Charles Mulligan, MD, FACS, FCCP 26 March 2015
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
221,200 new cases in 2015 158,040 lung cancer deaths 2015 86,380 male lung deaths 71,660 female lung deaths Leading cause of Cancer death in both men and women
100% 80% 60% 40% 1974-1976 1999-2007 20% 0% Breast Prostate Colon Lung Cancer Cancer Cancer Cancer
% Patients 5- yr Survival % Patients 5-yr Survival Localized 15 52 Localized 66 98.4 Regional 22 25.1 Regional 33 83.9 Distant 56 3.7 Distant 5 23.8 Unknown 6 7.9 Unknown 2 50.7 LUNG CANCER BREAST CANCER NCI SEER Cancer Statistics 2002-2008
85% caused by smoking Radon Asbestos Campaign for Tobacco-Free Kids is on Facebookhttps://www.facebook.com/tobaccofreekids Air pollution Genetic
Lung Cancer Incidence Tobacco Incidence
SPN / asymptomatic Hemoptysis Chest pain Paraneoplastic symptoms Metastatic symptoms
HISTORY AND PHYSICAL OLD X-RAYS CHEST CT
INDEX SUSPICION PET SCAN TISSUE TRANSTHORACIC NEEDLE BIOPSY BRONCHOSCOPY SURGICAL BIOPSY
CLINICAL PATHOLOGIC
T size N nodes M metastasis
CHEST CT (INCLUDE CUTS ADRENAL GLANDS) PET SCAN BRAIN IMAGING Bronchoscopy EBUS EUS Mediastinoscopy VATS CLINICAL PATHOLOGIC
Navigational Bronchoscopy Wang Needle Biopsy EBUS EUS
Level 2 Level 4 Level 5 Level 7 Level 10
Better visualization than Chamberlain for AP Window Sample more nodal stations Evaluate invasion adjacent structures
BRAIN ADRENAL BONE LIVER LUNG
Clinical Stage Pathologic Stage % patient MST 5-yr % patient MST 5-yr IA 7.2 60 50% 23 119 73% IB 11.1 43 43% 19.4 81 58% IIA 4.2 34 36% 16.2 49 46% IIB 19.5 18 25% 14.1 31 36% IIIA 27.5 14 19% 23.8 22 24% IIIB 6.6 10 7% 1.9 13 9% IV 23.9 6 2% 1.7 17 13%
TREATMENT
"http://commons.wikimedia.org/wiki/file:lung_small_cell_carcinoma 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
Chemotherapy mainstay treatment Radiation Therapy depend extent of disease Surgery rarely indicated
Stage determines treatment options Performance status determines therapy Molecular markers Surgical resection Radiation therapy Chemotherapy Molecular therapy Decision Treatment
SURGICAL RESECTION GOLD STANDARD PREOP EVALUATION OPERABLE VS RESECTABLE
COMORBIDS PULMONARY FUNCTION PHYSIOLOGIC FUNCTIONAL STATUS DISEASE CAN BE COMPLETELY RESECTED PATIENT CAN TOLERATE RESECTION
What are you looking for? Calcification and density Stability and growth rate Shape and margins Internal Composition Relationship Vascular / Airway
PNEUMONECTOMY LOBECTOMY SEGMENTECTOMY WEDGE RESECTION
KEY TO SAFE AND EASY RESECTION
CARINA RIGHT UPPER LOBE BRONCHUS INTERMEDIUS
LEVEL 11 R / SUMP NODE
TRUNCUS ANTERIOR ARTERY
SUPERIOR VEINS MIDDLE LOBE VEIN
POSTERIOR RECURRENT BRANCH
RIGHT LUNG: ANATOMY OF FISSURES
LEFT MAIN BROCHUS
Superior and Inferior Pulmonary Veins
Pulmonary Artery
THORACOTOMY VIDEO ASSISTED THORACIC SURGERY (VATS)
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
Spares latissimus and serratus Pain similar Improved shoulder function at 8 12 weeks? Operative Techniques in Thoracic and Cardiovascular Surgery, p70
Access incision up to 7 cm No rib spreading Port sites 2-4 (or more)
Stage I disease Easiest for peripheral 1/3 lesions, smaller than 3 cm Tumor generally less than 4 cm
Atlas of Minimally Invasive Thoracic Surgery
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?
