Non-Small Cell Lung Cancer. Signs and symptoms persistent cough persistent cough trouble breathing...

Non-Small Cell Lung Non-Small Cell Lung Cancer Cancer

Signs and symptomsSigns and symptoms

persistent cough persistent cough trouble breathing trouble breathing chest discomfort chest discomfort wheezingwheezing streaks of blood in streaks of blood in sputumsputum hoarseness hoarseness loss of appetite loss of appetite weight loss for no known reasonweight loss for no known reason feeling very tired feeling very tired

Diagnostic testsDiagnostic tests

chest X-rayschest X-rays CT, PET scanCT, PET scan sputum cytologysputum cytology fine-needle aspiration biopsyfine-needle aspiration biopsy bronchoscopybronchoscopy thoracoscopythoracoscopy thoracotomythoracotomy thoracentesisthoracentesis

NSCLCNSCLC

Non-small cell lung cancer (NSCLC) is Non-small cell lung cancer (NSCLC) is a heterogeneous aggregate of a heterogeneous aggregate of histologies. The most common histologies. The most common histologies are epidermoid or histologies are epidermoid or squamous carcinoma, squamous carcinoma, adenocarcinoma, and large cell adenocarcinoma, and large cell carcinoma. These histologies are carcinoma. These histologies are often classified together because often classified together because approaches to diagnosis, staging, approaches to diagnosis, staging, prognosis, and treatment are similar. prognosis, and treatment are similar.

Cellular ClassificationCellular Classification

Squamous cell carcinoma Squamous cell carcinoma Adenocarcinoma Adenocarcinoma Large cell carcinoma Large cell carcinoma Adenosquamous carcinoma.Adenosquamous carcinoma. Carcinomas with pleomorphic, Carcinomas with pleomorphic,

sarcomatoid or sarcomatous elementssarcomatoid or sarcomatous elements Carcinoid tumorCarcinoid tumor Carcinomas of salivary-gland type Carcinomas of salivary-gland type Unclassified carcinoma Unclassified carcinoma

NSCLCNSCLC

At diagnosis, patients with NSCLC At diagnosis, patients with NSCLC can be divided into 3 groups that can be divided into 3 groups that reflect both the extent of the disease reflect both the extent of the disease and the treatment approachand the treatment approach

NSCLCNSCLC

The The first groupfirst group - - tumorstumors that are that are surgically resectablesurgically resectable (generally stage I, (generally stage I, stage II, and selected stage III patients). stage II, and selected stage III patients).

Patients with resectable disease who have Patients with resectable disease who have medical contraindications to surgery are medical contraindications to surgery are candidates for curative radiation therapy.candidates for curative radiation therapy.

Adjuvant cisplatin-based combination Adjuvant cisplatin-based combination chemotherapy may provide a survival chemotherapy may provide a survival advantage to patients with resected stage advantage to patients with resected stage IB, stage II, or stage IIIA NSCLC.IB, stage II, or stage IIIA NSCLC.

NSCLCNSCLC

The The secondsecond groupgroup includes patients with includes patients with either locally (T3-T4) and/or regionally either locally (T3-T4) and/or regionally (N2-N3) (N2-N3) advanced lung canceradvanced lung cancer. This . This group has a diverse natural history.group has a diverse natural history.

- unresectable or N2-N3 disease : radiation unresectable or N2-N3 disease : radiation therapy in combination with chemotherapytherapy in combination with chemotherapy

- selected patients with T3 or N2 disease selected patients with T3 or N2 disease can be treated effectively with surgical can be treated effectively with surgical resection and either preoperative or resection and either preoperative or postoperative chemotherapy or postoperative chemotherapy or chemoradiation therapy. chemoradiation therapy.

NSCLCNSCLC final group: final group: metastatic disease (M1)metastatic disease (M1) at the at the

time of diagnosis time of diagnosis radiation therapy or chemotherapy for palliation radiation therapy or chemotherapy for palliation

of symptoms from the primary tumor.of symptoms from the primary tumor. platinum-based chemotherapy has been platinum-based chemotherapy has been

associated with short-term palliation of symptoms associated with short-term palliation of symptoms and with a survival advantage.and with a survival advantage.

patients previously treated with platinum patients previously treated with platinum combination chemotherapy may derive symptom combination chemotherapy may derive symptom control and survival benefit from docetaxel, control and survival benefit from docetaxel, pemetrexed, or epidermal growth factor receptor pemetrexed, or epidermal growth factor receptor inhibitor.inhibitor.

