Diagnostic procedures,  Staging and Surgery of Lung Cancer  <br />Balkan Masterclass in Clinical Oncology<br />11-15 May 2...
Symptoms and signs of lung cancer<br />Recognising the symptoms and signs of lung cancer is an important first step in est...
Symptoms and signs of lung cancer<br />1)  growth of the primary tumour<br />2)  intrathoracic metastasis of the tumour<br...
Symptoms and signs of the primary tumour<br /><ul><li>Cough -the most common symptom, in up to 75% of pts
Haemoptysis in up to 35% of patients
Recurrent or unresolved pneumonia
Dyspnoea in up to 60% of patients , wheeze and stridor
Chest pain</li></ul>Localization of lung cancer <br />central<br />peripheral<br />Atelectasis of right lung<br />Atelecta...
Symptoms and signs of intrathoracic metastasis<br />Superior vena cava obstruction<br />Pancoast’stumour and Horner’s synd...
Symptoms and signs of intrathoracic metastasis<br />Superior vena caval obstruction<br />SVCSis due to the compression or ...
Symptoms and signs of intrathoracic metastasis<br />Pancoast  tumour (superior sulcus tumour) <br /><ul><li>Early stage is...
  Tumour rising posteriorly in the apex of the upper</li></ul>  lobes near the brachial plexus, causing arm and<br />  sho...
  Horner’s Sy: involvement of the sympathetic chain</li></ul>  tumour causing unilateral enophthalmos, ptosis,<br />  mios...
Symptoms and signs of extrathoracic metastasis<br />Supraclavicular lymph nodes<br />Liver<br />·   Brain and Spinal cord<...
Constitutional symptoms<br />Anorexia, Cachexia…<br />Paraneoplastic syndromes<br /><ul><li>General
Endocrine – Cushing Sy, SIADH…
Cutaneous
Connective tissue
Haematological: thrombopenia, </li></ul>coagulopathy, trombophlebitis <br /><ul><li>MusculoSkeletal: finger clubbing, </li...
Diagnostic of suspected lung cancer<br />Noninvasive methods <br /><ul><li>anamnesis of the disease
 physical examination  </li></ul>- laboratory tests <br /><ul><li>Imaging:
chest X ray
CT scan , MRI, PET-CT
ultrasound of the abdomen
Bone scan…</li></ul>- Sputum cytology <br />Invasive procedures <br /><ul><li>Bronchoscopy (transbronchial</li></ul>  biop...
 Thoracotomy </li></ul>Histological or cytological specimens can be obtained<br />from the primary tumor, lymph node or di...
Imaging of Lung Cancer<br />Characterising and staging lung cancer, and also used to guide the best site for tissue sampli...
Ultrasound (US) guided percutaneous nodal sampling-
MEDIASTINAL LYMPH NODES STAGING</li></li></ul><li>Chest radiographs remain the first line of imaging investigation usually...
CT offers great anatomic detail, e.g. relationship of the tumour to the fissures (which may determine the type of resectio...
Magnetic resonance (MRI)  imaging for the assessment of  superior sulcus tumours, relation to vascular structures…<br />
Imaging of (Non small cell) Lung Cancer<br />PET–CT scanning has a NPV for N3 disease, which is equal to that of gold stan...
PET-CT<br />False-negativePET findings: little FDG avidity of the primary tumour, presence of a central tumour or of centr...
Invasive diagnostic proceduresCommon sites for tissue sampling<br />A tissue diagnosis of lung cancer is crucial to differ...
Invasive diagnostic proceduresA) Endoscopy<br />Bronchoscopy remains a standard in patients with intra-thoracic disease, r...
A) Endoscopy<br />Conventional or blind <br />transbronchial needle aspiration<br /> – TBNA  -  Enlarged LNs on CT<br />En...
Invasive diagnostic procedures<br />Endobronchial and endoscopic ultrasound have become established for the mediastinal st...
Staging of Lung CancerTNM7  Classification  (IASLC 2009.)<br />
T1a – T2b new (according to IASLC)<br />T1a<br />T1b<br />T2a<br />T2b<br />Spreading limited to<br /> the bronchial wall,...
