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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

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lung cancer non small cell staging prognosis treatment

Lung CancerNon-Small CellStaging/Prognosis/Treatment

Oncology Teaching

October 14, 2005

Lorenzo E Ferri

lung cancer
Lung Cancer

Highest cancer death rate for men and women

lung cancer pathology
Lung Cancer – Pathology
  • Non-Small Cell
    • Squamous Cell Carcinoma
    • Adenocarcinoma
    • BAC
    • Large Cell
  • Small Cell
  • Neuroendocrine (Carcinoid, Large cell NE, small)
staging
Staging
  • Staging should provide prognosis and dictate management
  • TNM Classification universally accepted
t status t1
T status – T1
  • 3 cm or less, completely covered by pleura, does not involve main bronchus
t status t2
T Status – T2
  • > 3cm
  • Visceral pleura
  • Main bronchus but > 2cm from carina
  • Atelectasis but not complete lung
t status t3
T status – T3
  • Chest wall
  • Diapragm
  • Mediastinal pleura
  • Pericardium
  • Main bronchus <2cm to carina
  • Complete atelectasis
t status t4
T Status – T4
  • Carina
  • Vertebrae
  • Great Vessel
  • Esophagus
  • Heart
  • Separate tumour nodule in same lobe
  • MALIGNANT pleural effusion
n status
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
m status
M Status
  • Common distant sites sites include
    • Brain, bone, liver, adrenal
  • Two nodules in same lung
stage i
Stage I
  • 1A – T1 N0
  • 1B – T2 N0
stage iib
Stage IIB
  • T2 N1
  • T3 N0
stage iiia
Stage IIIA
  • T1-3 N2
  • T3 N1
stage iiib
Stage IIIB
  • T0-3 N3
  • T4 N0-3
5 year survival
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

survival
Survival

Survival by Pathologic Stage

Survival by Clinical 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 invasive
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
staging investigations non invasive27
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%
pet ct
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

pet ct29
PET/CT

Does this need pathologic confirmation?

invasive staging bronchial mediastinal and pleural
Invasive StagingBronchial, Mediastinal and Pleural
  • Bronchial  Bronchoscopy – for proximal lesions (T3 vs T4)
  • Pleural 
    • Throracentesis – 60-65% accurate
    • Pleuroscopy and biopsy – more than 95%
slide31
Post-obstructive effusion

Are all effusions associated with known

lung cancer malignant?

mediastinal staging invasive
Mediastinal Staging - Invasive
  • CT and PET/CT – better but not perfect for mediastinal nodes
  • Mediastinoscopy is the gold standard!
    • Assesses N2 and N3
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
treatment36
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
treatment37
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)
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