1 / 38

Lung Cancer Non-Small Cell Staging/Prognosis/Treatment

Lung Cancer Non-Small Cell Staging/Prognosis/Treatment. Oncology Teaching October 14, 2005 Lorenzo E Ferri . Lung Cancer. Highest cancer death rate for men and women. Canadian Cancer Statistics 2004. Lung Cancer – Pathology. Non-Small Cell Squamous Cell Carcinoma Adenocarcinoma BAC

medwin
Download Presentation

Lung Cancer Non-Small Cell Staging/Prognosis/Treatment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Lung CancerNon-Small CellStaging/Prognosis/Treatment Oncology Teaching October 14, 2005 Lorenzo E Ferri

  2. Lung Cancer Highest cancer death rate for men and women

  3. Canadian Cancer Statistics 2004

  4. Lung Cancer – Pathology • Non-Small Cell • Squamous Cell Carcinoma • Adenocarcinoma • BAC • Large Cell • Small Cell • Neuroendocrine (Carcinoid, Large cell NE, small)

  5. Staging • Staging should provide prognosis and dictate management • TNM Classification universally accepted

  6. T status – T1 • 3 cm or less, completely covered by pleura, does not involve main bronchus

  7. T Status – T2 • > 3cm • Visceral pleura • Main bronchus but > 2cm from carina • Atelectasis but not complete lung

  8. T status – T3 • Chest wall • Diapragm • Mediastinal pleura • Pericardium • Main bronchus <2cm to carina • Complete atelectasis

  9. T Status – T4 • Carina • Vertebrae • Great Vessel • Esophagus • Heart • Separate tumour nodule in same lobe • MALIGNANT pleural effusion

  10. Lymph Node Mapping

  11. N Status • N0 – no regional LN metastases • N1 – LN mets in ipsilateral peribronchial and/or intrapulmonary • N2 – ipsilateral mediastinal or subcarinal • N3 – contralat mediastinal or supraclavicular nodes

  12. M Status • Common distant sites sites include • Brain, bone, liver, adrenal • Two nodules in same lung

  13. Stage I • 1A – T1 N0 • 1B – T2 N0

  14. Stage IIA • T1 N1

  15. Stage IIB • T2 N1 • T3 N0

  16. Stage IIIA • T1-3 N2 • T3 N1

  17. Stage IIIB • T0-3 N3 • T4 N0-3

  18. IA IB IIA IIB IIIA IIIB IV 60-75% 50-60% 50-60% 40-50% 15-30% 5-10% 0-5% 5 Year Survival • Overall 5 year survival = 15% (no change in 3 decades) Mountain 1997, Rami-Porta 2000, Naruke 1988

  19. Survival Survival by Pathologic Stage Survival by Clinical Stage MD Anderson 1975-1988

  20. Is all Stage IIIA (N2) the same? • Single vs multiple station • Bulky vs non-bulky • Station 5/6 in LUL cancer • Nodal vs extra-nodal disease

  21. Staging Investigations – non invasive • History and Physical! –hoarseness (T3 or N2) supraclavicular nodes (N3) • CXR – Size (rough), chest wall (T3), effusion (T4) • CT Chest/upper Abdo • T status – accurate • N status (>1 cm= 70% +, <1cm=7% +) • M status – adrenal, liver, lung, bone

  22. Staging Investigations – non invasive • MR – for T4 and M1 • thorax – not routine – for Pancoast • Brain – asymptomatic patients have brain mets in less than 3% Hillers et al Thorax 1994 • Bone Scan – asymptomatic patients have mets in less than 5%

  23. PET/CT • Technology is evolving • Allows for “one step” extrathoracic staging • Independent predictor for survival (low SUV) • What about mediastinum? • NPP must be very high if invasive staging is to be avoided • NPP=98% in a recent study (Pozo-Rodriguez JSO 2005) Not good for BAC, small lesions <0.5 cm

  24. PET/CT Does this need pathologic confirmation?

  25. Invasive StagingBronchial, Mediastinal and Pleural • Bronchial  Bronchoscopy – for proximal lesions (T3 vs T4) • Pleural  • Throracentesis – 60-65% accurate • Pleuroscopy and biopsy – more than 95%

  26. Post-obstructive effusion Are all effusions associated with known lung cancer malignant?

  27. Mediastinal Staging - Invasive • CT and PET/CT – better but not perfect for mediastinal nodes • Mediastinoscopy is the gold standard! • Assesses N2 and N3

  28. Endoscopic BiopsyEUS FNA TBNA

  29. What is really needed? • Do we need to invasively assess N2 disease in everyone? • Small peripheral lesion (esp SCC and BAC) have a low rate of mediastinal mets (1 cm=10%, 3 cm =25%) • CT/PET accuracy is improving • TBNA and EUS often obviate the need for M-scope Institution specific – U of T – everyone gets a M-scope McGill and rest of N.A. - selective

  30. Treatment • Stage IA – Lobectomy (VATS vs Thoracotomy) • Stage IB-IIB - Lobectomy + adjuvant Cx • Pancoast (T3N1) – neoadjuvant chemorads (EP 2cycles with 45 Gy) • Stage IIIA – • T3N1 (resected) – adjuvant Cx • N2 disease  ??? • Traditionally a non-surgical disease BUT….. • Neoadjuvant (Int 0139) - no Difference, but 27% vs 20% 5-yr survival - Albain et al ASCO 2005

  31. Treatment • Stage IIIB – definitive CxTx, BUT…. • Not all T4s are equal • T4N0-1 – aorta, vertebra, all other major vessels have been resected with reasonable 5 year survival (20-30%) Rendina JTCVS 1999

  32. Treatment • Stage IV • Palliative – median survival approx 6 months • Malignant effusion – if symptomatic • Thoracentesis  • if no improvement think lymphangetic spread, PE, etc • If symptomatically improved • if lung expands  Pleurodesis • If lung trapped  pleural drainage (tenkhoff vs repeated taps)

More Related