DECREASED CYTOKINE RELEASE DECREASED CHEST TUBE OUTPUT NON-INFERIOR TO OPEN SURGERY EQUIVALENT NODAL SAMPLING
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
SPECIAL CONSIDERATION
STANDARD RADIATION STEROETACTIC BODY RADIATION THERAPY
ALTERNATIVE FOR POOR RISK SURGICAL PATIENT HIGHER BIOLOGIC EFFECTIVE DOSE SHORTER COURSE TREATMENT
CHEMOTHERAPY RADIATION THERAPY SUPPORTIVE CARE
Clinical / pathologic number of N2 stations Extent of N2 disease Functional status Pulmonary function
Doublet chemotherapy Radiation up to 60GY Restage and surgery 3-6 weeks post induction Perioperative fluid and oxygen management
PERSONALIZED MEDICINE MOLECULAR THERAPY
3 5% NSCLC Insulin receptor family tyrosine kinases More common in light / never smokers More common in adenocarcinomas Treatment: crizotinib
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)
25% NSCLC Cell growth and tumor development Mutations = negative benefit chemotherapy and EGFR inhibitors Proc Am Thorac Soc April 15, 2009 vol. 6 no. 2 201-205
2% lung cancers Light smokers and never smokers Younger age Adenocarcinomas Increased sensitivity TKI s
NLST
Identify disease in an earlier, curable state Relatively easy test which is cost effective
15.9% 5-years survival Majority diagnosed in advanced stage Symptoms typically late finding Early stage usually asymptomatic
August 2002 2004 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
26,722 low assigned to LDCT 26,732 assigned to CXR 3 years imaging Followed up to 7 years
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
NLST MORTALITY Lung cancer deaths Deaths/ 100,00 patient years Other neoplasm Cardiovascul ar LDCT RESULTS CXR 356 443 247 309 416 442 486 470 Respiratory 175 226 Complication s of treatment Total deaths all cause 12 7 1865 1991
Positive LDCT CXR Negative No screen Positive Negative No screen IA 51.8 11.4 22.7 32.7 11.9 17.3 IB 11.2 4.5 8.6 14.9 4.4 8.9 IIA 4.1 4.5 1.9 5.1 1.5 3.1 IIB 3.1 6.8 10.2 4.0 4.4 4.8 IIIA 9.3 6.8 10.2 12.7 15.6 10.2 IIIB 7.7 34.8 16.1 9.8 17.8 13.7 IV 12.8 31.8 36.3 20.7 44.4 42
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
320 patients screened Age Number screened 40-49 746 50-59 351 60-69 233 70-79 377 Lung cancer Screening Breast cancer screening
20% reduction lung cancer specific mortality 6.7% reduction in all cause mortality Prevent 1 lung cancer death/ 320 patients LDCT
LDCT screening reduces lung cancer mortality Cost-effective Mortality reduction vs. harms of screening Does not replace SMOKING CESSATION!!!
American College of Chest Physicians and American Cancer Society American Association Thoracic Surgeons International Association for Study of Lung Cancer National Comprehensive Cancer Network
Age: 55-77 Asymptomatic 30 pack year or more smokers Current smoker or quit smoking within last 15 years Able to tolerate treatment
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
Monetary cost False positive results Risk of interventions Radiation exposure Anxiety
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
MEDICARE February 2015 Need formal counseling visit Annual adherence to scanning Willing and able to undergo treatment Smoking cessation strategy
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
LUNG LEADING CAUSE OF CANCER MORTALITY EARLIER THE STAGE THE BETTER THE OUTCOME MULTIPLE MODALITIES TO DIAGNOSE AND TREAT LUNG CANCER MORE RESEARCH NEEDED
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