Presentation on theme: "Rodney J. Landreneau, MD Professor of Surgery Heart, Lung & Esophageal Surgery Institute University of Pittsburgh Medical Center Management of Non-Small."— Presentation transcript:
Rodney J. Landreneau, MD Professor of Surgery Heart, Lung & Esophageal Surgery Institute University of Pittsburgh Medical Center Management of Non-Small Cell Lung Cancer St. Margaret Grand Rounds September 10,2009
Management of Non-Small Cell Lung Cancer CT surveillance for lung cancer Sublobar Resection vs. Lobectomy Role of surgical resection for regionally advanced lung cancer Adjuvant Systemic Therapy for regionally advanced “resectable” lung cancer CT surveillance for lung cancer Sublobar Resection vs. Lobectomy Role of surgical resection for regionally advanced lung cancer Adjuvant Systemic Therapy for regionally advanced “resectable” lung cancer
Lung Cancer Surveillance
Original Article Survival of Patients with Stage I Lung Cancer Detected on CT Screening The International Early Lung Cancer Action Program Investigators N Engl J Med Volume 355(17): October 26, 2006
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:
Conclusion ● Annual spiral CT screening can detect lung cancer that is curable ● Comparable screening efficacy as mammographic screening for breast cancer (prevalence 1.6%; incidence 0.6%) ● Cost effective - low energy, fast scanning about $200 ● Treatment of early stage disease less expensive than advanced disease
CT scans have radiation risks and sometimes detect cancers that would not have progressed, leading to risky procedures like biopsies and lung surgery when not needed. lung surgery lung surgery
The National Cancer Institute started in 2002 the $200 million “National Lung Screening Trial” comparing death rates among 55,000 people randomly assigned to have CT scans or chest X- rays. Results are not expected until 2010.
“Sublobar Resection” or “Lobectomy” for stage I lung cancer
Standard of Care For Peripheral Nodules 1940’s Pneumonectomy 1960’s Lobectomy 1990’s ?Segmentectomy/Wedge (and adjuvant local/systemic Rx) Surgical Resection of the Lung
Errett LE et al J Thorac Cardiovasc Surg Nov;90(5): Sublobar Resection vs. Lobectomy for Stage 1 Non-Small Cell Lung Cancer
Randomized Trial of Lobectomy Versus Limited Resection for T1 N0 Non-Small Cell Lung Cancer (125 Lobectomy, 122 Limited Resection) RJ Ginsberg, LV Rubinstein and Lung Cancer Study Group Ann Thorac Surg 1995;60:615-23
Lobectomy vs Limited Resection Time to death (from any cause) by treatment logrank p=0.088 (one-tailed) Ginsberg and Rubinstein Ann Thorac Surg
Wedge Resection Versus Lobectomy for Stage I (T1 N0 M0) Non-Small Lung Cancer Landreneau, et.al., J Thorac Cardiovasc Surg 1997;113:
Wedge vs Lobectomy for Stage I NSCLC p=0.889 Landreneau, et.al., J Thorac Cardiovasc Surg 1997;113:
Wedge vs Lobectomy for Stage I NSCLC Open WR VATS WR Vs.LobeP< Op Mortality (%)00Vs * Postop Stay (days) Vs * Local Recur (%) 1715 Vs * Local/Systemic Recurrence (%) 2423vs * *- 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:
! Local Recurrence !
Adjuvant Radiation Therapy ● External beam radiation therapy - Potential risk of increased injury to surrounding pulmonary parenchyma ● What is efficacy of intraoperative brachytherapy when external beam radiation may otherwise be applied?
Intraoperative Brachytherapy ● Not a new concept for lung cancer ● Mostly used for Stage IIIA disease - close or positive margins ● Improved local control ● What is it’s role in high risk patients with totally resectable disease where lobar resection is not feasible and adjuvant radiotherapy is recommended?
