ISBN : 974-422-081-3 1 : 2547 : 6,000 :

DALY-Disability Adjusted Life Years .. 2542 60 (DALY) 9.5 3 .. 2538-2540 2 4

( ) 4 2547

Diagnosis and Management of Lung Cancer : ACCP Evidence-Base Guidelines(1) Chest .. 2546 (cancer staging)

( ) 2547

.................................................................................................................... 1 .................................................................................................................. 1 ....................................................................................................................... 1 ................................................................................................... 2 .......................................................................................... 2 1 ............................................................ 4 2 ......................................................... 5 TNM STAGING OF NSCLC............................................................................................ 6 .............................................................................................................. 7 .................................................................................................................... 8 .................................................................................................................... 11 .................................................................................................................. 14 ..................................................................................................................... 15

1. 2. 3.

(2) (3) .. 2538-2540 (estimated incidence rate) 25.9 (ASR = 25.9) (ASR = 37.6) 10 (ASR = 10) (ASR = 19.5) (ASR = 17.2) (ASR = 16.0) : = 2 : 1 / // / 1

(5) 90 9-15 10 1 - 2 20 asbestos silica asbestos silica inert gas

1. Non-small cell lung cancer (NSCLC) 75-80 90(6) NSCLC squamous cell carcinoma adenocarcinoma large cell carcinoma adenosquamous cell carcinoma 2. Small cell lung cancer (SCLC) NSCLC SCLC

1. (7) , , , , , post obstructive pneumonia localized wheeze 2. , , , Horner syndrome, superior vena cava obstruction, pleural effusion cardiac tamponade 3. , 4. Paraneoplastic syndromes SIADH Cushing's syndrome SCLC hypercalcemia squamous cell 2

Abbreviations1. ASR 2. NSCLC 3. SCLC 4. NR 5. SPN 6. L.N. 7. TB 8. TTNA 9. TBNA 10. CXR 11. CT 12. MRI 13. US 14. CM 15. CAT 1(8) 16. Rx 17. T 18. N 19. M 20. m 21. LR 22. LRprev 23. ex.sm. 24. SIADH = = = = = = = = = = = = = = = = = = = = = = = = = Age-standardized incidence rate Non-small cell lung cancer Small cell lung cancer No report Solitary pulmonary nodule Lymph node Tuberculosis Transthoracic needle aspiration Transbronchial needle aspiration Chest X-ray Computed Tomography Magnetic Resonance Imaging Ultrasonography Contrast media Category 1 : 2 HRZE(S)/4HR Treatment Tumor Node Metastasis month Likelihood ratio probability of an individual with the condition having the test result probability of an individual without the condition having the test result Likelihood ratio for overall prevalence of malignancy Ex-smoker Syndrome of inappropriate antidiuretic hormone

3

Diagnostic Approach of Lung Cancerand/or

Clinically suspected

No Rx TB CAT 1

* **

:

1 4

Staging of Lung Cancer

* limited-stage disease; lesion restricted to the ipsilateral hemithorax within a single radiation port.

2 5

TNM STAGING OF NSCLC(9)

6

mediastinum (T) (N) (M) NSCLC TNM American Joint Committee on Cancer (AJCC)(10) 5 1 1 5 NSCLC TNM(10) 0 IA IB IIA IIB IIIA IIIB IV TNM Classification Carcinoma in situ T1N0M0 T2N0M0 T1N1M0 T2N1M0 or T3N0M0 T1-3N2M0 or T3N1M0 T4 Any N M0 or Any T N3M0 Any T Any N M1 5 (%) NR 61 38 34 24 13 5 1

7

Solitary pulmonary nodulePulmonary nodule mass soft tissue density density infiltration nodule mass nodule 3 . mass 3 . (11)

Solitary pulmonary nodule(12) 1. Neoplasm 1.1 Malignancy: primary carcinoma of the lung, metastasis, lymphoma 1.2 Benign: hamartoma, hemangioma 2. Inflammation 2.1 Granuloma: tuberculosis, histoplasmosis, cryptococcosis, nocardiosis 2.2 Fungal ball 2.3 Organizing pneumonia, abscess 3. Vascular 3.1 Infarction 3.2 Arteriovenous malformation 4. Development 4.1 Bronchogenic cyst 4.2 Pulmonary sequestration

(12)1. nodule mass 2. 2 6 round pneumonia 2 benign 2 6 12 bronchioloalveolar cell carcinoma metastatic renal cell carcinoma 3. calcification 3.1 benign lesion central calcification laminated calcification complete calcification popcorn calcification 8

3.2 benign malignant(12) eccentric calcification strippled calcification 4. (12) 4.1 microlobulation () spiculation corona radiata () malignant benign granuloma organizing pneumonia 4.2 malignancy 4.3 (well-defined and smooth) benign metastasis (13) pulmonary nodule pulmonary nodule interlobar fissure mediastinal mass pleural mass extrapulmonary lesion rib lesion solitary pulmonary nodule(13)

a

b

a) solitary pulmonary nodule right upper lobe calcification b) CT calcification (eccentric calcification) 9

Solitary pulmonary nodule(14) 1. ( ) 50 1.5-2.2 . 3 50 70 1.5-2.2 . 1-2 80 50 2.3-3.2 . 1-2 80 70 2.3-3.2 . 2 96 2. 3.