Prognostic determinants after Prognostic determinants after surgery surgery

Presence of pulmonary symptoms. Presence of pulmonary symptoms. Large tumor size (>3 cm). Large tumor size (>3 cm). Nonsquamous histology. Nonsquamous histology. Metastases to multiple lymph nodes Metastases to multiple lymph nodes

within a TNM-defined nodal stationwithin a TNM-defined nodal station Vascular invasion Vascular invasion Increased numbers of tumor blood Increased numbers of tumor blood

vessels in the tumor specimen. vessels in the tumor specimen.

NSCLCNSCLC

For patients with inoperable disease, For patients with inoperable disease, prognosis is adversely affected by prognosis is adversely affected by poor PS and weight loss of >10%. poor PS and weight loss of >10%.

Stage 0 Non-Small Cell Lung Stage 0 Non-Small Cell Lung CancerCancer

Surgical resection using the least Surgical resection using the least extensive technique possible extensive technique possible (segmentectomy or wedge resection) (segmentectomy or wedge resection) to preserve maximum normal to preserve maximum normal pulmonary tissue because these pulmonary tissue because these patients are at high risk for second patients are at high risk for second lung cancers. lung cancers.

Endoscopic photodynamic therapy Endoscopic photodynamic therapy

Stage IStage I : : T1, N0, M0, T2, N0, M0T1, N0, M0, T2, N0, M0

Surgery is the treatment of choice Surgery is the treatment of choice --lobectomy or limited resectionlobectomy or limited resection

Patients with inoperable stage I disease and Patients with inoperable stage I disease and with sufficient pulmonary reserve may be with sufficient pulmonary reserve may be candidates for radiation therapy with candidates for radiation therapy with curative intentcurative intent

Patients with stage IB disease may benefit Patients with stage IB disease may benefit from adjuvant platinum-based from adjuvant platinum-based combination chemotherapy. combination chemotherapy.

5 year OS 27-71%5 year OS 27-71%

Stage II:Stage II: T1, N1, M0; T2, N1, M0; T3, T1, N1, M0; T2, N1, M0; T3, N0, M0N0, M0

Lobectomy; pneumonectomy; or segmental, Lobectomy; pneumonectomy; or segmental, wedge, or sleeve resection as appropriate. wedge, or sleeve resection as appropriate.

Radiation therapy with curative intent (for Radiation therapy with curative intent (for potentially operable patients who have medical potentially operable patients who have medical contraindications to surgery).contraindications to surgery).

Adjuvant chemotherapy with or without other Adjuvant chemotherapy with or without other modalities after curative surgery modalities after curative surgery

5 year OS 10-60%5 year OS 10-60%

Stage IIIAStage IIIA T1-2 N2; T3 N1-2 T1-2 N2; T3 N1-2 Surgery alone in operable patients without bulky Surgery alone in operable patients without bulky

lymphadenopathy. lymphadenopathy.

Radiation therapy alone, for patients who are not Radiation therapy alone, for patients who are not suitable for neoadjuvant chemotherapy plus suitable for neoadjuvant chemotherapy plus surgery. surgery.

Chemotherapy combined with other modalities.Chemotherapy combined with other modalities. 5 year OS 2-28%5 year OS 2-28%

Stage IIIBStage IIIB Any T, N3, M0; T4, any N, Any T, N3, M0; T4, any N, M0M0

initial chemotherapy, chemotherapy plus initial chemotherapy, chemotherapy plus radiation therapy, or radiation therapy alone, radiation therapy, or radiation therapy alone, depending on the sites of tumor involvement and depending on the sites of tumor involvement and their performance status (PS). their performance status (PS).

patients with malignant pleural effusion are patients with malignant pleural effusion are rarely candidates for radiation therapy and should rarely candidates for radiation therapy and should generally be treated similarly to generally be treated similarly to stagestage IV IV patients. patients.

