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Practical approach to lung cancer
This document provides an overview of lung cancer, including: - The four most common causes of lung masses are benign lesions, primary lung cancer, metastatic disease, and lung abscess. - There are two main types of lung cancer - small cell lung cancer and non-small cell lung cancer, which is most common. - Symptoms of lung cancer can include cough, breathing problems, weight loss, chest pain, and fatigue, though early-stage cancers may be asymptomatic. - Diagnostic tests include chest x-rays, CT scans, sputum cytology, bronchoscopy, and biopsies. Staging helps determine prognosis and treatment.
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An overview of practical approach to lung cancer by Dr. Gamal Rabie Agmy. Relevant credentials.
Focus on lung masses, including causes like benign lesions, primary lung cancer, metastatic disease, and lung abscess.
Characteristics of benign lung masses: small size, calcified density, well-defined margins.
Importance of locating, describing size, and identifying features of lung masses for potential malignancy.
A clinical scenario involving a young male with multiple cavitating lung abscesses leading to septic emboli.
Methodical approach to identify small cancers in radiographs; emphasizes clinical history for diagnosis.
Categorization of lung cancer types: Small Cell (20-25%) and Non-Small Cell Lung Cancer (80%).
Discussion on causes, risk factors, early and late signs of lung cancer, including diverse symptoms.
Various diagnostic tests like CXR, CT Scans, and biopsies, focusing on their role in identifying lung cancer.
Potential post-operative complications arising post lung cancer surgery, including respiratory failure.
Various treatment modalities: surgery, radiation therapy, and chemotherapy, along with their types.
Introduction to complementary therapies like acupuncture and herbal medicine which may aid lung cancer treatment.
New classifications based on histopathology, diagnostic criteria improvements and various tumor types.
New TNM staging guidelines for lung cancer, detailing criteria for determining prognosis and treatment direction.
Recommendations for managing lung cancer, focusing on case studies and predictors of malignancy.
Comparison of diagnostic tools and techniques including radial EBUS, CT-guided aspiration, and virtual bronchoscopy.
Enhanced utility of advanced diagnostic procedures using electromagnetic navigation and radial probe ultrasound in lung cancer.
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Practical approach to lung cancer
- 2. Practical Approach toLung Cancer Gamal Rabie Agmy, MD, FCCP Professor of Chest Diseases, Assiut university
- 3.
- 4. Common causes ofa mass on a CXR • Benign lesions • Primary lung cancer • Metastatic disease • Lung abscess There are many other causes, but these are four important ones. Often the history and physical examination will indicate the likely cause.
- 5. Features of BenignMasses • Small (<3 cm) • Similar density to bone (i.e. calcified) • Well defined margins • Age of patient (<30 = usually benign) • No change in size over time …so always compare with previous CXRs if available
- 6. Where is themass?
- 7. Where is themass? Here, of course. But how would you describe it accurately?
- 8. Important points whenyou a see a mass • Where is it? • How big is it? • Are there any other masses? • Are there any other features of malignancy? – e.g. rib destruction – e.g. pleural effusion – e.g. mediastinal widening (implies enlarged lymph nodes)
- 9. Describing this mass “Thereis an ~8cm soft tissue mass at the right hilum. There are no other abnormal features.”
- 10.
- 11. Describe this CXR “Thereare extensive bilateral pulmonary masses of varying size.”
- 12. What is thediagnosis? That depends on the clinical history. In a patient with known malignancy, these are almost certainly disseminated pulmonary metastases
- 13. Clinical Case: A 19year old unemployed male is admitted to AMAU with breathlessless and fever. He has venepuncture wounds on his arms. Look at his CXR on the next slide. Try to workout what the diagnosisis.
- 15. Multiple ill-defined massesin both lungs
- 16. Diagnosis = Septicemboli=Multiple cavitating lung abscesses in a intravenous drug user
- 17. Some masses aredifficult to see… …can you find this one?
- 18. Some masses aredifficult to see… …a methodical approach to looking at CXRs will reduce the chance of missing small cancers like this one
- 19. Where is themass here?
- 20. It is NOTin the lung. Where is it?
- 21. Metastasis to right7th posterior rib This is a rib metastasis. Look closely to see interruption of the rib, which is destroyed and expanded.
