Lung Cancer Non-Small Cell Staging-Prognosis-Treatment

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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 Large Cell

• Small Cell • Neuroendocrine (Carcinoid, Large cell NE, small)

Staging

• Staging should provide prognosis and dictate management • TNM Classification universally accepted

T status – T1
• 3 cm or less, completely covered by pleura, does not involve main bronchus

T Status – T2
– > 3cm – Visceral pleura – Main bronchus but > 2cm from carina – Atelectasis but not complete lung

T status – T3
– – – – – Chest wall Diapragm Mediastinal pleura Pericardium Main bronchus <2cm to carina – Complete atelectasis

T Status – T4
• • • • • • Carina Vertebrae Great Vessel Esophagus Heart Separate tumour nodule in same lobe • MALIGNANT pleural effusion

Lymph Node Mapping

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
• Common distant sites sites include
– Brain, bone, liver, adrenal

• Two nodules in same lung

Stage I
• 1A – T1 N0

• 1B – T2 N0

Stage IIA
• T1 N1

Stage IIB
• T2 N1 • T3 N0

Stage IIIA
• T1-3 N2 • T3 N1

Stage IIIB
• T0-3 N3 • T4 N0-3

5 Year Survival
• Overall 5 year survival = 15% (no change in 3 decades)

• IA • IB • IIA • IIB • IIIA • IIIB • IV

• 60-75% • 50-60% • 50-60% • 40-50% • 15-30% • 5-10% • 0-5%
Mountain 1997, Rami-Porta 2000, Naruke 1988

Survival

Survival by Clinical Stage

Survival by Pathologic Stage
MD Anderson 1975-1988

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
• 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 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
• 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/CT

Does this need pathologic confirmation?

Invasive Staging
Bronchial, 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 - Invasive
• CT and PET/CT – better but not perfect for mediastinal nodes • Mediastinoscopy is the gold standard!
– Assesses N2 and N3

Endoscopic Biopsy
EUS FNA TBNA

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
• 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

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

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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