SPN and Lung Cancer

1. SPN and Lung Cancer Adam J. Hayek, DO PGY-6 Pulmonary and Critical Care Fellow

2. GOALS • Lung Cancer Incidence & Mortality • Dealing with Incidental Found Nodules • You are responsible for all ED “un” necessary imaging • Lung Cancer Screening • Molecular Evolution • Molecular Evaluation • New directed therapy • Make you a believer that in the near future lung cancer will be a chronic illness just like COPD with even better survival • Acquired Resistance • Liquid Biopsy

3. Cancer Statistics 2015 American Cancer Society, Cancer Statistics; 2015

4. Survival Trend American Cancer Society, Cancer Statistics; 2015

5. Survival Trend Why?? American Cancer Society, Cancer Statistics; 2015

6. Lung Cancer Survival • Symptomatic Lung Cancer generally advanced stage disease and not currently curable • Lung Cancer at Diagnosis: 2002-2008 • 226,000 New Diagnosis • Localized 15% • Regional 22% • Distant 56% Wender et al CA Cancer J Clin 2013

7. Screening Screening PSA Mammography Colonoscopy LDCT CMS 2/15/2015 American Cancer Society, Cancer Statistics; 2015

8. National Lung Cancer Screening Trial (NLST) • Age 55-74 • Smoker • Former smoker quit < 15 yrs ago • 30 pkyr • 20% reduction in lung cancer • Young, et al. • Subgroup analysis of 18,714 with spirometry • 34% had COPD accounting for 52% cancer cases Young, et al. AJRCCM 2015;192:1060-1067

9. SPN • Found round or oval area of increased opacity • Spiculated or lobulated • Can be non solid, part solid or solid • <3 cm

10. DDx Benign: Malignant: Lung cancer Metastasis Carcinoid Lymphoma • Pneumonia • Granuloma • Hamartoma • AVM • Pulmonary arterypseudoaneuyrsm • Intrapulmonarylymphnodes • Inflammatory

11. Metastatic Melanoma

12. Metastatic Colon Cancer

13. AVM

14. Hamartoma

15. Intrapulmonary Lymph Node

17. Intrapulmonary Lymph Node • Location • Subcarinal • Peripheral, sub pleural • Shape • Trianglular or angular • Elliptical • Semicircular

18. Describe Lesion • Calcifications • Fat • Vascular Lesion • Intrapulmonary Lymph Node • Size • Morphology • Round, Lobulated, speculated • Solid, subsolid, Ground Glass

19. Calcification Benign Malignant

20. Malignancy Risk Factor • Suspicious morphology • Upper Lobe Location • Multiple nodules

21. FleischnerSociety Guidelines est. 1969 • Founded by 8 radiologist in 1969 • International, multidisciplinary medical society for thoracic radiology • Meet annually • 12 radiologist on working group for updating guidelines based on best evidence available • https://fleischnersociety.org/

22. 2017 Fleischner Society Guidelines • Morphology and size • Solid • <6 mm • 6-8 mm • >8 mm • Ground Glass or Part Solid • <6 mm • >6 mm

23. RISK: High vs Low • low risk patients: • Minimal or absent history of smoking and or other known risk factors • HIGH risk patients: • history of smoking • Other known risk factors • First degree relative with lung cancer, or exposure to asbestos, radon, uranium

24. Solitary nodule: < 6 mm

25. Solid Nodule 6-8 mm

26. Solid Nodule

28. Solid Nodule >8 mm • If Resolved • Likely infection and no further work up needed • Decreased in size • Likely infection but needs follow up to resolution • Unchanged • Workup • PET Imaging • FOB, TTNB, Sx

29. Multiple Nodules

30. Subsolid nodules

31. Solitary GGN: < 6 mm

32. Solitary GGN < 6 mm

33. Solitary GGN: > 6 mm

34. Solitary GGN: > 6 mm

35. Part solid nodule: < 6 mm

36. Part solid nodule: >6 mm

37. Part solid or multiple nodule: > 6 mm

38. Subsolid Nodule • Pure ground glass nodule or part solid nodule • Solitary or multiple nodules • May be infectious • Assumed to be adenocarcinoma in situ (AIS) formerly referred to bronchioloalveolar (BAC) • Part solid more likely to be malignant

39. Lung Adenocarcinomas • Premalignant • Atypical Adenomatous hyperplasia • Adenocarcinoma in situ • Malignant • <5 mm minimally invasive adenocarcinoma • >5 mm Invasive adenocarcinoma

40. Use the correct calculator LDCT SPN: https://brocku.ca/node/21910/done?sid=137297 Incidental SPN: http://reference.medscape.com/calculator/solitary-pulmonary-nodule-risk

42. Nodule • Driver Mutations: • EGFR • ALK (FISH) • MET • ROS

43. Obtaining Tissue • Transbronchial Needle Aspiration (TBNA) • Sensitivity 78% (14-100%) • Specificity 100% • FALSE NEGATIVE 28% (0-66%) • If negative, evaluate (pre biopsy) pretest probability of cancer in context of Sn 78% with FN rate 28% • Higher with navigational bronchoscopy • Average Sn 77% and FN rate 22% Detterbeck FC, et al. Chest. 2007;132:202S-220S.

44. Go for radiographic staging lesion • Distant mets (liver, adrenals, supraclavicular LN, bone mets) • Careful with bone metsbc with processing cannot do genetic tests • Please, Please , Please do not have IR do biopsy if they have mediastinal or hilar lymphadenopathy • IR biopsy if in peripheral ¼-1/3 of lung zone • IF UNSURE CALL, IT’S FREE AND SAFE FOR PATIENT

45. EBUS W or W/O ROSE • Molecular Testing (KRAS, EGFR an ALK) • Achieved in 85% (108/126) • 90% Successful in EBUS PLUS ROSE • 80% Successful in EBUS Alone • 18 Failures (6 EBUS+ROSE; 12 EBUS Alone) • Pathology failure (0 EBUS+ROSE, 6 EBUS Alone) • EBUS+ROSE more likely to have bronchoscopy terminated after single biopsy site (59% vs 44%) • EBUS+ROSE prevents need for repeat diagnostic procedure for molecular testing in 1:10 patients Trisolini, et al, Chest 2015; 148: 1430-1437

46. NSCLC 2012 Adapted from W. Pao and N Girard, Lancet Oncol, 2011

47. Adapted from W. Pao and N Girard, Lancet Oncol, 2011

48. Actionable Mutations

49. Stage IV NSCLC

50. Current Molecular Based Therapies