- 22. • There aremany causes of lung masses • A good clinical history will often suggest the diagnosis • A new lung mass in an elderly patient is almost certainly malignant
- 23. Types of LungCancer Two main Types of Lung Cancer: Small Cell Lung Cancer (20-25% of all lung cancers) Non Small Cell Lung Cancer (most common ~80%)
- 24. Small Cell LungCancer
- 25. Non-small cell lungcancer • 1. Squamous cell carcinoma • 2. Adenocarcinoma • 3. Large cell carcinomas
- 26. Lung Cancer Re-cap SmallCell Lung Cancer Non-Small-Cell Lung Cancer Squamous cell Adenocarinoma
- 27. Causes and Riskfactors of Lung Cancer
- 28. Signs and Symptomsof Lung Cancer • Sometimes lung cancer does not cause any symptoms and is only found in a routine x-ray. • If a person with lung cancer does have symptoms, they will depend on the location of the tumour in their lung. • It is also imperative to note that the same symptoms can be caused by other conditions, so may not necessarily mean cancer. • Therefore it is important to consult a doctor when symptoms are present. • Signs and symptoms also depend upon the location, size of the tumor, degree of obstruction and existence of metastases
- 29. Signs and Symptomsof Lung Cancer There are 4 types of signs and symptoms of lung cancer: 1) Localized – involving the lung. 2) Generalized – involves other areas throughout the body if the cancer has spread. 3) Paramalignant syndromes 4) Thoracic oncology medical emergencies
- 30. Localized Signs andSymptoms Cough Breathing Problems, SOB, stridor Change in phlegm Lung infection, hemoptysis Hoarseness, Hiccups Wt loss Chest Pain and tightness Pancoats Syndrome Horner’s Syndrome Pleural Effusion Superior Vena Cava Syndrome Fatigue
- 31. Generalized Signs and Symptoms •Bone pain • Headaches, mental status changes or neurologic findings • Abdominal pain, elevated liver function tests, enlarged liver, gastrointestinal disturbances (anorexia, cachexia), jaundice, hepatomegaly r/t liver involvement • Weight loss • Endocrinal , metabolic and vascular changes
- 32. Thoracic onchology medical emergencies •Superior vena cava obstruction • Tumor and pulmonary embolism • Tumor lysis syndrome • Hypercalcaemia • Pericardial tamponade • Massive pleural effusion
- 33. Early/late Signs andSymptoms Of Lung Cancer Early Signs Late signs Cough/chronic cough Bone pain, spinal cord compression Dyspnea Chest pain/tightness Hemoptysis Dysphagia Chest/shoulder pain Head and neck edema Recurring temperature Blurred vision, headaches Recurring respiratory infections Weakness, anorexia, weight-loss, cachexia Pleural effusion Liver metastasis/regional spread
- 34. Diagnostic Tests • CXR •CT Scans • Sputum cytology • Fibreoptic bronchoscopy • Transthoracic fine needle aspiration • MRI
- 35. Laboratory Tests BloodTests *CBC-to check red/white blood cell & platelets -to check bone marrow and organ function *Blood Chemistry Test-to assess how organs are functioning such as liver and kidney Biopsy-to determine if the tumor is cancer or not -to determine the type of cancer -to determine the grade of cancer (slow or fast)
- 36.
- 37. Endoscopy • Bronchoscopy • Mediastinoscopy •VATS (video assisted thoracoscopic surgery)
- 38.
- 39.
- 40.
- 41. Post-op complications forthose with lung cancer • Airway obstruction, dyspnea, hypoxemia, respiratory failure • Anesthesia side effects (N/V) • Bleeding (hypotension, cardiogenic shock) • Cardiac dysthymias, CHF, fluid overload • Fever, sepsis • Pneumonia • Pneumothorax • Pulmonary embolus • Wound dehiscence • Prolonged hospitalization • Death
- 42. Medical Management The threemain cancer treatments are: *surgery (lung resections) *radiation therapy *chemotherapy Other types of treatment that are used to treat certain cancers are hormonal therapy, biological therapy or stem cell transplant.
- 43. Side effects oftreatments Surgery Radiation Chemotherapy Pain fatigue Anemia, thrombocytopenia Hemotomas Decreased nutritional intake Fatigue Hemmorhage Radiodermatitis Alopecia, SOB Altered respiratory function Decreased hematopoietic function Cold, pale Risk for atelectasis, pneumonia, hypoxia Risk for Pneumonitis, esophagitis, cough Tingling Risk for DVT N/V Irritable Grief Dizzy, weak
- 44. Lung resections • Lobectomy:a single lobe of lung is removed • Bilobectomy: 2 lobes of the lung are removed (only on R side) • Sleeve resection: cancerous lobe is removed and segment of the main bronchus is resected • Pneumonectomy: removal of entire lung • Segmentectomy: a segment of the lung is removed • Wedge resection: removal of a small, pie-shaped area of the segment • Chest wall resection with removal of cancerous lung tissue: for cancers that have invaded the chest wall
- 45. Complimentary Therapies • Includesacupuncture and massage and pharmacological approaches such as vitamins and herbal medicine. • One study showed that herbal medicine is used by approximately 48% of lung cancer patients in China. • These herbal therapies combined with chemotherapy increases survival in non-small-cell lung cancer by up to 42%, compared with chemotherapy alone.