10

TABLE 1 LIKELIHOOD RATIOS FOR MALIGNANCY IN SOLITARY PULMONARY NODULES IN MEN(14) Probability of this Finding Among Men with : Likelihood Ratio Finding Malignant Nodules Benign Nodules for Malignancy* Diameter of nodule, cm < 1.5 0.025 0.232 0.1 1.5-2.2 0.255 0.501 0.5 2.3-3.2 0.348 0.203 1.7 3.3-4.2 0.193 0.045 4.3 4.3-5.2 0.118 0.018 6.6 5.3-6.0 0.065 0.002 29.4 Patient's age, yr < 35 0.011 0.155 0.1 36-44 0.111 0.329 0.3 45-49 0.096 0.136 0.7 50-59 0.200 0.138 1.5 60-69 0.454 0.220 2.1 70-83 0.129 0.023 5.7 Smoking history Never smoked 0.03 0.21 0.15 Pipe or cigar only 0.05 0.15 0.3 Ever smoked cigarettes 0.92 0.83 1.5 Current smoker or quit within past 9 yr Average number of cigarettes per day: 1-9 0.03 0.10 0.3 10-20 0.27 0.27 1.0 21-40 0.38 0.19 2.0 41 0.24 0.06 3.9 Quit Smoking, yr 70 44.4 < 1.5 (LR=5.7) (LR=0.1) 50-59 29.1 (LR=1.5) 41 60-69 36.4 (LR=3.9) (LR=2.1) > 70 60.9 (LR=5.7) 50-59 51.2 (LR=1.5) 21-40 60-69 59.5 (LR=2) (LR=2.1) > 70 80.0 1.5-2.2 (LR=5.7) (LR=0.5) 50-59 67.2 (LR=1.5) 41 60-69 74.1 (LR=3.9) (LR=2.1) > 70 88.6 (LR=5.7) 50-59 78.1 (LR=1.5) 21-40 60-69 83.3 (LR=2) (LR=2.1) > 70 93.1 2.3-3.2 (LR=5.7) (LR=1.7) 50-59 87.4 (LR=1.5) 41 60-69 90.7 (LR=3.9) (LR=2.1) > 70 96.4 (LR=5.7) 12 () (.) (.) () 50-59 (LR=1.5) < 1.5 (LR=1.5) 60-69 (LR=0.1) (LR=2.1) > 70 (LR=5.7) 50-59 (LR=1.5) 1.5-2.2 (LR=1.5) 60-69 (LR=0.5) (LR=2.1) > 70 (LR=5.7) 50-59 (LR=1.5) 2.3-3.2 (LR=5.7) 60-69 (LR=1.7) (LR=2.1) > 70 (LR=5.7) (%) 13.6 18.1

37.4

44.1

52.4

75.0

72.8

78.9

91.1

(14) 70 (LRprev = 0.7)

= LRage LRsize LRsmoke LRprev 1+ LRage LRsize LRsmoke LRprev

100%

70 2.3-3.2 . 2 = LRage LRsize LRex.sm. LRprev 1+ LRage LRsize LRex.sm. LRprev

=

5.7 1.7 3.9 0.7 1+ 5.7 1.7 3.9 0.7

100%

= 96.4%

100%

50-59 1.5 . = 1.5 x 0.1 1.5 0.7 100% = 13.6% 1 + 1.5 0.1 1.5 0.7

13

References1. Block AJ, editor. Diagnosis and management of lung cancer: ACCP evidence-bases guidelines. Chest 2003;123. 2. Trends in lung cancer incidence and mortality-United States, 1998. Tobacco topics 1990-1999: chronic disease and health promotion adapted from the MMWR. Untied States, 1999. p. 253. 3. Sriplung H, Sontipong S, Martin N, Wiangnon S, Vootiprux V, Cheirsilpa A et al, editors. Cancer in Thailand vol.III, 1995-1997. Bangkok, Thailand; 2003. p.44 4. WHO. National cancer control programmes: policies and managerial guidelines, 2nded. Geneva; 2002. 5. Alberg AJ, Samet JM. Epidemiology of lung cancer. Chest 2003;123:21s-49s. 6. Vatanasapt V, Martin N, Sriplung H, editors. Cancer in Thailand 1988-1991 IARC technical report no.16, Lyon: International Agency for Research on Cancer; 1993. 7. Beckles MA, Spiro SG, Colice GL, Rudd RM. Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests and paraneoplastic syndromes. Chest 2003;123: 97s-104s. 8. Tuberculosis Cluster, Bureau of AIDS, Tuberculosis and Sexual Transmitted Diseases, Ministry of Public Health. Management of tuberculosis: Modified WHO modules of managing tuberculosis at district level. : ; 2546. 7. 9. Silvestri GA, Tanoue LT, Margolis ML, Barker J, Detterbeck F. The noninvasive staging of non-small cell cancer: the guidelines. Chest 2003;123:147s-49s. 10. Mountain CF. Revisions in the international system for staging lung cancer. Chest 1997;111: 1710-7. 11. Reed JC. Solitary pulmonary nodule. In: Reed JC, editor. Chest radiology. 4th ed. Missouri: MosbyYear Book; 1997. p. 328-54. 12. Fien AM, Feinsilver SH, Ares CA. The solitary pulmonary nodule: a systemic approach. In: Fishman AP, Elias JA, Fishman JA, Grippi MA, editors. Pulmonary diseases and disorders. 3rd ed. New York: McGrawHill; 1998. p. 1727-37. 13. . Solitary pulmonary nodule. : , . Chest X-ray. : ; 2546. 139-66. 14. Cummings SR, Lillington GA, Richard RJ. Estimating the probability of malignancy in solitary nodules. A Bayesian approach. Am Rev Respir Dis. 1986 Sep; 134(3) : 449-52.

14

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. .. .. .. . .. .. . .. ... ... .. ... ... ... ... .. .. .. .. .. .. ..

15