Slide 1 Investigation and management of lung cancer Robert Rintoul Department of Thoracic Oncology Papworth Hospital Slide 2 Epidemiology Second most common cancer in the UK (after breast). 38 000 new cases per annum in UK. Most common cause of cancer death in UK (34 000 pa). Male:female ratio was 6:1, now 3:2. Slide 3 Risk factors/aetiology Smoking 90% Risk of lung cancer related to number cigarettes smoked and time smoked Smoke 1 14 cigarettes per day, 8 times more likely to develop lung cancer than never smoker Smoke 25 cigarettes per day, 25 times increased risk. 20 per day for 40 years, risk is 8 times greater than 40 per day for 20 years.
Slide 4 Risk factors/aetiology Passive smoking Never smoker married to a smoker is at 30% increased risk of lung cancer compared to someone married to a neversmoker. Asbestos Lung cancer in those previously exposed to asbestos is 7 times greater than in those with no asbestos exposure If smoke and previous asbestos up to 50 times increased risk Slide 5 Risk factors/aetiology Age Family history Ionizing radiation Environmental carcinogens Chemicals, radon, air pollution/diesel fumes Previous lung scarring Other cancers Slide 6 Symptoms/Signs Some patients may have no symptoms or signs. No symptoms specific to lung cancer Cough Dyspnoea Haemoptysis Slow to resolve infection Lethargy Weight loss Stridor Hoarse voice Chest pains
Slide 7 Symptoms/Signs SVCO Paraneoplastic syndromes Horner s syndrome Symptoms/signs due to metastases Slide 8 Slide 9
Slide 10 Slide 11 Types of lung cancer NSCLC 80% Squamous 45% (25% in US) Adenocarcinoma 25% (40% in US) Large cell 10% SCLC 15% (falling slowly) Slide 12 Diagnosis and Staging algorithm CXR CT Scan Diagnostic tests Staging tests Treatment plan
Slide 13 Staging Staging is the measurement of the extent of disease in a patient in order to allow logical grouping of that patient with others who have similar disease for prognostic, analytic or therapeutic purposes. Slide 14 Staging in lung cancer Why do it? Choose most appropriate therapy Predicts survival Slide 15 Diagnostic and staging tests CXR CT Scan Look at where disease is and target biopsies appropriately. Bronchoscopy CT guided biopsy Lung, liver, adrenals Ultrasound
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Slide 19 Slide 20 TNM classification T Tumour N Lymph node M Metastasis Slide 21 T PRIMARY TUMOUR T1 T2 Tumour 3cm in greatest dimension, Tumour > 3cm but 7cm (1) or tumour that surrounded by lung or visceral pelura (1) involves main bronchus, 2cm distal to the carina (2) invades visceral pleura (3) without bronchoscopic evidence of invasion associated with atelectasis or obstructive more proximal than the lobar bronchus (2) pneumonitis that extends to the hilar region but does T1a: Tumour 2cm in greatest dimension not involve the entire lung (4) T2a: Tumour > 3cm but 5cm in greatest dimension T1b: Tumour > 2cm but 3cm in greatest dimension T2b: Tumour > 5cm but 7cm in greatest dimension
Slide 22 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) Slide 23 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) USED TO BE T4 Slide 24 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) oesophagus (6)
Slide 25 T PRIMARY TUMOUR T4 T4 vertebral body (7) Separate tumour nodule(s) in a different carina (8) ipsilateral lobe (9) USED TO BE M1 Slide 26 Metastasis to ipsilateral peribronchial or hilar nodes Metastasis to ipsilateral mediastinal or subcarinal nodes Husband: Imaging in Oncology Metastasis to contralateral mediastinal / hilar or scalene / supraclavicular nodes Slide 27 3 Mountain 1997
Slide 28 Advanced imaging tests Structure: CT Brain Magnetic Resonance Imaging (MRI) Selected patients: Pancoast tumours; brain metastases; bone metastases Function: FDG Positron Emission Tomography (PET) Integrated PET CT Slide 29 Fused images Slide 30 Staging of potential metastases Surgical staging tests Mediastinoscopy VATS Radiological Ultrasound/CT guided biopsy Endoscopy Endobronchial ultrasound Endoscopic ultrasound
Slide 31 Staging Group N0 a T1 IA b N1 IIA N2 IIIA N3 IIIB M1 a IB IIA T2 b IIA IIB T3 IIB IIIA IIIA IIIA IIIB IIIB T4 IIIA IIIA IIIB IIIB a M1 b Slide 32 Slide 33 Treatment for NSCLC Surgical resection (8 10%) Stage 1,2 Gives best chance of long term cure Only 8% of lung cancers resected in UK Radical radiotherapy (5 10%) Not as good as surgery but can be useful for those unfit for surgery Palliative treatments (75 80%) Stage 3, 4 Chemotherapy Palliative radiotherapy Active supportive care
Slide 34 Why can we not try to cure more patients? Advanced disease at presentation Poor performance status/frail Co morbidities (IHD, CVA, PVD, Renal impairment) Poor lung function COPD Slide 35 Potential surgical resection Points to consider Performance status PS 0 4 Co morbidities Lung function how functionally impaired will the patient be after surgery? FEV1 2.0 L for a pneumonectomy FEV1 1.5 L for a lobectomy Slide 36
Slide 37 Adjuvant chemotherapy Chemotherapy given post operatively to try to mop up any residual cancer cells Recent studies suggest that it confers a survival advantage of about 5% Slide 38 Radical radiotherapy Useful if patient has limited disease that can be encompassed in a radiotherapy field but, Does not want an operation Is not fit for an operation Limited FEV1 Other co morbidities eg IHD, CVD, PVD Given over 4 weeks (20 fractions) Slide 39
Slide 40 Palliative therapies Chemotherapy as primary treatment Not curative; aimed at alleviating symptoms Improve survival by a few months May confer about 5% increase in survival at 1 year Radiotherapy Give 1 or 2 fractions for a specific reason Haemoptysis, bone pain, brain metastases, skin metastases, SVCO. Slide 41 Treatment for SCLC Generally regarded as systemic disease Surgery only in exceptional cases Mainstay of treatment is chemotherapy Limited disease chemotherapy with radiotherapy to the chest and prophylactic cranial radiotherapy Extensive disease chemotherapy