A meta-analysis of patient data from 11 A meta-analysis of patient data from 11 randomized clinical trials showed that randomized clinical trials showed that neoadjuvant or concurrent cisplatin-based neoadjuvant or concurrent cisplatin-based combinations plus radiation therapy resulted in a combinations plus radiation therapy resulted in a 10% reduction in the risk of death compared with 10% reduction in the risk of death compared with radiation therapy alone. radiation therapy alone.

Stage IVStage IV Any T, any N, M1 Any T, any N, M1

External-beam radiation therapy, External-beam radiation therapy, primarily for palliative relief of local primarily for palliative relief of local symptomatic tumor growth.symptomatic tumor growth.

Cisplatin- based chemotherapy. Cisplatin- based chemotherapy.

SCLCSCLC

Without treatmentWithout treatment, small cell carcinoma , small cell carcinoma of the lung has the most aggressive of the lung has the most aggressive clinical course of any type of pulmonary clinical course of any type of pulmonary tumor, with tumor, with median survival from median survival from diagnosis of only 2 to 4 monthsdiagnosis of only 2 to 4 months. .

Compared with other cell types of lung Compared with other cell types of lung cancer, small cell carcinoma has a greater cancer, small cell carcinoma has a greater tendency to be widely disseminated by the tendency to be widely disseminated by the time of diagnosis but is much more time of diagnosis but is much more responsive to chemotherapy and responsive to chemotherapy and irradiation. irradiation.

SCLCSCLC

With incorporation of current With incorporation of current chemotherapychemotherapy regimens into the regimens into the treatment program, treatment program, survival is survival is prolonged, with at least a 4- to prolonged, with at least a 4- to 5-fold5-fold improvement in median improvement in median survival compared with patients who survival compared with patients who are given no therapy. are given no therapy.

The overall survival at 5 years is 5% The overall survival at 5 years is 5% to 10%.to 10%.

Cellular ClassificationCellular Classification

Small cell carcinoma. Small cell carcinoma. Mixed small cell/large cell carcinoma. Mixed small cell/large cell carcinoma. Combined small cell carcinoma (i.e., Combined small cell carcinoma (i.e.,

small cell lung cancer combined with small cell lung cancer combined with neoplastic squamous and/or neoplastic squamous and/or glandular components). glandular components).

Limited-stage diseaseLimited-stage disease

tumor confined to the hemithorax of tumor confined to the hemithorax of origin, the mediastinum, and the origin, the mediastinum, and the supraclavicular nodes, which can be supraclavicular nodes, which can be encompassed within a tolerable radiation encompassed within a tolerable radiation therapy port. No universally accepted therapy port. No universally accepted definition of this term is available, and definition of this term is available, and patients with pleural effusion, massive patients with pleural effusion, massive pulmonary tumor, and contralateral pulmonary tumor, and contralateral supraclavicular nodes have been both supraclavicular nodes have been both included within and excluded from limited included within and excluded from limited stage by various groups. stage by various groups.

Extensive-stage diseaseExtensive-stage disease

Extensive-stage small cell lung Extensive-stage small cell lung cancer means tumor that is too cancer means tumor that is too widespread to be included within the widespread to be included within the definition of limited-stage disease definition of limited-stage disease above. Patients with distant above. Patients with distant metastases (M1) are always metastases (M1) are always considered to have extensive-stage considered to have extensive-stage disease disease

Prognostic factorsPrognostic factors

good performance status, female good performance status, female gender, and limited-stage diseasegender, and limited-stage disease

patients with involvement of the patients with involvement of the

central nervous system or liver at the central nervous system or liver at the time of diagnosis have a significantly time of diagnosis have a significantly worse outcome worse outcome

Limited-Stage Small Cell Lung Limited-Stage Small Cell Lung Cancer- treatmentCancer- treatment

Combination chemotherapy with chest Combination chemotherapy with chest irradiationirradiation: :

EC: etoposide + cisplatin + 4,500 cGy chest EC: etoposide + cisplatin + 4,500 cGy chest radiation therapyradiation therapy

Combination chemotherapyCombination chemotherapy especially in especially in patients with impaired pulmonary function or poor patients with impaired pulmonary function or poor performance status. performance status.