- 46. The new WHOclassificationof lung cancer Aims and Structure • Introduction • Small biopsies, immunuhistochemical and molecular testing • Adenocarcinoma • Squamouscell carcinoma • Neuroendocrine tumors • Large cell carcinoma,Adenosquamouscarcinoma, Sarcomatoid carcinoma • Other tumors • Summary and outlook
- 47. The new WHOclassification of lung cancer The original publication (JTO 2011) J Thorac Oncol 2011
- 48. The new WHOclassification of lung cancer Work flow for diagnostics of lung cancer J Thorac Oncol 2011
- 49. The new WHOclassificationof lung cancer Basis for the new classification Sica et al., Am J Surg Pathol 2010 1. Analysis of all differentiation patterns in 5% steps 2. Definition of the predominant pattern Warth et al., J Clin Oncol 2012; 30:1438-46
- 50. The new WHOclassificationof lung cancer Adenocarcinoma • Lepidic adenocarcinoma • Acinar adenocarcinoma • Papillaryadenocarcinoma • Micropapillaryadenocarcinoma • Solid adenocarcinoma • Invasive mucinousadenocarcinoma • Colloid adenocarcinoma • Fetal adenocarcinoma • Enteric adenocarcinoma • Minimal invasiveadenocarcinoma (MIA) • Preinvasive lesions Atypical adenomatoushyperplasia (AAH) Adenocarcinomain situ (AIS)
- 51. p=0.007 p=0.001 p=0.002 p=0.011 lepidic acinar papillarymicropapillary solid lepidic acinar papillary micropapillary solid p=0.002 p=0.001 lepidic acinar papillary micropapillary solid G1 G2 G3 G1 G2 G3 G1 G2 G3 Groupingof thedifferentiationpatternsaccordingto prognosisin 3 groups (Grading) G1 = lepidic; G2 = acinar; G3 = papillary, solid, micropapillary The new WHO classification of lung cancer Prognostic relevance of histomorphology Warth et al., J Clin Oncol 2012 Warth et al., J Clin Oncol 2012
- 53. The new WHOclassificationof lung cancer Correlation of the differentiation patterns with tumor size and percentage of metastaseslep id ic acinar p ap illary solid m icrop apillary 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 maximaldiameter(incm) Lymphnode metastases Lepidic: 7% Acinar: 46% Papillary: 43% Solid: 51% Micropapillary: 76% Differentiationpatterns and tumorsize Impact on lymph nodedissection? Warth et al., J Clin Oncol 2012 Warth et al., J Clin Oncol 2012
- 54. The new WHOclassificationof lung cancer Radiomorphologic parameters A B C E F G H D Smooth margins Part-solid tumor Spheroid configuration Spiculated margins Ground-glass opacity Solid tumor with pleural tags Necrosis Lobulated margins Lederlin et al., Eur Respir J 2013; 41:943-51
- 55. A p=0.660 C p=0.508 GGO solid p=0.087 B semi-solid GGO solid semi-solid GGO solid semi-solid Survival (Stage I– IV) und CT-attenuation factors Adenocarcinomas with 100% GGO show a 100% OS, DFS and DSS (only few cases) The prognosis of pure solid adenocarcinomas may be worse than that of semi-solid adenocarcinomas The new WHO classificationof lung cancer Radio- and histomorphologic correlations Lederlin et al., Eur Respir J 2013; 41:943-51
- 56. The new WHOclassification of lung cancer Immunohistochemistry Warth et al. Histopathology 2012; 61:1017-25
- 57. The new WHOclassificationof lung cancer Selection of marker panels 1. TTF-1 (and CK 5/6) 2. p40 (and CK7) 3. NapsinA and Desmocollin-3 Initial marker panels with doublestaining Warth et al. Histopathology 2012; 61:1017-25
- 58. The new WHOclassification of lung cancer Molecular markers in pulmonary adenocarcinomas Kris et al., J Clin Oncol 2011
- 59. Perez-Moreno P etal., Clin Cancer Res 2012; 18:2443-51 The new WHO classification of lung cancer Molecular markers in squamous cell carcinomas
- 60. The new WHOclassificationof lung cancer Squamous cell carcinoma • Keratinizing squamous cell carcinoma • Non-keratinizing squamous cell carcinoma • Basaloid squamous cell carcinoma • Preinvasive lesion Squamouscell carcinoma in situ
- 61. The new WHOclassificationof lung cancer Keratinizing squamous cell carcinoma • Solid (strand-like) growth pattern • Keratinization, intercellular bridges • Immunohistochemistry: p40, p63, CK5/6 (CK14)
- 62. The new WHOclassificationof lung cancer Basaloid squamous cell carcinoma
- 63. The new WHOclassificationof lung cancer Neuroendocrine tumors • Small cell carcinoma (SCLC) • Large cell neuroendocrine carcinoma (LCNEC) • Carcinoid tumor Typical carcinoid (TC) Atypical carcinoid (AC) • Preinvasive lesion Diffuse idiopathicpulmonarycell hyperplasia (DIPNECH)
