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

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






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

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