1. Lung Cancer 2017 Standard of Care Screening, Diagnosis, Management
Jeremiah Martin MBBCh FRCSI MSCRD

2. DISCLOSURE The speaker and members of the planning committee do not have a conflict of interest in this topic. There is no commercial support for this program.

4. Now we will turn our attention to cancer mortality
Now we will turn our attention to cancer mortality. Lung cancer is by far the leading cause of cancer death among males (27%), followed by prostate (8%) and colorectal (8%) cancers. Among females, lung (26%), breast (14%), and colorectal (8%) cancers are the leading causes of cancer death.

5. Smoking as a risk factor

6. Smoking Cessation

7. Smoking Demographics

8. Lung Cancer Age-Adjusted Incidence Rates by State
Data Source: CDC

9. Lung Cancer Age-Adjusted Mortality Rates by State
Data Source: CDC

10. Incidence by Area Development District
Data Source: Kentucky Cancer Registry

11. What is cancer?
In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues.

13. Numbers…
… we can change

14. 15%
Survival at 5 years

15. Patients discovered with stage III / IV
70%
Patients discovered with stage III / IV

16. Patients stage I/ II don’t get surgery
40%
Patients stage I/ II don’t get surgery

17. Lung Cancer Survival Dependent on cell type Non-Small Cell (NSCLC)
Adenocarcinoma / Squamous Cell Large Cell Neuroendocrine
Small Cell
Represents 15% of lung cancers
6% 5-year survival
Treatment can add 6-12 months

19. Improving Outcomes in Lung Cancer
Increase Awareness
Decrease risk factors
Early detection
Clinical suspicion
Screening
Early stage-directed therapy

20. Lung Neoplasms
Where do they come from?

21. Differential Diagnosis
Pulmonary Nodule
Benign
Infectious
Treat
Inflamm.
Observe
Malignant
Carcinoma
Staging

22. Differential Diagnosis
Structural / Inflammatory Possibilities (benign)
Arteriovenous Malformation
Atelectasis
Rheumatoid nodule
Sarcoidosis
Wegener Granulomatosis

23. Differential Diagnosis
Infectious Possibilities (benign)
Aspergillosis
Blastomycosis
Coccidiomycosis
Histoplasmosis
Hydatid Cysts
Lung Abscess
Nocardiosis
Tuberculosis

24. Differential Diagnosis
Malignancy
Non small cell lung cancer
Small cell lung cancer
Carcinoid tumor

25. Imaging Tools
CXR CT
PET
MRI

26. Diagnostic / Therapeutic Tools
Needle biopsy
Bronchoscopy
Endobronchial Ultrasound
Mediastinoscopy
VATS (Video-assisted thoracic surgery)
Thoracotomy
Less Invasive
More Invasive

27. Workup of a pulmonary nodule
History
Generally asymptomatic
May have cough
Occasionally may present with pain, hemoptysis, weight loss, neurologic symptoms - concern for advanced disease
Any prior malignancy?
Smoking history?
Exposure history?

28. Workup of a pulmonary nodule
History
Look for smoking-associated diseases Coronary artery disease Peripheral vascular disease
Ask about general health screening (possibility of metastatic disease) Colonoscopy Mammography in women

29. Workup of a pulmonary nodule
Physical Examination
General appearance
Signs of smoking
Lymphadenopathy
Detailed pulmonary examination

30. Workup of a pulmonary nodule
Look at all available images, and ask for old studies for comparison
At this point consider referral for evaluation by a thoracic surgeon

31. Workup of a pulmonary nodule
LIKELY BENIGN
LIKELY MALIGNANT

32. Workup of a pulmonary nodule
If it’s cancer:
Treatment depends on stage, type
If it’s an infectious nodule:
May need treatment, may resolve
If it’s old scar tissue:
It will remain the same

33. Which is most likely?

34. Risk Assessment Age Gender Smoking history History of prior malignancy
Surgical risk Cardiac risk assessment Pulmonary function testing

35. “assume the worst hope for the best!”
Risk Assessment
“assume the worst hope for the best!”

36. Stage-Based Treatment of Cancer
LOCAL THERAPY
SYSTEMIC THERAPY
Surgery
Radiation
Chemotherapy I II
III IV

37. Stage-Based Treatment

38. “TNM” staging system Tumor Nodes Metastases
Lung Cancer Staging
“TNM” staging system Tumor Nodes Metastases

39. Chart illustrates the descriptors from the 7th edition of the TNM staging system for lung cancer.
UyBico S J et al. Radiographics 2010;30:
©2010 by Radiological Society of North America

40. Lung Cancer Staging
From a clinical perspective: work by outruling the worst possibilities:
1) Metastatic Disease
2) Nodal Disease
3) Local Tumor Invasion / Surgical Candidacy

41. Lung Cancer Staging Look for evidence of metastatic disease PET scan
Brain MRI
If Mets present: confirm tissue diagnosis by least invasive means possible then definitive chemo-/radiation therapy

42. Lung Cancer Staging Most common sites for metastases Other lung Brain
Bone
Adrenal glands
Liver

43. Lung Cancer Staging Primary Tumor Mediastinal Lymph Node
Adrenal metastases
Left iliac bony metastasis

44. Lung Cancer Staging Look for evidence of nodal disease EBUS
Mediastinoscopy
If N2 disease present: refer for chemo-/radiation therapy may be a candidate for resection depending on response to treatment

