Work-up and Management of Lung Cancer

KEYWORDS
•Cancer
• Lung Anatomy
• Diagnostic Images
• Surgical Procedures
• Prognosis
Korean War Memorial
 Cancer Mortality
• Site Deaths
• Lung 157,400 213,000 (2007)
• Colon 48,100
• Breast 40,600
• Prostate 31,500
• Pancreas 28,900

Greenlee et al, CA Cancer J Clin 2001;51:15-36

Cancer Mortality

Greenlee et al, CA Cancer J Clin 2001;51:15-36

 Lung Cancer: The problem
• If cancer identified early- then survival is much
better

• Stage 1 - 70-80% chance of survival at 5 years

• Smoking – most significant cause of lung cancer

 Case History; KB
• 49 year patient
• Abnormal CxR
• PMH; Melanoma excision right supra-clavicular
area 5 years previously
• 60 pack year of smoking

• ALWAYS EVALUATE SYMPTOMS AND

PHYSICAL FINDINGS
Tracheal tree Anatomy
 CAT Scan for Lung Cancer

• Malignancy sugestion
– Spiculated margins
– Vascular convergence
– Pseudocavitation
– True Cavitation
• 85% positive for > 15
It is here !!!
mm thick wallls
 The Dilemma
• Is this a cancer?
• Can operation cure the cancer?
• Can operation help control the cancer or its
symptoms?
• palliation?
• Can the patient withstand the treatment?
Is this a cancer? Pre Test Probability for Lung Nodule
malignancy

http://www.chestx-ray.com
With no disclosures !
Pre Test Probability / Logistic regression
• What next?

– Tumor is the rumor

– Tissue is the issue
– Cancer is the answer?
 Work-up and Management of Lung Cancer

Determination of Stage
• Chest x-ray
• CT scans
• PET scan
• Needle biopsy
• Bronchoscopy
• Surgical biopsy (Mediastinoscopy / VATS)
 Lung Cancer Staging

• CT scan accuracy
T3 = 91 %
T4 = 27 % Cangemi et al, 1996

T3 / T4 = 50 % Gdeedo at al, 1997

T4 tumors are over staged 26 % of the times and under

staged 12 % Cetinkaya et al, 2002

Clin Cancer Res 2005; 11(13 Suppl)

Bronchoscopy
Bronchoscopy
Make Dx - central
tumors
Plan resection; central
tumors
R/O endobronchial
tumor in opposite lung or
another lobe
Intervention
 CT guided Biopsy
• Use CT scan to guide
biopsy
• Needle placed into tumor
to get cancer tissue
• Some pitfalls
– Needle may miss cancer
cells (false negative result)
– Pneumothorax
– If resection is planned
treatment does not change
 PET Scan
• Injection of a drug (FDG) which is taken up by
cancer cells
• Does not provide anatomic detail
• But more accurate than CT scan
• UPMC: PET versus CT; accuracy 85% vs 59%, .
 International System for Staging
Lung Cancer (revised 5/96)

• Stage I (Single tumor nodule only)

• Stage II (hilar /non-mediastinal nodes and T3N0
• Stage III (mediastinal nodes, satellite tumor same lobe
and invasion mediastinal structures)
• Stage IV (distant metastases)

• Ref: Mountain Chest 1997:111;1710

 Case History - KB
• PET/CT scan
– Intense uptake in the 3.5
cm mass in the RUL
suspicious for malignancy
– Small 1cm R tracheal
node-mild uptake; non- T2 N2 M0 – Possible III A
specific

What clinical stage is the tumor ?

T 123N123Mx01
Management of NSCLC Based on Stage

• Stage IA; (T1N0)

• operate only
• Stage IB, (T2N0), II (T1N1, T2N1, T3N0)
• operate then give adjuvant chemotherapy
• Stage IIIA;(T1-3, N2)
• Neo-adjuvant therapy then surgery
• Stage IIIB/IV
• No surgery
 KB - Approach
PET PET
• What next ? Positive Positive
1. Surgical removal? Normal size Enlarged
2. Chemotherapy? Node Node
3. Follow-up in 6 months ? PET PET
Negative Negative
4. Further investigation for
Normal size Enlarged
better staging before
Node Node
treatment?
 Mediastinoscopy

• Operation to biopsy lymph

nodes near the trachea
• Small incision in neck
• Usually a day-case
• May make the diagnosis
• Results may direct treatment
• But requires general anesthesia
Cervical Mediastinoscopy
 The Dilemma
• Can operation cure the cancer?

• Can the patient withstand the treatment?