Surgical resection followed by chemotherapySurgical resection followed by chemotherapy or chemotherapy plus chest radiation therapyor chemotherapy plus chest radiation therapy

PCI PCI prophylactic cranial irradiation prophylactic cranial irradiation

Limited-Stage Small Cell Lung Limited-Stage Small Cell Lung CancerCancer

combination chemotherapy is superior to combination chemotherapy is superior to single-agent treatment, single-agent treatment,

current programs yield overall objective current programs yield overall objective response rates of 65% to 90% and response rates of 65% to 90% and complete response rates of 45% to 75%complete response rates of 45% to 75%

because of the frequent presence of occult because of the frequent presence of occult metastatic disease, chemotherapy is the metastatic disease, chemotherapy is the cornerstone of treatment for patients with cornerstone of treatment for patients with limited-stage small cell lung cancer. limited-stage small cell lung cancer.


combined modality therapy produces combined modality therapy produces significant improvement in survival significant improvement in survival compared with chemotherapy alonecompared with chemotherapy alone

two meta-analyses showed an two meta-analyses showed an improvement in 3-year survival rates of improvement in 3-year survival rates of about 5% for those receiving about 5% for those receiving chemotherapy and radiation therapy chemotherapy and radiation therapy compared with those receiving compared with those receiving chemotherapy alone. Most of the benefit chemotherapy alone. Most of the benefit occurred in patients younger than 65 occurred in patients younger than 65 years. years.

Combined modality treatment Combined modality treatment

Studies strongly suggest that Studies strongly suggest that minimal tumor doses in the range of minimal tumor doses in the range of 4,000 cGy to 4,500 cGy or more 4,000 cGy to 4,500 cGy or more (standard fractionation) are (standard fractionation) are necessary to effectively control necessary to effectively control tumors in the thorax. tumors in the thorax.

Combined modality treatment Combined modality treatment median survivals: 18 to 24 months and median survivals: 18 to 24 months and

40% to 50% 2-year survival with <3% 40% to 50% 2-year survival with <3% treatment-related mortalitytreatment-related mortality

once-daily and twice-daily chest radiation once-daily and twice-daily chest radiation schedules have been used in regimens schedules have been used in regimens with etoposide and cisplatin. with etoposide and cisplatin.

One randomized study showed a modest One randomized study showed a modest survival advantage in favor of twice-daily survival advantage in favor of twice-daily radiation therapy given over 3 weeks, radiation therapy given over 3 weeks, compared with once-daily radiation compared with once-daily radiation therapy given over 5 weeks (26% vs. 16% therapy given over 5 weeks (26% vs. 16% at 5 years, at 5 years, PP = .04). = .04).


Combined modality treatment is Combined modality treatment is associated with increased morbidity associated with increased morbidity and, in some trials, increased and, in some trials, increased treatment-related mortality from treatment-related mortality from pulmonary and hematologic toxic pulmonary and hematologic toxic effects; proper administration effects; proper administration requires close collaboration between requires close collaboration between medical and radiation oncologists medical and radiation oncologists

PCI prophylactic cranial irradiation PCI prophylactic cranial irradiation

Patients whose cancer can be Patients whose cancer can be controlled outside the brain have a controlled outside the brain have a 60% actuarial risk of developing 60% actuarial risk of developing central nervous system metastases central nervous system metastases within 2 to 3 years after starting within 2 to 3 years after starting treatment. The majority of these treatment. The majority of these patients relapse only in their brain, patients relapse only in their brain, and nearly all of those who relapse in and nearly all of those who relapse in their central nervous system die of their central nervous system die of their cranial metastasestheir cranial metastases

PCI- prophylactic cranial irradiation PCI- prophylactic cranial irradiation

Patients who have achieved a Patients who have achieved a complete remission can be complete remission can be considered for prophylactic cranial considered for prophylactic cranial irradiation (PCI). irradiation (PCI).

PCI prophylactic cranial irradiation PCI prophylactic cranial irradiation

The risk of developing central nervous The risk of developing central nervous system metastases can be reduced by system metastases can be reduced by >50% by the administration of PCI in >50% by the administration of PCI in doses of 2,400 cGydoses of 2,400 cGy

a meta-analysis of 7 randomized trials a meta-analysis of 7 randomized trials evaluating the value of PCI reported evaluating the value of PCI reported improvement in brain recurrence, disease-improvement in brain recurrence, disease-free survival, and overall survival with the free survival, and overall survival with the addition of PCI. The 3-year overall survival addition of PCI. The 3-year overall survival was improved from 15% to 21% with PCI. was improved from 15% to 21% with PCI.