T3 – T4 new (according to IASLC)<br />Chest wall invasion <br />including Pancoast tu<br />without invasion of <br />verte...
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BALKAN MCO 2011 - D. Jovanovic - Diagnostic procedures, staging and surgery of lung cancer

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Transcript of "BALKAN MCO 2011 - D. Jovanovic - Diagnostic procedures, staging and surgery of lung cancer "

  1. 1. Diagnostic procedures, Staging and Surgery of Lung Cancer <br />Balkan Masterclass in Clinical Oncology<br />11-15 May 2011<br />Dubrovnik, Croatia<br />Dragana Jovanovic<br />Clinical Hospital of Pulmonology<br />Clinical Centre of Serbia<br />Belgrade<br />
  2. 2. Symptoms and signs of lung cancer<br />Recognising the symptoms and signs of lung cancer is an important first step in establishing the diagnosis <br />Provides information on disease stage and prognosis.<br />By the time lung cancer causes symptoms and signs, the patient often has advanced disease that is beyond cure.<br />When they do occur, are often nonspecific, causing further delay in diagnosis<br />
  3. 3. Symptoms and signs of lung cancer<br />1) growth of the primary tumour<br />2) intrathoracic metastasis of the tumour<br />3) extrathoracic metastasis<br />4) paraneoplastic syndromes<br />5) constitutional effects of cancer<br />Most frequent:<br />- Cough ± hemoptysis <br />- Different degree of dyspnoea<br />- Pain of different intensity <br />- Loss of appetite and body weight loss<br />- Fatigue<br />
  4. 4. Symptoms and signs of the primary tumour<br /><ul><li>Cough -the most common symptom, in up to 75% of pts
  5. 5. Haemoptysis in up to 35% of patients
  6. 6. Recurrent or unresolved pneumonia
  7. 7. Dyspnoea in up to 60% of patients , wheeze and stridor
  8. 8. Chest pain</li></ul>Localization of lung cancer <br />central<br />peripheral<br />Atelectasis of right lung<br />Atelectasis of left upper lobe<br />
  9. 9. Symptoms and signs of intrathoracic metastasis<br />Superior vena cava obstruction<br />Pancoast’stumour and Horner’s syndrome<br /> Recurrent laryngeal nerve palsy<br /> Phrenic nerve palsy<br /> Dysphagia<br /> Cardiac involvement<br /> Chest wall invasion<br /> Pleural disease<br />
  10. 10. Symptoms and signs of intrathoracic metastasis<br />Superior vena caval obstruction<br />SVCSis due to the compression or invasion of vena cava with tumor mass and intraluminal thrombus, presents with oedema and plethora of the face, dilated veins on the neck, upper torso and arms, with headache and cerebral oedema.<br />SVCS is a poor prognostic factor.<br />
  11. 11. Symptoms and signs of intrathoracic metastasis<br />Pancoast tumour (superior sulcus tumour) <br /><ul><li>Early stage is without respiratory symptoms.
  12. 12. Tumour rising posteriorly in the apex of the upper</li></ul> lobes near the brachial plexus, causing arm and<br /> shoulder pain and muscle atrophy<br /><ul><li>Destruction ofthe I & II ribs and/or vertebral body.
