Download Lung Cancer Overview and Epidemiology

Southwest Oncology Group
Spring 2011 Meeting
Thursday, April 14, 2011; San Francisco, Ca
Kristine Deano Abueg, RN, MSN, OCN©; Kaiser Permanente Oncology Clinical Trials
LUNG CANCER OVERVIEW & EPIDEMIOLOGY
Objective: Identify major carcinomas of the lung.
Objective: Discuss trends in lung cancer incidence and survival in
lung cancer.
SCLC,
15%
Major groups:


Small Cell Lung Cancer (SCLC) and Non-Small Lung Cancer
(NSCLC).
Significant differences in pathology, clinical course, and treatment
NSCLC
85%
Epidemiology:



nd
Figure 1. Histological distribution of lung cancer
2 most common cause of cancer
st
1 most common cause of death due to cancer
Significant decline in incidence/mortality for African American and White Males; Increase in
incidence/mortality for females of both races.
Source for incidence and mortality data: Surveillance, Epidemiology, and End
Results (SEER) Program and the National Center for Health Statistics. Additional
statistics and charts are available at http://seer. cancer.gov/.
20
15
10
5
Small 5 year
survival
Non Small Cell
0
Figure 2: Lung cancer survival trends: % of diagnosed patients alive after 5
years of diagnosis. Historical trends in 5 year survival (%) have remained
stagnant
Inferences and Implications


Decreasing incidence of lung cancer since 1975. Thought to
be tied to smoking cessation efforts
Minimal change in mortality since 1975 – have we made
progress in treatment?
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER SCREENING
Controversial role and future directions
Objective: Discuss current recommendations and controversies surrounding lung cancer screening.
Current Controversy
o Survival increases with early detection (ie earlier stage)
o U.S. preventive services task Force (USPSTF) – recommends against population based
screening (full text available at http://www.preventiveservices.ahrq.gov)
 Rationale:
 insufficient evidence for screening of asymptomatic persons with Rating: I
Recommendation:
o low dose computerized tomography (LDCT)
o chest x-ray (CXR)
o sputum cytology
o -or a combination of these tests.
 Screening strategies ≠ decreased mortality
 Risks: Invasive nature & ↑false-positive tests in certain populations
o Therefore, the USPSTF could not determine the balance between the benefits and harms of
screening for lung cancer
Research Directions – is lung cancer screening in our future?
National Lung Screening Trial (NLST, ACRIN A6554)
 www.cancer.gov/clinicaltrials.
 N= 53,000 current or former smokers
 Objective: risk/benefit of low-dose spiral CT vs. Chest X-ray
 Data: (November 4, 2010) - final data is as yet unpublished, comments below based on NCI press
release date 11/1/2010. Available at http://www.cancer.gov/newscenter/qa/2002/nlstqaQA
o 20% reduction in mortality due to lung cancer with low-dose helical CT vs. CXR.
o 7% reduction in all-cause mortality with low-dose helical CT vs. CXR
International Early Lung Cancer Action Program (I-ELCAP)
 http://www.ielcap.org/index.htm
 Objective: Benefit of annual screening with CT for high risk patients
 Data:
o High rate of detection of early stage lung cancer.
o 80% survival in treated population
o 100% mortality in non-treated population
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER CLINICAL COURSE


Objective: Discuss main presenting symptom associated with lung cancer
Objective: Discuss the typical diagnostic events for a patient with suspected lung cancer
What are the common presenting symptoms of a lung cancer patient?
 Early stage lung cancer usually asymptomatic
 Symptoms typically indicative of advancing disease.
Local-Regional effects
Extrathoracic Involvement
Systemic Symptoms
Often due to mechanical
Due to mechanical impact or
Can occur throughout treatment
impact of tumor on
neuroendocrine impact of
course
intrathoracic structures
distant metastases. Effect varies
by site of metastases.
Oncologic Emergencies
 Cough
 Brain:
o Headache
 Superior vena cava
 Dsypnea
o Change in LOC
syndrome
 Airway obstruction
o Seizures
 Cardiac effusion and
 Bronchorrhea
o Focal weakness
tamponade
 Hemoptysis

