1. Lung cancer Gene Kukuy, MD Cardiothoracic Surgery

2. Overview Lung cancer is bad Statistics Staging Treatment

3. CA CANCER J CLIN 2013;63:11–30

5. Stage at presentation

6. Estimate for LA Total Prostate Lung Breast Colon NHL 20,950 3,410 3,320 2,530 2,060 920

7. Lung cancer distribution: Small cell 18% Adenocarcinoma 32% Squamous 29% Large cell 9% Carcinoid 5% NSCLC

10. Staging

12. NCCN.org v2.2010

13. Survival by stage J Thorac Oncol. 2007;2: 706–714 Clinical Pathological

14. Initial workup Abnormal CXR

15. Workup CT chest PET/CT Bronch PFT MRI brain Cardiac stress

16. PET/CT

18. Bronchoscopy

19. Lymph node sampling Mediastinoscopy –Access to 2/4/7 Chamberlain –Access to 5/6 VATS EBUS

22. Resection –Which resection? –Enough lung?

23. Spirometry FEV 1 and DLCO (diffusing capacity)

25. V/Q

41. Sleeve resection

42. Possible complications?

43. Residual Tumor After Resecion R0 - No residual (No identifiable tumor remaining; negative surgical margins) R1 - Microscopic residual (Microscopically positive margins but no visible tumor remaining) R2 - Gross residual (Gross (visible or palpable) tumor remaining)

44. SCLC Prognosis — The most important prognostic factor in patients with SCLC is the extent of disease (stage) at presentation. For patients with limited stage disease, median survivals range from 15 to 20 months, and the reported five-year survival rate is 10 to 13 percent. In contrast, for patients with extended stage disease, the median survival is 8 to 13 months, and the five-year survival rate is 1 to 2 percent.

45. Specific targeted therapies are widely used for patients with two molecular subsets of NSCLC ●Activating mutations in the epidermal growth factor receptor (EGFR) define a subset of patients with adenocarcinoma that more frequently affect patients who are never smokers, women, and/or of Asian ethnicity. These patients are generally highly responsive to EGFR tyrosine kinase inhibitors (erlotinib, gefitinib, afatinib) and have a significantly better prognosis than those without EGFR mutations.erlotinibgefitinibafatinib ●The presence of the EML4-ALK fusion oncogene defines another NSCLC subset that is more frequent in nonsmokers or former smokers and occurs at a younger age. These patients are highly responsive to crizotinib, an inhibitor of the anaplastic lymphoma kinase (ALK).crizotinib

46. Final Review Evaluate stage ? Resection candidate ? Neoadjuvant therapy Surgery