By M. Ugolf. Soka University of America.
Need adequate bx specimen to establish dx (vs atypical carcinoid cheap extra super avana 260mg with amex, lymphoproliferative dz) 6 discount 260 mg extra super avana. Jensik - Peripheral Stage I (n=168) a) Wedge or segmentectomy b) 53% 5-year c) 45 pts died of disease buy extra super avana 260 mg without a prescription, 16/45 - local recurrence 2 discount extra super avana 260mg online. Ginsberg & Rubinstein a) Randomized: lesser resection vs lobectomy b) Loco-regional recurrence: 17 buy extra super avana 260 mg free shipping. Recommendation (Glenn’s): May be useful for high-risk, elderly pt with limited reserve D. Mediastinal lymph node dissection - necessary for pathologic + surgical staging 1. A-P window - Left a) Supraaortic and superior mediastinal palpable nodes excised 3. T2 = >3cm or any size w/ visceral pleural invasion or atelectasis extending to hilum and >2cm distal to carina E. Prognostic factors a) tumor size and # of nodes b) Not -age sex, pleural involvement c)? Radiation a) No randomized, controlled data b) Patterson (retrospective) - 56% vs 30% 5-yr C. Sleeve pneumonectomy a) Bulky central tumor in proximity to or involving carina or tracheobronchial angle b) 4-31% operative mortality c) Anastomotic dehiscence à 100% mortality d) 16-23% 5-yr survival D. Pearson’s mediastinoscopic contraindications to resectability a) Contralateral nodal dz b) Extranodal extension c) High paratracheal nodal dz 4. Cytology negative, non-bloody, not an exudate - exclude this pleural effusion for staging purposes 3. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. A twenty-five-year follow-up of ninety-three resected typical carcinoid tumors of the lung. Sources for further reading Textbook Chapters Chapter 19, Section I: Neoplasms of the Lung - Carcinoma of the Lung. Chapters 21-7: Lung Carcinomas, Diagnosis and Staging of Lung Cancer, Surgical Treatment of Lung Carcinoma, Superior Sulcus Tumors, Limited Pulmonary Resection, Bronchoplastic Techniques for Lung Resection, Multimodality Therapy of Carcinoma of the Lung: Irradiation, Chemotherapy, and Immunotherapy. T Primary Tumor Tx - positive cytology only To - no evidence of tumor Tis - carcinoma in situ T1 - size < 3 cm no pleural invasion distal to lobar bronchus T2 - size > 3 cm any size invading the visceral pleura associated atelectesis or pneumonitis to the hilum >2 cm from the carina T3 - any size with chest wall, diaphragm, mediastinal pleura, or pericardium, (i. N Nodal Involvement N0 - no nodes N1 - peribronchial or ipsilateral hilar N2 - ipsilateral mediastinum or subcarinal N3 - any contralateral node ipsilateral supraclavicular or scalene nodes 3. Sources for further reading Textbook Chapters Chapter 19, Section I: Neoplasms of the Lung - Carcinoma of the Lung. Chapters 21-7: Lung Carcinomas, Diagnosis and Staging of Lung Cancer, Surgical Treatment of Lung Carcinoma, Superior Sulcus Tumors, Limited Pulmonary Resection, Bronchoplastic Techniques for Lung Resection, Multimodality Therapy of Carcinoma of the Lung: Irradiation, Chemotherapy, and Immunotherapy. Mutation results in overproduction of a protein or loss of regulatory function of protein production 3. Graham and Singer in 1933 reported the first successful pneumonectomy for lung carcinoma 6. In 1950, Churchill proposed that a lobectomy could be effective in the resection of lung carcinomas Lung Cancer Study Group randomized 247 patients to compare segmentectomy versus lobectomy in the treatment of lung cancer a. Controversy exists over pre-op routine bone and brain scans for asymptomatic patients f. Primary tumors confined to the lung and >2 cm distal to carina, with metastases to peribronchial or ipsilateral hilar lymph nodes b. And/or metastases confined to the ipsilateral mediastinal of subcarinal lymph nodes (N2) Surgical Treatment of T3 (Chest Wall Invasion) Non-Small Cell Lung Carcinoma (exclusive of superior sulcus tumors) 1. Includes pulmonary resection with contiguous soft tissue and rib resection and chest wall reconstruction b. When peripheral tumors is attached to parietal pleura, extrapleural resection can be attempted with good success or en bloc resection will be required c. Most important prognostic factor is whether a complete resection can be performed Surgical Treatment of T3 (Proximity to carina) Non-Small Cell Lung Cancer 1. Most important diagnostic procedure is bronchoscopy in order to determine proximity of the tumor to the carina 2. Indication is for bulky tumors in proximity to or involving the carina or tracheobronchial angle v. Number of nodes affected survival, upper paratracheal nodes affected survival with an overall 5 year survival of 20% i.