Gastrointestinal
 Pleural effusion
 Wheezing
 Bone: Pain
 Malignant spinal cord
 Hoarseness
compression
Paraneoplastic Syndromes
 Hypercalcemia of
malignancy
 Syndrome of
inappropriate
Antidiuretic hormone
(SIADH)
 Ectopic
andreocorticitropic
hormone
(Tyson, L.B. “Patient Assessment” in Lung Cancer, Site Specific Series, Houlihan, N.G., Ed.
Oncology Nursing Society, 2006.
Diagnostic Testing for lung cancer
Presenting
symptoms
Physical workup
Physical Exam
CBC
Chemistry panel
Chest X-ray →Chest CT
R/O Lung cancer:
Diagnostic Testing
Pathology:
• Needle Aspiration (often
with CT)
• Bronchoscopy
• Broncheoalveolar lavage
Staging
• PET/MRI/CT
• Brain scan if symptomatic
• Mediastinoscopy
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
SMALL CELL LUNG CANCERS
SCLC Stage Distribution:
Stage at Diagnosis
Top Five:
1)
2)
3)
4)
5)
It’s so distinct that everything else is “non” small cell.
Represents 15% of all bronchogenic cancers
Nearly all cases of SCLC are attributable to smoking
Very rapid spread: Majority of SCLC diagnosed during extensive stage
More responsive to chemotherapy and radiation therapy – but less curable
Statistics




30%
Localized
Extensive
70%
New Cases in 2010: 222,520
Death 157,300
Median survival 6-16 weeks without tx.
Represents decreasing trend with decreasing smoking
5 year survival by stage (%) and
subtype
25
Staging
20
Only two stages: limited vs. extensive
Traditional TNM stage ≠ prognostic value
o Limited (ipsilateral involvement)
 Main tumor: one hemithorax
 Nodal involvement: mediastinal, contralateral
hilar, or ipsilateral supraclavicular or scalene –
must be captured in single radiation port.
o Extensive
 Hallmark structures: cannot be captured by
definition above
 malignant pleural effusion
 Spread beyond supraclavicular areas
Clinical Course:

15
SCLC
10
5
0
Localized
Regional
Distant
Effect of Therapy on 2-yr Survival
Weeks since dx


90
80
70
60
50
40
30
20
10
0
80
48
Presenting symptoms: Unusual to present asymptomatic
12
6
o Constitutional: fatigue, anorexia, weight loss
o Due to primary tumor: cough, dyspnea, hemoptysis
o Indicators of intrathoracic spread: superior vena
Limited LImited Extensive Extensive
Stage
Stage
Stage
Stage
cava syndrome, laryngeal palsy causing
Untreated
Treated
Untreated
Treated
hoarseness, dysphagia, stridor
o Indicators of distant spread: Neuro (brain), bone
pain (bone), Abd pain (liver)
o Paraneoplastic syndromes (SCLC and neuroendocrine): Syndrome of Inappropriate Antidiuretic
hormone (SIADH)
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
Superior Vena Cava Syndrome
a. What is it? Compression of the superior vena cava (great vessel) by a tumor. Usually associated with
bronchogenic carcinoma (lung and lymphoma)
b. Presenting symptoms/signs
i. Dyspnea, coughing
ii. Facial/upper trunk swelling, jugular vein distention
iii. Hoarseness, paralyzed vocal chord
iv. Diagnosis: radiology
c. Treatment
i. Palliative radiation therapy or chemotherapy (SCLC)
ii. Surgical: thrombectomy or stent placement
Treatment options in SCLC: To Cut or Not to Cut…That is the question
50% to 80% 5-year survival benefit of surgical resection for patients diagnosed with solitary pulmonary nodules
in SCLC…however data is questionable, because very, very few resectable limited stage patients could be
identified. (Szczesny et al 2003)
Treatment Options: Chemotherapy
Stage
Treatments
NCI Clinical Trials
Compiled from data retrieved from NCI (PDQ ®) and National Comprehensive Cancer
Network TM Version 3.2011)
Limited

Chemotherapy with concurrent chest rads
Extensive

Chemo: preference for platinum based doublet such as
cisplatin/etoposide
Clinical trial

Limited Stage Trials
Extensive Stage Trials
SWOG studies:


