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Lung cancer and pulmonary nodules
Resident’s seminar 02/01/2006
Elsa B. Valsdottir
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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%
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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%
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Benign nodules
Hamartoma 8% (popcorn lesion)
Granuloma
ScarringHemangioma
Schwannoma
Fibroma
Lipoma
Leiomyoma
Clear cell tumor
Teratoma
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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
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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
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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
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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
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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
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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
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Signs and symptoms
Cough
Hemoptysis
Dyspnea
Pain
Dysphagia
Horner’s syndrome
Pancoast’s syndrome
SVC obstruction
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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
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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
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Lung cancer: nodal stations
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Nodal stations, cont
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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 –
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Resectable tumors
Stages I and II Stage IIIA?
N2 dz Downstaging with neoadjuvant tx
Selected cases of IIIB (T4)
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Lung cancer: Pre-operative workup CT (brain) PET: 97% sensitive, 78% specific Bronchoscopy Mediastinoscopy PFTs
FEV1 DLCO (diffusing capacity for carbon monoxide) Oxygen consumption
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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
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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
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Lung cancer: Surgical options VATS Segmentectomy Lobectomy Sleeve resection Pneumonectomy
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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
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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
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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
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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