1. Matthew Kilmurry, M.D. St. Mary’s General Hospital Grand River Hospital

2. I have no conflicts of interest

3. 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

4. Causes  Smoking  Radon exposure  Asbestos exposure  Second hand smoke  Genetics

5. Types of Lung Cancer  Primary  Secondary Colonic mets Other primaries

6. 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

7. Primary lung cancer  Small cell  Non small cell Accounts for 75-80 % of primary lung tumors

8. Screening  No accepted screening method Studies using CT, CXR and sputum  High index of suspicion smokers

9. 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

11. Nodal stations

12. Surgical Approach  Diagnosis: Is this cancer?  Metastases: Is there spread?  Suitability: Is the patient healthy enough for surgery?

13. Diagnosis  History and physical  Chest X-ray  CT scan  Percutaneous biopsy  Bronchoscopy

14. Metastases  History and physical  Upper abdominal imaging  Bone scan and CT head  PET scan  Mediastinoscopy

15. Nodal stations

16. Suitability  History and physical  PFT’s  Cardiac investigations 2D echo Stress test Nuclear medicine  CPET  Quantitative V/Q scan

17. 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

18. 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%

19. 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

20. Case # 1

21.  Bronchoscopy and mediastinoscopy showed no evidence of mets  Thoracotomy confirmed diagnosis and had lobectomy  Right upper lobe nodule unchanged over two years

22. 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

23. Case # 2

24.  CT chest showed large tumour with no evidence of mets  Biopsy shows NSCLC  PET scan shows no evidence of metastatic disease

25. Case # 2  Mediastinoscopy showed metastatic disease in lymph nodes  Referred for chemoradiotherapy  Possible candidate for surgery

26. Palliation  Majority of work with chemo and radiotherapy  Pain and symptom management vital  Surgery sometimes required Pleural effusions Endobronchial tumours

27. 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

28. 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

29. 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