1. Lung cancer and pulmonary nodules Resident’s seminar 02/01/2006 Elsa B. Valsdottir

2. Lung nodules In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma? a) 5% b) 20% c) 35% d) 50% e) 75%

3. Lung nodules In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma? a) 5% b) 20% c) 35% d) 50% e) 75%

4. Benign nodules Hamartoma 8% (popcorn lesion) Granuloma Scarring Hemangioma Schwannoma Fibroma Lipoma Leiomyoma Clear cell tumor Teratoma

5. Pulmonary nodule A healthy 59 yoM with 40 pack year hx has a new 1 cm nodule in the RUL on routine CXR. CT confirmes a spikulated lesion with lymphadenopathy. His PFTs are normal. The most appropriate management would be: a) chemotherapy b) CT guided needle bx c) thoracoscopic wedge resection d) RU lobectomy e) radiotherapy

6. Algorithm from Greenfield

7. Pulmonary nodule A healthy 59 yoM with 40 pack year hx has a new 1 cm nodule in the RUL on routine CXR. CT confirmes a spikulated lesion with lymphadenopathy. His PFTs are normal. The most appropriate management would be: a) chemotherapy b) CT guided needle bx c) thoracoscopic wedge resection d) RU lobectomy e) radiotherapy

8. Lung cancer: Incidence, epidemiology Leading cause of cancer death (28%) 2nd most common cancer  >173,000 cases/year  Overall 5 year survival 12% Decreasing incidence and mortality in men Incidence plateaued in women but mortality still rising Cause: TOBACCO (85-90%)  arsenic, asbestos, genetics, COPD, CLL, AIDS

9. Lung cancer: Classification Small cell carcinoma 20% Non-small cell carcinoma:  Adenocarcinoma 40%  Squamous cell carcinoma 20-25%  Adenosquamous carcinoma  Large cell carcinoma  Carcinoid  Carcinoma of salivary gland type  Unclassified

10. Small cell lung cancer Which of the following statements about small cell lung cancer is NOT true? a) Surgical therapy is rarely indicated b) The etiology is unknown c) Paraneoplastic endocrine syndromes are common d) Chemotheraputic agents are generally effective e) Prophylactic radiotion therapy can reduce brain metastasis

11. Small cell lung cancer Which of the following statements about small cell lung cancer is NOT true? a) Surgical therapy is rarely indicated b) The etiology is unknown c) Paraneoplastic endocrine syndromes are common d) Chemotheraputic agents are generally effective e) Prophylactic radiotion therapy can reduce brain metastasis

12. Signs and symptoms Cough Hemoptysis Dyspnea Pain Dysphagia Horner’s syndrome Pancoast’s syndrome SVC obstruction

13. Primary Tumor (T) Description T1 A small tumor that is not locally advanced or invasive Criteria: <3 cm in size; surrounded by lung or visceral pleura; not extending into the main bronchus T2 A larger tumor that is minimally advanced or invasive Criteria: >3 cm in size; may invade the visceral pleura; may extend into the main bronchus but remains >2 cm from the main carina; may cause segmental or lobar atelectasis T3 Any size tumor that is locally advanced or invasive up to but not including the major intrathoracic structures Criteria: any size; may involve the chest wall, diaphragm, mediastinal pleura, parietal pericardium; main bronchus within 2 cm of the main carina (not involving the main carina); may cause atelectasis of the entire lung T4 Any size tumor that is advanced or invasive into the major intrathoracic structures Criteria: any size; invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, main carina; malignant pericardial or pleural effusion; presence of satellite tumor nodule(s) within the primary tumor lobe Regional Lymph Node Involvement (N) Description N1 Metastatic disease to nodes within the ipsilateral lung Criteria: direct extension to intrapulmonary nodes; metastasis to ipsilateral peribronchial and/or hilar nodes (nodal stations 10 through 14) N2 Metastatic disease to nodes beyond the ipsilateral lung but not contralateral to the primary tumor Criteria: metastasis to the ipsilateral mediastinal and/or subcarinal nodes (nodal stations 1 through 9) N3 Metastatic disease to nodes distant to those included in N2 Criteria: metastasis to contralateral mediastinal and/or hilar nodes, ipsilateral or contralateral scalene and/or supraclavicular nodes Metastases (M)Description MOLocal or regional disease, no distant metastases M1Disseminated disease, distant metastases present

14. StagingDescription IAT1N0M0 IBT2N0M0 IIAT1N1M0 IIBT2N1M0, T3N0M0 IIIAT3N1M0, T(1-3)N2M0 IIIBT4N(0-3)M0, T(1-4)N3M0 IVT(any)N(any)M1 Staging

15. Lung cancer: nodal stations

16. Nodal stations, cont

17. Survival Non-Small Cell Lung Cancer: 5-year Survival (%) by Stage 7 7 StageClinicalPathologic IA6167 IB3857 IIA3455 IIB22-2438-39 IIIA9-1323-25 IIIB3-7 IV1–

18. Resectable tumors Stages I and II Stage IIIA?  N2 dz  Downstaging with neoadjuvant tx Selected cases of IIIB (T4)

19. Lung cancer: Pre-operative workup CT (brain) PET: 97% sensitive, 78% specific Bronchoscopy Mediastinoscopy PFTs  FEV1  DLCO (diffusing capacity for carbon monoxide)  Oxygen consumption

20. PFTs Which one of the following inducates a high risk for RF after pulmonary resection? a) Preoperative FEV1 = 500 ml b) Preoperative PaCO2 = 38 mm Hg c) V/Q scan showing 30% perfusion to operative side d) Predicted postop FEV1 = 1.1L

21. PFTs Which one of the following inducates a high risk for RF after pulmonary resection? a) Preoperative FEV1 = 500 ml b) Preoperative PaCO2 = 38 mm Hg c) V/Q scan showing 30% perfusion to operative side d) Predicted postop FEV1 = 1.1L

22. Lung cancer: Surgical options VATS Segmentectomy Lobectomy Sleeve resection Pneumonectomy

23. VATS for Stage 1 lung cancer Pros:Cons: less painoncologic validity less LOStech. difficult better cosmesisseeding of tumor Better survival due to less immunologic response (IgG, CRP, IL-6, TNF etc)? Roviaro et al: Long-term Survival After VATS Lobectomy for Stage 1 Lung Cancer. CHEST 2004;126:725-732

24. Lung cancer screening

25. Take home message: New CT techniques detect suspicious nodules 3x more than CXR, malignant tumors 4x and stage 1 tumors 6x Henschke et al: Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet, 1999;354:99-105

26. Surgery after Chemo/XRT for Stage IIIA Can be considered in fit patients but does not neccessarily increase overall survival Albain et al: Phase III study of consurrent chemotherpy and radiotherapy (CT/RT) vs CT/RT followed by surgical resection for stage IIIA (pN2) non-small cell lung cancer (NSCLC): Outcomes update of NOrth American Intergroup 0139 (RTOG 9309). ASCO Annual Meeting 2005

27. Adjuvant chemo for resected Stages IB-II lung ca Newer adjuvant chemo prolongs overall and recurrence free survival Winton et al: A prospective randomised trial of adjuvant vinorelbine (VIN) and cisplatin (CIS) in completely resected stage IB and II non small cell lung cancer (NSCLC) Intergroup JRB.10. J Clin Onc 2004;22:7018