- 64. The new WHOclassificationof lung cancer Neuroendocrine tumors: SCLC, LCNEC, TC, DIPNECH)
- 65. The new WHOclassificationof lung cancer Other tumors • Large cell carcinoma • Adenosquamous carcinoma • Sarcomatoid carcinoma • Pleomorphic, spindlecell, and giant cell carcinoma • Carcinosarcoma • Pulmonaryblastoma • Other and unclassified carcinomas • Lymphoepithelioma-like carcinoma • NUT carcinoma
- 66. The new WHOclassificationof lung cancer Other tumors • Salvary gland-type tumors • Mucoepidermoid carcinoma • Adenoid cystic carcinoma • Epithelial-myoepithelial carcinoma • Pleomorphicadenoma • Papillomas • Squamouscell papilloma • Glandular papilloma • Mixed squamous cell and glandular papilloma • Adenomas • Sclerosing pneumocytoma • Alveolar adenoma • Mucinouscystadenoma • Mucus gland adenoma
- 67. The new WHOclassificationof lung cancer Other tumors • Mesenchymal tumors • Pulmonaryhamartoma • Chondroma • PEComatous tumors • Congenital peribronchial myofibroblastic tumor • Diffuse pulmonarylymphangiomatosis • Inflammatorymyofibroblastic tumor • Epitheloid haemangioendothelioma • Pleuropulmonary blastoma • Synovial sarcoma • Pulmonaryartery intimal sarcoma • Pulmonarymyxoid sarcoma with EWSR1-CREB1 translocation • Myoepithelial tumors / myoepithelial carcinoma • Other mesenchymal tumors
- 68. The new WHOclassificationof lung cancer Other tumors • Lymphohistiocytotic tumors • Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) • Diffuse large B-cell lymphoma • Lymphomatoid granulomatosis • Intravascular large B-cell lymphoma • PulmonaryLangerhanscell histiocytosis • Erdheim-Chester disease • Tumors of ectopic origin • Germ cell tumors • Intrapulmonarythymoma • Melanoma • Meningioma • Metastases to the lung
- 69. The new WHOclassificationof lung cancer Summary and outlook • The new WHO classification is applicable on resection specimens, small biopsiesand cytologic materials. • It provides pathways / algorithms for the diagnosis of the relevant types of lung cancer. • It is based on histopathology, immunohistochemistry, and molecular pathologywith regards to prognosis and treatment. • The most obvious progress has been achieved for the classification of pulmonary adenocarcinoma, which shows relevant correlationsof clinical, radiological and pathological (including genetic) findings. • For squamous cell carcinoma, the new WHO classification is clearer. It reveals different genetic alterations compared with adenocarcinoma. • Neuroendocrine tumors of the lungs are better visiblein one single chapter, for the first time. There are more precise diagnosticcriteria. • Taken together, the new WHO classification provides the basis for all disciplines dealing with lung cancer not only in interdisciplinarytumor boards and thus achieves better diagnostics and treatment of lung cancer for the sake of our patients.
- 70. New Guidelines forthe Classification of Lung Cancer: TNM and Classification changes in the 8th Edition.
- 71. Lung Cancer Anew data base was created following the successful conclusion of the previous revision. 94,708 cases (4,667 EDC) collected from 35 centres in 16 countries recruited 1999-2010. JTO publications to date: Database, 2014; 9: 1618 - 1624. T descriptors, 2015; 10: 990 - 1003. M descriptors, 2015; 10: 1515 - 1522. N descriptors, 2015: 10: 1675 - 1684. Stage groupings, 2016; 11: 39 - 51. Proposals submitted to UICC/AJCC mid 2015.
- 72. cT1-cT2 by sizeonly, 1-cm increments by Size Only cT1-2 N0 M0 NSCLC 0% 20% 40% 60% 80% 100% 0 2 4 6 8 10 Years After Diagnosis CT1A: 0.1-1 cm CT1A: 1.1-2 cm CT1B: 2.1-3 cm CT2A: 3.1-4 cm CT2A: 4.1-5 cm CT2B: 5.1-6 cm CT2B: 6.1-7 cm Deaths / N 69 / 802 541 / 3161 601 / 2480 464 / 1534 213 / 563 107 / 245 62 / 121 5-Year Estimate 92% (90, 94) 83% (81, 84) 75% (74, 77) 68% (65, 70) 59% (55, 64) 52% (45, 59) 43% (33, 53) Similar graphs for any N
- 73. Lung Cancer -T category Proposals (1). Retain 7e size cut points. Create new cut points at 1cm and 4 cm. Subdivide T1: T1a: ≤ 1 cm; T1b: >1 & ≤ 2 cm; T1c: < 2cm & ≤ 3 cm. Redefine T2a as >3- ≤ 4 cm. Redefine T2b as >4- ≤ 5 cm. Reclassify tumours >5 cms but =/< 7cms as T3. Reclassify tumours > 7cms as T4.