PCIPCI

The majority of patients with small The majority of patients with small cell lung cancer have cell lung cancer have neuropsychological abnormalities neuropsychological abnormalities present before the start of cranial present before the start of cranial irradiation and have no detectable irradiation and have no detectable decline in their neurological status decline in their neurological status for as long as 2 years after the start for as long as 2 years after the start of their cranial irradiation of their cranial irradiation

Extensive-Stage Small Cell Lung Extensive-Stage Small Cell Lung CancerCancer

Combination chemotherapy with one of the Combination chemotherapy with one of the following regimens with or without PCI given to following regimens with or without PCI given to patients with complete responses:patients with complete responses:

-CAV: cyclophosphamide + doxorubicin + -CAV: cyclophosphamide + doxorubicin + vincristine. vincristine.

-CAE: cyclophosphamide + doxorubicin + -CAE: cyclophosphamide + doxorubicin + etoposide.etoposide.

-EP or EC: etoposide + cisplatin or carboplatin. -EP or EC: etoposide + cisplatin or carboplatin. -ICE: ifosfamide + carboplatin + etoposide.-ICE: ifosfamide + carboplatin + etoposide.-Cisplatin + irinotecan -Cisplatin + irinotecan irradiation reserved for nonresponding patients irradiation reserved for nonresponding patients

Skin cancerSkin cancer

Basal cell carcinoma Basal cell carcinoma squamous cell carcinoma squamous cell carcinoma Although these 2 types of skin cancer Although these 2 types of skin cancer

are the most common of all are the most common of all malignancies, they account for malignancies, they account for <0.1% of patient deaths due to <0.1% of patient deaths due to cancer. cancer.

Skin cancerSkin cancer

Both of these types of skin cancer Both of these types of skin cancer are more likely to occur in individuals are more likely to occur in individuals of light complexion who have had of light complexion who have had significant exposure to sunlight, and significant exposure to sunlight, and both types of skin cancer are more both types of skin cancer are more common in the southern latitudes of common in the southern latitudes of the Northern hemisphere. the Northern hemisphere.

Basal Cell Carcinoma of the SkinBasal Cell Carcinoma of the Skin

Mohs micrographic surgeryMohs micrographic surgery- the tumor is - the tumor is microscopically delineated until it is completely microscopically delineated until it is completely removed. Indications:removed. Indications:

tumors with poorly defined clinical borders; tumors with poorly defined clinical borders; tumors with diameters >2 cm; tumors with diameters >2 cm; tumors with histopathologic features showing tumors with histopathologic features showing

morpheaform or sclerotic patterns; morpheaform or sclerotic patterns; tumors arising in regions where maximum tumors arising in regions where maximum

preservation of uninvolved tissue is desirable, preservation of uninvolved tissue is desirable, such as eyelid, nose, finger, and genitalia. such as eyelid, nose, finger, and genitalia.

cure rates have been reported at 96% cure rates have been reported at 96%


Simple excision- Simple excision- tumor recurrence is not tumor recurrence is not uncommon because only a small fraction uncommon because only a small fraction of the total tumor margin is examined of the total tumor margin is examined pathologically. Recurrence rate for primary pathologically. Recurrence rate for primary tumors >1.5 cm in diameter is at least tumors >1.5 cm in diameter is at least 12% within 5 years; if the primary tumor 12% within 5 years; if the primary tumor measures >3 cm, the 5-year recurrence measures >3 cm, the 5-year recurrence rate is 23.1%. Primary tumors of the ears, rate is 23.1%. Primary tumors of the ears, eyes, scalp, and nose have recurrence eyes, scalp, and nose have recurrence rates ranging from 12.9% to 25%. rates ranging from 12.9% to 25%.


Electrodesiccation and Electrodesiccation and curettage.curettage. This method is the most This method is the most widely employed method for widely employed method for removing primary basal cell removing primary basal cell carcinomas. Although it is a quick carcinomas. Although it is a quick method for destroying the tumor, method for destroying the tumor, adequacy of treatment cannot be adequacy of treatment cannot be assessed immediately since the assessed immediately since the surgeon cannot visually detect the surgeon cannot visually detect the depth of microscopic tumor invasion. depth of microscopic tumor invasion.


