Diagnosis and Staging of Non-Small Cell Lung Cancer Carlos Eduardo Oliveira Baleeiro, MD November 18, 2017
Disclosures I do not have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. / Diagnosis and Staging of Non-Small Cell Lung Cancer 2
Agenda Why What Where When Who How / Diagnosis and Staging of Non-Small Cell Lung Cancer 3
Why Why do we care about lung cancer Worldwide, lung cancer occurred in approximately 1.8 million patients in 2012 and caused an estimated 1.6 million deaths In the United States, lung cancer occurs in about 225,000 patients and causes over 160,000 deaths annually: Lung cancer is the leading cause of cancer death and the second most common cancer among both men and women in the United States. Both the absolute and relative frequency of lung cancer has risen dramatically. Around 1953, lung cancer became the most common cause of cancer deaths in men, and in 1985, it became the leading cause of cancer deaths in women. / Diagnosis and Staging of Non-Small Cell Lung Cancer 4
Why Lung cancer is the leading cause of cancer death / American Cancer Society Diagnosis and Staging of Non-Small Cell Lung Cancer 5
Why Progress in lung cancer survival rates has lagged behind (for now) / Diagnosis and Staging of Non-Small Cell Lung Cancer CDC 6
Local impact of lung cancer Incidence rates by state, 2014 / Diagnosis and Staging of Non-Small Cell Lung Cancer 7
Local impact of lung cancer Deaths from lung cancer by state, 2014 / Diagnosis and Staging of Non-Small Cell Lung Cancer 8
What Non-small cell lung cancer (NSCLC) The term lung cancer, or bronchogenic carcinoma, refers to malignancies that originate in the airways or pulmonary parenchyma. Approximately 95 percent of all lung cancers are classified as either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC). The generic term NSCLC should be avoided as a single diagnostic term. Cigarette smoking is the number one cause of lung cancer. Lung cancer also can be caused by using other types of tobacco (such as pipes or cigars), breathing secondhand smoke, being exposed to substances such as asbestos or radon at home or work, and having a family history of lung cancer. / Diagnosis and Staging of Non-Small Cell Lung Cancer 9
What Non-small cell lung cancer (NSCLC) Adenocarcinoma Squamous cell carcinoma Large cell carcinoma / Diagnosis and Staging of Non-Small Cell Lung Cancer 10
What Non-small cell lung cancer (NSCLC) diagnosis Most patients who present with signs and symptoms due to lung cancer have more advanced disease. Signs and symptoms may include: - Cough 50 to 75 percent - Hemoptysis 25 to 50 percent - Dyspnea 25 percent - Chest pain 20 percent - Less common manifestations include the signs and symptoms or laboratory abnormalities of distant metastases or paraneoplastic syndromes. Asymptomatic patients may come to clinical attention during screening or following the incidental detection of imaging abnormalities. / Diagnosis and Staging of Non-Small Cell Lung Cancer 11
Where Where does it go? Goals of initial evaluation are to assess these features: Clinical extent and stage of disease Optimal target site and modality for the first tissue biopsy Specific histological subtype Presence of comorbidities, secondary complications, and paraneoplastic syndromes that influence treatment options and outcome Patient values and preferences that influence diagnostic and therapeutic choices / Diagnosis and Staging of Non-Small Cell Lung Cancer 12
Where Staging of NSCLC, The Tumor, Node, Metastasis (TNM) staging The purpose of TNM staging is to provide a description of the anatomic extent of cancer that can be easily communicated to others, assist in treatment decisions, and serve as an indicator of prognosis. It allows a way to compare cases, particularly in regards to the outcomes associated with different therapeutic options. TNM staging for lung cancer (NSCLC) is an internationally accepted system used to characterize the extent of disease. It combines features of the tumor into disease stage groups that correlate with survival and are linked to recommendations for treatment. UTDOL, Reproduced from: Goldstraw P, Chansky K, Crowley J, et al. The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM / Diagnosis and Staging of Non-Small Cell Lung Cancer Classification for Lung Cancer. J Thorac Oncol 2016; 13 11:39.
