Charles Mulligan, MD, FACS, FCCP 26 March 2015
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1 Charles Mulligan, MD, FACS, FCCP 26 March 2015
2 Review lung cancer statistics Review the risk factors Discuss presentation and staging Discuss treatment options and outcomes Discuss the status of screening and its role in early detection
3 221,200 new cases in ,040 lung cancer deaths ,380 male lung deaths 71,660 female lung deaths Leading cause of Cancer death in both men and women
4 100% 80% 60% 40% % 0% Breast Prostate Colon Lung Cancer Cancer Cancer Cancer
5 % Patients 5- yr Survival % Patients 5-yr Survival Localized Localized Regional Regional Distant Distant Unknown Unknown LUNG CANCER BREAST CANCER NCI SEER Cancer Statistics
6
7 85% caused by smoking Radon Asbestos Campaign for Tobacco-Free Kids is on Facebookhttps:// Air pollution Genetic
8 Lung Cancer Incidence Tobacco Incidence
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10 SPN / asymptomatic Hemoptysis Chest pain Paraneoplastic symptoms Metastatic symptoms
11 HISTORY AND PHYSICAL OLD X-RAYS CHEST CT
12 INDEX SUSPICION PET SCAN TISSUE TRANSTHORACIC NEEDLE BIOPSY BRONCHOSCOPY SURGICAL BIOPSY
13 CLINICAL PATHOLOGIC
14 T size N nodes M metastasis
15 CHEST CT (INCLUDE CUTS ADRENAL GLANDS) PET SCAN BRAIN IMAGING Bronchoscopy EBUS EUS Mediastinoscopy VATS CLINICAL PATHOLOGIC
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19 Navigational Bronchoscopy Wang Needle Biopsy EBUS EUS
20 Level 2 Level 4 Level 5 Level 7 Level 10
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24 Better visualization than Chamberlain for AP Window Sample more nodal stations Evaluate invasion adjacent structures
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26 BRAIN ADRENAL BONE LIVER LUNG
27 Clinical Stage Pathologic Stage % patient MST 5-yr % patient MST 5-yr IA % % IB % % IIA % % IIB % % IIIA % % IIIB % % IV % %
28 TREATMENT
29 " SMALL CELL LUNG CANCER "Squamous carcinoma lung cytology" by Nephron - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Common NON SMALL CELL LUNG CANCER
30 Chemotherapy mainstay treatment Radiation Therapy depend extent of disease Surgery rarely indicated
31 Stage determines treatment options Performance status determines therapy Molecular markers Surgical resection Radiation therapy Chemotherapy Molecular therapy Decision Treatment
32 SURGICAL RESECTION GOLD STANDARD PREOP EVALUATION OPERABLE VS RESECTABLE
33 COMORBIDS PULMONARY FUNCTION PHYSIOLOGIC FUNCTIONAL STATUS DISEASE CAN BE COMPLETELY RESECTED PATIENT CAN TOLERATE RESECTION
34 What are you looking for? Calcification and density Stability and growth rate Shape and margins Internal Composition Relationship Vascular / Airway
35 PNEUMONECTOMY LOBECTOMY SEGMENTECTOMY WEDGE RESECTION
36
37 KEY TO SAFE AND EASY RESECTION
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39 CARINA RIGHT UPPER LOBE BRONCHUS INTERMEDIUS
40 LEVEL 11 R / SUMP NODE
41 TRUNCUS ANTERIOR ARTERY
42 SUPERIOR VEINS MIDDLE LOBE VEIN
43 POSTERIOR RECURRENT BRANCH
44 RIGHT LUNG: ANATOMY OF FISSURES
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46 LEFT MAIN BROCHUS
47 Superior and Inferior Pulmonary Veins
48 Pulmonary Artery
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50
51
52 THORACOTOMY VIDEO ASSISTED THORACIC SURGERY (VATS)
53 Pancoast tumors use formal posterior lateral Thoracotomy 6-10 cm, predominant lateral incision Minimal rib spreading Center over the fissure / hilum Deslaurier etal; Operative Techniques in Thoracic and Cardiovascular Surgery; p53
54 Spares latissimus and serratus Pain similar Improved shoulder function at 8 12 weeks? Operative Techniques in Thoracic and Cardiovascular Surgery, p70
55 Access incision up to 7 cm No rib spreading Port sites 2-4 (or more)
56 Stage I disease Easiest for peripheral 1/3 lesions, smaller than 3 cm Tumor generally less than 4 cm
57 Atlas of Minimally Invasive Thoracic Surgery
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61 Hospital stay ½ to 1 day shorter Perioperative pain similar early Cessation of narcotic sooner Return to functional status faster? Able to begin adjuvant therapy sooner?