Cryosurgery-Cryosurgery- may be considered for may be considered for patients with small, clinically well-patients with small, clinically well-defined primary tumors. It is defined primary tumors. It is especially useful for debilitated especially useful for debilitated patients with medical conditions that patients with medical conditions that preclude other types of surgery. preclude other types of surgery.


Radiation therapy: Radiation therapy: for patients with for patients with primary lesions requiring difficult or primary lesions requiring difficult or extensive surgery (e.g., eyelids, nose, or extensive surgery (e.g., eyelids, nose, or ears) ears)

Cosmetic results are generally good to Cosmetic results are generally good to excellent with a small amount of excellent with a small amount of hypopigmentation or telangiectasia in the hypopigmentation or telangiectasia in the treatment port. treatment port.

Radiation therapy can also be used for Radiation therapy can also be used for lesions that recur after a primary surgical lesions that recur after a primary surgical approach. approach.

Squamous Cell Carcinoma of the Squamous Cell Carcinoma of the SkinSkin

Localized squamous cell carcinoma of the Localized squamous cell carcinoma of the skin is a highly curable disease.The skin is a highly curable disease.The traditional methods of treatment involve traditional methods of treatment involve the use of cryosurgery, radiation therapy, the use of cryosurgery, radiation therapy, electrodesiccation and curettage, and electrodesiccation and curettage, and simple excision. simple excision.

Of all treatment methods available, Mohs Of all treatment methods available, Mohs micrographic surgery has the highest 5-micrographic surgery has the highest 5-year cure rate for both primary and year cure rate for both primary and recurrent tumors. recurrent tumors.

Lymphadenectomy is indicated when Lymphadenectomy is indicated when regional lymph nodes are involved. regional lymph nodes are involved.

Melanoma malignumMelanoma malignum

most melanomas arise in the skin, most melanomas arise in the skin, they may also arise from mucosal they may also arise from mucosal surfaces or at other sites to which surfaces or at other sites to which neural crest cells migrate neural crest cells migrate

Melanoma occurs predominantly in Melanoma occurs predominantly in adults, and more than 50% of the adults, and more than 50% of the cases arise in apparently normal cases arise in apparently normal areas of the skin areas of the skin

PrognosisPrognosis

Thickness and/or level of invasion of the Thickness and/or level of invasion of the melanoma, mitotic index, presence of melanoma, mitotic index, presence of tumor infiltrating lymphocytes, number of tumor infiltrating lymphocytes, number of regional lymph nodes involved, and regional lymph nodes involved, and ulceration or bleeding at the primary site ulceration or bleeding at the primary site affect the prognosis. affect the prognosis.

Patients who are younger, female, and Patients who are younger, female, and who have melanomas on the extremities who have melanomas on the extremities generally have a better prognosis. generally have a better prognosis.

PrognosisPrognosis

For disease clinically confined to the For disease clinically confined to the primary site, the greater the primary site, the greater the thickness and depth of local invasion thickness and depth of local invasion of the melanoma, the higher the of the melanoma, the higher the chance of lymph node or systemic chance of lymph node or systemic metastases and the worse the metastases and the worse the prognosis prognosis

Stage Stage

Clark’sClark’s classificationclassification ( (levellevel of of invasioninvasion))TNM TNM definitionsdefinitionsClinicalClinical stagingstaging AJCC AJCC stagestage groupingsgroupingsPathologicPathologic stagingstaging AJCC AJCC stagestage groupingsgroupings


localized melanoma: surgical localized melanoma: surgical excision with margins proportional to excision with margins proportional to the microstage of the primary lesion the microstage of the primary lesion

melanomas that have spread to melanomas that have spread to regional lymph nodes may be regional lymph nodes may be curable with excision of the primary curable with excision of the primary tumor and removal of the involved tumor and removal of the involved lymph nodes lymph nodes


adjuvant high-dose interferon was adjuvant high-dose interferon was shown to increase relapse-free and shown to increase relapse-free and overall survival when compared to overall survival when compared to observation observation

adjuvant chemotherapy does not adjuvant chemotherapy does not improve survival improve survival

Patients with distant metastasisPatients with distant metastasis

Treatment in clinical trials:Treatment in clinical trials: combination chemotherapycombination chemotherapy biological response modifiers (such biological response modifiers (such

as specific monoclonal antibodies, as specific monoclonal antibodies, interferons, IL-2, or tumor necrosis interferons, IL-2, or tumor necrosis factor-alfa), vaccine immunotherapy, factor-alfa), vaccine immunotherapy, or chemoimmunotherapy. or chemoimmunotherapy.