  13. 13. Horner’s Sy: involvement of the sympathetic chain</li></ul> tumour causing unilateral enophthalmos, ptosis,<br /> miosis and anhydrosis of the face. <br />
  14. 14. Symptoms and signs of extrathoracic metastasis<br />Supraclavicular lymph nodes<br />Liver<br />· Brain and Spinal cord<br />· Bone<br />Skin<br />Coeliac lymph nodes…<br />Adrenal glands<br />Symptoms and signs that predict extrathoracic metastasis<br />ACCP 2007<br />
  15. 15. Constitutional symptoms<br />Anorexia, Cachexia…<br />Paraneoplastic syndromes<br /><ul><li>General
  16. 16. Endocrine – Cushing Sy, SIADH…
  17. 17. Cutaneous
  18. 18. Connective tissue
  19. 19. Haematological: thrombopenia, </li></ul>coagulopathy, trombophlebitis <br /><ul><li>MusculoSkeletal: finger clubbing, </li></ul>hypertrophic osteoarthropathy <br /><ul><li>Neurological: sensory neuropathy,</li></ul> Lambert-Eaton Sy (myasthenicsy)<br />
  20. 20. Diagnostic of suspected lung cancer<br />Noninvasive methods <br /><ul><li>anamnesis of the disease
  21. 21. physical examination </li></ul>- laboratory tests <br /><ul><li>Imaging:
  22. 22. chest X ray
  23. 23. CT scan , MRI, PET-CT
  24. 24. ultrasound of the abdomen
  25. 25. Bone scan…</li></ul>- Sputum cytology <br />Invasive procedures <br /><ul><li>Bronchoscopy (transbronchial</li></ul> biopsy, brush or needlebiopsy) <br />- Cervical lymph node biopsy <br /><ul><li>FNAB - Percutaneous fine-needle</li></ul> aspiration biopsy <br />- Pleural punction/biopsy, Pleeuroscopy<br />- VATS - Video-assisted thoracoscopy <br /><ul><li>Mediastinoscopy
  26. 26. Thoracotomy </li></ul>Histological or cytological specimens can be obtained<br />from the primary tumor, lymph node or distant metastases or malignant effusions. <br />The least invasive procedure should be used.<br />
  27. 27. Imaging of Lung Cancer<br />Characterising and staging lung cancer, and also used to guide the best site for tissue sampling:<br /><ul><li>Computed tomography (CT) guided percutaneoustransthoracic biopsies or
  28. 28. Ultrasound (US) guided percutaneous nodal sampling-
  29. 29. MEDIASTINAL LYMPH NODES STAGING</li></li></ul><li>Chest radiographs remain the first line of imaging investigation usually<br />
  30. 30. CT offers great anatomic detail, e.g. relationship of the tumour to the fissures (which may determine the type of resection), to mediastinal structures, or to the pleura and chest wall.<br />Carefulness to exclude<br /> a patient from surgery <br />based on CT criteria <br />alone<br />
  31. 31. Magnetic resonance (MRI) imaging for the assessment of superior sulcus tumours, relation to vascular structures…<br />
  32. 32. Imaging of (Non small cell) Lung Cancer<br />PET–CT scanning has a NPV for N3 disease, which is equal to that of gold standard mediastinoscopy.<br /><ul><li>MEDIASTINAL LYMPH NODES STAGING</li></ul>DISTANT MTS<br />
  33. 33. PET-CT<br />False-negativePET findings: little FDG avidity of the primary tumour, presence of a central tumour or of centrally located N1 nodes, both of which may obscure nearby existing mediastinal LN mts. <br />False-positive findings - FDG uptake is not tumour specific, and can be found in all active tissues with high glucose metabolism, in particular inflammation. <br />Clinically relevant FDG-avid mediastinal LNs should always be examined with the most appropriate tissue sampling technique.<br />
  34. 34. Invasive diagnostic proceduresCommon sites for tissue sampling<br />A tissue diagnosis of lung cancer is crucial to differentiate nonsmall cell lung cancer (NSCLC) from small cell lung cancer. <br />
  35. 35. Invasive diagnostic proceduresA) Endoscopy<br />Bronchoscopy remains a standard in patients with intra-thoracic disease, routinely performed, provides important diagnostic as well as staging information. <br /> Evaluation of the endobronchial extension of the tu, which can be decisive for the extent of resection or for RT planning.<br />Autofluorescence bronchoscopy aids in the diagnosis of pre-invasive lesions and early lung cancers, <br />
  36. 36. A) Endoscopy<br />Conventional or blind <br />transbronchial needle aspiration<br /> – TBNA - Enlarged LNs on CT<br />Endoscopic ultrasonography: EUS–FNA and EBUS–TBNA<br />improved accuracy of endoscopic mediastinal LN sampling techniques. Suboptimal NPV 60% to 80%, requires a confirmatory surgical staging procedure in the case of a nonmalignant NA.<br />EUS–FNA - preferred for staging of <br /> inferior mediastinal LNs<br />