- 74. Lung Cancer -T category Proposals (2). Size now a descriptor in all T categories. Reclassify tumours invading diaphragm as T4. Reclassify tumours < 2cms from carina or collapse/consolidation of whole lung as T2. Remove rarely used descriptor, i.e. Mediastinal invasion.
- 75. Size of solidcomponent • Size of solid component in part-solid tumors as a T descriptor Travis W et al. J Thorac Oncol 2016; in press.
- 76. • Tis (AIS),Tis (SQC): Stage 0 • T1a(mi) or T1mi: Stage 1A1 New T categories Travis W et al. J Thorac Oncol 2016; in press.
- 77. N-Category Pathologic- R0 Clinical Pathologic-all Clinical,nonsurgicalcases R 0 0 % 2 0 % 4 0 % 6 0 % 8 0 % 1 0 0 % 0 2 4 6 Y E A R S A F T E R R E S E C T IO N N 0 N 1 N 2 N 3 E v e n t s / N 2 3 2 1 / 1 1 5 2 9 6 0 3 / 1 4 9 5 1 0 6 0 / 2 0 5 5 1 8 / 5 0 M S T N R N R 4 6 .0 N R 6 0 M o s 7 9 % 5 6 % 4 3 % 5 4 % A n y R 0 % 2 0 % 4 0 % 6 0 % 8 0 % 1 0 0 % 0 2 4 6 Y E A R S A F T E R R E S E C T IO N N 0 N 1 N 2 N 3 E v e n t s / N 2 4 1 3 / 1 1 7 1 2 6 3 8 / 1 5 6 9 1 2 0 6 / 2 2 6 5 3 3 / 6 6 M S T N R 7 1 .9 4 3 .0 3 9 .0 6 0 M o s 7 9 % 5 6 % 4 1 % 3 9 % 7777 C lin ic a l N S t a g e 0 % 2 0 % 4 0 % 6 0 % 8 0 % 1 0 0 % 0 2 4 6 Y E A R S A F T E R E N T R Y N 0 N 1 N 2 N 3 E v e n t s / N 5 3 5 / 1 8 4 6 9 8 / 2 0 8 2 4 9 / 4 7 1 9 7 / 1 7 6 M S T N R 3 2 .2 2 6 .5 1 3 .8 6 0 M o s 5 9 % 3 8 % 3 3 % 2 4 % C lin ic a l N S t a g e - M 0 N o n s u r g ic a l 0 % 2 0 % 4 0 % 6 0 % 8 0 % 1 0 0 % 0 1 2 3 4 5 Y E A R S A F T E R E N T R Y N 0 N 1 N 2 N 3 E v e n t s / N 9 3 / 1 4 9 8 / 1 5 8 5 / 1 3 6 9 0 / 1 5 3 M S T 1 7 .0 1 5 .2 1 4 .8 1 2 .9 6 0 M o s 1 8 % 3 1 % 0 % 1 9 %
- 78. Number of PositiveLevels N1 Single vs N1 Multiple vs N2 Single N2 Stations vs N2 Single N2+N1 vs N2 Multiple N2 Stations “N2 single” = 1 N2 station and no N1 stations “N2 single + N1” = 1 N2 stationplus at least 1 N1 station “N2 multiple N2” must have multiple N2 stations Split out N2 single vs N2 single N2+N1 0% 20% 40% 60% 80% 100% 0 2 4 6 8 10 YEARS AFTER RESECTION 1. N1 Single 2. N1 Multiple 3. N2 Single 4. N2 Single+N1 5. N2 Multiple N2 Events / N 448 / 1156 153 / 322 271 / 628 324 / 615 474 / 805 MST 79.3 60.9 68.9 43.9 38.0 12 Mos 88% 84% 87% 86% 83% Logrank P-value < .0001 Combination of pNanatomy and pNn indicates prognosis well.
- 79. Lung Cancer -N category Proposals. Retain 7th edition N categories. pN data showing the number of stations/nodes combined with anatomical location may better indicate prognosis than anatomical location alone did not conform to validation process but may be a “Proposal for Testing”. pN1a single N1 station involvement. pN1b multiple N1 station involvement. pN2a1 single “skip” N2 station involvement. pN2a2 single N2 station with N1 positive station(s). pN2b multiple N2 station involvement.
- 80. Prognostic Impact of M1aDescriptors Survival By M1a Descriptor M1a Cases from EDC Only 0% 20% 40% 60% 80% 100% 0 2 4 6 Survival, Years Pleural/Pericardial Nodule(s) Contra/Bilateral Tumor Nodule(s) Pleural/Pericardial Effusion Multiple M1a Descriptors Events / N 35 / 52 59 / 93 52 / 80 57 / 92 Median in Months 14.3 (10.6, 18.8) 12.0 (9.8, 15.4) 11.3 (7.5, 15.9) 9.7 (6.6, 15.1) Prognosis for the different M1a descriptors is similar.