Recurrent MelanomaRecurrent Melanoma Resection of isolated single or localized metastases from Resection of isolated single or localized metastases from

skin, visceral, or brain sites in selected patients is skin, visceral, or brain sites in selected patients is sometimes associated with prolonged survival. sometimes associated with prolonged survival.

Palliative radiation therapy for bone, spinal cord, or brain Palliative radiation therapy for bone, spinal cord, or brain metastases.metastases.

Palliative biologic therapy and/or chemotherapy in phase Palliative biologic therapy and/or chemotherapy in phase

I and II clinical trials. I and II clinical trials.

Palliative treatment with interleukin-2 or interferon can Palliative treatment with interleukin-2 or interferon can occasionally result in prolonged survival. occasionally result in prolonged survival.

Isolated hyperthermic limb perfusion for extremity Isolated hyperthermic limb perfusion for extremity recurrences. recurrences.

Primary brain tumorsPrimary brain tumors Anaplastic astrocytoma and glioblastoma Anaplastic astrocytoma and glioblastoma

account for approximately 38% account for approximately 38% meningiomas and other mesenchymal meningiomas and other mesenchymal

tumors account for approximately 27%.tumors account for approximately 27%. pituitary tumors, schwannomas, CNS pituitary tumors, schwannomas, CNS

lymphoma, oligodendrogliomas, lymphoma, oligodendrogliomas, ependymomas, low-grade astrocytomas, ependymomas, low-grade astrocytomas, and medulloblastoma and medulloblastoma

Pirmary spinal tumorsPirmary spinal tumors

Schwannomas, meningiomas, Schwannomas, meningiomas, and ependymomas account for and ependymomas account for as much as 79% of primary as much as 79% of primary spinal tumorsspinal tumors


headache; headache; gastrointestinal symptoms such as gastrointestinal symptoms such as

nausea, loss of appetite, and nausea, loss of appetite, and vomiting; vomiting;

changes in personality, mood, mental changes in personality, mood, mental capacity, and concentration.capacity, and concentration.

focal cerebral syndromes such as focal cerebral syndromes such as seizures seizures


Of all patients with brain tumors, Of all patients with brain tumors, 70% with primary tumors and 40% 70% with primary tumors and 40% with metastatic brain tumors develop with metastatic brain tumors develop seizures at some time during the seizures at some time during the clinical course. clinical course.

TreatmentTreatment

Surgical removal is recommended for most Surgical removal is recommended for most types of brain tumors, in most locations, types of brain tumors, in most locations, removal should be as complete as possible removal should be as complete as possible within the constraints of preservation of within the constraints of preservation of neurologic function.neurologic function.

An exception to this role for surgery is An exception to this role for surgery is deep-seated tumors such as pontine deep-seated tumors such as pontine gliomas, which are diagnosed on clinical gliomas, which are diagnosed on clinical evidence and treated without initial evidence and treated without initial surgery approximately 50% of the time. surgery approximately 50% of the time.

TreatmentTreatment

Radiation therapy has a major role in Radiation therapy has a major role in the treatment of patients with most the treatment of patients with most tumor types and can increase the tumor types and can increase the cure rate or prolong disease-free cure rate or prolong disease-free survival. survival.

may also be useful in the treatment may also be useful in the treatment of recurrences in patients initially of recurrences in patients initially treated with surgery alone. treated with surgery alone.

TreatmentTreatment

Chemotherapy may prolong survival Chemotherapy may prolong survival in patients with some tumor types in patients with some tumor types and has been reported to lengthen and has been reported to lengthen disease-free survival in patients with disease-free survival in patients with gliomas, medulloblastoma, and some gliomas, medulloblastoma, and some germ cell tumors. germ cell tumors.

TreatmentTreatment

Dexamethasone, mannitol, and Dexamethasone, mannitol, and furosemide are used to treat the furosemide are used to treat the peritumoral edema associated with peritumoral edema associated with brain tumors. Use of anticonvulsants brain tumors. Use of anticonvulsants is mandatory for patients with is mandatory for patients with seizures. seizures.

