Case Discussion (lung cancer)

1. Case Discussion (lung cancer) Pınar Çelik TTS 15. Annual Congress 11-15 April 2012 Antalya

2. Conflict of interest • I don’t have any conflict of interest

3. Synchronous lung cancer is determination of second primary lung cancer in a patient with lung cancer at diagnosis.

4. Synchronous lung cancer • Occurance rate: 0.8% - 14.5% • 5-year survival rate: 0%-76% • Reasons of difference in survival: Difficulties in diagnosis, BAC, inclusion of patients with carcinoid tumours and satellite noduls, few cases, second tumour is metastatic

5. Synchronous lung cancer • If the tumours histological types are different it is separate primary lung cancers • If the tumours histological types are same; One of them is primary, other one is metastase Synchronous lung cancer

6. Martini-Melamed criteria 1. Tumours should be located distantly and separately 2. Histological types a. Different histology b. If same histology They should be located at different segment, lobe or lung and Originated from carcinoma insitu No presence of carcinoma at shared lymphatic drainage No extrapulmonary metastases at the diagnosis Martini N, Melamed MR. J Thorac Cardiovasc Surg 1975

7. Antakli criteria Antakli T. et al. Ann Thorac Surg 1995 1. Different histology 2. Same histology with two or more of the following a. Anatomically distinct b. Associated premalignant lesion c. No systemic metastases d. No mediastinal lymph node spread e. Different DNA ploidy

8. Staging ? Pastorina U. Eur J Cancer 2001;37: 75-90 There is no specific staging at synchronous lung cancer (TNM) Staging of each tumour should be done separately, advanced one should be recorded. Synchronous lung cancers was not discussed at last staging, their assessment was done as metastases of each other.

9. Staging Detterbeck FC, Jones DR et al. Chest 2003 Bury T. et al. Eur Resp J 1997 When the synchronous lung cancer diagnosis is done distant metastases assessment and mediastineal staging should be done Mediastinal metastases should be proved invasively Cranial MR should be seen PET-CT should be done Pulmonary capacity should be evaluated

10. PET-CT Allen-Auerbach M, Yeom K, Park J. et al. J Nucl Med. 2006 • Standardized PET-CT has not true positive or negative rates in patients with nodule <1 cm • Spatial resolution of PET-CT is 6-8 mm • PET-CT is not reliable in patients with lesion located at lower zone • Duration of shot is longer than spiral CT • Respiratory artefact

11. Staging (case) Evaluation of distant metastases and mediastinal staging was done with PET-CT Pulmonary capacity of patient was evaluated Invasive staging was not done Lesion at contralateral lung was not clarified at diagnosis (synchronous lung cancer, metastases, benign lesion?)

12. Thorax CT(case) A 40x25 mm lobulated, pleura based lesion with malignant nature located at apical segment of upper lobe of right lung was seen. Invasion to chest wall or ribs was not observed. There was no mediastinal, hilar or axillary pathological lymphadenopathy.

13. Thorax CT(case) A 17x13 mm lesion with irregular border located at laterobasal segment of lower lobe of left lung was seen. This lesion was causing retraction at major fissure. A 8 mm subpleural nodule at laterobasal segment of lower lob of left lung was seen.

14. PET-CT (case) A pleura based lesion located at apical segment and posteromedial of posterior segment of upper lob of right lung was including posterolateral of right 3.rib (local invasion). The central of lesion was hypometabolic, border of lesion was hypermetabolic (SUV max 6.1), There was diffuse increase at right shoulder joint and muscle (SUV max 3.2), linear increase in sternum (SUV max 3.3). SUV value of nodule and mass located at lower lobe of left lung was not mentioned, probable due to low FDG value.

