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Lung cancer and pulmonary
nodules
Resident’s seminar 02/01/2006
Elsa B. Valsdottir
Lung nodules
In the general population, what percentage of
asymptomatic solitary lung nodules are
carcinoma?
a)
5%
b)
20%
c)
35%
d)
50%
e)
75%
Lung nodules
In the general population, what percentage of
asymptomatic solitary lung nodules are
carcinoma?
a)
5%
b)
20%
c)
35%
d)
50%
e)
75%
Benign nodules
Hamartoma 8% (popcorn lesion)
Granuloma
Scarring
Hemangioma
Schwannoma
Fibroma
Lipoma
Leiomyoma
Clear cell tumor
Teratoma
Pulmonary nodule
A healthy 59 yoM with 40 pack year hx has a new 1
cm nodule in the RUL on routine CXR. CT
confirmes a spikulated lesion with
lymphadenopathy. His PFTs are normal. The most
appropriate management would be:
a)
chemotherapy
b)
CT guided needle bx
c)
thoracoscopic wedge resection
d)
RU lobectomy
e)
radiotherapy
Algorithm from Greenfield
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
Pulmonary nodule
A healthy 59 yoM with 40 pack year hx has a new 1
cm nodule in the RUL on routine CXR. CT
confirmes a spikulated lesion with
lymphadenopathy. His PFTs are normal. The most
appropriate management would be:
a)
chemotherapy
b)
CT guided needle bx
c)
thoracoscopic wedge resection
d)
RU lobectomy
e)
radiotherapy
Lung cancer: Incidence, epidemiology


Leading cause of cancer death (28%)
2nd most common cancer





>173,000 cases/year
Overall 5 year survival 12%
Decreasing incidence and mortality in men
Incidence plateaued in women but mortality
still rising
Cause: TOBACCO (85-90%)

arsenic, asbestos, genetics, COPD, CLL, AIDS
Lung cancer: Classification


Small cell carcinoma 20%
Non-small cell carcinoma:

Adenocarcinoma 40%

Squamous cell carcinoma 20-25%

Adenosquamous carcinoma
Large cell carcinoma
Carcinoid
Carcinoma of salivary gland type
Unclassified




Small cell lung cancer
Which of the following statements about small cell lung
cancer is NOT true?
a)
Surgical therapy is rarely indicated
b)
The etiology is unknown
c)
Paraneoplastic endocrine syndromes are common
d)
Chemotheraputic agents are generally effective
e)
Prophylactic radiotion therapy can reduce brain
metastasis
Small cell lung cancer
Which of the following statements about small cell lung
cancer is NOT true?
a)
Surgical therapy is rarely indicated
b)
The etiology is unknown
c)
Paraneoplastic endocrine syndromes are common
d)
Chemotheraputic agents are generally effective
e)
Prophylactic radiotion therapy can reduce brain
metastasis
Signs and symptoms
Cough
Hemoptysis
Dyspnea
Pain
Dysphagia
Horner’s syndrome
Pancoast’s syndrome
SVC obstruction
Primary
Tumor (T)
Description
T1
A small tumor that is not locally advanced or invasive
Criteria: <3 cm in size; surrounded by lung or visceral pleura; not extending into the
main bronchus
T2
A larger tumor that is minimally advanced or invasive
Criteria: >3 cm in size; may invade the visceral pleura; may extend into the main bronchus but
remains >2 cm from the main carina; may cause segmental or lobar atelectasis
T3
Any size tumor that is locally advanced or invasive up to but not including the
major intrathoracic structures
Criteria: any size; may involve the chest wall, diaphragm, mediastinal pleura, parietal pericardium;
main bronchus within 2 cm of the main carina (not involving the main carina); may cause atelectasis
of the entire lung
T4
Any size tumor that is advanced or invasive into the major intrathoracic structures
Criteria: any size; invades the mediastinum, heart, great vessels, trachea, esophagus, vertebral
body, main carina; malignant pericardial or pleural effusion; presence of satellite tumor nodule(s)
within the primary tumor lobe
Regional
Lymph Node
Involvement (N)
Description
N1
Metastatic disease to nodes within the ipsilateral lung
Criteria: direct extension to intrapulmonary nodes; metastasis to ipsilateral peribronchial and/or hilar
nodes (nodal stations 10 through 14)
N2
Metastatic disease to nodes beyond the ipsilateral lung but not contralateral to the
primary tumor
Criteria: metastasis to the ipsilateral mediastinal and/or subcarinal nodes
(nodal stations 1 through 9)
N3
Metastatic disease to nodes distant to those included in N2
Criteria: metastasis to contralateral mediastinal and/or hilar nodes, ipsilateral or contralateral
scalene and/or supraclavicular nodes
Metastases (M)
Description
MO
Local or regional disease, no distant metastases
M1
Disseminated disease, distant metastases present
Staging
Staging
Description
IA
T1N0M0
IB
T2N0M0
IIA
T1N1M0
IIB
T2N1M0, T3N0M0
IIIA
T3N1M0, T(1-3)N2M0
IIIB
T4N(0-3)M0, T(1-4)N3M0
IV
T(any)N(any)M1
Lung cancer: nodal stations
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
Nodal stations, cont
Survival
Non-Small Cell Lung Cancer:
5-year Survival (%) by Stage7
Stage
Clinical
Pathologic
IA
61
67
IB
38
57
IIA
34
55
IIB
22-24
38-39
IIIA
9-13
23-25
IIIB
3-7
IV
1
–
Resectable tumors