- 81. Prognostic Impact ofSingle & MultipleMetastaticLesions in a Single Organ vs MultipleMetastaticSites The datawe have suggest the number of metastaticlesions may be more prognostic than the site of metastasis. Additionally,prognosisbased on a single distantmetastatic lesion may be more similar to M1a. M1 Details ByNumber of Lesions EDC Data Only 0% 20% 40% 60% 80% 100% 0 2 4 6 8 Survival, Years M1a M1b, Single Organ/Lesion M1b, Single Organ/Mult. Lesions M1b, Multiple Organs Events / N 220 / 324 159 / 225 180 / 229 202 / 247 Median in Months 11.5 (10, 13.4) 11.4 (9.6, 13.2) 7.0 (5.6, 7.8) 4.8 (4.3, 6.6)
- 82. Lung Cancer -M category Proposals. Retain M1a category for intrathoracic metastases. Reclassify M1b as single distant metastasis in one organ. Create M1c for multiple metastases in a single or multiple organs. Consequent changes for Stage IVA and B
- 83. N0-N1 N2-N3 T2b(5-7cm)-T4 T1-T2(4-5cm) N0 N1 All T1 T2 (3-4cm)-T2(4- 5cm) T1a/T1bT1C T1aN0 T1b2N0 T1A T1b T1cN0 T2(4-5)N0T2(3-4)N0 T2(5-7cm)- T3 T2(5-7)-T3 N1 N0 N1 T3(>7)-T4 N0-1 T1-T2(4-5cm) T2(5-7)-T4 N2 N3 N2 N3 T2(5-7)-T4 N3 T2(5-7)-T4 N2T1-T2(4-5) N2 T1-T2(4-5) N3 T3(>7cm)- T4 T2 (3- 4cm) T2 (4-5cm) T2(5-7)-T3 N0 T1 - T2 (4-5cm) N1 Tree based on 25,911 M0 Training Cases, best stageBranches based on best splits, STRATIFIED on type of database submission. (Registry vs. Not) Red = Terminal node groups
- 84. 0 24 4872 Months 0% 20% 40% 60% 80% 100% Events / N MST 24 Month 60 Month IA1 46 / 544 NR 97% 92% IA2 357 / 2079 NR 94% 83% IA3 362 / 1616 NR 90% 77% IB 360 / 1274 NR 87% 70% IIA 145 / 403 NR 78% 60% IIB 400 / 973 66.0 73% 53% IIIA 1379 / 2141 29.0 55% 36% IIIB 1051 / 1441 18.2 44% 25% IIIC 554 / 650 12.7 25% 14% IVA 256 / 357 12.1 22% 8% IVB 222 / 266 4.8 10% 0% Proposal 6 Clinical Stage
- 85. Events / NMST 24 Month 60 Month IA1 105 / 985 NR 96% 90% IA2 568 / 3821 NR 94% 84% IA3 579 / 2960 NR 92% 80% IB 1094 / 4144 NR 89% 73% IIA 373 / 1098 NR 83% 65% IIB 1445 / 3518 NR 77% 56% IIIA 2143 / 3862 42.0 65% 41% IIIB 815 / 1172 22.0 47% 24% IIIC 38 / 47 10.5 31% 12% 0 24 48 72 Months 0% 20% 40% 60% 80% 100% Proposal 6 Pathologic Stage
- 86. 0 24 4872 Months 0% 20% 40% 60% 80% 100% Events / N MST 24 Month 60 Month IA1 126 / 1223 NR 96% 90% IA2 636 / 4135 NR 93% 82% IA3 623 / 3097 NR 90% 78% IB 1157 / 4308 NR 88% 72% IIA 392 / 1133 NR 82% 64% IIB 1532 / 3715 NR 76% 55% IIIA 3126 / 5184 36.0 61% 38% IIIB 1719 / 2339 19.7 43% 22% IIIC 581 / 677 11.2 25% 11% IVA 256 / 357 12.1 22% 8% IVB 222 / 266 4.8 10% 0% Validation Set Proposal 6; Best Stage
- 87. Proposed Stage Groups(1). Stage 0 Tis(AIS, SCIS) Stage IA (1-3) T1mi, a-c, N0 M0 Stage IB T2a, N0 M0 Stage IIA T2b, N0 M0 Stage IIB T3, N0 M0 T1-2, N1 M0 Stage IIIA T3, N1 M0 T4, N0-1 M0 T1-2, N2 M0
- 88. Proposed Stage Groups(2). Stage IIIB T1-2, N3 M0 T3-4, N2 M0 Stage IIIC T3-4, N3 M0 Stage IVA T any, N any M1a-b Stage IVB T any, N any M1c
- 89. Proposed Stage Groupingsfor 8e N0 N1 N2 N3 v7 New v7 New v7 New v7 New T1a IA IA1 IIA IIB IIIA IIIA IIIB IIIB T1b IA IA2 IIA IIB IIIA IIIA IIIB IIIB T1c IA IA3 IIA IIB IIIA IIIA IIIB IIIB T2a 1B IB IIA IIB IIIA IIIA IIIB IIIB T2b IIA IIA IIB IIB IIIA IIIA IIIB IIIB T3 IIB IIB IIIA IIIA IIIA IIIB IIIB IIIC T4 IIIA IIIA IIIA IIIA IIIB IIIB IIIB IIIC M1a IV IVA IV IVA IV IVA IV IVA M1b IV IVA IV IVA IV IVA IV IVA M1c IV IVB IV IVB IV IVB IV IVB