  37. 37. Invasive diagnostic procedures<br />Endobronchial and endoscopic ultrasound have become established for the mediastinal staging of NSCLC.<br />Surgical biopsy and mediastinoscopy are still considered to be gold standard investigations:<br />Cervical mediastinoscopy - for staging the upper mediastinal LNs in early stage I/II LC<br />Anterior mediastinotomy<br /> aortopulmonary window and para-aortic LNs (5,6)<br />Video-assisted thoracic surgery (VATS) - useful add-on to cervical mediastinoscopy - reaches inferior mediastinal nodes<br />
  38. 38. Staging of Lung CancerTNM7 Classification (IASLC 2009.)<br />
  39. 39. T1a – T2b new (according to IASLC)<br />T1a<br />T1b<br />T2a<br />T2b<br />Spreading limited to<br /> the bronchial wall, <br />may extend <br />proximal <br />to the main<br /> bronchus<br />Tu ≤2cm<br />Tu ≥3cm, <br /> ≤5cm<br />Tu ≥2cm, <br /> ≤3cm<br />Tu ≤5cm<br />Invasion of <br />the visc. pleura<br />Tu involves <br />main bronchus,<br />2cm or more <br />distal to carina<br />Associated atelectasis or<br />Obstruct.pneumonitis that <br />does not involve entire lung<br />Tu ≥5cm, ≤7cm<br />(with or without <br />other descriptors<br />Tumour ≤2cm and Tu ≥2cm, ≤3cm<br />Any bronchoscopic invasion should <br />not extend proximal to the lobar <br />bronchus<br />
  40. 40. T3 – T4 new (according to IASLC)<br />Chest wall invasion <br />including Pancoast tu<br />without invasion of <br />vertebral body or <br />spinal canal, <br />subclavian vessels,<br />brachial plexus <br />(c8 or above)<br />T3<br />T4<br />Tu invades <br />trachea and/or<br />SVC or other<br />great vessel<br />Tu ≥7cm<br />Tu invades<br />aorta and/or<br />Rec.lar.n.<br />Phrenic n. or<br />par.peric.<br />invasion<br />Tu involves<br />carina<br />Invasion of <br />par.med.pleura <br />Tu invades<br />adj. vert.body<br />Additional tu nodule(s) <br />in the lobe of the primary<br />Diaphragmatic <br />invasion<br />Tu invades esophagus,<br />Mediastinum and/or heart<br />Pancoast tu<br />with invasion of <br />vert. body or <br />spinal canal, <br />subcl. vessels,<br />brachial plexus<br />c8 or above)<br />Tu accompanied <br />by ipsilat. nod.,<br />different lobe<br />Tu in the main bronchus<br />Less than 2cm from <br />the carina and/or <br />assoc. atelectasis or<br />Obstr.oneumonitis <br />of the entire lung<br />
  41. 41. N status<br />N1 - ipsilateral hilar<br /> N2 - ipsilateral mediastinal and / or - subcarinal<br />N3 - contralateral mediastinal / hilar - supraclavicular bilateral - Scalenus lymph node bil.<br />
  42. 42. M status<br />M1b<br />M1a<br />Distant mts<br />Brain<br />Contralateral<br />pulmonary <br />nodules<br />Primary tu<br />Distant nodal mts<br />(beyond regional <br />nodes)<br />Bone<br />Adrenal<br />Liver<br />Malignant pericardial<br />effusion/nodules<br />Malignant pleural<br />effusion/nodules<br />
  43. 43. Staging of NSCLC – tumour resectability and fitness for Surgery<br />The aim is to determine the stage as accurately as possible: to avoid false-positive interpretations (leading to a false stage III/IV dg in early stage pts), and false-negative interpretations (leading to a false early stage dg in pts with mediastinal LN disease). <br />Resectability needs to be estimated as precisely as possible.<br />Fitness for Surgery: comorbidities, assessment of pulmonary reserve, age… <br />
  44. 44. Surgery of Stage I/II Non small cell Lung Cancer (NSCLC)<br />Cornerstone of early stage NSCLC treatment, but only in stage I 5-year survival over 50% <br />Lobectomy including systematic lymph node dissection is standard of care for stage I and II NSCLC (resulting in a 5-year survival for IA ranging from 69% to 89%, for IB from 52% to 75%, for IIA from 45% to 52% and 33% for IIB).<br />Pneumonectomy rarely indicated in these stages<br />
  45. 45. Lung Cancer – NSCLC-Stage IA,B – T1N0, T2N0 -<br />
  46. 46. Surgery of Stage I/II Non small cell Lung Cancer<br />Sublobar resection of small peripheral tumours: segmentectomy and large wedge excision.<br /><ul><li>Significantly higher local recurrences in the segmentectomy group with a trend, but not significant survival benefit for lobectomies.