Where Staging of NSCLC / Diagnosis and Staging of Non-Small Cell Lung Cancer 14
Where Staging of NSCLC, nodal stations / Diagnosis and Staging of Non-Small Cell Lung Cancer 15
Where Staging of NSCLC, anatomic stage and prognostic groups The TNM staging system relies on anatomic groupings of disease with similar prognoses rather than on molecular characterization. The TNM staging system predicts survival, but should not be used alone to dictate treatment. Periodic revisions are necessary because advanced imaging techniques and treatments continue to evolve and impact survival. / Diagnosis and Staging of Non-Small Cell Lung Cancer 16
Where Staging of NSCLC, anatomic stage and prognostic groups / Diagnosis and Staging of Non-Small Cell Lung Cancer 17
When When should we screen Lung cancer is an aggressive and heterogeneous disease and survival remains low. Lung cancer is unique though since it has an identifiable addictive etiologic agent in 85-90% of cases. Staging at time of diagnosis impacts survival and treatment options. Screening has been used to impact survival in many diseases. Although effective mass screening of high-risk groups could potentially be of benefit, randomized trials of screening with the use of chest radiography with or without cytologic analysis of sputum specimens had shown no reduction in lung-cancer mortality. / Diagnosis and Staging of Non-Small Cell Lung Cancer 18
When When should we screen: The National Lung Screening Trial The NLST, a randomized trial of screening with the use of low-dose CT as compared with screening with the use of chest radiography, was a collaborative effort of the Lung Screening Study (LSS), administered by the NCI Division of Cancer Prevention, and the American College of Radiology Imaging Network (ACRIN), sponsored by the NCI Division of Cancer Treatment and Diagnosis, Cancer Imaging Program. The trial enrolled participants from August 2002 through April 2004; screening took place from August 2002 through September 2007. Participants were followed for events that occurred through December 31, 2009. - Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening The National Lung Screening Trial Research Team N Engl J Med 2011; 365:395-409 / Diagnosis and Staging of Non-Small Cell Lung Cancer 19
When When should we screen: The National Lung Screening Trial In the NLST, a 20.0% decrease in mortality from lung cancer was observed in the low-dose CT group as compared with the radiography group. The rate of positive results was higher with low-dose CT screening than with radiographic screening by a factor of more than 3 - Reduced Lung-Cancer Mortality with Low- Dose Computed Tomographic Screening The National Lung Screening Trial Research Team N Engl J Med 2011; 365:395-409 / Diagnosis and Staging of Non-Small Cell Lung Cancer 20
Who Who should get screened The U.S. Preventive Services Task Force recommends yearly lung cancer screening with low dose CT (LDCT) for people who: Have a history of heavy smoking, and Smoke now or have quit within the past 15 years, and Are between 55 and 80 years old. - Heavy smoking means a smoking history of 30 pack years or more. / Diagnosis and Staging of Non-Small Cell Lung Cancer 21
How Diagnostic and staging modalities Initial evaluation: Clinical: - Every patient with suspected lung cancer should undergo a thorough history and physical exam. The presence of signs or symptoms typically indicates advanced disease and portends a poor prognosis. The clinical evaluation should be symptom-directed with particular attention to nonpulmonary symptoms that might suggest metastases Laboratory and pulmonary evaluation: - Performance status - Pulmonary function testing / Diagnosis and Staging of Non-Small Cell Lung Cancer 22
How Diagnostic and staging modalities, pulmonary function testing / Diagnosis and Staging of Non-Small Cell Lung Cancer 23 ESMO Consensus Guidelines
How Diagnostic and staging modalities Initial evaluation: Radiographic staging The clinical staging of patients with suspected lung cancer, in particular NSCLC, starts with radiographic imaging. Determining the highest radiographic stage prior to biopsy facilitates the selection of a modality that optimizes tissue sampling for diagnosis. Initial CT chest with upper abdomen imaging PET scanning/pet-ct / Diagnosis and Staging of Non-Small Cell Lung Cancer 24
How Diagnostic and staging modalities A diagnosis of lung cancer should not be made without definitive pathology. At a minimum, this involves selecting a biopsy site and obtaining an adequate sample for microscopic examination. Additional consideration needs to be given to obtaining a large enough sample for supplemental immunohistochemical and genetic analysis. Biopsy modalities: Bronchoscopy, advanced bronchoscopy (EBUS, EMN) CT guided FNA Surgical biopsy (may also provide treatment) Biopsies of distal metastatic sites / Diagnosis and Staging of Non-Small Cell Lung Cancer 25
Summary Diagnosis and staging of lung cancer Lung cancer is the leading cause of cancer death and the second most common cancer among both men and women in the United States. Screening high risk patients has a significant impact on cancer mortality. Appropriate staging and tissue diagnosis are essential for adequate evaluation and treatment planning. This should include a thorough histological an molecular assessment of the tumor if possible. Smoking cessation and a multidisciplinary approach are essential to optimal care. Patients successfully treated still require follow-up and comprehensive care. / Diagnosis and Staging of Non-Small Cell Lung Cancer 26