- 90. Stage shifts dueto T changes in the 8e. Descriptor T 7e T 8e N0 N1 N2 N3 Size >4 - 5cms T2a IB IIA IIIA IIIB T2b IIA IIB IIIA IIIB T2b IIA IIB IIIA IIIB Tumour Size = change of stage due to change of T descriptor
- 91. Stage shifts dueto T changes in the 8e. Descriptor T 7e T 8e N0 N1 N2 N3 Size >5 - 7cms T2b IIA IIB IIIA IIIB T3 IIB IIIA IIIA IIIB T3 IIB IIIA IIIB IIIC Tumour Size = change of stage due to change of T descriptor = change of stage grouping in 8e
- 92. Stage shifts dueto T changes in the 8e. Descriptor T 7e T 8e N0 N1 N2 N3 Size >7cms T3 IIB IIIA IIIA IIIB T4 IIIA IIIA IIIB IIIB T4 IIIA IIIA IIIB IIIC Tumour Size (and diaphragm invasion) = change of stage due to change of T descriptor = change of stage grouping in 8e
- 93. 1. Multiple primarytumours: – One TNM for each tumour 2. Separate tumour nodules: – T3, T4, M1a 3. Multiple adenos with GGO/lepidic features: – Highest T (#/m) N M 4. Pneumonic type adenocarcinoma: – T3, T4, M1a Cancers with multiple lesions Detterbeck F et al. J Thorac Oncol 2016; 4 papers in press.
- 94. 8th Edition ofTNM All proposals have been published in JTO Free to non-members of IASLC. IASLC has submitted proposals to UICC/AJCC on Lung Cancer, Thymic malignancies and Mesothelioma July/August 2015. Publication presently scheduled for late 2016 (WCLC 2016 in Vienna). IASLC educational products available at WCLC Vienna, free/discounted for members. To be enacted January 2017.
- 95. Practical approach toLung cancer diagnosis, staging and molecular testing
- 96. • Define therole of radial probe ultrasound and navigationbronchoscopy for the diagnosis of the lung cancer • Outline a cost effectiveapproachto the diagnosis of primary tumor and mediastinalstaging based on patient-andimaging-related variables • Summarizethe publishedevidenceand guidelines pertinentto the diagnosis, staging and molecular testingfor NSCLC Practical Approach to Lung Cancer diagnosis, staging and molecular testing
- 97. Case 1 • 55y/o male • Smoker • Poor lung function • PET indeterminate
- 98. 1. Observation withfollow-up chestCT 1. Bronchoscopy with electromagneticnavigation 2. CT-guided needle aspiration 3. ConventionalBronchoscopicbiopsyusing fluoroscopy What should be done next?
- 99. 1. Observation withfollow-up chestCT 2. Bronchoscopy with electromagnetic navigation 3. CT-guided needle aspiration 4. ConventionalBronchoscopicbiopsyusing fluoroscopy What should be done next?
- 100. A. Volume doublingtime B.NoduleSize A. NoduleLocation B. Enhancement Which of the Following is Not a Predictor of Malignancy?
- 101. 4% A. Volumedoublingtime 0% B. NoduleSize 74% C. NoduleLocation 22% D. Enhancement Which of the Following is Not a Predictor of Malignancy?
- 102. 1. VDT of25-400 days is highly suggestiveof malignancy 2. Larger size and enhancementby dynamicCT also predictmalignancy 3. Location has not been reliably shownto predictmalignancy Predictors of Malignancy
- 103. Structured Approach tothe Managementof Pulmonary Nodules High probability • Surgeryif able • Biopsy and SBRT if not surgical candidate Intermediate probability • What is the likelihood of cancer? Clinical suspicion Predictioncalculators Low probability • Observation • Biopsy?
