CANCERUL BRONHOPULMONARDR. CRISTINA GRIGORESCUEF LUCRRICLINICA DE CHIRURGIE TORACICUMF GR.T.POPA IAI

CANCERUL BRONHOPULMONARCauz major de deces n SUA.171900 cazuri noi n 2003 n SUA -12,8% din cazuri noi.Rata de supravieuire la 5 ani 14% n SUA, 8% n Europa i China.Factori :Fumatul,asbest,arsenic, beriliu, hidrocarburi aromate, nitrolacuri,nichel, crom, radon, siliciu,formaldehide,fibre sintetice,infecii pulmonare cronice(tbc pulmonar, abces),BPOC.

CANCERUL BRONHOPULMONARINVESTIGAII PARACLINICERadiografia toracic PA , profil,Computer tomografia toracic cu substan de contrast,Fibrobronhoscopia cu periaj i biopsie seriat,Puncia biopsie transtoracic pentru noduli periferici,Ecografia toracic i abdominal,PET scan,Mediastinoscopia(video), mediatinotomia anterioar,VATS pentru evaluarea leziunilor pleurale n caz de pleurezie cu citologie negativ sau pentru biopsia nodulilor pulmonari periferici,Scintigrafia pulmonar de perfuzie/ventilaie,Spirometria, pletismografia cu msurare de TLCO,Teste biologice de snge.

CANCERUL BRONHOPULMONARSEMNE CLINICE DE PREZENTARE LA MEDICTuse 29- 87%Hemoptizie- 9- 57% Durere toracic 6- 60%dispnee 3- 58%Wheezing sau stridor 2-14%pleurezie 7%Disfagia 2%Sindrom de ven cav superioar 4-11%Sindrom Pancoast 3-5%Paralizie de nerv frenic 1% Anorexie,scdere ponderal important.

CANCERUL BRONHOPULMONARsemne generate de metastazeMetastaze osoase:dureri osoase,Metastaze neurologice: de cuaz central sau compresiune/invazie medular periferic,Mts. n glande suprarenale,Mts. hepatice,n alte organe: plmn controlateral, esuturi moi.

CANCERUL BRONHOPULMONARSINDROAME PARANEOPLAZICEMetabolice: - hipercalcemia (secreie parathormon), - sindrom Cushing (secreie ACTH), - sindrom carcinoid , - ginecomastia (secreie prolactin), - hipoglicemie(secreie de insulin), - hipertiroidism(secreie de TSH)

CANCERUL BRONHOPULMONARSINDROAME PARANEOPLAZICENeurologice -encefalopatie, - degenerare cerebral subacut, - neuropatie periferic, - polimiozit, - neuropatie autonom, - mioclonie.

CANCERUL BRONHOPULMONARSINDROAME PARANEOPLAZICEScheletale - degete hipocratice, - osteoartropatie hipertrofic pneumicHematologice - anemia, -reacii leucemoide, -tromboctoz, -trombocitopenia, -eosinophilia, -aplazie de celule roii, -coagulare intravascular diseminat.

CANCERUL BRONHOPULMONARSINDROAME PARANEOPLAZICECutanate i musculare - hyperkeratosis, - dermatomyositis, - acanthosis nigricans, - erytremie, - hypertricosis lanuginosa acquisitaaltele -sindrom nefrotic, -hiperuricemie, -hiperamilayemie, -anorexie-caexia.

CANCERUL BRONHOPULMONARdiagnostic i stadializareDiagnostic : citologia sputei, fibrobronhoscopie cu aspirat, periaj i biopsie,CT toracic,radiografieBiopsie transcutanat cu ac fin : Indicaii1.Pacient cu risc operator crescut,2.Pacient cu risc sczut de malignitate bazat pe semne clinice i radiologice.3. Diagnosticul definitiv de benignitate este un noroc!,4. Pacientul prefer s tie diagnosticul de cancer nainte de intrarea n sala de operaie.5. Pacientul nu este operabil, dar diagnosticul histopatologic este necesar pentru terapie adjuvant chimio i radioterapic

CANCERUL BRONHOPULMONARnodulul solitar pulmonarCaracteristici radiologice - diametru>2cm, - prezena de prelungiri spiculiforme, - localizare n lobii superioriCaracteristici clinice - vrsta>40 ani - istoric de fumtor activIstoric de alt cancer, antec. heredocolaterale de cancer bronhopulmonar.