Stages I and II
Stage IIIA?



N2 dz
Downstaging with neoadjuvant tx
Selected cases of IIIB (T4)
Lung cancer: Pre-operative workup





CT (brain)
PET: 97% sensitive, 78% specific
Bronchoscopy
Mediastinoscopy
PFTs



FEV1
DLCO (diffusing capacity for carbon monoxide)
Oxygen consumption
PFTs
Which one of the following inducates a high risk
for RF after pulmonary resection?
a)
Preoperative FEV1 = 500 ml
b)
Preoperative PaCO2 = 38 mm Hg
c)
V/Q scan showing 30% perfusion to
operative side
d)
Predicted postop FEV1 = 1.1L
PFTs
Which one of the following inducates a high risk
for RF after pulmonary resection?
a)
Preoperative FEV1 = 500 ml
b)
Preoperative PaCO2 = 38 mm Hg
c)
V/Q scan showing 30% perfusion to
operative side
d)
Predicted postop FEV1 = 1.1L
Lung cancer: Surgical options





VATS
Segmentectomy
Lobectomy
Sleeve resection
Pneumonectomy
VATS for Stage 1 lung cancer
Pros:
less pain
less LOS
better cosmesis

Cons:
oncologic validity
tech. difficult
seeding of tumor
Better survival due to less immunologic response
(IgG, CRP, IL-6, TNF etc)?
Roviaro et al: Long-term Survival After VATS Lobectomy for Stage 1 Lung Cancer.
CHEST 2004;126:725-732
Lung cancer screening
QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
Lung cancer screening
Take home message: New CT techniques
detect suspicious nodules 3x more than CXR,
malignant tumors 4x and stage 1 tumors 6x
Henschke et al: Early Lung Cancer Action Project: overall design and
findings from baseline screening. Lancet, 1999;354:99-105
Surgery after Chemo/XRT for Stage
IIIA
Can be considered in fit patients but does not
neccessarily increase overall survival
Albain et al: Phase III study of consurrent chemotherpy and radiotherapy
(CT/RT) vs CT/RT followed by surgical resection for stage IIIA (pN2)
non-small cell lung cancer (NSCLC): Outcomes update of NOrth
American Intergroup 0139 (RTOG 9309). ASCO Annual Meeting 2005
Adjuvant chemo for resected Stages
IB-II lung ca
Newer adjuvant chemo prolongs overall and
recurrence free survival
Winton et al: A prospective randomised trial of adjuvant vinorelbine (VIN) and
cisplatin (CIS) in completely resected stage IB and II non small cell lung cancer
(NSCLC) Intergroup JRB.10. J Clin Onc 2004;22:7018