Lung cancer and pulmonary nodules

Resident’s seminar 02/01/2006

Elsa B. Valsdottir

Lung nodules

In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma?

a) 5%

b) 20%

c) 35%

d) 50%

e) 75%

Lung nodules

In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma?

a) 5%

b) 20%

c) 35%

d) 50%

e) 75%

Benign nodules

Hamartoma 8% (popcorn lesion)

Granuloma

ScarringHemangioma

Schwannoma

Fibroma

Lipoma

Leiomyoma

Clear cell tumor

Teratoma

Pulmonary nodule

A healthy 59 yoM with 40 pack year hx has a new 1 cm nodule in the RUL on routine CXR. CT confirmes a spikulated lesion with lymphadenopathy. His PFTs are normal. The most appropriate management would be:

a) chemotherapyb) CT guided needle bxc) thoracoscopic wedge resectiond) RU lobectomye) radiotherapy

Algorithm from Greenfield

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Pulmonary nodule

A healthy 59 yoM with 40 pack year hx has a new 1 cm nodule in the RUL on routine CXR. CT confirmes a spikulated lesion with lymphadenopathy. His PFTs are normal. The most appropriate management would be:

a) chemotherapyb) CT guided needle bxc) thoracoscopic wedge resectiond) RU lobectomye) radiotherapy

Lung cancer: Incidence, epidemiology Leading cause of cancer death (28%) 2nd most common cancer

>173,000 cases/year Overall 5 year survival 12%

Decreasing incidence and mortality in men Incidence plateaued in women but mortality

still rising Cause: TOBACCO (85-90%)

arsenic, asbestos, genetics, COPD, CLL, AIDS

Lung cancer: Classification

Small cell carcinoma 20% Non-small cell carcinoma:

Adenocarcinoma 40% Squamous cell carcinoma 20-25% Adenosquamous carcinoma Large cell carcinoma Carcinoid Carcinoma of salivary gland type Unclassified

Small cell lung cancer

Which of the following statements about small cell lung cancer is NOT true?

a) Surgical therapy is rarely indicatedb) The etiology is unknownc) Paraneoplastic endocrine syndromes are commond) Chemotheraputic agents are generally effectivee) Prophylactic radiotion therapy can reduce brain

metastasis

Small cell lung cancer

Which of the following statements about small cell lung cancer is NOT true?

a) Surgical therapy is rarely indicatedb) The etiology is unknownc) Paraneoplastic endocrine syndromes are commond) Chemotheraputic agents are generally effectivee) Prophylactic radiotion therapy can reduce brain

metastasis

Signs and symptoms

Cough

Hemoptysis

Dyspnea

Pain

Dysphagia

Horner’s syndrome

Pancoast’s syndrome

SVC obstruction

PrimaryTumor (T)

Description

T1A small tumor that is not locally advanced or invasive

Criteria: <3 cm in size; surrounded by lung or visceral pleura; not extending into the main bronchus

T2A larger tumor that is minimally advanced or invasive

Criteria: >3 cm in size; may invade the visceral pleura; may extend into the main bronchus but remains >2 cm from the main carina; may cause segmental or lobar atelectasis

T3

Any size tumor that is locally advanced or invasive up to but not including themajor intrathoracic structuresCriteria: any size; may involve the chest wall, diaphragm, mediastinal pleura, parietal pericardium; main bronchus within 2 cm of the main carina (not involving the main carina); may cause atelectasis of the entire lung

T4

Any size tumor that is advanced or invasive into the major intrathoracic structuresCriteria: any size; invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, main carina; malignant pericardial or pleural effusion; presence of satellite tumor nodule(s) within the primary tumor lobe

RegionalLymph Node

Involvement (N)Description

N1Metastatic disease to nodes within the ipsilateral lung

Criteria: direct extension to intrapulmonary nodes; metastasis to ipsilateral peribronchial and/or hilar nodes (nodal stations 10 through 14)

N2

Metastatic disease to nodes beyond the ipsilateral lung but not contralateral to theprimary tumorCriteria: metastasis to the ipsilateral mediastinal and/or subcarinal nodes (nodal stations 1 through 9)

N3Metastatic disease to nodes distant to those included in N2

Criteria: metastasis to contralateral mediastinal and/or hilar nodes, ipsilateral or contralateral scalene and/or supraclavicular nodes

Metastases (M) Description

MO Local or regional disease, no distant metastases

M1 Disseminated disease, distant metastases present

Staging Description

IA T1N0M0

IB T2N0M0

IIA T1N1M0

IIB T2N1M0, T3N0M0

IIIA T3N1M0, T(1-3)N2M0

IIIB T4N(0-3)M0, T(1-4)N3M0

IV T(any)N(any)M1

Staging

Lung cancer: nodal stations

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Nodal stations, cont

Survival

Non-Small Cell Lung Cancer:5-year Survival (%) by Stage7

Stage Clinical Pathologic

IA 61 67

IB 38 57

IIA 34 55

IIB 22-24 38-39

IIIA 9-13 23-25

IIIB 3-7   

IV 1 –

Resectable tumors

Stages I and II Stage IIIA?

N2 dz Downstaging with neoadjuvant tx

Selected cases of IIIB (T4)

Lung cancer: Pre-operative workup CT (brain) PET: 97% sensitive, 78% specific Bronchoscopy Mediastinoscopy PFTs

FEV1 DLCO (diffusing capacity for carbon monoxide) Oxygen consumption

PFTs

Which one of the following inducates a high risk for RF after pulmonary resection?

a) Preoperative FEV1 = 500 ml

b) Preoperative PaCO2 = 38 mm Hg

c) V/Q scan showing 30% perfusion to operative side

d) Predicted postop FEV1 = 1.1L

PFTs

Which one of the following inducates a high risk for RF after pulmonary resection?

a) Preoperative FEV1 = 500 ml

b) Preoperative PaCO2 = 38 mm Hg

c) V/Q scan showing 30% perfusion to operative side

d) Predicted postop FEV1 = 1.1L

Lung cancer: Surgical options VATS Segmentectomy Lobectomy Sleeve resection Pneumonectomy

VATS for Stage 1 lung cancerPros: Cons:

less pain oncologic validity

less LOS tech. difficult

better cosmesis seeding of tumor

Better survival due to less immunologic response (IgG, CRP, IL-6, TNF etc)?

Roviaro et al: Long-term Survival After VATS Lobectomy for Stage 1 Lung Cancer. CHEST 2004;126:725-732

Lung cancer screening

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Lung cancer screening

Take home message: New CT techniques detect suspicious nodules 3x more than CXR, malignant tumors 4x and stage 1 tumors 6x

Henschke et al: Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet, 1999;354:99-105

Surgery after Chemo/XRT for Stage IIIA

Can be considered in fit patients but does not neccessarily increase overall survival

Albain et al: Phase III study of consurrent chemotherpy and radiotherapy (CT/RT) vs CT/RT followed by surgical resection for stage IIIA (pN2) non-small cell lung cancer (NSCLC): Outcomes update of NOrth American Intergroup 0139 (RTOG 9309). ASCO Annual Meeting 2005

Adjuvant chemo for resected Stages IB-II lung ca Newer adjuvant chemo prolongs overall and

recurrence free survival

Winton et al: A prospective randomised trial of adjuvant vinorelbine (VIN) and cisplatin (CIS) in completely resected stage IB and II non small cell lung cancer (NSCLC) Intergroup JRB.10. J Clin Onc 2004;22:7018