15. PET-CT (case) • Shreve PD, Anzai Y, Wahl RL. Radiographics 1999 • Sarji SA. Biomed Imaging Interv J 2006 • Prabhakar HB, Sahani Dv et al. Radiographics 2007 A pleura based lesion located at apical segment and posteromedial of posterior segment of upper lob of right lung was including posterolateral of right 3.rib (local invasion). The central of lesion was hypometabolic, border of lesion was hypermetabolic (SUV max 6.1) (Malign lesion) There was diffuse increase at right shoulder joint and muscle (SUV max 3.2), linear increase in sternum (SUV max 3.3) (degeneration and by-pass) SUV value of nodule and mass located at lower lobe of left lung was not mentioned, probable due to low FDG value.

16. Which lesion firstly operated? • Kocaturk CI, Gunluoglu MZ, Cansever L. et al. Eur J Cardiothorac Surg 2010, Ferguson MK et al. J Thorac Cardiovasc Surg 1985 In bilateral synchronous lung cancers, thoracotomy should be done to the one which has more advanced stage. In bilateral synchronous lung cancers, if one of the tumours has definite diagnosis and the other one has no histopathological diagnosis, thoracotomy should be done to the one which has no histopathological diagnosis.

17. Surgery and treatment(case) • Right lung was oparated (the one has advanced stage, but lesion at left lung did not have diagnosis). • Surgery: Partial resection of right 2-3-4 ribs+right upper lobectomy+MLND • Postoperation pathology (pStageT3N0M0) • Tumour exceeded visceral and parietal pleura and invaded to ribs. • Tumour smooth tissue was close to the surgery border but ther was no continuity. • Postoperation RT was applied • Adjuvant KT? • Follow up (3 month interval)

18. Chest wall invasion (T3N0M0) • Total resection • Only parietal pleura invasion; exstrapleural resection • More deeper invasions “en block” resection • MLND • Surgical border negative  no need for postoperative RT • Surgical border positive  postoperative RT

19. Thorax CT (9. month of follow up) • At the bronchial stubby location, residual-recurrent mass was observed. • A 19x13 mm lesion with irregular border located at laterobasal segment of lower lobe of left lung was seen. This lesion was causing retraction at major fissure and had malignant nature. With the comparison of previous CT , there was minimal increase in dimension, evident increase in density of mass. • Also 8.5x6.5 mm stable subpleural nodule at laterobasal segment of lower lob of left lung was seen.

20. PET-CT (9.month of follow up) • Increase in F-18 FDG at fibrotic area located at apical segment of upper lobe of right lung (SUV max 2.7). • Moderate increase in F-18 FDG at 15.3x15.6 mm irregular lesion that was located at laterobasal segment of lower lobe of left lung (SUV max 2.2) and increase in SUV max value of this lesion was observed at respiratory gating imaging af late phase (SUV max 3.0). • At rectosigmiod junction focal invrease in activity (SUV max 3.0).

21. PET-CT ( 9. month of follow up)

22. PET-CT (9.month of follow up) • Increase in F-18 FDG at fibrotic area located at apical segment of upper lobe of right lung (SUV max 2.7) (RT) • Moderate increase in F-18 FDG at 15.3x15.6 mm irregular lesion that was located at laterobasal segment of lower lobe of left lung (SUV max 2.2) and increase in SUV max value of this lesion was observed at respiratory gating imaging af late phase (SUV max 3.0) (malign lesion) • At rectosigmiod junction focal increase in activity (SUV max 3.0). (GIS N uptake or malign lesion) • Shreve PD, Anzai Y, Wahl RL. Radiographics 1999 • Sarji SA. Biomed Imaging Interv J 2006 • Prabhakar HB, Sahani Dv et al. Radiographics 2007

23. ACCP Recommendations Shen KR, Meyers BF, Larner JM et al. ACCP evidence-based clinical practice guidelines. Chest 2007 Suppl In patients who have two synchronousprimary NSCLCs and are being considered forcurativesurgicalresection, invasivemediastinalstaging and extrathoracic imaging (head CT/MRI plus either whole-body PETor abdominalCT plus bone scan) are recommended. Involvementof mediastinal nodes and/or metastaticdisease represents a contraindication to resection (1C). In patients suspected of having two synchronousprimary NSCLCs, a thorough searchfor an extrathoracic primary cancer to rule outthe possibility that both of the lung lesionsrepresent metastases is recommended (1C). In patients (not suspected of having asecond focus of cancer) who are found intraoperativelyto have a second cancer in a differentlobe, resection of each lesion is recommended,provided that the patient has adequate pulmonaryreserve and there is no N2 nodal involvement (1C).

