Lung Lymph Nodes

Importance of the Lymph Nodes

Nodes on the side (hilar or N1) are not as significant if nodes in the middle or higher up are involved (N2 or mediastinal nodes)

Lymph Node Stations

N2 Nodes: all N2 nodes lie within the mediastinal pleural envelope on the ipsilateral side

10. hilar, 11. interlobar, 12 lobar nodes bronchi, 12 segmental, 14. subsegmental

N1 Nodes: all N1 nodes lie distal to the mediastinal pleural reflection and within the visceral pleura

1. highest mediastinal, 2. upper paratracheal, 3. prevascular/ retrotracheal, 4. lower paratracheal, 5. subaortic/AP window, 6. para-aortic, 7.subcarcinal, 8. paraesophageal, 9. pulmonary ligament

Superior Mediastinal Nodes (1-4) 1. Highest Mediastinal: above the left brachiocephalic vein. 2. Upper Paratracheal: above the aortic arch, but below the left brachiocephalic vein. 3. Pre-vascular or Pre-vertebral: these nodes are not adjacent to the trachea like the nodes in station 2. They are either anterior to the vessels (3A) or behind the esophagus, which is prevertebral (3P). 4. Lower Paratracheal (including Azygos Nodes): below upper margin of aortic arch down to level of main bronchus.

Aortic Nodes (5-6) 5. Subaortic (A-P window): nodes lateral to ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk, but lateral to these vessels. 6. Para-aortic (ascending aorta or phrenic): nodes lying anterior and lateral to the ascending aorta and the aortic arch.

Inferior Mediastinal Nodes (7-9) 7. Subcarinal. 8. Paraesophageal (below carina). 9. Pulmonary Ligament: nodes lying within the pulmonary ligaments.

Hilar, Interlobar, Lobar, Segmental and Subsegmental Nodes (10-14) 10-14: these are located outside of the mediastinum.They are all N1-nodes.

Reading a Chest Xray

Reading a CT Scan

Cross Section Anatomy of the Chest

Cross Section Anatomy of the Chest

PET Scan Anatomy

spineSpinal cord

ribs

Xray versus CT versus PET scan

PET/CT Scan showing lung cancer in three different planes

Types of Lung Cancer

Non-small cell carcinoma (NSCC)– Adenocarcinoma– Squamous cell– Large cell

Small cell carcinoma

Stages of Lung Cancer

Stage I – small spot no nodes Stage II – larger or nodes on the side of the

lung (hilar or N1 nodes) Stage III – very large tumor or lymph nodes in

the middles of the chest (mediastinum or N2 nodes)

Stage IV – metastases to other organs

Treatment of Lung Cancer

Stage I and II – surgery (if possible) and sometime postOp chemo or radiation

Stage III – usually chemo plus radiation, sometime followed by surgery

Stage IV – chemo or radiation, depending on the site of spread

In the simulation process the CT and PET scan images are used to create a computer plan

PET/CT Lung Cancer Image

Initial CT Lung Image Prior to PET Fusion

Initial CT

PET Scan

Fused on Treatment Planning

Computer

In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment

Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)

Computer generated images of small lung cancer (in blue) in the left upper lung and the radiation target zone (green) that surrounds it

Computer generated images showing the radiation beam passing through the patient to hit the small lung cancer

Computer generated images showing the volume and dose of normal lung receiving radiation

The computer monitors the total lung dose to keep it below a dose level that could cause problems

Computer generated lung cancer target in red

and radiation zone (yellow) surrounds it

Using CT scans the computer can generate the target for a cancer in the upper part of the lung

Using CT scans the computer can generate the target for a small cancer growing inside the trachea

Computer generated images to target the tumor

Tomotherapy images showing the radiation zone in red surrounds the cancer area (in blue) and limits the dose of radiation that hits the normal lung, heart or spinal cord

Cyberknife of Tampa Bay

Cyberknife for Lung Cancer

Radiation Results

Some lung cancers (like small cell) shrink quickly, other cancers may take weeks or months to slowly regress

PET Scan showing complete remission of the cancer in the left lung at 7 months

PET scan showing near complete remission, 2 months after radiation alone for NSCL

PET scan showing degree of tumor shrinkage 6 weeks after completion chemoradiation for NSCL lung cancer (the tumor will continue to shrink for weeks to months)

Very large lung cancer, prior to radiation

PET scan of the same patients, 2 years later, there is still a large density in the lung, but it is ‘cold’ on the PET scan, so just radiation fibrosis or scar tissue

Side Effects of Lung Radiation

Side Effects of Lung Radiation

Esophagus – sore throat or trouble swallowing

Trachea or lungs – cough or shortness of breath

Chest wall – tenderness Skin – sunburn Fatigue

Radiation Prescription for #

Cancer

Target

diagnosis: Stage # NSCL of #number of radiation treatments: #