62 DECREASED CYTOKINE RELEASE DECREASED CHEST TUBE OUTPUT NON-INFERIOR TO OPEN SURGERY EQUIVALENT NODAL SAMPLING
63 Maximum 5-7 cm access incision Divide latissimus and serratus No rib spreading Average 3 day stay 5-7 cm or greater incision Divide latissimus / spare serratus Minimal rib spreading Average 4 day stay VATS OPEN
64 SPECIAL CONSIDERATION
65 STANDARD RADIATION STEROETACTIC BODY RADIATION THERAPY
66
67 ALTERNATIVE FOR POOR RISK SURGICAL PATIENT HIGHER BIOLOGIC EFFECTIVE DOSE SHORTER COURSE TREATMENT
68 CHEMOTHERAPY RADIATION THERAPY SUPPORTIVE CARE
69 Clinical / pathologic number of N2 stations Extent of N2 disease Functional status Pulmonary function
70 Doublet chemotherapy Radiation up to 60GY Restage and surgery 3-6 weeks post induction Perioperative fluid and oxygen management
71 PERSONALIZED MEDICINE MOLECULAR THERAPY
72 3 5% NSCLC Insulin receptor family tyrosine kinases More common in light / never smokers More common in adenocarcinomas Treatment: crizotinib
73 10% NSCLC More common in non-smokers Cell proliferation, differentiation, migration/motility, adhesion, protection from apoptosis, enhance survival and gene transcription Treat with Erlotinib (Tarceva)
74 25% NSCLC Cell growth and tumor development Mutations = negative benefit chemotherapy and EGFR inhibitors Proc Am Thorac Soc April 15, 2009 vol. 6 no
75 2% lung cancers Light smokers and never smokers Younger age Adenocarcinomas Increased sensitivity TKI s
76 NLST
77 Identify disease in an earlier, curable state Relatively easy test which is cost effective
78 15.9% 5-years survival Majority diagnosed in advanced stage Symptoms typically late finding Early stage usually asymptomatic
79 August enrolled Followed through December 2009 Low dose CT scan (LDCT) versus chest x-ray (CXR) Reported in November 2010 Published August 2011 New England Journal Medicine
80 26,722 low assigned to LDCT 26,732 assigned to CXR 3 years imaging Followed up to 7 years
81 CT : 1 6 non-calcified nodules > 4 mm CXR: any nodule or mass Abnormalities such as effusion or lymph nodes Any other clinically significant disease other than lung cancer
82
83 NLST MORTALITY Lung cancer deaths Deaths/ 100,00 patient years Other neoplasm Cardiovascul ar LDCT RESULTS CXR Respiratory Complication s of treatment Total deaths all cause
84 Positive LDCT CXR Negative No screen Positive Negative No screen IA IB IIA IIB IIIA IIIB IV
85 96.4% false positive 1060 lung cancers found 356 deaths from lung cancer 94.5% false positive study 941 lung cancers found 443 deaths from lung cancer LDCT CXR
86 320 patients screened Age Number screened Lung cancer Screening Breast cancer screening
87 20% reduction lung cancer specific mortality 6.7% reduction in all cause mortality Prevent 1 lung cancer death/ 320 patients LDCT
88 LDCT screening reduces lung cancer mortality Cost-effective Mortality reduction vs. harms of screening Does not replace SMOKING CESSATION!!!
89 American College of Chest Physicians and American Cancer Society American Association Thoracic Surgeons International Association for Study of Lung Cancer National Comprehensive Cancer Network
90 Age: Asymptomatic 30 pack year or more smokers Current smoker or quit smoking within last 15 years Able to tolerate treatment
91 Died lung cancer 18/1000 Died of all causes 70/1000 Died lung cancer 21/1000 Died of all causes 75/1000 Low Dose CT CXR
92 Monetary cost False positive results Risk of interventions Radiation exposure Anxiety
93 False alarm 365/1000 False alarm leading to invasive test 25/1000 Major complications from procedures 3/1000 False alarm 142/1000 False alarm leading to invasive test 7/1000 Major complications from procedures 1/1000 CT Scan CXR
94 MEDICARE February 2015 Need formal counseling visit Annual adherence to scanning Willing and able to undergo treatment Smoking cessation strategy
95 MEDICARE February 2015 Radiology facility meets criteria 1. Volumetric CT dose index 3.0 mgy standard 2. Standardized lung nodule identification, classification and reporting system 3. Make available smoking cessation intervention 4. Submits data to a CMS approved registry
96
97 LUNG LEADING CAUSE OF CANCER MORTALITY EARLIER THE STAGE THE BETTER THE OUTCOME MULTIPLE MODALITIES TO DIAGNOSE AND TREAT LUNG CANCER MORE RESEARCH NEEDED
98 Lung cancer screening lead to earlier detection and improved survival Identification of blood marker to detect and or screen for lung cancer Genetic manipulation to prevent development of lung cancer
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