Transcript Surgery in Lung Cancer - Windsor Cancer Research Group

Cancer Education Day
May 13, 2016
Surgery for Lung Cancer
• Dr A Elalem
• Thoracic surgeon
• Windsor Regional hospital
Disclosures
• No Disclosure to report
• No conflict of interest
High lights
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Epidemiology of Lung cancer
Presentation and diagnosis
Staging
Treatment in general
Surgical treatment
Questions?
Epidemiology of Lung cancer
• Most frequently diagnosed cancer worldwide
– About 1.35 million new cases diagnosed
worldwide each year
• Leading cause of cancer deaths in the United
States
Canadian Cancer Statistics 2015
Epidemiology of Lung cancer
• For men in Ontario, prostate cancer is the most
frequently diagnosed type of cancer.
• In 2015:
• An estimated 9,700 men will be diagnosed with
prostate cancer.
• An estimated 5,100 men will be diagnosed with
colorectal cancer.
• An estimated 4,600 men will be diagnosed with lung
cancer
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Risk factors
• Cigarette smoking
• Second-hand smoke
• Occupational exposure (asbestos,
motor vehicle emissions, pollutants, radon)
• Genetics
• Low level radiation
• Smoking and low intake of beta carotene.
Cell types
Small Cell
Squamous cell
Adenocarcinoma
Large-cell
(undifferentiated)
Carcinoid
Presentation
Symptoms:
• Some of the early warning
signs of lung cancer are:
• A cough that doesn’t go away
• Chest pain
• Hoarseness
• Weight loss and loss of appetite
• Bloody or rust-colored sputum
• Shortness of breath
• Fever without a known reason
• Recurring infections such as
bronchitis or pneumonia
NSCLC - Stages at Presentation
7%
Stage II
31%
Stage III
24%
Stage I
38%
Stage IV
Fry WA, et al. Cancer. 1996;77:1949-1995.
Presentation
Presentation
Investigation
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Chest X-Ray
CT scan +/- Biopsy
MRI
PET scan
Bone scan
Bronchoscopy
EBUS-TBA
Clinical Staging
Imaging
CT{chest and upper abdomen}
MRI Superior sulcus tumor, Pancoast
– MRI Head if symptoms, Adenoca
– for Small cell Lung cancer
– May be in stage III disease NSCLC
– All patient in academic centers !!
PET- if a radical treatment is considered
Bone scan, Complementary to PET ??
Clinical Staging
– CT/US guided needle aspiration: thoracentesis,
cervical lymph node, liver
– EUS: left adrenal metastasis
– In metastastatic disease, biopsy the easiest site
Clinical Staging
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CT scan Alone Was not very good Why?
40% of suspicious LN are benign by size criteria.
20% of non-suspicious LN are malignant.
Meta-analysis:
Sensitivity: 51-64%*
Specificity: 77-82%**
Clinical T1N0 ( 5-15% has positive LN on surgical
staging)
Clinical Staging
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PET scan: Was not great too why?
Systematic review of 44 studies;
Sensitivity:74%
Specificity:84%
Meta-analysis: Enlarged LN
Sensitivity:100%
Specificity:78%
False positive:25%
Gold Ann Int med 2003; 139-879
Clinical Staging
PET scan(continue):
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Meta-analysis: Non-enlarged LN
Sensitivity:82%
Specificity:93%
False Negatice:20%
Gold Ann Int med 2003; 139-879
Surgical staging
Bronchoscopy/ EBUS-TBA
Mediastinoscopy
Mediastinotomy
Thoracoscopy(VATS)
Thoracotomy
VATS( video assisted thoracic surgery)
Surgical staging
Surgical staging(EBUS)
EBUS and Staging
Sensitivity
Specificity
Diagnositc
Accuracy
CT
76.9%
55.3%
60.8%
PET
80%
70.1%
72.5%
EBUS-TBNA
92.3%
100%
98%
Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung
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Cancer. Chest 2006; 130:710-718
TNM Stages of lung cancer
Stage
Ia
Ib
IIa
IIb
IIIa
IIIb
IV
T
N
M
T1a
N0
M0
T1b
N0
M0
T2a
N0
M0
T1a
N1
M0
T1b
N1
M0
T2a
N1
M0
T2b
N0
M0
T2b
N1
M0
T3
N0
M0
T1
N2
M0
T2
N2
M0
T3
N2
M0
T3
N1
M0
T4
N0
M0
T4
N1
M0
T4
N2
M0
T1
N3
M0
T2
N3
M0
T3
N3
M0
T4
N3
M0
T Any
N Any
M1a or 1b
Pre operative Clinical Assessment
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History and physical
Cardio-pulmonary evaluation
PFT
Echo +/- cardiac MIBI
6 min walk
Optimize lung function
Smoking cessation.
Surgical treatment by stage
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Lobectomy
Bilobectomy ( only Right side)
Sleeve resection
Pneumonectomy
Segmentectomy
Wedge resection
Chest wall with Lung resections
Surgical treatment by stage
• Stage I &II
• Surgery is the main stay in treatment.
• There is a good body of evidence to support
that.
