Lung cancer and pulmonary nodules

Lung cancer and pulmonary nodules: 

Lung cancer and pulmonary nodules Resident’s seminar 02/01/2006 Elsa B. Valsdottir

Lung nodules: 

Lung nodules In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma? 5% 20% 35% 50% 75%

Lung nodules: 

Lung nodules In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma? 5% 20% 35% 50% 75%

Benign nodules: 

Benign nodules Hamartoma 8% (popcorn lesion) Granuloma Scarring Hemangioma Schwannoma Fibroma Lipoma Leiomyoma Clear cell tumor Teratoma

Pulmonary nodule: 

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: chemotherapy CT guided needle bx thoracoscopic wedge resection RU lobectomy radiotherapy

Algorithm from Greenfield: 

Algorithm from Greenfield

Pulmonary nodule: 

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: chemotherapy CT guided needle bx thoracoscopic wedge resection RU lobectomy radiotherapy

Lung cancer: Incidence, epidemiology: 

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: 

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: 

Small cell lung cancer Which of the following statements about small cell lung cancer is NOT true? Surgical therapy is rarely indicated The etiology is unknown Paraneoplastic endocrine syndromes are common Chemotheraputic agents are generally effective Prophylactic radiotion therapy can reduce brain metastasis

Small cell lung cancer: 

Small cell lung cancer Which of the following statements about small cell lung cancer is NOT true? Surgical therapy is rarely indicated The etiology is unknown Paraneoplastic endocrine syndromes are common Chemotheraputic agents are generally effective Prophylactic radiotion therapy can reduce brain metastasis

Signs and symptoms: 

Signs and symptoms Cough Hemoptysis Dyspnea Pain Dysphagia Horner’s syndrome Pancoast’s syndrome SVC obstruction

Staging: 

Staging

Lung cancer: nodal stations: 

Lung cancer: nodal stations

Nodal stations, cont: 

Nodal stations, cont

Survival: 

Survival

Resectable tumors: 

Resectable tumors Stages I and II Stage IIIA? N2 dz Downstaging with neoadjuvant tx Selected cases of IIIB (T4)

Lung cancer: Pre-operative workup: 

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: 

PFTs Which one of the following inducates a high risk for RF after pulmonary resection? Preoperative FEV1 = 500 ml Preoperative PaCO2 = 38 mm Hg V/Q scan showing 30% perfusion to operative side Predicted postop FEV1 = 1.1L

PFTs: 

PFTs Which one of the following inducates a high risk for RF after pulmonary resection? Preoperative FEV1 = 500 ml Preoperative PaCO2 = 38 mm Hg V/Q scan showing 30% perfusion to operative side Predicted postop FEV1 = 1.1L

Lung cancer: Surgical options: 

Lung cancer: Surgical options VATS Segmentectomy Lobectomy Sleeve resection Pneumonectomy

VATS for Stage 1 lung cancer: 

VATS for Stage 1 lung cancer Pros: 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: 

Lung cancer screening

Lung cancer screening: 

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: 

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 : 

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