SWOG s0802 A Randomized Phase II Trial of Weekly Topotecan with and without AVE0005 (Aflibercept;
NSC-724770) in Patients with Platinum Treated Extensive Stage Small Cell Lung Cancer (E-SCLC)
CTSU/CALGB 30610 Phase III Comparison of Thoracic Radiotherapy Regimens in Patients with Limited
Small Cell Lung Cancer Also Receiving Cisplatin and Etoposide - Phase III Intergroup
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
NON-SMALL CELL LUNG CANCER
Key facts:
1) Represents 85% of all lung cancers
2) TNM staging provides critical prognostic information and guides treatment options
3) Sub-divided into 2 major types
a. Non-squamous
i. Adenocarcinoma (including bronchoalveolar)
ii. Large-Cell Carcinoma
iii. Others
Major Bronchogenic Tumors
b. Squamous cell
Classifications
4) Adenocarcinoma = most frequently dx’d lung cancer
type.
Histology and Subtypes: Based on the World Health
organization/International Association for the study of lung
cancer histological classification of non-small cell lung
carcinoma (NSCLC)
Squamous
30%
Small Cell
15%
Squamous cell carcinoma
 Papillary.
 Clear cell.
 Small cell.
 Basaloid.
Adenocarcinoma
 Acinar
 Papillary.
 Bronchioloalveolar carcinoma.
o Nonmucinous.
o Mucinous.
o Mixed mucinous and nonmucinous or
indeterminate cell type.
 Solid adenocarcinoma with mucin.
 Adenocarcinoma with mixed subtypes.
 Variants.
o Well-differentiated fetal
adenocarcinoma.
o Mucinous (colloid) adenocarcinoma.
o Mucinous cystadenocarcinoma.
o Signet ring adenocarcinoma.
o Clear cell adenocarcinoma
Large Cell
15%
Adenocarcin
oma
40%
Large cell carcinoma
 Variants.
o Large cell neuroendocrine carcinoma.
o Combined large cell neuroendocrine carcinoma.
o Basaloid carcinoma.
o Lymphoepithelioma-like carcinoma.
o Clear cell carcinoma.
o Large cell carcinoma with rhabdoid phenotype.
Other Major Subtypes: Adenosquamous carcinoma, Carcinomas with pleomorphic, sarcomatoid, or
sarcomatous elements; carcinoid tumor; Carcinomas of salivary gland type, Unclassified carcinoma.
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
Epidemiology
70%
60%
5 year survival (%) by stage at
diagnosis
50%
NSCLC Stage Distribution:
Stage at Diagnosis
Most NSCLC is detected with distant
mets (M1,M2)
40%
30%
20%
10%
16%
Localized (I, II)
NSCLC
0%
AJCC AJCC AJCC AJCC
Stage I Stage II Stage III Stage IV
Regional (III)
Distant
54%
22%
Based on the proposed AJCC 7th ed, the International Association for the
Study of Lung Cancer estimates that the overall 5-year survival rate of
patients with pathologic stage I disease to be 58% to 73%; stage II to be
36% to 46%; stage III to be 9% to 24%; and stage IV to be 13%.[Goldstraw
2007]
Does histology (sub-type) play a role in survival?



General trends favors non-squamous histology
Suggests interaction between histology and chemotherapy
Suggests interaction between histology and tumor markers, with implications for targeted therapy
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
NON-SMALL CELL LUNG CANCER: Tumor Size (T) STAGING
www.cancerstaging.org
"Systems do not exist in Nature but only in men’s minds."
Claude Bernard (1813-1878); as quoted by Dr. A. De la Guerra, February 2010


Objective: Discuss T (primary tumor staging)
Objective: Discuss changes in T (primary tumor staging) from the 6th edition AJCC to 7th edition AJCC
th
th
Summary of major changes in T staging from 6 ed. AJCC to 7 ed AJCC:




