1. Lung Cancer Non-Small Cell Staging/Prognosis/Treatment Oncology Teaching October 14, 2005 Lorenzo E Ferri

2. Lung Cancer Highest cancer death rate for men and women

3. Canadian Cancer Statistics 2004

4. Lung Cancer – Pathology Non-Small Cell –Squamous Cell Carcinoma –Adenocarcinoma –BAC –Large Cell Small Cell Neuroendocrine (Carcinoid, Large cell NE, small)

5. Staging Staging should provide prognosis and dictate management TNM Classification universally accepted

6. T status – T1 3 cm or less, completely covered by pleura, does not involve main bronchus

8. T Status – T2 –> 3cm –Visceral pleura –Main bronchus but > 2cm from carina –Atelectasis but not complete lung

10. T status – T3 –Chest wall –Diapragm –Mediastinal pleura –Pericardium –Main bronchus <2cm to carina –Complete atelectasis

12. T Status – T4 Carina Vertebrae Great Vessel Esophagus Heart Separate tumour nodule in same lobe MALIGNANT pleural effusion

14. Lymph Node Mapping

15. N Status N0 – no regional LN metastases N1 – LN mets in ipsilateral peribronchial and/or intrapulmonary N2 – ipsilateral mediastinal or subcarinal N3 – contralat mediastinal or supraclavicular nodes

16. M Status Common distant sites sites include –Brain, bone, liver, adrenal Two nodules in same lung

17. Stage I 1A – T1 N0 1B – T2 N0

18. Stage IIA T1 N1

19. Stage IIB T2 N1 T3 N0

20. Stage IIIA T1-3 N2 T3 N1

21. Stage IIIB T0-3 N3 T4 N0-3

23. 5 Year Survival IA IB IIA IIB IIIA IIIB IV 60-75% 50-60% 40-50% 15-30% 5-10% 0-5% Overall 5 year survival = 15% (no change in 3 decades) Mountain 1997, Rami-Porta 2000, Naruke 1988

24. Survival Survival by Clinical Stage Survival by Pathologic Stage MD Anderson 1975-1988

25. Is all Stage IIIA (N2) the same? Single vs multiple station Bulky vs non-bulky Station 5/6 in LUL cancer Nodal vs extra-nodal disease

26. Staging Investigations – non invasive History and Physical! –hoarseness (T3 or N2) supraclavicular nodes (N3) CXR – Size (rough), chest wall (T3), effusion (T4) CT Chest/upper Abdo –T status – accurate –N status (>1 cm= 70% +, <1cm=7% +) –M status – adrenal, liver, lung, bone

27. MR – for T4 and M1 –thorax – not routine – for Pancoast –Brain – asymptomatic patients have brain mets in less than 3% Hillers et al Thorax 1994 Bone Scan – asymptomatic patients have mets in less than 5% Staging Investigations – non invasive

28. PET/CT Technology is evolving –Allows for “one step” extrathoracic staging –Independent predictor for survival (low SUV) –What about mediastinum? NPP must be very high if invasive staging is to be avoided –NPP=98% in a recent study (Pozo-Rodriguez JSO 2005) Not good for BAC, small lesions <0.5 cm

29. PET/CT Does this need pathologic confirmation?

30. Invasive Staging Bronchial, Mediastinal and Pleural Bronchial  Bronchoscopy – for proximal lesions (T3 vs T4) Pleural  –Throracentesis – 60-65% accurate –Pleuroscopy and biopsy – more than 95%

31. Are all effusions associated with known lung cancer malignant? Post-obstructive effusion

32. Mediastinal Staging - Invasive CT and PET/CT – better but not perfect for mediastinal nodes Mediastinoscopy is the gold standard! –Assesses N2 and N3

33. Endoscopic Biopsy EUS FNA TBNA

34. What is really needed? Do we need to invasively assess N2 disease in everyone? Small peripheral lesion (esp SCC and BAC) have a low rate of mediastinal mets (1 cm=10%, 3 cm =25%) CT/PET accuracy is improving TBNA and EUS often obviate the need for M-scope Institution specific – U of T – everyone gets a M-scope McGill and rest of N.A. - selective

35. Treatment Stage IA – Lobectomy (VATS vs Thoracotomy) Stage IB-IIB - Lobectomy + adjuvant Cx –Pancoast (T3N1) – neoadjuvant chemorads (EP 2cycles with 45 Gy) Stage IIIA – –T3N1 (resected) – adjuvant Cx –N2 disease  ??? Traditionally a non-surgical disease BUT….. Neoadjuvant (Int 0139) - no Difference, but 27% vs 20% 5-yr survival - Albain et al ASCO 2005

36. Treatment Stage IIIB – definitive CxTx, BUT…. –Not all T4s are equal T4N0-1 – aorta, vertebra, all other major vessels have been resected with reasonable 5 year survival (20-30%) Rendina JTCVS 1999

37. Treatment Stage IV –Palliative – median survival approx 6 months –Malignant effusion – if symptomatic Thoracentesis  –if no improvement think lymphangetic spread, PE, etc –If symptomatically improved »if lung expands  Pleurodesis »If lung trapped  pleural drainage (tenkhoff vs repeated taps)