• Can operation help control the cancer or its

symptoms?
• palliation?
Lung Cancer Survival

5 year survival

“”new IA” IA < 2cm

77.5 %
“new IB” > 2cm
69.3 %
“New” IIA
T2N0=T1N1
49.8 %

Asamura et al, J Thorac Cardiovasc Surg.2006;132(2):316-19

Complete resection is mandatory

J. Surg Oncol 25: 153, 1984

 Determination of Physical
Condition
• History & Exam
• Pulmonary function tests
• EKG / cardiac stress test
• Split lung function / VQ scan
– Provides quantitative information on lung function;
useful for the marginal candidate
 Pre-op Physiological Tests; KB

• Pulmonary function
• FEV1 2.8 (79%), FVC 2.8
(78%), DLCO 60%

•Cardiac Perfusion scan

No perfusion defects.
•LVEF 71%
•Stress Test
Negative for chest pain and EKG changes
Lung Resection
 Surgical Resection of the Lung

Standard of Care For Peripheral Nodules

1940’s Pneumonectomy
1960’s Lobectomy
1990’s ?Segmentectomy/Wedge (and
adjuvant local/systemic Rx)
 Lung Resection

• Best operation is removal of whole lobe

(lobectomy)
• Sometimes removing the whole lung
(pneumonectomy)
• Compromise operation is removing a segment
(segmentectomy) or a smaller area of lung (wedge
resection)
Sublobar Resection is sometimes an option

S e g m e n te c to m y

L im it e d P u lm o n a r y R e s e r v e P e r ip h e r a l L o c a t io n P a llia t io n

FE V1 I s o la t e d M e t a s ta s e s
D LC O
 Comparison of Standard Rx
Modalities for Stage I NSCLC
Modality 5-year survival Local Recurrence
(most occur within
2 years)
Lobar resection 60-70% 6.4%

Sub-lobar 60% 17.2%

resection
(segmentectomy /wedge)
External Beam 5-20% 50%
Radiation only
 Lung resection

• Standard treatment is lobectomy

• 5-year survival 60-80% for stage I cancer
• Usually open incision used
• requires rib spreading and removal small portion of a rib
• Sometimes minimally invasive approach possible
• VATS; video-assisted thoracic surgery
• Robotic resection
Open Surgery (Thoracotomy)
Minimally Invasive Surgery
(VATS)
VATS procedure
 VATS Lobectomy:
Instrumentation

Standard instrumentation Open /close and rotation only

 Advantages of VATS
• Less pain
• Smaller incisions / better cosmesis
• Quicker return to normal function

• But –not possible in all patients

713 patients
2548 stapler fires
1 mechanical failure
Robotic-assisted VATS Lobectomy
daVinci® Surgical System
 Surgeon at Console

Surgeon Assistant
Surgeon
“playing” on surgeon
“working” at patients front
video
on video
 Very High-risk patient

• Sub-Lobar resection
• Brachytherapy
• Radio-frequency ablation (RFA)
• Stereotactic radiosurgery
To decrease local recurrence

125
Iodine radio-active seeds into the sutures
 • 3 components
• An RFA generator
• An active electrode
• Dispersive electrodes
• RF energy (alternating
current ) moves from the
active->dispersive->active
electrodes, resulting in
Multiple tines for applying frictional heating of tissue
RF energy
• When temperature >60° C,
tissue dies
RadioTherapeutics
 RFA
• Over 300 cases reported in literature
• Initial results are encouraging
• Technique is safe
• Long-term results are not yet available
Thermal lesion 7 days post-RFA

Thermal lesion

Hemorrhagic
rim

Bronchiole
 Results- Tumor Response After RFA

Pre-RFA 1 month post-RFA 3 months post-RFA

Tumor Progression After RFA

Pre-RFA 3 months post-RFA

 CyberKnife® System
• Image guided radiation
• System consists of:

• 1. Radiation delivered by a robotic

arm
• 2. Image tracking system which
monitors patient position during
the treatment & adjusts radiation
accordingly
• 3) Requires placement of markers
(fiducials) close to tumor
 Lung Resection Conclusions

● For early stage lesions, resection offers the best chance at cure

● Lobectomy remains the gold-standard

● Lobectomy mortality rates of < 3% can be achieved in high-volume

centers

● Major morbidity is related primarily to pulmonary complications and

pleural problems

● Most important prognostic determinants are lymph node status,

completeness of resection, co-morbidity index, age, gender, histology as
well as surgeon/hospital volume
 Our patient KB is still waiting decision !
• Mediastinoscopy was negative
• Is the patient a surgical candidate ?
– YES
• Lobectomy + Systematic Lymph node dissection
• FINAL Pathology
– Adenocarcinoma
• p Stage T 2 N0 MO = IB
• Follow-up forever
 Summary

• Lung cancer is common

• Surgery best option for early stage cancers
– Lobectomy /VATS lobectomy (usual risk)
– Segment or wedge (for moderate risk patients)
– RFA/ cyberknife for the high-risk patient)
 STOP SMOKING…… WHY??

• Death of 440,000 Americans each year

• Men < 13.2 years
• Women < 14.5 years

• Cost $ 157,000,000,000 /year

“THE END”

Muito obrigado !
 Case
• 67 y.o. male with a h/o diabetes and stroke who was found to
have an abnormal CXR. He underwent a chest CT that
confirmed the abnormal finding
• Smoke: former, quit 4-5 yrs ago
 Case
– PFTs:
• FEV1: 2.19 (59%)
• FVC: 3.15 (67%)
• FEV1/FVC: 70
• DLCO: 34%
– Quant. V/Q scan: 50% R/L perfusion

Ref. Case 150

 Pathology Case 1

Poorly differentiated squamous cell carcinoma with features of basaloid

carcinoma (tumor size 2.1cm)
Surgical margins are negative
AJCC stage I (pT1NoMx)
Work-up and Management of Lung Cancer

Surgery ?
 What is the best operation?
• Right lung
– 3 lobes
– Each lobe has segments
• Left lung 1
– 2 lobes
– Each lobe has segments
How the CAT scan works ?

Are they all the same ?