Kaplan-Meier Survival Curves for 484 Participants with Lung Cancer and
302 Participants with Clinical Stage I Cancer Resected within 1 Month after
Diagnosis
The International Early Lung Cancer Action Program
Investigators. N Engl J Med 2006;355:1763-1771
Wedge vs Lobectomy for
Stage I NSCLC
120
% Survival
100
80
Wedge
Lobectomy
60
40
p=0.889
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10
20
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50
60
Landreneau, et.al.,
J Thorac Cardiovasc Surg 1997;113:691-700
Lobectomy vs Limited Resection
120
100
80
60
40
20
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Lobectomy
Limited Resection
10
8
12
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84
96
60
72
36
48
logrank p=0.088 (one-tailed)
12
24
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% Survival
Time to death (from any cause) by treatment
Ginsberg and Rubinstein
Ann Thorac Surg
Wedge vs Lobectomy for
Stage I NSCLC
Open
WR
VATS
WR
Vs.
Lobe
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Vs.
3.3
0.20*
Postop Stay
(days)
7.7
6.5
Vs.
10.1
0.0002*
Local Recur (%)
17
15
Vs.
5
0.08*
Local/Systemic
Recurrence (%)
24
23
vs.
17
0.43*
Op Mortality (%)
P<
*- all WR (n=95) vs. Lobe (n=124) Statistical Methods: Life Table Analyses
Obtained by Log Rank and Wilcoxson Tests
Landreneau, et.al.,
J Thorac Cardiovasc Surg
1997;113:691-700
Surgery for stage III-A
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Heterogeneous stage !!
T1 to T3, N2, M0
T3, N1, M0
T4, N0 or N1, M0
Stage IIIa – “Bulky
Stage IIIa – “Minimal Involvement
Surgery for stage III-A
• Induction (pre-operative )
Chemo-radiotherapy for Stage III-a nonsmall cell lung cancer
Standard of Care ???
Surgery for stage III-A
• Intergroup trial 0139
Chemo-radiation vs Chemo-radiation
followed by surgical resection of Stage IIIa
NSCLC
Kathy Albain et al.
ASCO 2005
Lancet 2009;374:379-86
Conclusion
• N0 at surgery greatly influence 5 years survival
• Trimodality therapy is not recommended if
pneumonectomy is required due to high
mortality
• Surgical resection can be considered in fit
patient after induction chemo-rads if
lobectomy is feasible.
Surgery for stage III-B
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No role for surgery
Very bulky disease
Any T, N3, M0
T4, N2, M0
Surgery for stage IV
• Any T, any N, M1a
• Any T, any N, M1b
• The overall consensus:
surgery
• BUT ??!!
no role for
Surgery for stage IV
• Exception to this role:
• Solitary brain, pulmonary or adrenal mets
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Thoracic disease is resectable(Ro resection)
Good performance status, younger patients
Mets are resectable with acceptable morbidity
Mediastinum is cleared.
Surgery for stage IV
• Any evidence
• Supported by several retrospective reviews.
Surgery for stage IV
• Metastasectomy for Synchronous Solitary Non-Small Cell Lung Cancer
Metastases
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Mario Tönnies, MD, Joachim Pfannschmidt, MDcorrespondenceemail, Torsten T. Bauer, MD, Jens Kollmeier, MD, Simone
Tönnies, Dirk Kaiser, MD
• Between 1997 and 2009, 99 patients underwent complete solitary
synchronous NSCLC metastasis resection in a single center.
• Conclusions
They conclude that metastasectomy for synchronous
oligometastatic disease in NSCLC can be performed in
selected patients. It appears reasonable that such patients
should be considered as surgical candidates if mediastinal
lymph node involvement is excluded.
Annals of Thoracic surgery. July 2014Volume 98, Issue
1, Pages 249–256
Surgery for stage IV
• Radical treatment of synchronous oligometastatic non-small cell lung
carcinoma (NSCLC): Patient outcomes and prognostic factors.
• Retrospective review of 61 Patients
• Surgery and /or radiation therapy
• The 1- and 2-year OS were, 54% and 38%, respectively.
• Again the thoracic disease should be resectable(R0) resection)
Gwendolyn H.M.J, Lung cancer, October 2013Volume 82, Issue 1,(Netherland)
Surgery for stage IV
• Metastasectomy for Synchronous Solitary
Non-Small Cell Lung Cancer Metastases
Mario Tönnies, MD, (Germany)
99 Patients
Retrospective review
OS was 38%
OS was 45.%% for ipsilateral or cotralateral pulmonary metastasis.
Grade was also important G1-2 vs G3
Annals of thoracic surgery, July 2014Volume 98, Issue 1,
Surgery for stage IV
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Other roles of surgery in stage IV NSCLC
Malignant pleural effusion:
Options
1) Talc pleurodesis
2) Pleurex catheter
Thank you
Can you guess where is this?
Question #1
Which of the following statements does NOT describe a
feature of small cell lung carcinoma?
A. Most patients are smokers.
B. Abundant mucin production is associated
C. Paraneoplastic syndromes are associated.
D. A majority of cases have neurosecretory-type
granules.
Question #2
• Malignant pleural effusion is considered:
1) T4- Stage III-A
2) M1- Stage IV
Question #3
• Which of the following is true
1. 15% of lung cancer patient are asymptomatic at
presentation
2. 35% of lung cancer patient are asymptomatic at
presentation
3. 7-10%of lung cancer patient are asymptomatic at
presentation