Addition of new size landmarks:
o AJCC 6th: 3cm
o AJCC 7th: 2cm, 3cm, 5cm, and 7cm
T1 subdivided into T1a and T1b; T2 subdivided into T2a and T2b
Downstaging of separate nodules in the same lobe to T3
Subdivision of pleural invasion (VPI) by tissue layer: PL1 (elastic layer); PL2 (cisceral pleural surface), and PL3 (parietal
pleura)
AJCC 6th Edition
Tx
T0
Tis
T1
Primary tumor cannot be assessed
No evidence of primary tumor
Carcinoma in Situ
T2
Tumor with any of the following features of size or extent:
 >3cm or greater
 Involves main bronchus, 2cm or more distal to the carina
 Tumor of any size that involves visceral pleura
 Atelectasis or obstructive pneumonitis that extends to the
hilar region but does not involve the entire lung
 Any invasive tumor =<3cm in longest dimension
 Surrounded by lung or visceral pleura
 Not in main bronchus: No bronchoscopic invasion more
proximal that the lobar bronchus
th
AJCC 7 edition
http://www.cancerstaging.org/staging/posters/lung24x30.pdf
Tx
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in Situ
T1
 Any invasive tumor =<3cm in longest dimension
 Surrounded by lung or visceral pleura
 Not in main bronchus: No bronchoscopic invasion
more proximal that the lobar bronchus
T1a =<2cm
T1b >2cm to =<3cm
T2
T2a
T2b
T3
 Tumor of ANY size that directly invades any of the
following structures: chest wall, diaphragm, mediastinal
pleura, parietal pericardium -or Tumor in the main bronchus, <2cm distal to the carina but
without involvement of the carina -or Associated with atelectasis or obstructive pneumonitis of
the entire lung
T3
T4
Tumor of any size that directly invades and of the following:
Mediastinum, heart, great vessels, trachea, esophagus,
vertebral body, carina, Separate nodules of multicentric
tumor of similar histology existing in the same lobe; or
tumor with malignant pleural effusion.
T4
 >3cm to <=7cm with any of the following
o Involves main bronchus (peribronchial)– and/or
o 2cm or more distal to the carina - and/or
o Invades visceral pleura (PL1 [beyond the
elastic layer] or PL2[ to the pleural surface]) –
and/or
o Associated with atelectasis or obstructive
pneumonitis that extends to the hilar region but
does not involve the entire lung
>3cm to =<5cm
>5cm to =<7cm
 >7cm and/or invades any of the following
o Parietal pleural (PL3)
o Chest wall (including superior sulcus tumors)
o Diaphragm
o Phrenic nerve
o Mediastinal pleura
o Parietal pericardium
 Or tumor in the main bronchus <2cm distal to the
carina but without involvement of the carina
 Associated with atelectasis or obstructive
pneumonitis of the entire lung
Separate nodules of multicentric tumor of similar
histology existing in the same lobe
Tumor of any size that directly invades and of the
following: Mediastinum, heart, great vessels, trachea,
recurrent laryngeal nerve, esophagus, vertebral body,
carina, separate tumor nodules in a different
ipsilateral lobe
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER: NODAL (N) STAGING



o
Objective: Discuss changes to AJCC node classifications
Objective: Discuss changes to node descriptors and
th
groupings proposed in the AJCC 7 edition.
Where are the nodes: STATION
Node descriptors by Station

“Reports are inconsistent regarding the
relationship to prognosis of metastases to
specific lymph node stations” (Mountain, 1997)
 However: “Andre, 2000: # stations and method
of detection was clinically significant.
 Many variations
o Naruke lymph node map (Japan)
o Mountain and Dressler (North America
and Europe)
 Recent re-organization:
o International Association for the Study of
Lung Cancer (IASLC), 2009 (Memorial
Sloan Kettering Cancer Center, 2009) –
recommended and used as the basis for
th
AJCC 7 edition Rusch, et al (2009) © Journal of
Thoracic Oncology. Published by Lippincott Williams &
Wilkins. Used with permission
o
Familiarity useful for radiology interpretation and CRF
reporting
No changes to N staging in AJCC 7th edition
o
N0
N1
N2
N3
Proposed changes to subdivide each N component to describe extent of involvement (i.e. # of zones involved),
but data was not validated and thus will not be part of the new TNM changes…clinical trial opportunity?
Regional Lymph Nodes
No regional lymph node mets
Mets to ipsilateral peribronchial and/or ipsilateral hilar
lymph nodes, and intrapulmonary nodes including
involvement by direct extension of the primary tumor.
Metastases to ipsilateral mediastinal and/or subcarinal
nodes
Metastases to contralateral mediastinal, contralateral
hilar, ipsilateral or contralateral scalene, or
supraclavicular lymph node(s).
“Simplified”
Negative Nodes
+ nodes near primary tumor
+ nodes on ipsilateral mediastinum or subcarina
+ supraclavicular or scalene nodes (above collar
bone) or + contralateral nodes
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER: METASTASES (M) STAGING