CANCERUL BRONHOPULMONARNodulul solitar pulmonarDiagnostic diferenial CBP cu TBC pulmonar,ntrziere n stabilirea diagnosticului prin tratament tuberculostatic, chiar n absena BK!Evaluarea radiologic se face la T2,Ulterior continuare investigaii- complian sczut a pacientului i stadiu avansat.

CANCERUL BRONHOPULMONARNodul solitar pulmonar : diagnostic diferenialTumori benigne:hamartom, chist bronhogenetic, lipom.Tumori maligne:metastaze, Altele: chist hidatic, abces pulmonar, infarct pulmonar, sarcoidoz ,nodulul luetic, micoze, tbc pulmonar (tuberculom, cavern plin), broniectazii, hernie diafragmatic, tumori mediatinale,tumori neurogene (neurinom).

CANCERUL BRONHOPULMONARSemne precoce ale unei tumori pulmonare:1. O densitate n parenchimul pulmonar,2. mas cavitar,3. arie cu densitate slab definit segmentar,4. leziune nodular, infiltrare local de-alungul vaselor pulmonare,5. consolidare a unui segment,6. zon triunughiular ce merge de la aprex i se extinde spre hil,7. o mas medastinal,8.o lrgire a hilului pulmonar,9. emfizem obstructiv segmentar sau lobar,10. atelectazie segmentar.

CANCERUL BRONHOPULMONARsemne radiologicenodul pulmonar

CANCERUL BRONHOPULMONARclasificare anatomopatologicSquamous cell carcinoma,Small cell carcinoma - pure small cell carcinoma, - small- large cell carcinoma, - combined small cell carcinoma (with areas of squamous or glandular differentiation),Adenocarcinoma - variant: bronchioloalveolar carcinoma,Large cell carcinoma,Adenosquamous carcinoma,Sarcoame.

CANCERUL BRONHOPULMONARclasificare TNMTumora primar (T) Tx citologie pozitiv fr eviden de leziune neoplazic bronhoscopic sau radiologic T0 fr eviden a unei tumori. Tis Carcinom in situ T1 Tumor 3cm; prinde bronhia primitiv >2 cm distal de carin ; invadeaz pleura visceral; asociat cu atelectazie sau penumonit obstructiv ce se extinde spre regiunea hilar frr a prinde ntregul plmn.

CANCERUL BRONHOPULMONARclasificare TNMT3 tumor de orice mrime dar care invadeaz: perete toracic( inclusiv apertura superioar) ,diafragm, pleur mediastinal, pericard; sau orice tumor ce se dezvolt

CANCERUL BRONHOPULMONARclasificare TNMRegional lymph nodes (N) Nx Regional lymph nodes cannot be assessed N0No regional lymph node metastases N1 Metastases to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes involved by direct extension of primary tumour N2 Metastases to ipsilateral mediastinal and/or subcarinal lymph nodes N3 Metastases to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral saclene or supraclavicular lymph nodes

CANCERUL BRONHOPULMONARclasificare TNMDistant metastases (M) Mx Presence of distant metastases cannot be assessed M0 No distant metastases M1Distant metastases present Stage grouping TNM subsets 0Carcinoma in situ IA T1N0M0 IB T2N0M0 IIA T1N1M0 IIB T2N1M0 T3N0M0 IIIA T3N1M0 T1N2M0 T2N2M0 T3N2M0IIIB T4N0M0 T4N1M0 T4N2M0 T1N3M0 T2N3M0 T3N3M0 T4N3M0 IV Any T Any N M1

Algoritm terapeutic n cancerul bronhopulmonarNSCLCComprehensive clinical evaluationClinical examination negativeChest CT *T4 = 1. defined 2. indeterminate : VATS surgery. ** LN Positive = sample LN= a)N2 Positive- unresectable and induction protocol b)N3 Positive- unresectable *** LN Negative = Surgery

CANCERUL BRONHOPULMONAR

CANCERUL BRONHOPULMONAR Algoritm terapeutic n cancerul bronhopulmonar

Examen clinic suspeceaz M1.*Organ specific= specific scan=a) negative scan =follow chest CT sequence, b) positive scan= treat M1.**Organ nonspecific findings= scan succesive organs= a)negative scan= follow chest CT sequence, b) positive scan= treat M1.