Lung Cancer Treatment: Surgical Approaches

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Lung Cancer Treatment: Surgical Approaches

  1. 1. Matthew Kilmurry, M.D. St. Mary’s General Hospital Grand River Hospital
  2. 2. I have no conflicts of interest
  3. 3. The problem  2003 numbers for Ontario 7500 new cases 6300 deaths  Only 25% of cases are surgically resectable  Breast cancer in 2007 was 8000 new cases and 2000 deaths
  4. 4. Causes  Smoking  Radon exposure  Asbestos exposure  Second hand smoke  Genetics
  5. 5. Types of Lung Cancer  Primary  Secondary Colonic mets Other primaries
  6. 6. Resection of pulmonary mets  Several prognostic factors Disease free interval Number of mets Resectability  30% long term survival  Do not assume it is a met Old study suggests 73% of pulmonary nodules in patients with previous cancer will be new primary
  7. 7. Primary lung cancer  Small cell  Non small cell Accounts for 75-80 % of primary lung tumors
  8. 8. Screening  No accepted screening method Studies using CT, CXR and sputum  High index of suspicion smokers
  9. 9. Staging  Stage I: no lymph node involvement  Stage II: lymph nodes involved or tumor invading into chest wall  Stage III: mediastinal nodal involvement or bad tumour factors  Stage IV: metastatic disease
  10. 10. Nodal stations
  11. 11. Surgical Approach  Diagnosis: Is this cancer?  Metastases: Is there spread?  Suitability: Is the patient healthy enough for surgery?
  12. 12. Diagnosis  History and physical  Chest X-ray  CT scan  Percutaneous biopsy  Bronchoscopy
  13. 13. Metastases  History and physical  Upper abdominal imaging  Bone scan and CT head  PET scan  Mediastinoscopy
  14. 14. Nodal stations
  15. 15. Suitability  History and physical  PFT’s  Cardiac investigations 2D echo Stress test Nuclear medicine  CPET  Quantitative V/Q scan
  16. 16. Treatment  Stage I and II are generally offered surgery with stage II getting post op chemo  Some stage III can be offered surgery – usually after chemoradiotherapy  Rare stage IV patients can be offered surgery Solitary brain mets
  17. 17. Treatment  Lobectomy preferred approach Limited resection has higher recurrence and worse long term suvival  Stage survival, 5 years Stage I – 60-70% Stage II – 40-50% Stage III – 15-25% Stage IV – 0-10%
  18. 18. Case # 1  65 year old male previous smoking history  Chest X-ray done as part of annual health exam  CT confirmed mass in LUL Small lesion also noted in RUL
  19. 19. Case # 1
  20. 20. Case # 1  Bronchoscopy and mediastinoscopy showed no evidence of mets  Thoracotomy confirmed diagnosis and had lobectomy  Right upper lobe nodule unchanged over two years
  21. 21. Case # 2  68 year old woman had pneumonia like symptoms which led to chest X-ray  Smoker of 1 pack per day for 45 years
  22. 22. Case # 2
  23. 23. Case # 2  CT chest showed large tumour with no evidence of mets  Biopsy shows NSCLC  PET scan shows no evidence of metastatic disease
  24. 24. Case # 2  Mediastinoscopy showed metastatic disease in lymph nodes  Referred for chemoradiotherapy  Possible candidate for surgery
  25. 25. Palliation  Majority of work with chemo and radiotherapy  Pain and symptom management vital  Surgery sometimes required Pleural effusions Endobronchial tumours
  26. 26. Thoracic DAU  Run through Grand River Cancer Center  Multidisciplinary clinic with respirologists and thoracic surgeons  Referrals accepted through GRCC Main criteria is newly abnormal chest X-ray
  27. 27. Thoracic Program  Combined thoracic surgery at St. Mary’s General Hospital  CCO pushing to eliminate low volume thoracic centers  Working to keep thoracic surgery in Kitchener-Waterloo
  28. 28. Conclusions  Lung cancer is a major health concern in Ontario  Surgery offers best chance for cure in resectable cases  Multidisciplinary care required and available in our region

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