24. Surgical approach to bilateral synchronous lung cancer Kocaturk CI, Gunluoglu MZ, Cansever L et al. Eur J Cardiothorac Surg 2010

25. Surgical approach to unilateral synchronous lung cancer Kocaturk CI, Gunluoglu MZ, Cansever L et al. Eur J Cardiothorac Surg 2010

26. Diagnosis and treatment (case) • 1. Moderate differantial squamous cell carcinoma • Right upper lobectomy+partial resection of right 2-3-4 ribs+MLND • Postoperative RT was given, KT was not. • 2. Synchronous tumour, adenocarcinoma mix type after 9 month later • Resected with wide surgery border, not added to lobectomy, postoperative RT or KT were not given.

27. Survival Kocaturk CI, Gunluoglu MZ, Cansever L et al. Eur J Cardiothorac Surg 2010 Between 2001 and 2008, survival analysis of 26 consecutive patients diagnosed with synchronous lung cancer • 5 year survival: 49.7% • Unilateral: 40.6% • Bilateral: 62.8% • Prognostic factors • Pneumonectomy : bad • Adjuvant KT : good

28. Survival Tanvetyanon HT, Finley DJ, Fabian T, Voltolini L, Kocaturk CI, Fulp WJ et al. ASCO 2012 Between 2001-2008 years survival analysis of multicentered 6 study that include 467 patient applied curative resection due to synchronous multiplelung cancers; • Mean survival was 52 month, postoperative mortality 1.9% • Prognostic factors • Age • Male gender • N1, N2 • Unilateral tumours • Different histopathological type, increase mortality

29. Prognosis (case) Good prognostic factors • Bilateral tumours • No presence of N1, N2 • Complete resection • Pneumonectomy was not done Bad prognostic factors • Male gender • Different histology • KT was not given

30. Thank you

31. Metachronous lung cancer is new lung cancer development after curative surgery due to primary lung cancer.

32. Metachronous lung cancer Martini N, Melamed MR. J Thorac Cardiovasc Surg 1975 Shen KR, Meyers BF et al. ACCP evidence-based clinical practice guidelines. Chest. 2007 Suppl • Differenthistopathology • Ifthetumours’ histopathology is same; • Diseasefreedurationmorethan 2 years(ACCP 4 years) • Originatedfromcarcinoma in situ • Location of secondcancer at differentlobeorlung • No presence of carcinoma at sharedlymphaticdrainage • No extrapulmonarymetastases at thediagnosis

33. Metachronous lung cancer Antakli T. An Thorac Surg 1995 • Different histology • Same histology with two or more of the following Anatomically distinct Associated premalignant lesion No systemic metastases No mediastinal lymph node spread Different DNA ploidy

34. ACCP recommendation Shen KR, Meyers BF et al. ACCP evidence-based clinical practice guidelines. Chest. 2007 Suppl In patients who have a metachronousNSCLC and are beingconsidered for curativesurgical resection, invasive mediastinal stagingand extrathoracic imaging (head CT/MRI pluseither whole-body PET or abdominal CT plusbone scan) arerecommended. Involvement ofmediastinal nodes and/or metastatic diseaserepresents a contraindication to resection (1C).

35. Treatment Treatment of metachronous lung cancer is complete resection like primary lung cancer. Presence of mediastinal and distant metastases shold be looked before surgical treatment. Patient’ respiratory capacity determines the surgical procedure. If lobectomy or segmentectomy was done for primary lung cacer before, complementary pneumonectomy can be done for tumours located same side. If right pneumonectomy was done before, only limited resection can be applied to the left lung.

36. Survival Antakli T et al. Ann Thorac Surg 1995 Pastorina U. Eur J Cancer 2001. 2 year survival 52% 5 year survival 20%