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Non Small Cell Lung Cancer Introduction Mira Wollner RAMBAM MEDICAL CENTER.

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Presentation on theme: "Non Small Cell Lung Cancer Introduction Mira Wollner RAMBAM MEDICAL CENTER."— Presentation transcript:

1 Non Small Cell Lung Cancer Introduction Mira Wollner RAMBAM MEDICAL CENTER

2 Epidemiology Most frequent cause of cancer diagnosed in the US – about 12% of all cancer NSCLC represents ~ 80% of lung cancer In year 2004 ~ 173,770 new cases and 160,440 deaths Leading cause of cancer deaths in both men ( 32%) and women (25%) 75% of new cases present with non resectable disease Overall 5 year survival < 15% American Cancer Society, Cancer Facts & Figures 2005 SEER Cancer Statistics, 1998-2002. http://seer.cancer.gov

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4 Newly Diagnosed NSCLC in Israel 1999 = 1338 2002 = 1450

5 Etiology  Cigarette smoking responsible for > 80% cases  Use of filter  Tar content  Variation of tobacco blends  Contains ~ 300 chemicals and up to 40 potent carcinogens (nitrate)  Recent changes in histological dominant type (due to changes in tobacco blend and use of filter) American Cancer Society, Cancer Facts & Figures 2005 SEER Cancer Statistics, 1998-2002. http://seer.cancer.gov

6 Histology  Adenocarcinoma ( 45%) Atypical Alveolar Hyperplasia ( precursor)  Broncho-alveolar carcinoma  Squamous cell carcinoma ( 33%)  Large cell carcinoma ( 9% )  Adenosquamous carcinoma  Pleomorphic carcinoma  Carcinoma of salivary gland  Carcinoid American Cancer Society, Cancer Facts & Figures 2005 SEER Cancer Statistics, 1998-2002. http://seer.cancer.gov

7 Diagnosis  Medical history  Physical exam  Labs  Imaging studies  CXR  CT-scan  PET-CT scan  Bone scan

8 Diagnosis Bronchoscopy (FOB) Mediastinoscopy Histology  Sputum  FNA (cytology/biopsy)  thoracotomy

9 Methods of Spread  Vascular channels  Lymphatic channels  Airborne or lymphatic (satellite nodules)  Lymphatic spread to regional lymph nodes: bronchopulmonary (segmental and lobar (N1), mediastinal (N2-3),supraclavicular (N3)  Retrograde lymphatic spread (pleural surface)  Direct invasion  Systemic dissemination

10 TNM stage grouping Stage 0TisNOMO Stage IT1NOMO T2NOMO Stage IIT1N1MO T2N1MO Stage III AT1N2MO T2N2MO T3NOMO T3N1MO T3N2MO Stage III BAny TN3MO T4Any NMO Stage IVAny TAny NM1

11 Stage I disease > 2 cm OR OR N0: No lymph node involvement No lobar bronchusinvolvement T  3 cm T1N0M0 T2N0M0 T  3 cm T + visceral pleura involved T + atelectasis

12 Stage II disease > 2 cm OR OR N1: Intrapulmonary and/or hilar nodes involved No lobar bronchusinvolvement T  3 cm T1N1M0 T2N1M0 T  3 cm T + visceral pleura involved T + atelectasis

13 Stage IIIA disease 2 cm 2 cm T2 OR OR OR OR T1 N1: peribronchial or ipsilateral hilar T  3 cm No lobar bronchus involvement T  mediastinal pleura pleura (or pericardium) (or pericardium) T  chest wall (or diaphragm) (or diaphragm) T3 N0M0 T3N1M0 T3N2M0 T1 N2M0 T2N2M0 T  3 cm T + visceral pleura involved T + atelectasis N2: ipsilateral mediastinal and subcarinal

14 Stage IIIB disease Any T, N3, M0Any N, T4, M0 ScaleneSupraclavicular N3: lymph nodes involvedT4: mediastinal involvement Any T Any N T4

