1. Cancer Education Day May 13, 2016

2. Surgery for Lung Cancer Dr A Elalem Thoracic surgeon Windsor Regional hospital

3. Disclosures No Disclosure to report No conflict of interest

4. High lights Epidemiology of Lung cancer Presentation and diagnosis Staging Treatment in general Surgical treatment Questions?

5. Epidemiology of Lung cancer Most frequently diagnosed cancer worldwide – About 1.35 million new cases diagnosed worldwide each year Leading cause of cancer deaths in the United States

6. Canadian Cancer Statistics 2015

7. Epidemiology of Lung cancer For men in Ontario, prostate cancer is the most frequently diagnosed type of cancer. In 2015: An estimated 9,700 men will be diagnosed with prostate cancer. An estimated 5,100 men will be diagnosed with colorectal cancer. An estimated 4,600 men will be diagnosed with lung cancer

8. Risk factors Cigarette smoking Second-hand smoke Occupational exposure (asbestos, motor vehicle emissions, pollutants, radon) Genetics Low level radiation Smoking and low intake of beta carotene.

9. Cell types

10. Presentation Symptoms: Some of the early warning signs of lung cancer are: A cough that doesn’t go away Chest pain Hoarseness Weight loss and loss of appetite Bloody or rust-colored sputum Shortness of breath Fever without a known reason Recurring infections such as bronchitis or pneumonia

11. Fry WA, et al. Cancer. 1996;77:1949-1995. 31% Stage III 31% Stage III 38% Stage IV 38% Stage IV % 24% I Stage I % 24% I Stage I 7% Stage II 7% Stage II NSCLC - St ages at Presentation

12. Presentation

14. Investigation Chest X-Ray CT scan +/- Biopsy MRI PET scan Bone scan Bronchoscopy EBUS-TBA

15. Clinical Staging Imaging CT{ chest and upper abdomen } MRI Superior sulcus tumor, Pancoast – MRI Head if symptoms, Adenoca – for Small cell Lung cancer – May be in stage III disease NSCLC – All patient in academic centers !! PET- if a radical treatment is considered Bone scan, Complementary to PET ??

16. Clinical Staging – CT/US guided needle aspiration: thoracentesis, cervical lymph node, liver – EUS: left adrenal metastasis – In metastastatic disease, biopsy the easiest site

17. Clinical Staging CT scan Alone Was not very good Why? 40% of suspicious LN are benign by size criteria. 20% of non-suspicious LN are malignant. Meta-analysis: Sensitivity: 51-64%* Specificity: 77-82%** Clinical T1N0 ( 5-15% has positive LN on surgical staging)

18. Clinical Staging PET scan: Was not great too why? Systematic review of 44 studies; Sensitivity:74% Specificity:84% Meta-analysis: Enlarged LN Sensitivity:100% Specificity:78% False positive:25% Gold Ann Int med 2003; 139-879

19. Clinical Staging PET scan(continue): Meta-analysis: Non-enlarged LN Sensitivity:82% Specificity:93% False Negatice:20% Gold Ann Int med 2003; 139-879

20. Surgical staging Bronchoscopy/ EBUS-TBA Mediastinoscopy Mediastinotomy Thoracoscopy(VATS) Thoracotomy

21. VATS( video assisted thoracic surgery)

22. Surgical staging

23. Surgical staging(EBUS)

24. 24 EBUS and Staging SensitivitySpecificity Diagnositc Accuracy CT76.9%55.3%60.8% PET80%70.1%72.5% EBUS-TBNA92.3%100%98% Yasufuku et al. Comparison of Endobronchial Ultrasound, PET, and CT for Lymph Node Staging of Lung Cancer. Chest 2006; 130:710-718

25. TNM Stages of lung cancer StageTNM Ia T1aN0M0 T1bN0M0 IbT2aN0M0 IIa T1aN1M0 T1bN1M0 T2aN1M0 T2bN0M0 IIb T2bN1M0 T3N0M0 IIIa T1N2M0 T2N2M0 T3N2M0 T3N1M0 T4N0M0 T4N1M0 IIIb T4N2M0 T1N3M0 T2N3M0 T3N3M0 T4N3M0 IVT AnyN AnyM1a or 1b

26. Pre operative Clinical Assessment History and physical Cardio-pulmonary evaluation PFT Echo +/- cardiac MIBI 6 min walk Optimize lung function Smoking cessation.

27. Surgical treatment by stage Lobectomy Bilobectomy ( only Right side) Sleeve resection Pneumonectomy Segmentectomy Wedge resection Chest wall with Lung resections

28. Surgical treatment by stage Stage I &II Surgery is the main stay in treatment. There is a good body of evidence to support that.