th
Objective: Discuss changes to AJCC metastatic classifications in the AJCC 7 edition
Objective: Identify common sites of metastases
th
th
Major Changes: Upstaging of pericardial and pleural effusions as M1a (7 ed) from T4 (6 ed)
AJCC 6th Edition
Mx
M0
M1
Distant tumor cannot be assessed
No evidence of distant metastases tumor
 Distant metastasis
 Additional nodules in the contra lateral lung
th
AJCC 7 edition
http://www.cancerstaging.org/staging/posters/lung24x30.pdf
NA
(MS designation has been eliminated)
M0
No evidence of distant metastases tumor
M1a
Intrathoracic metastases
Pleural dissemination (malignant pleural or pericardial
effusions, pleural nodules). – or
Additional nodules in the contralateral lung (same
histology).
M1b
Extrathoracic metastases: Distant metastasis
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER: Changes to Groupings
th
th
Bold: AJCC 7 (AJCC 6 )
T and M Descriptors
6th Edition TNM
N0
N1
N3
N2
Stage
7th Edition TNM
Stage
Stage
Stage
T1a (≤ 2 cm)
IA
IIA
IIIA
IIIB
T1b (> 2-3 cm)
IA
IIA
IIIA
IIIB
T2a (> 3-5 cm)
IB
IIA (IIB)
IIIA
IIIB
T2b (> 5-7 cm)
IIA (IB)
IIB
IIIA
IIIB
T3 (> 7 cm)
IIB (IB)
IIIA (IIB)
IIIA
IIIB
T3 invasion
T3
IIB
IIIA
IIIA
IIIB
T4 (same lobe nodules)
T3
IIB (IIIB)
IIIA (IIIB)
IIIA (IIIB)
IIIB
T4 (extension)
T4
IIIA (IIIB)
IIIA (IIIB)
IIIB
IIIB
M1 (ipsilateral lung)
T4
IIIA (IV)
IIIA (IV)
IIIB (IV)
IIIB (IV)
T4 (pleural effusion)
M1a
IV (IIIB)
IV (IIIB)
IV (IIIB)
IV (IIIB)
M1 (contralateral lung)
M1a
IV
IV
IV
IV
M1 (distant)
M1b
IV
IV
IV
IV
T1 (≤ 3 cm)
T2 (> 3 cm)
Key changes:
th
th
1) “Wet IIIB” [AJCC 6 ] is now IV [AJCC 7 ]
2) Distribution of multicentric nodules: same ipsilateral lobe has been downstaged
AS presented by Dr. Joan Schiller, MD in presentation “New Issues in Staging and Adjuvant Treatment of the Early-Stage NSCLC Patient” available
at http://www.clinicaloptions.com
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
Staging Examples - All examples available from the American Joint Committee on Cancer at
http://www.cancerstaging.org/staging/index.html
Case #1
 Clinical Staging history: Pathologically confirmed (CT guided FNA) adenocarcinoma; Radiological
staging: 2cm primary lesion in right lower lobe. No hilar or mediastinal adenopathy. PET/CT without
evidence of distant metastases.
o T____
o N_____
o M____
o Stage Group______
 Based on findings, surgical resection with nodal sampling planned. What surgical resection
technique would be recommended? Select one
a) Wedge Resection
b) Lobectomy
c) Pneumonectomy
 Pathological staging: size of tumor 3.4 cm; moderately differentiated; visceral pleural involved (PL2),
margins negative. Margin sampling: 4 peribronchial, 1 paraesophageal, 1 paratracheal, and 1
subcarinal node. All nodes negative
o T____
o N_____
o M____
o Stage Group______
Case #2
 Clinical Staging history: Pathologically confirmed (CT guided FNA) adenocarcinoma in RUL;
Radiological staging: 5.3cm primary lesion in RUL. Mediastinoscopy and CT + for mediastinal nodes
o T____
o N_____
o M____
o Stage Group______
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER TREATMENT OPTIONS
Options by Stage
Stage
Groupings
Treatments
NCI Clinical Trials
Compiled from data retrieved from NCI (PDQ ®) and National Comprehensive Cancer
TM
Network
Version 3.2011)
In-Situ
Stage i
Tis, N0, M0
T1, N0, M0
T2, N0, M0




Surgery
Curative Surgical Resection
Curative RT (if medically inoperable)
Clinical trial: recurrence prevention (adjuvant chemo in highrisk patients)
Stage 0 trials
Stage I trials
Stage II
T1, N1, M0
T2, N1, M0
T3, N0, M0