15 Mediastinal lymph node map Mountain CF, Dresler CM. Chest 1997; 111:1718-1723

16 Involvement of lymphatic metastatic spread in non-small cell lung cancer accordingly to the primary cancer location  Skip metastases to level 10 (hilar) ~ 5%  Skip metastases to mediastinal LN ~ 19%  Mediastinal LN dissection must be the standard procedure Kotoulas CS et al 2004 Lung Cancer;44:183-191

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22 Patterns of failure after resection of NSCLC CHRIS R. KELSEY,., KIM L. LIGHT, AND LAWRENCE B. MARKS, 2006 Int. J. Radiation Oncology Biol. Phys., Vol. 65, No. 4, pp. 1097–1105

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27 Treatment algorithm Glotocan, Epidemiology Lung Cancer, 2002 NSCLC Diagnosis Resectable I – II – IIIA 28% Surgery (RT) Adjuvant CT Locally advanced IIIA Unresectable IIIB 33% Combined Chemo-radiotherapy Consolidation Unresectable IIIB Metastatic IV 39% 1 st line chemotherapy

28 Survival and Frequency Mountain Chest 1997; 111:1718-1723 Stage Frequency (%) 5-year survival % Clinical Pathological IA~ 10 61 67 IB 38 57 IIA~ 13 34 55 IIB 24 39 IIIA~ 22 13 25 IIIB~ 22~ 5 IV~ 32<1

29 Surgery Lobectomy = gold standard for early stage  Limited recection showed higher local recurrence rate (15%) then lobectomies (5%) for T1N0 tumors Ginsberg RJ et al. Ann Thorac Surg 1995;60:615

30 Sites of Recurrence Following Complete Surgical Resection Mountain CF, McMurtrey MJ, Frazier OH. Current results of surgical treatment for lung cancer. Cancer Bull 1980;32:105–108

31 Resected LN-negative Failure AuthorStagePts NoChest % Distant % Feld et allT1N0162917 T2N01961130 Pairolero et all T1N0170615 T2N0158623 Thomas et all T1N0 Sq22657 T1N0 non-Sq 346917

32 Resected LN-positive Failure AuthorStagePts NoChest %Distant % Feld et allT1N1 32922 Pairolero et all T1N1 182839 Martini et allT1-2N1sq 931631 T1-2N1 adeno 114854 T2-3N2sq 461352 T2-3N2 adeno 1031761

33 Completely Resected Stage II or IIIA With Postoperative Adjuvant Therapy (ECOG) Keller SM, Adak S, Wagner H, Herscovic A, et al. New Engl J Med 2000,343;17:1217-1222

34 Completely Resected Stage II or IIIA With Postoperative Adjuvant Therapy (continuing) Keller SM, Adak S, Wagner H, Herscovic A, et al. New Engl J Med 2000,343;17:1217-1222

35 Patterns of Failure S. Lee et al. Postoperative adjuvant chemotherapy and radiotherapy for stage II and III non-small cell lung cancer (NSCLC) Lung Cancer 37 (2002) 65/71

36 Prognostic Factors S. Lee et al. Postoperative adjuvant chemotherapy and radiotherapy for stage II and III non-small cell lung cancer (NSCLC) Lung Cancer 37 (2002) 65/71

37 Are All T1-2 Tumors the Same? Mulligan CR et al. Ann Thorac Surg 2006;81(1):220-226 Tumor size (cm)5 year survival (%) ≤148,6 1-245,9 2-325,6 3-427 4-514,4 >511,6

38 Outcome After Surgical Resection in Operable NSCLC Pisters and Le Chevalier. J Clin Oncol 2005;23:3270-3278 Stage 5 year survival (%) Relapse (%) Local Distant IAT1N0M0 67 10 15 IBT2N0M0571030 IIAT1N1M055 IIBT2N1M039 12 40 T3N0M038 IIIAT3N1M0251560 T1N2M023

39 Prognostic factors  TNM Stage  Tumor size  Pathological N2  Extend of LN involvement (single vs multiple)  Occult vs Bulky  Type of surgery  wedge/segmentectomy vs lobectomy  LN sampling vs dissection  Positive surgical margins  age > 60 years  PS/QoL


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