lung cancer non-small cell staging/prognosis/treatment oncology teaching october 14, 2005 lorenzo e...

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)