45. Mediastinal Staging N3 N1 N2 Tumor N1 – Ipsilateral (Intrapulmonary)
N2 – Ipsilateral medistinal and subcarinal
N3 – Contralateral mediastinal

46. Mediastinal Staging Better if directed towards target
EBUS Non-invasive
Immediate results
Mediastinoscopy More invasive (still outpatient)
‘Gold standard’ More tissue

47. Lung Cancer Staging Clinical Stage: Pathologic Stage:
Operative candidate?
Pathologic Stage:
Final resected specimen and lymph nodes

48. Multi-Disciplinary Care
Radiology Pulmonology Thoracic Surgery Medical Oncology Radiation Oncology

49. Lung Cancer Staging Clinical Stage: Pathologic Stage:
Operative candidate?
Pathologic Stage:
Final resected specimen and lymph nodes

50. Surgical Management Anatomic dissection of the hilum
Remove the entire lobe
Remove draining lymph nodes
Multi-specialty discussion of treatment plan

51. Surgical Approach

52. Minimally Invasive Surgery
Video Assisted Thoracoscopy (VATS)
Variety of techniques
Common feature:
Thoracoscope
anatomic hilar dissection
no rib spreading
Anterior two-incision approach video

53. VATS / Thoracoscopic Lobectomy
Video File MiddleLobectomy.wmv?dl=0

54. Advantages of VATS
Better tolerated in the elderly with fewer complications
Increased likelihood of compliance with adjuvant therapy
Decreased length of stay, decreased hospital cost
Quicker return to function / less pain
Cattaneo SM, et al. "Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications". Ann. Thorac. Surg. 85 (1): 231–5;
Nicastri DG, et al. "Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance". J Thorac Cardiovasc Surg 135 (3): 642–7.
Casali G, et al. "Video-assisted thoracic surgery lobectomy: can we afford it?". Eur J Cardiothorac Surg 35 (3): 423–8.

55. Advantages of VATS 3 weeks postoperatively
Todd L Demmy, Jackie J Curtis, Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study, The Annals of Thoracic Surgery, Volume 68, Issue 1, July 1999, Pages ,

56. Why is VATS not standard of care
National adoption is very slow
Only 50% of anatomic resections in the US are performed using minimally invasive techniques
Learning curve
Robotics is helping

57. KCR Data 2010-2012 Review of Kentucky Cancer Registry data
Robust pathology information
Survival data updated with linkage to external sources

58. Results

59. Results
All p1a
12 mo
24 mo
VATS
94%
86%
Open
88%
79%

60. Other New Technologies
Navigational Bronchoscopy Allows biopsy of peripheral nodules

61. Lung Cancer Surgery – The Future
Minimally Invasive
VATS
Robotics
Parenchymal Sparing operations
Segmentectomy
Extended wedge-resection

62. Advances in Radiation / Chemotherapy
Stereotactic radiation (SBRT)
Cyberknife

63. SBRT Large radiation dose per fraction
Precisely delivered to target area
Minimal damage to surrounding tissues
Disadvantage – no tissue, no lymph nodes

64. SBRT
Treatment of choice for early stage, medically inoperable patients. Control of symptomatic metastases.
Ongoing trials: SBRT vs Surgery for small peripheral tumors
RTOG 0236: 59 biopsy proven T1/2N0M0
3-year primary control rate was 98%
3-year disease free survival was 48%
Distant relapse

65. Advances in Chemotherapy
Traditional management:
Platinum based chemotherapy
Systemic toxicities high, tolerance poor
Poor response rate, particularly in NSCLCA

66. Advances in Chemotherapy
NSCLCA
Adenocarcinoma
EGFR expression seen in 15 % Erlotinib – 150mg PO daily
EML4-ALK gene rearrangements / fusion seen in 4% Crizotinib – 250mg PO BID
Newer targets: RAS, BRAF, MET, RET etc.

67. Advances in Chemotherapy
Immunotherapy
Nivolumab (approved March 2015)
Pembrolizumab (approved October 2015)

68. Advances in Chemotherapy
Immunotherapy
Nivolumab (approved March 2015)
Pembrolizumab (approved October 2015)

69. Lung Cancer Screening National Lung Screening Trial
55 – 74 years of age
30 pack-year history of smoking
Low-dose helical CT scanning
Mortality reduction of 20% when compared with CXR screening
How to implement this…

70. Lung Cancer Screening

71. Lung Cancer Screening Program
Positive
Referral to Surgeon
Consultation
Counselling
Smoking Cessation
Intermediate
Short Followup
CT-Scan
Negative
Return in 1 year
AACR
Database

72. Summary Lung cancer is the most common cause of cancer death in the US
Smoking is the biggest risk factor
Prevention, risk factor modification are the keys to improving survival

73. Summary Screening may effect a stage-shift in lung cancer diagnosis
Early stage-directed therapy is key
Significant advances in Surgery, Chemotherapy, and Radiation therapy for lung cancer

74. Safety  Quality  Service  Relationships  Performance
Any Questions?
Jeremiah Martin
Marion Hochstetler
(740)
Safety  Quality  Service  Relationships  Performance