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Lung CancerLung CancerNon-Small CellNon-Small Cell
Staging/Prognosis/TreatmentStaging/Prognosis/Treatment
Oncology Teaching
October 14, 2005
Lorenzo E Ferri
Lung CancerLung Cancer
Highest cancer death rate for men and women
Canadian Cancer Statistics 2004
Lung Cancer – PathologyLung Cancer – Pathology
• Non-Small Cell– Squamous Cell Carcinoma
– Adenocarcinoma
– BAC
– Large Cell
• Small Cell• Neuroendocrine (Carcinoid,
Large cell NE, small)
StagingStaging
• Staging should provide prognosis and dictate management
• TNM Classification universally accepted
T status – T1T status – T1
• 3 cm or less, completely covered by pleura, does not involve main bronchus
T Status – T2T Status – T2
– > 3cm– Visceral pleura– Main bronchus
but > 2cm from carina
– Atelectasis but not complete lung
T status – T3T status – T3
– Chest wall– Diapragm– Mediastinal pleura– Pericardium– Main bronchus
<2cm to carina– Complete atelectasis
T Status – T4T Status – T4
• Carina• Vertebrae• Great Vessel• Esophagus• Heart• Separate tumour
nodule in same lobe• MALIGNANT
pleural effusion
Lymph Node MappingLymph Node Mapping
N StatusN 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
M StatusM Status
• Common distant sites sites include– Brain, bone, liver, adrenal
• Two nodules in same lung
Stage IStage I
• 1A – T1 N0
• 1B – T2 N0
Stage IIAStage IIA
• T1 N1
Stage IIBStage IIB
• T2 N1
• T3 N0
Stage IIIAStage IIIA
• T1-3 N2
• T3 N1
Stage IIIBStage IIIB
• T0-3 N3
• T4 N0-3
5 Year Survival 5 Year Survival
• IA• IB• IIA• IIB• IIIA• IIIB• IV
• 60-75%• 50-60%• 50-60%• 40-50%• 15-30%• 5-10%• 0-5%
• Overall 5 year survival = 15% (no change in 3 decades)
Mountain 1997, Rami-Porta 2000, Naruke 1988
SurvivalSurvival
Survival by Clinical Stage Survival by Pathologic Stage
MD Anderson 1975-1988
Is all Stage IIIA (N2) the same?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
Staging Investigations – non invasiveStaging 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
• 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%
Staging Investigations – non invasiveStaging Investigations – non invasive
PET/CTPET/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
PET/CTPET/CT
Does this need pathologic confirmation?
Invasive StagingInvasive Staging Bronchial, Mediastinal and PleuralBronchial, Mediastinal and Pleural
• Bronchial Bronchoscopy – for proximal lesions (T3 vs T4)
• Pleural – Throracentesis – 60-65% accurate– Pleuroscopy and biopsy – more than 95%
Are all effusions associated with known lung cancer malignant?
Post-obstructive effusion
Mediastinal Staging - InvasiveMediastinal Staging - Invasive
• CT and PET/CT – better but not perfect for mediastinal nodes
• Mediastinoscopy is the gold standard!– Assesses N2 and N3
Endoscopic BiopsyEndoscopic BiopsyEUS FNAEUS FNATBNATBNA
What is really needed?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
Treatment 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
TreatmentTreatment
• 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
TreatmentTreatment
• 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)