1. Lung Cancer in 2011 Dr. Natasha Leighl, MD MMSc FRCPC Medical Oncologist, Princess Margaret Hospital Assistant Professor, Medicine, University of Toronto

2. Lung Cancer: a growing problem One of the most common cancers in Canadians, and the leading cause of cancer deaths (27%)One of the most common cancers in Canadians, and the leading cause of cancer deaths (27%) 1.4 million new cases per year, 1.2 million deaths1.4 million new cases per year, 1.2 million deaths Most present with advanced disease, severe symptomsMost present with advanced disease, severe symptoms North American incidence falling in men, rising in womenNorth American incidence falling in men, rising in women Peak incidence in 70sPeak incidence in 70s Most ex-smokers, about 30% smokers, 15% nonsmokersMost ex-smokers, about 30% smokers, 15% nonsmokers

3. Estimated new cases in Canada, 2011 Canadian Cancer Statistics 2011 25,500 22,200 23,600 25,300

4. Estimated cancer deaths, Canada 2011 Canadian Cancer Statistics 2011 4,100 95% 4,100 95% 8,900 61% 8,900 61% 5,100 87% 5,100 87% 20,600 18% 5 yr OS 5 yr OS

5. Cancer Research Dollars

6. Research Funding 7% of Canadian research dollars go to lung cancer, less than 1% of donations7% of Canadian research dollars go to lung cancer, less than 1% of donations Breast cancer support, services outnumber lung cancer by more than 10 to 1Breast cancer support, services outnumber lung cancer by more than 10 to 1 Approximately $23,000 research dollars spent per breast cancer patient, compared to $1,800 per lung cancer patientApproximately $23,000 research dollars spent per breast cancer patient, compared to $1,800 per lung cancer patient

7. Causes of Lung Cancer SMOKING!!!! (87%)SMOKING!!!! (87%) Occupational exposureOccupational exposure –Asbestos, arsenic, nickel, petroleum –Radon, Radiation Passive smokingPassive smoking AgeAge ? Genetic predisposition? Genetic predisposition ?Environmental exposures-air pollution?Environmental exposures-air pollution

8. Lung Cancer Types 15% Small Cell 85% Non-small Cell (NSCLC) Bronchial Pluripotential Stem Cell

9. Histological Types of Lung Cancer 0 0 25 50 75 Percent 1962-1968 1972-1978 1963-1988 NCI Gazdar and Linnoila, Seminars Oncol 1988; 15(3): 215 Squamous cell Adenocarcinoma BAC Large cell Other

10. T stage T1 -  3 cm, not in main bronchus

11. T stage T1 -  3 cm, not in main bronchus T2 - >3 ( 3 (<7)cm,  2cm from carina, inv’n visceral pleura, subtotal atelectasis

12. T stage T1 -  3 cm, not in main bronchus T2 - >3 ( 3 (<7)cm,  2 cm from carina, inv’n visceral pleura, subtotal atelectasis T3 – >7 cm, invade chest wall, diaphragm, med pleura, parietal pericard, total atelect, satellite nodules same lobe

13. T stage T1 -  3 cm, not in main bronchus T2 - >3 (<7)cm,  2 cm from carina, invn visceral pleura, subtotal atelectasis T3 – >7cm, invade chest wall, diaphragm, med pleura, parietal pericard, total atelect, satellite nod same lobe T4 – inv med, hrt, grt vessels, trachea, esoph, vert body, carina, nodules ipsilat lung, malignant pl effusion

14. N stage N1 – ipsilateral peribronchial, pulmonary nodes

15. N stage N1 – ipsilateral peribronchial, pulmonary nodes N2 – ipsilateral mediastinal, subcarinal nodes

16. N stage N1 – ipsilateral peribronchial, pulmonary nodes N2 – ipsilateral mediastinal, subcarinal nodes N3 – contralateral med, hilar, any scalene, supraclav nodes

17. M Stage M1a – nodule in contralateral lung, malignant effusion M1b – distant mets Common Sites: LiverBoneBrainAdrenals Pleura, Pericardium, Other Lung

19. Survival by Pathologic Stage

20. Changes to Staging - 2009 Current system implemented in 2009 Key changes from 1996 system: –Tumors more than 7 cm moving from T2 to T3 –Changing classification of same lobe satellite nodules from T4 to T3 –Changing ipsilateral lung but different lobe metastases from M1 to T4, and contralateral lung nodules from M1 to “M1a” –Changing malignant effusions from T4 to M1a

21. Old Clinical Stage Current Clinical Stage

22. Old Pathologic stage Current Pathologic Stage

23. What tests do you need? DiagnosisDiagnosis –Bronchoscopy (>90%) / mediastinoscopy (node), endobronchial ultrasound (with nodal biopsy, EBUS) –Needle aspirate or biopsy (>95%), sputum x 3(80% v 20%) –Video-Assisted Thoracoscopic Surgery (VATS) –Thoracentesis (pleural effusion) StagingStaging –Chest X-ray / CT Scan (Chest + Upper Abdomen) –Mediastinoscopy (assess node involvement), EBUS –Blood counts, chemistry –Bone scan (if indicated) –CT / MRI brain (if indicated) –FDG PET for SPN, resectable, Stage III NSCLC in Ontario

24. PET for NSCLC PET image courtesy of Dr Nevin Murray, BC Cancer Agency

25. PET in NSCLC Solitary Pulmonary Nodules –FNA or biopsy best approach –Meta-analyses (no RCTs): –Sensitivity 96-97%, Specificity 78-86% –False negatives in low grade tumours (e.g. BAC, GGOs) –False positives in inflammatory conditions –So if biopsy not possible, PET uptake + - intervene. If negative, follow (CT q3m x 2 y)

26. PET in NSCLC Staging of Primary Lung Cancer –11 systematic reviews, 3 RCTs, 22 other studies –Standard staging +/- PET 51% relative reduction in futile thoracotomies in one trial; no difference in 2 nd trial –PET vs. Standard Staging Shorter time to diagnosis (14 days vs. 23) Fewer mediastinoscopies, invasive tests to stage med –Indicated in addition to standard staging for resectable and stage 3 NSCLC –In early stage patients upstaged by PET (up to 15%), should verify results to confirm true positive

27. PET in SCLC Limited evidence in SCLC PET accuracy in staging 83-99% (limited versus extensive stage disease) Better to map out primary tumour and involved nodes, less sensitive for metastatic disease May be helpful tool in radiation planning