Adverse Reactions: The most common adverse effect is myelosuppression gastrointestinal intolerance order extra super avana 260 mg with amex, headaches generic extra super avana 260 mg on-line, and insomnia may occur but tend to resolve if ingestion is continued discount extra super avana 260 mg on line. Less frequent unwanted effects include thrombocytopenia buy discount extra super avana 260mg on-line, acute cholestatic hepatitis purchase extra super avana 260 mg online, and myopathy. Cerebrospinal fluid concentrations of the drug are approximately 20% of serum concentrations. Adverse Reactions: The major clinical toxicity associated with didanosine therapy is dose- dependent pancreatitis. Other reported adverse effects have included peripheral neuropathy, diarrhea, hepatotoxicity, hematocytopenias, and central nervous system toxicity (headache, irritability). A rise in uric acid during therapy with didanosine may precipitate attacks of gout in susceptible individuals. As with zidovudine, lamivudine requires 172 intracellular triphosphorylation for activation. Potential side effects are headache, insomnia, fatigue, and gastrointestinal discomfort, though these are typically mild. Like zidovudine, intracellular activation by triphosphorylation is catalyzed by cellular enzymes; competitive inhibition of the reverse transcriptase and chain termination result. It is available in oral formulation only and is typically prescribed in combination with zidovudine. Zalcitabine therapy is associated with a dose-dependent peripheral neuropathy that appears to occur more frequently in patients with low serum cobalamin levels and in those with a history of excessive ethanol consumption. Other reported toxicities include pancreatitis, esophageal ulceration and stomatitis, and arthralgias. Coadministration of drugs that cause either peripheral neuropathy or pancreatitis may increase the frequency of these adverse effects. Less common adverse effects include pancreatitis, arthralgias, and elevation in serum transaminases. Resistance: Resistance to indinavir is mediated by the expression of multiple and variable protease amino acid substitutions. At least two-thirds of indinavir-resistant strains are cross- resistant to saquinavir and ritonavir; however, saquinavir-resistant isolates tend to retain susceptibility to indinavir. Thrombocytopenia, nausea, diarrhea, and irritability have also been reported in some patients. Increased levels of antihistamines, cisapride, and benzodiazepines may also occur with potential toxicity from these drugs. The most common adverse effects of ritonavir are gastrointestinal disturbances, circumoral paresthesia, elevated hepatic aminotransferase levels, altered taste, and hypertriglyceridemia. Caution is advised when administering the drug to persons with impaired hepatic function. As with other agents of this class, it is likely that combination therapy with nucleoside agents will be optimal clinically. To date there is little evidence of cross-resistance between saquinavir and other protease inhibitor compounds or between saquinavir and nucleoside analogs. Nonnucleoside reverse transcriptase inhibitors interfere with the function of reverse transcriptase by binding directly to the enzyme in a noncompetitive fashion. Delavirdine differs structurally from nevirapine, a dipyridodiazepinone derivative nonnucleoside reverse transcriptase inhibitor. All nonnucleoside reverse transcriptase inhibitors appear to bind to a common region of reverse transcriptase and exhibit similar kinetic characteristics in their mode of retroviral inhibition. Spectrum: Delavirdine is a highly specific antiretroviral agent with a very limited spectrum of activity. Adverse reactions: Rash is the major toxicity associated with delavirdine therapy. Rash usually is evident within 1-3 weeks (median: 11 days) following initiation of delavirdine therapy and typically is diffuse, maculopapular, erythematous, and often pruritic; rash occurs mainly on the upper body and proximal arms with decreasing intensity of the lesions on the neck and face and progressively less on the rest of the trunk and limbs. Nevirapine is a highly specific antiretroviral agent with a very limited spectrum of activity.