Brain Stem GliomasBrain Stem Gliomas

Brain stem gliomas have relatively Brain stem gliomas have relatively poor prognoses that correlate with poor prognoses that correlate with histology (when biopsies are histology (when biopsies are performed), location, and extent of performed), location, and extent of tumor. The overall median survival tumor. The overall median survival time of patients in studies has been time of patients in studies has been 44 to 74 weeks. The best results 44 to 74 weeks. The best results have been attained with have been attained with hyperfractionated radiation therapy.hyperfractionated radiation therapy.

Pilocytic AstrocytomasPilocytic Astrocytomas- grade I - grade I tumors (WHO)tumors (WHO)

Surgery alone if the tumor is totally Surgery alone if the tumor is totally resectable. resectable.

Surgery followed by radiation Surgery followed by radiation therapy to known or suspected therapy to known or suspected residual tumor residual tumor

Diffuse Astrocytomas- grade II Diffuse Astrocytomas- grade II astrocytic tumorastrocytic tumor

Surgery plus radiation therapy; Surgery plus radiation therapy; Or surgery alone if the patient is Or surgery alone if the patient is

younger than 35 years and if the younger than 35 years and if the tumor does not contrast-enhance on tumor does not contrast-enhance on a computed tomographic scan. a computed tomographic scan.

Anaplastic AstrocytomasAnaplastic Astrocytomas-grade -grade III tumorsIII tumors

Surgery plus radiation therapy. Surgery plus radiation therapy. Surgery plus radiation therapy and Surgery plus radiation therapy and

chemotherapy chemotherapy clinical trials that evaluate clinical trials that evaluate

hyperfractionated irradiation, accelerated-hyperfractionated irradiation, accelerated-fraction radiation, stereotactic fraction radiation, stereotactic radiosurgery, radiosensitizers, radiosurgery, radiosensitizers, hyperthermia, interstitial brachytherapy, hyperthermia, interstitial brachytherapy, or intraoperative radiation therapy used in or intraoperative radiation therapy used in conjunction with external-beam radiation conjunction with external-beam radiation therapytherapy

GlioblastomaGlioblastoma- grade IV tumors- grade IV tumors

Surgery plus radiation therapy and Surgery plus radiation therapy and chemotherapy chemotherapy

Surgery plus radiation therapy Surgery plus radiation therapy

Patients with newly diagnosed Patients with newly diagnosed glioblastoma multiformeglioblastoma multiforme

A randomized study of RT versus RT plus A randomized study of RT versus RT plus temozolomide followed by 6 months of temozolomide followed by 6 months of adjuvant temozolomide: a statistically adjuvant temozolomide: a statistically significant increase in median survival of 3 significant increase in median survival of 3 months in the combination-treated group.months in the combination-treated group.

The 2-year survival rate was 26.5% in the The 2-year survival rate was 26.5% in the combination group compared with only combination group compared with only 10.4% in the radiation-only group. The 10.4% in the radiation-only group. The treatment is relatively safe and well treatment is relatively safe and well tolerated. tolerated.

Oligodendrogliomas Oligodendrogliomas

Oligodendrogliomas behave much like Oligodendrogliomas behave much like diffuse astrocytomas diffuse astrocytomas

Standard treatment options:Standard treatment options: Surgery plus radiation therapy; however, Surgery plus radiation therapy; however,

some controversy exists. Some physicians some controversy exists. Some physicians treat these patients with surgery alone if treat these patients with surgery alone if the patient is younger than 45 years and if the patient is younger than 45 years and if the tumor does not contrast-enhance on a the tumor does not contrast-enhance on a computed tomographic scan.computed tomographic scan.

Ependymal TumorsEpendymal Tumors

Surgery plus radiation therapy (brain Surgery plus radiation therapy (brain irradiation with or without spinal irradiation with or without spinal irradiation)irradiation)

Embryonal Cell Tumors: Embryonal Cell Tumors: MedulloblastomaMedulloblastoma

Surgery plus craniospinal irradiationSurgery plus craniospinal irradiation

Non-Small Cell Lung Cancer. Signs and symptoms persistent cough persistent cough trouble breathing...

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