Comparison Between Sublobar Resection and 125Iodine Brachytherapy After Sublobar Resection in High-Risk Patients with Stage I Non–Small-Cell Lung Cancer Comparison Between Sublobar Resection and 125Iodine Brachytherapy After Sublobar Resection in High-Risk Patients with Stage I Non–Small-Cell Lung Cancer R. Santos, A. Colonias, D. Parda, M. Trombetta, RH Maley, R. Macherey, S. Bartley, T. Santucci, RJ Keenan, RJ Landreneau Surgery 2003, Oct;134(4): 691-7
Sublobar Resection (n=102) Sublobar Resection With Brachy (n=96) Local Recurrence19 (18.6%)1 (1%) p=.0001 Hospital Mortality0 (0%)3 (3%) p=ns Hospital Stay7 days8 days p=ns Survival % 1, 2, 3 and 4 year93, 73, 68, 60%96, 82, 70, 67% p=ns Systemic Recurrence 29 (28.4)22 (23%) p=ns Pre-op FEV 1% predicted 65%53% p=nsResults The FEV 1 did not change postoperatively in the sublobar resection with brachytherapy group in the interval of follow-up
Lobectomy vs Sublobar Resection “Effect of Tumor Size on Prognosis in Patients with Non-Small Cell Lung Cancer: The Role of Segmentectomy as a Type of Lesser Resection” “Effect of Tumor Size on Prognosis in Patients with Non-Small Cell Lung Cancer: The Role of Segmentectomy as a Type of Lesser Resection” Okada M, Nishio W, Sakamoto T, Uchino K, Yuki T, Nakagawa A, Tsubota N. “J Thorac Cardiovasc Surg Jan;129(1):87-93” An evaluation of surgical resection in 1272 NSCLC patients
TUMOR SIZE Segmental ResectionLobectomy Wedge Resection 20 mm or less mm More than 30 mm Lobectomy vs Sublobar Resection 5 Year Cancer Specific Survival “Stage I” “Okada, M, et al J Thorac Cardiovasc Surg Jan;129(1):87-93”
Efficacy of Anatomic Segmentectomy in the Treatment of Stage I NSCLC Matthew J. Schuchert M.D., Brain L. Pettiford M.D., Samuel Keeley M.D., Thomas A. D’Amato M.D., Ph.D., Arman Kilic B.S., Hiran C. Fernando M.D., John Close M.A., Ricardo Santos M.D., James R. Landreneau, James D. Luketich M.D., Rodney J. Landreneau M.D. Division of Thoracic Surgery Heart, Lung and Esophageal Surgery Institute UPMC Health System Pittsburgh, Pennsylvania
Patient and Tumor Characteristics Stage IA Anatomic Segmentectomy (n=182) Lobectomy (n=246) Stage IA109 (60%) 114 (46%) Tumor Size Mean (cm) Range (cm) Schuchert MJ., et. Al.; STS 2007
Stage IA – Segmentectomy vs Lobectomy Cumulative Survival Time (months) Lobectomy Segmentectomy log rank = Schuchert MJ., et. Al.; STS 2007 Overall Survival
ASCO 2005 ANITA : OS months Survival Distribution Function [ ] Hazard Ratio 0.013P-value Median months NVB + CDDP OBS. Obs NVB + CDDP
ChemotherapyObservation MOS 95 months 78 months P value 0.10 HR (90% CI) 0.80 ( ) Survival Time (Years) Probability Observation Chemo ASCO 2006 (137/155 of total events) ABSTR #7007 CALGB OVERALL SURVIVAL
Adjuvant Chemotherapy Standard of Care - Stages IIA-B - IIIA NSCLC - Maybe Larger IB ??? ● Good performance status patients with “R0” Anatomic Resection - Stages IIA-B - IIIA NSCLC - Maybe Larger IB ???
City of Pittsburgh Pennsylvania Thank You
Still Empiric Therapy Approach!!
Drug Resistance Testing
Clinical Correlation in Non-Small Cell Lung Cancer
Results Overall Survival BLOTS9900Depierre PreopControlPreopControl Median OS (months) year (%) year (%) Pisters, et. Al. - ASCO 2005; JCO 2002
Management of Non-Small Management of Non-Small Cell Lung Cancer Lung Cancer Survival
Still Empiric Therapy Approach!!
Dr. Henschke has asserted that allowing hundreds of thousands of people to die in the meantime is unethical. Therefore, “off study” CT screening should be approved by insurance for high risk patients!