Download Lung Cancer: A Surgeon’s Perspective

Matthew Kilmurry, M.D.
St. Mary’s General Hospital
Grand River Hospital
I have no conflicts of interest
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

Causes
 Smoking




Radon exposure
Asbestos exposure
Second hand smoke
Genetics
Types of Lung Cancer
Primary
 Secondary

 Colonic mets
 Other primaries
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
Primary lung cancer
Small cell
 Non small cell

 Accounts for 75-80 % of primary lung tumors
Screening

No accepted screening method
 Studies using CT, CXR and sputum

High index of suspicion
 smokers
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

Nodal stations
Surgical Approach
Diagnosis: Is this cancer?
 Metastases: Is there spread?
 Suitability: Is the patient healthy enough
for surgery?

Diagnosis
History and physical
 Chest X-ray
 CT scan
 Percutaneous biopsy
 Bronchoscopy

Metastases
History and physical
 Upper abdominal imaging
 Bone scan and CT head
 PET scan
 Mediastinoscopy

Nodal stations
Suitability
History and physical
 PFT’s
 Cardiac investigations

 2D echo
 Stress test
 Nuclear medicine
CPET
 Quantitative V/Q scan

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
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%
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
Case # 1
Case # 1
Bronchoscopy and mediastinoscopy
showed no evidence of mets
 Thoracotomy confirmed diagnosis and
had lobectomy
 Right upper lobe nodule unchanged
over two years

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

Case # 2
Case # 2
CT chest showed large tumour with no
evidence of mets
 Biopsy shows NSCLC
 PET scan shows no evidence of
metastatic disease

Case # 2
Mediastinoscopy showed metastatic
disease in lymph nodes
 Referred for chemoradiotherapy
 Possible candidate for surgery

Palliation
Majority of work with chemo and
radiotherapy
 Pain and symptom management vital
 Surgery sometimes required

 Pleural effusions
 Endobronchial tumours
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
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

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