- 104. Surgery for Non-Malignantdisease • 39% of patients screened with low-dose chest CT had at least one abnormal finding in NLST which required additional evaluation • A benign diagnosis was found in 24% of patients undergoing surgery Aberle DR et al. N. Engl J Med 2011; 365:395-409
- 105. Which of theFollowing is Most Influential in Predicting a Successful Biopsy? A. Radial ultrasoundview(concentricvs eccentric) B. Air bronchus sign C. Lesion size D. Distance from the pleura
- 106. Which of theFollowing is Most Influential in Predicting a Successful Biopsy? 18% A. Radial ultrasoundview(concentricvs eccentric) 47% B. Air bronchus sign 29% C. Lesion size 6% D. Distance from the pleura
- 107. Radial Ultrasound View RadialprobeEndobronchialultrasoundprovides informationregardingairway positionrelative to the targetlesion
- 108. Radial EBUS Position •Diagnosticyield with a concentricviewis 84% • Diagnosticyield with a eccentricviewis 48% • concentricviewobtainedin 63% of cases • Eccentricviewobtained in 31% of cases Chen A, et al. Ann Am Thorac Soc 2014; 11: 578-528 Yamada N, et al. Chest 2007; 132: 603-608
- 109. Air Bronchus Sign •More data for ENB with conflicting results • Prospective study of 51 patients showed a significantdifference in yield usingENB when a bronchus sign was present(79% vs 31%) • Retrospective reviewof 55 patients showed no significantdifference Seijo LM et al. Chest 2010; 138: 1316-1321 Brownback KR et al. J Bronchology Interv Pulmonol 2012; 19: 91-97
- 110. Lesion Size Meta-analysis including20 studies using different advanced diagnostic bronchoscopy showed a diagnostic yield of 60.9% for nodules <20 mm vs. 82.5% for nodules >20 mm Wang- Memoli JS et al. Chest 2012; 142: 385-393
- 111. Distance From thePleura • No reliable data commenting on relative location of the nodule in relation to how peripheral it is • Some data suggests little difference in yield by anatomic lobe Yamada N et al. Chest 2007; 132: 603-608
- 112. Which of theFollowing Instruments Has the Highest Diagnostic Yield? A. Forceps B. Brush C. Needle D. Bronchial washing
- 113. Which of theFollowing Instruments Has the Highest Diagnostic Yield? 42% A. Forceps 17% B. Brush 42% C. Needle 0% D. Bronchial washing
- 114. Prospective study of182 patients randomized to radial EBUS +CDP (forceps and brush)vs radial EBUS+TBNA+CDP Diagnosticyield of TBNA+CDP was 78.4% vs 60.6% in the CDP only arm TBNA alone was diagnosticin 62.5% of cases vs 48.9 (forceps ) and 19.8% (washing) Pneumothoraxrate betweengroups did notdiffer(2.2%) Chao TY, et al. Chest 2009; 136: 229-236 Diagnostic Yield by Instrument
- 115. Which of theFollowing techniques Has the Highest Diagnostic Yield? A. Radial probeEndobronchialultrasound B. Electromagneticnavigation C. Virtual bronchoscopy D. CT guided needle aspiration
- 116. Which of theFollowing techniques Has the Highest Diagnostic Yield? 28% A. Radial probe Endobronchial ultrasound 9% B. Electromagneticnavigation 0% C. Virtual bronchoscopy 63% D. CT guidedneedleaspiration
- 117. CT Guided NeedleAspiration Diagnosticyield 75-90% Rate of complication 8-64% Chest tube Hospitalizations Prolongedair leak Dependentupon locationof nodule and caliber of needle Geraghty P, et al. Radiology 2003; 229(2):475-481 Baaklini WA, et al. Chest 2000; 117: 1049-1954
- 118. Virtual Bronchoscopy Any platforminwhich three dimensionalreconstructionsof endoscopicviewsare createdbased on imaging modalitiessuch as CT
- 119. Virtual Bronchoscopy • Providesapathway to the target lesion • No sensor tracked during procedure
- 120. Virtual Bronchoscopy Diagnosticvield Wang –Memoli JS et al. Chest 2012; 142: 385 - 393
- 121. Electromagnetic Navigation VirtualBronchoscopic images generated from a CT scan Electromagnetic sensor is tracked during procedure Sensor position is superimposed on virtual airway reconstruction using various forms of registration
- 122. Electromagnetic Navigation Pathway andlocation provided
- 123. Virtual Bronchoscopy Diagnosticvield Wang –Memoli JS et al. Chest 2012; 142: 385 - 393
- 124. Radial probe EndobronchialUltrasound • Utilizesradial ultrasoundprobe • Mini-probe inserted throughthe working channel of a flexible bronchoscope • Frequency is 20Mhz
- 125.
- 126. Virtual Bronchoscopy Diagnosticvield Wang –Memoli JS et al. Chest 2012; 142: 385 - 393
- 127. Which of theFollowing is True Regarding Advanced Diagnostic Procedures? A. Radial probe EBUS is a navigational tool B. Electromagneticnavigation providesreal-time tracking of targetlesions C. Combining modalitieshas resulted in improved diagnosticyieldsover individual modalities D. Virtual bronchoscopywas recommendedby the ACCP for the diagnosisof early stage lung cancer