Complete Resection and LN dissection
Curative RT (if medically inoperable)
Modest benefit to adjuvant chemotherapy (cisplatin based)
(Pignon, 2008)
Clinical trial: adjuvant radiation
Stage II trials

Stage IIIA
T1, N2, M0
T2, N2, M0
T3, N1, M0
T3, N2, M0
Resectable N2 (uncommon):
 Complete resection, CMLND & adjuvant chemo (cisplatin
based).
 Clinical trial: adjuvant radiation; adjvuvant chemo/rads;
surgery and chemo sequence
UN-Resectable N2:
 Concurrent chemo/rads
 Radiation therapy for medically unfit patients
 Palliative radiation for symptomatic local involvement
Chest Wall tumor (T3, N1, M0)
 Resection
 Resection with adjuvant radiation
 Radiation alone
 Chemo/rads/surgery
Stage IIIB
Any T, N3, M0
T4, any N, M0
T4 (structure invasion) or N3 (above collar bone, or
contralateral) disease
 Concurrent chemo rads
 Rads alone in medically unfit
 Palliative radiation for symptomatic local involvement
No clinical trials as of
03/19/2011
Improved survival with cisplatin-based chemo
Assess for EGFR mutation (+ → erlotinib; - cetuximab)
Addition of bevacizumab in non-squamous histology
Second ling chemo with docetaxel, pemetrexed, or erlotinib
Stage IV trials
Stage IV
Any M
Stage IIIA trials
Suggested Reference: NCCN Lung guidelines: Http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER TREATMENT OPTIONS
Surgical Resection


Objective: Identify appropriate populations by stage medical operability and stage (respectability)
Objective: Define appropriate surgical techniques

Mainstay of early stage (Stage I and II) lung cancers




Goal: Remove identified tumor and all affected lymphatic drainage
Populations:
o Stage I: curative
o Stage II: curative with adjuvant chemotherapy
o Stage III: reserved for select patients; dependent on structure & lymphovascular invasion
Resectability based on
o Medical operability
o Tumor accessibility
Determination of medical operability: Pre-surgical workups (i.e. common eligibility criteria?) Worrisome
pre-existing conditions



Pulmonary: Spirometry minimum values
o Forced expiratory volumes (FEV1 ) in 1 second < 40%
o Diffusing capacity of carbon monoxide (DLCO) < 40%
o V02max < 15 ml/kg/min
Cardiac:
o CHF as indicated on MUGA/ECHO and PE. LVEF <50%
o Ischemic heart disease as indicated on EKG
o Recent Myocardial infarction
o Unstable angina
Other significant systemic co morbidities
o Diabetes Mellitus
o
Renal insufficiency
o
o
Hepatic insufficiency
Immunosuppression
Thoracotomy Options
(illustrations © Terese Winslow, available from www.cancer.gov)
Description
Indications
Localized removal of
tumor with sufficient
margin.
<1cm tumor
(controversial)
Poor lung function
* associated with
↓survival Parenchyma
sparing
Removal of entire
lobe
Removal of entire
ipsilateral lung
Generally preferred
surgical approach
“gold standard”
Centrally located tumor;
or extension into multiple
lobes
VATS: Video assisted thoractomy
VATS
Open lobectomy
Blood tx
Pneumonectomy
Reintubation
Lobectomy
Arrhythmia
Wedge Resection
(limited resection)
Significant reduction in
complications(Paul, et al 2010)
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
Primary tumor resection: Less is more? Or is More...More? – Lobectomy vs. Limited Resection
NCCN recommends lobectomy
Lobectomy or pneumonectomy requirement for most trials
Ginsberg & Rubinstein, 1995:
 No significant perioperative benefit in morbidity, mortality, or late post-op pulmonary function with
limited resection
 Increased mortality and locoregional recurrence with limited resection
o Active trials: CALGB/ECOG 140503
 Compare the disease-free survival of patients with small (≤ 2 cm) peripheral stage IA non-small
cell lung cancer undergoing lobectomy vs. sublobar resection (wedge resection or
segmentectomy).
 Treatment Arms:
 Arm I: Patients undergo lobectomy by open thoracotomy or video-assisted thorascopic surgery
(VATS).
 Arm II: Patients undergo a wedge resection or anatomical segmentectomy by open thoracotomy
or VATS.
 Trial identifier: NCT00499330
Nodes Resection: Less is more?: Complete Ipsilateral Mediastinal Lymph Node Dissection (CMLND) vs.
Lymph Node Sampling
o Modest benefit to CMLND
o Decision based on pre-operative radiology staging
o Darling, et al 2011
 NO significant benefit for CMLND if sampling was negative for EARLY stage NSCLC
o
o
o