  47. 47. Patients unfit for lobectomy should undergo a segmentectomy</li></ul>VATS lobectomy more and more applied in many centres for tumours generally <5 cm; similar locoregional recurrences and better survival<br />
  48. 48. Surgery of Lung Cancer – NSCLC- stage IIB – T3N0<br />Tumors proximally of carina<br />Pneumonectomy,<br />sleevelobectomy,<br />sleevePneumonectomy<br /> 5-year survival rate <br /> 30% to 40%<br />(Martini et al, Lung Tumors, Springer-Verlag,1988).<br />(Pitz et al,Ann Thorac Surg 62:1016, 1996).<br />
  49. 49. Locally advanced NSCLC (stage III)<br />Locally advanced or stage III disease accounts for 30% of patients with NSCLC. <br />Treatment of stage III NSCLC very difficult and controversial mainly because of the large heterogeneity in this group.<br />
  50. 50. Locally advanced NSCLC (stage III)<br />Stage IIIA: 5-year survival - 24% <br />Stage IIIB: 5-year survival rate - 9%<br />Stage IIIA NSCLC (10%–15% ) - heterogeneous group from apparently resectabletumours with occult nodal microscopic metastasis to unresectable, bulky multistation nodal disease.<br />stageIIIA– centrally located<br />RESECTABLE<br />stage IIIB T4 N3<br />NOT RESECTABLE<br />
  51. 51. Subclassification of stage III NSCLC<br />
  52. 52. Chest wall invasion: IIIA - T4 N0,1<br />En blocresection<br /><ul><li>Tumour invading parietalpleura</li></ul>andmuscles and ribs<br />5-year survival rate = 26% - 35%<br />(Gould et al, Int J Radia Oncol B iol Phys, 45:91-5,1999).<br />
  53. 53. Surgery of Non small cell Lung Cancer- superior sulcus tumor -<br />IIIA T3-4 N0<br />
  54. 54. Stage IIIA – Downstaging:Tumour becomes Resectable<br />Staging PET-CTPET-CTafter induction th<br />
  55. 55. Surgery of NSCLC with solitary metastasis<br />Solitary metastasis:<br />Brain<br />Lung <br />Adrenal gland<br />
  56. 56. SCLC – Diagnosis and Staging<br />medical history and physical examination, <br /> chest X-ray, <br />complete blood count including differential count, liver, lung and renal function tests, lactate dehydrogenase (LDH) and sodium levels <br />CT scan of the chest and abdomen including the liver and adrenal glands<br />Symptoms or abnormal physical examination suggesting metastasis - additional tests may include:<br /> bone scintigraphy, CT scan or MRI of brain, bone marrow aspiration and biopsy<br />
  57. 57. Small Cell Lung Cancer - SCLC<br />Classification: - IASLC proposed to apply TNM 7<br />revised VALSG staging system<br />Limited Disease vs Extensive Disease<br /> (tumour confined to one hemithorax<br /> with mts in regional LNs) (distant mts)<br />
  58. 58. Surgery of SCLC<br />Very Limited Disease (T1–2, N0) as primary treatment<br />Limited Disease if Lobectomy possible?<br />Residual tumour after ChemoRadiotherapy completed if excision, sublobar resection or Lobectomy possible<br />

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