I ELCAP lung cancer

• 213000 new case of lung cancer , 5 years
  survival just only 15%\
• Past few decade is static
• Because 50% case was advance cancer
  when they come to Dr
• In the past decade increase interest in
  the role of low dose spiral CT
• CXR missed 70-80% of lung cancer detect
  by the CT
• CT screening trials have report higher
  rate of early lung cancer 70-80%(stage Ia)
• Average size of CT :1.5cm
• Average size of CXR : 3cm
• SEER new diagnosed lung cancer stage I
  ONLY 25%
• Can increase 10x of operation
• But not all screen detect cancer are
  curable some were stage III at the time
  of diagnosis
• Interval lung cancer (cancer that develop
  between annual screening CT scan) rapid
  growth and frequently small cell lung
• Most controversial is cost effect
•   From 1993 ELCAP..I-ELCAP
•   CT screen for lung cancer
•   15% has positive result
•   6% has repeat positive result
   Definition of Positive
• At least I solid pr part solid noncalcified
  nodule 5mm or more in diameter
• Or at least one nonsolid noncalcified
  nodule 8mm or more in diameter
• If there is noncalcified nodule but too
  small ,…semipositive ..calling for repeat
  one year later.
     Repeat screening;
• Growth in size
• Growth in consistency
• Growth in soilid componant in semi-
  solid or previois non solid nodule
   The I-ELCAP regimen
 provides recommendation
      for the work up
• Follow their protocol 90% of biopsy
  result in malignancy
• Recommendation turned out to be
  quite successful
• None of biopsy without
  recommendation was cancer
• 85% of the screen–diagnosis is stage I
• Also found the tumor size in this stage I cancer
  is more smaller
• The % of stage I lung cancer were much higher
  than SEER data(surveillance,epidermiology, and
  end result )program.
• Long term F/U10 years survival rate regardless of
  stage and tx was 80%
• Clinical stage I 10 years survival was 92 %
      Pathology of lung
   adenocarcinoma and CT
    screening specimens
• Major subtype of adenocarcinoma
• 2004 WHO major subtype : mixed
  subtype,acinar, papillary, BAC (mucinous
  nonmucinous, mix)
• Some subtype is more invasive and some
  are sensitive to iressa
• EGFR and K ras mutation
• CT screening 94% was adenocarcinoma
  Molecular pathways to
   lung adenocarcinoma
• Adenocarcinoam is more and or esp in
  women and young patient and nonsmoker
• Microarray expression studies
  demonstrate that gene expression is very
  different in smoker and nonsmoker
• Smoking activation to RAS signaling
• Non-smoking associated activation of
  EGFR signaling
Limited resection for small
   peripheral carcinoma
• Systematic nodal dissection could
  improved stage-specific survival and may
  improved overall survival. So lobectomy
  and SND still is standard choice
• <1cm tumor has 10 % node metastasis
• 2cm tumor has 20-40% has node
  metastasis and 2/3 is N2
• But due to CT screening: the tumor is
  more smaller so limited resection could we
  try in select case?
• GGA( Ground glass attenuation )>50% of
  the total tumor size have a similary good
  prognosis (Noguchi classification)sublobar
  resection may be appropriate in selected
  case, but can cure? Wary .
Pre-invasive lesion (patho)
• 1999: squamous dysplasia and
  carcnoma in situs
• 2004: atypical adenomatous
  hyperplasia, diffuse idiopathic
  pulmonary neuroendocrine cell
• May be multicentri
 Iatrogenic contribution
  to thoracic neoplasm
• Given continuing advances od early detection and
  supportive care and therapy : cancer survivor in
  USA is 3x since 1971 and increasing by 2% each
• Cancer survivor is about 3.5% of US population
• We will meet second primary or late sequelae or
  treatment relate problem
• Treatment-associated lung tumor: such as R/T
  and C/T
     Lung cancer staging:
      intrathoracic nodal
• 1982 a landmark paper by Dr pearson:
  mediastinal nodal metastasis could elude
  pre-op staging even in CT become routine
  and in which mediastinoscopy was well
• 38% of case were upstaged at
  thoracotomy..Unexpect n2 disease
• N2 has only 20% 5 years survival
• Correct staging may improve survival
• Radical or en block to describe nodal dissection
• 1996 workshop: SND
• Definition: number or node and at lease three
  mediastinal nodal station, and include one
  subcarina region
• Review SND . Find 18% unexpect n2, no rescue
• SND : better staging and find more ln deposit .
• But early concern is add the
  morbility of surgery.
• N0 survival was related to the
  number of node excised at
  Definition of complete
• Lns specimens should include at lease
  six lymph node, three removed from
  intrapulmonary or hilar status and
  three removed from mediastinal
  station,one of which must be the
  subcarina station.
• Other suggest: more extensive
  sectioning and immunohistochemical
  stain will find more subtle nodal
              PET CT
•   18-FDG
•   Phosphorylate
•   18-FDG-6-phosphate
•   Inside the tumor cell could not
    degrade and trapped in cell and
• For SPN or lung mass 0.7cm -4cm
  can confirmed the maliganant
• Sensitivity 92-94%
• Specificity 86-90%
• Duke : only 5% stage Ia is negative
      False positive and
• False positive:TB or other grnulomatous
  disease; such as histoplasmosis
  coccidiomycosis or inflammatory
  process ;rheumatoid nodule, sarcoidosis or
  cryptogenic organizing pneumonia ,BOOP
• False negative: carcinoid tumor BAC well
  differential adenocarcinoma or metastatic
  tumor from renal cell ca of testicular
  ca( most carcinoid are positive)
• <1cm may not be detect
• Limit is 7-8mm
• Serum glucose result in decrease
  intracellular FDG uptake
• At Mayo clinic do not perform PET
  scan unless blood glucose <150mg/dl
PET in staging or node or
• CT sensitivity 61% ,specificity 79%
• PET            80%              90%
• Due to false positive, if there are no documented
  distal metastasis , must be biopsy before patient
  be judge as unresectable
• 10-15% false positive , so if identified distal
  metas, esp one site metas, we would perform
  biopsy to get the potential curative thoracotomy
PET vs isotope bone scan
• Isotope bone scan have larger bone
• If we already have PET scan , we
  have no reason obtaining a bone scan
• But except brain . MRI or brain scan
  is better.

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