An Update: Lung Cancer Andy Barlow Consultant in Respiratory Medicine Lead Clinician for Lung Cancer (West Herts Hospitals NHS Trust) Lead for EBUS-Harefield Hospital (RB&HFT)
Summary Lung cancer epidemiology Lung Cancer Staging Case 1-discussion1 What is EBUS-TBNA? Why do it? Future challenges and conclusions
UK: Epidemiology of Lung Cancer How Common is it? Lung cancer is the most common cancer in the world: 1.2 million new cases per year UK: 1 in 7 new cancer cases 38,400 new patients annually In Britain, one person every fifteen minutes is diagnosed with lung cancer 1. Lung cancer and smoking UK. CancerStats. Cancer Research UK, April 2004 2. ASH(UK) web site
UK: Epidemiology of Lung Cancer How Common is it? Watford 64/100 000 000 population/yr 200 confirmed cases per year: WHHT NHS Trust 17 cases per month: approx 1 case per working day 5 follow-up visits to break bad news/week
UK: Epidemiology of Lung Cancer Who gets it: Gender
UK: Epidemiology of Lung Cancer Cigarettes About 12 million adults in the UK smoke cigarettes - 28% of men and 24% of women In the United Kingdom about 450 children start smoking every day About one fifth of Britain's 15 year-olds 18% of boys and 26% of girls - are regular smokers - despite the fact that it is illegal to sell cigarettes to children aged under16
T PRIMARY TUMOUR T1 T2 Tumour 3cm in greatest dimension, surrounded by lung or visceral pelura (1) without bronchoscopic evidence of invasion more proximal than the lobar bronchus (2) T1a: Tumour 2cm in greatest dimension T1b: Tumour > 2cm but 3cm in greatest dimension Tumour > 3cm but 7cm (1) or tumour that -involves main bronchus, 2cm distal to the carina (2) -invades visceral pleura (3) -associated with atelectasis or obstructive pneumonitis that extends to the hilar region but des not involve the entire lung (4) T2a: Tumour > 3cm but 5cm in greatest dimension T2b: Tumour > 5cm but 7cm in greatest dimension
T PRIMARY TUMOUR T3 T3 Tumour > 7cm (1) or one that directly invades any of the following: -chest wall (2) including superior sulcus tumours (3) -diaphragm (4) -phrenic nerve (5) -mediastinal pleural (6) -parietal pericardium (7)
T PRIMARY TUMOUR T3 Tumour in the main bronchus < 2cm distal to the carina but without involvement of the carina (8) or associated atelectasis or obstructive pneumonitis of the entire lung (9) or separate tumour nodule(s) in the same lobe (10)
T PRIMARY TUMOUR T4 T4 Tumour of any size that invades any of the following: -mediastinum (1) -heart (2) -great vessels (3) -trachea (4) -recurrent laryngeal nerve (5) -esophagus (6)
T PRIMARY TUMOUR T4 T4 -vertebral body (7) -carina (8) Separate tumour nodule(s) in a different ipsilateral lobe (9)
N REGIONAL LYMPH NODES N1 N2 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N REGIONAL LYMPH NODES N3 Metastasis in: -contralateral mediastinal (1) -contralateral hilar (2) -ipsilateral or contralateral scalene, or supraclavicular lymph node(s) (3)
M METASTASIS M1 Metastasis in: -M1a: separate tumour nodule(s) in a contralateral lobe (1) tumour with pleural nodules or malignant pleural (2) or pericardial effusion (3) -M1b: distant metastasis
2009 TNM CLASSIFICATION Goldstraw P, Crowley J, Chansky K, Giroux DJ, Groome PA, Rami-Porta R, Postmus PE, Rusch V, Sobin L, on behalf of the International Association for the Study of Lung Cancer International Staging Committee and participating institutions. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of Malignant Tumours. J Thorac Oncol 2007;2:706-14.
2009 TNM CLASSIFICATION - Stage I (A & B) : should be treated with surgery alone - Stage II (A & B): adjuvant chemotherapy following surgical resection - Stage IIIA: marginally resectable locally advanced tumours candidates for an induction therapy, chemo- or chemo- radiotherapy - Stage IIIB: non resectable tumours - Stage IV: advanced disease subdivided in M1a, limited to thorax, and M1b, with distant metastases.
Nodal disease 28-38% of NSCLC cases have nodal involvement at presentation
Mediastinal/hilar node map CT: Meta-analysis. analysis. 42 studies. 1980-1988 (using a node size greater than 1.0 cm as abnormal) a pooled sensitivity of 83%, specificity of 81% and accuracy of 81%. 20% false negative rate. 20% false positive rate. CT-PET: Improved sensitivity/specificity..tissue STILL REQUIRED MEDIASTINOSCOPY--- Non-invasive methods: EBUS/EUS
Case 78 year-old man COPD (FEV1 40% predicted) Performance status 2 MRC dyspnoea score 2 200 yards ET Ischaemic heart disease/lbbb/hypertension X-smoker: 60 pack year burden Cough and haemoptysis for 4/52
EBUS TBNA
Bronchoscopic view
Ultrasound view
Where do we stand now? NICE guidelines currently recommend that all patients with nodal disease suggested on PET scan should have tissue confirmation (unless there is a discrete chain of hot nodes) ESTS guidelines for staging NSCLC Invasive staging for PET+hilar N1 disease, low FDG- uptake in primary tumour with LN> 16mm on CT EBUS/EUS are new minimally invasive techniques with poor NPV. Negative results require Mediastinoscopy
EBUS/EUS service: the future Re-staging following neo-adjuvant chemo in stage 3a disease Routine pre-operative staging? ASTER trial
West Herts Raw data, October 2010-February 2011 53 cases of cancer diagnosed Biopsy attempted in 45/53 Tissue diagnosis in 41/53 (77%) Bronchoscopy: 18 CT/USS Bx: 16 Pleural fluid: 4 Surgery: 4 Non-small cell lung Cancer: 32 (78%) Squamous 11, AdenoCa 16, NOS 5 Small Cell Lung Cancer: 8 (19.5%) Mesothelioma: 1 (2%)
Key Range Low and medium low risk Medium high risk High risk
Conclusions Accurate staging crucial to identifying suitable treatment modalities New, minimally invasive techniques offer a viable alternative to mediastinoscopy Referring patients at an earlier stage critical to improving lung cancer survival