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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER TREATMENT OPTIONS
Chemotherapy


Objective: Discuss appropriate populations for chemotherapy by stage
Objective: Discuss general chemotherapy classes used in adjuvant and metastatic NSCLC

Appropriate, but controversial, in many settings
o Stage I: controversial benefit
o Stage II: adjuvant post-resection, but benefits are very modest and with significant toxicity
o Stage III: combined modality therapy: rad onc and chemo.
 Sequential chemotherapy/radiation more beneficial than radiation therapy alone (Sause, 2000)
 Concomitant radiochemotherapy more beneficial than sequential radiochemotherapy,
but with increased AE’s (especially esophageal toxicity) Auperin (2010
o Stage IV: palliation

What to use?
o Preference for 4-6 cycles of platinum (Cisplatin or Carboplatin) doublets
 Paclitaxel
 Gemcitabine
 Etoposide
 Docetaxel
 Vinorelbine
 Pemetrexed
o Cisplatin vs. Carboplatin controversial
 Conflicting results
 Cisplatin contraindicated in patients with multiple co-morbidities and poor PS
o Elderly population: individualized treatment
o Significant research (serum samples and tissue blocs !!) on identifying early predictors of
adjuvant chemo benefit
o At best we can only offer 5-10% survival benefit with adjuvant chemotherapy

Targeted Therapies? (Stage III & IV) - suspicion that any benefit is reserved for specific
molecular subgroups
o KRAS mutation not predictive nor prognostic
o epidermal growth factor receptor (EGFR) inhibitors :
 monoclonal antibody cetuximab. (Juneko, 2010)
 anti-EGFR Tyrosine Kinase Inhibitors: Erlotinib and Gefitinib (disappointing,
inconsistent study results)
o vascular endothelial growth factors:

monoclonal antibody bevacizumab
 Anti-VEGFR tyrosine kinase inhibitors: sunitinib only in clinical trial
o Anaplastic lymphoma kinase (ALK) inhibitors:
 Crizotinib in the ALK mutant population – in clinical trial
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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
LUNG CANCER TREATMENT OPTIONS
Radiation Therapy


Objective: Discuss appropriate populations for radiation therapy by stage
Objective: Discuss key toxicities

Appropriate for
o Stage I – resected with positive margins
o Stage II – chemo/rads
o Stage III - chemo/rads
o Stage IV – palliation and local control
Toxicities:
o Radiation pneumonitis
 Incidence > fist 1-6 months
 s/S: Nonproductive cough, shortness of breath, weakness, fever with CT changes in radiation
portal
o Pulmonary fibrosis
 Incidence – occurs gradually months to years post tx
 S/S: shortness of breath, decreased lung elasticity, poor PFT’s

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SWOG 2011 Spring Meeting: Lung Cancer; K Abueg
REFERENCES
Recommended References used throughout this presentation:







th
Greene, F. (2002) American Joint Committee on Cancer, 6 edition, Cancer Staging Handbook. Chicago: Springer
th
Edge, S (2010) American Joint Committee on Cancer, 7 edition, Cancer Staging Handbook. Chicago: Springer
Clinical Care Options Oncology inPractice point of care textbook:
http://www.clinicaloptions.com/inPractice/Index/Oncology.aspx Govidan, R (ed)
Lung Cancer, Site Specific Series; Houlihan, N.G., Ed. Oncology Nursing Society, 2006.
National Cancer Institute: PDQ® Non-Small Cell Lung Cancer Treatment. Bethesda, MD: National Cancer Institute. Date last
modified 03/01/2011 Available at: http://www.cancer.gov/cancertopics/pdq/treatment/non-small-celllung/healthprofessional. Accessed 03/19/2011
National Comprehensive Cancer Network Clinical practice Guidelines in Oncology (NCCN Guidelines TM), Version 3.2011.
Available at http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
Surveillance, Epidemiology, and End Results (SEER) Program and the National Center for Health Statistics. Statistics and
charts are available at http://seer. cancer.gov
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