29. Kaplan-Meier Survival Curves for 484 Participants with Lung Cancer and 302 Participants with Clinical Stage I Cancer Resected within 1 Month after Diagnosis The International Early Lung Cancer Action Program Investigators. N Engl J Med 2006;355:1763-1771

30. Wedge vs Lobectomy for Stage I NSCLC p=0.889 Landreneau, et.al., J Thorac Cardiovasc Surg 1997;113:691-700

31. Lobectomy vs Limited Resection Time to death (from any cause) by treatment logrank p=0.088 (one-tailed) Ginsberg and Rubinstein Ann Thorac Surg

32. Wedge vs Lobectomy for Stage I NSCLC Open WR VATS WR Vs.LobeP< Op Mortality (%)00Vs.3.30.20* Postop Stay (days) 7.76.5Vs.10.10.0002* Local Recur (%) 1715 Vs. 5 0.08* Local/Systemic Recurrence (%) 2423vs.170.43* *- all WR (n=95) vs. Lobe (n=124) Statistical Methods: Life Table Analyses Obtained by Log Rank and Wilcoxson Tests Landreneau, et.al., J Thorac Cardiovasc Surg 1997;113:691-700

33. Surgery for stage III-A Heterogeneous stage !! T1 to T3, N2, M0 T3, N1, M0 T4, N0 or N1, M0

34. Stage IIIa – “Bulky

35. Stage IIIa – “Minimal Involvement

36. Surgery for stage III-A Induction (pre-operative ) Chemo-radiotherapy for Stage III-a non- small cell lung cancer Standard of Care ???

37. Surgery for stage III-A Intergroup trial 0139 Chemo-radiation vs Chemo-radiation followed by surgical resection of Stage IIIa NSCLC Kathy Albain et al. ASCO 2005 Lancet 2009;374:379-86

42. Conclusion N0 at surgery greatly influence 5 years survival Trimodality therapy is not recommended if pneumonectomy is required due to high mortality Surgical resection can be considered in fit patient after induction chemo-rads if lobectomy is feasible.

43. Surgery for stage III-B No role for surgery Very bulky disease Any T, N3, M0 T4, N2, M0

44. Any T, any N, M1a Any T, any N, M1b The overall consensus: no role for surgery BUT ??!! Surgery for stage IV

45. Exception to this role: Solitary brain, pulmonary or adrenal mets Provided: 1.Thoracic disease is resectable(Ro resection) 2.Good performance status, younger patients 3.Mets are resectable with acceptable morbidity 4.Mediastinum is cleared.

46. Surgery for stage IV Any evidence Supported by several retrospective reviews.

47. Surgery for stage IV Metastasectomy for Synchronous Solitary Non-Small Cell Lung Cancer Metastases Mario Tönnies, MD, Joachim Pfannschmidt, MDcorrespondenceemail, Torsten T. Bauer, MD, Jens Kollmeier, MD, Simone Tönnies, Dirk Kaiser, MD Between 1997 and 2009, 99 patients underwent complete solitary synchronous NSCLC metastasis resection in a single center. Conclusions They conclude that metastasectomy for synchronous oligometastatic disease in NSCLC can be performed in selected patients. It appears reasonable that such patients should be considered as surgical candidates if mediastinal lymph node involvement is excluded. Annals of Thoracic surgery. July 2014Annals of Thoracic surgery. July 2014Volume 98, Issue 1, Pages 249–256

48. Surgery for stage IV Radical treatment of synchronous oligometastatic non-small cell lung carcinoma (NSCLC): Patient outcomes and prognostic factors. Retrospective review of 61 Patients Surgery and /or radiation therapy The 1- and 2-year OS were, 54% and 38%, respectively. Again the thoracic disease should be resectable(R0) resection) Gwendolyn H.M.J, Lung cancer, October 2013Volume 82, Issue 1,(Netherland)ung cancer, October 2013

49. Surgery for stage IV Metastasectomy for Synchronous Solitary Non-Small Cell Lung Cancer Metastases Mario Tönnies, MD, (Germany) 99 Patients Retrospective review OS was 38% OS was 45.% for ipsilateral or cotralateral pulmonary metastasis. Grade was also important G1-2 vs G3 Annals of thoracic surgery, July 2014Volume 98, Issue 1,

50. Surgery for stage IV Other roles of surgery in stage IV NSCLC Malignant pleural effusion: Options 1) Talc pleurodesis 2) Pleurex catheter

51. Thank you

52. Can you guess where is this?

53. Question #1 Which of the following statements does NOT describe a feature of small cell lung carcinoma? A. Most patients are smokers. B. Abundant mucin production is associated C. Paraneoplastic syndromes are associated. D. A majority of cases have neurosecretory-type granules.

54. Question #2 Malignant pleural effusion is considered: 1) T4- Stage III-A 2) M1- Stage IV

55. Question #3 Which of the following is true 1.15% of lung cancer patient are asymptomatic at presentation 2.35% of lung cancer patient are asymptomatic at presentation 3.7-10%of lung cancer patient are asymptomatic at presentation