Lung Cancer: A Surgeons Perspective

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Lung Cancer A SurgeonsPerspective

• Matthew Kilmurry, M.D.
• St. Marys General Hospital
• Grand River Hospital

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I have no conflicts of interest
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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

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Causes

• Smoking
• Radon exposure
• Asbestos exposure
• Second hand smoke
• Genetics

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Types of Lung Cancer

• Primary
• Secondary
• Colonic mets
• Other primaries

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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

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Primary lung cancer

• Small cell
• Non small cell
• Accounts for 75-80 of primary lung tumors

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Screening

• No accepted screening method
• Studies using CT, CXR and sputum
• High index of suspicion
• smokers

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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

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Nodal stations
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Surgical Approach

• Diagnosis Is this cancer?
• Metastases Is there spread?
• Suitability Is the patient healthy enough for
  surgery?

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Diagnosis

• History and physical
• Chest X-ray
• CT scan
• Percutaneous biopsy
• Bronchoscopy

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Metastases

• History and physical
• Upper abdominal imaging
• Bone scan and CT head
• PET scan
• Mediastinoscopy

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Nodal stations
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Suitability

• History and physical
• PFTs
• Cardiac investigations
• 2D echo
• Stress test
• Nuclear medicine
• CPET
• Quantitative V/Q scan

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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

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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

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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

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Case 1
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Case 1

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

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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

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Case 2
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Case 2

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

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Case 2

• Mediastinoscopy showed metastatic disease in
  lymph nodes
• Referred for chemoradiotherapy
• Possible candidate for surgery

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Palliation

• Majority of work with chemo and radiotherapy
• Pain and symptom management vital
• Surgery sometimes required
• Pleural effusions
• Endobronchial tumours

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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

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Thoracic Program

• Combined thoracic surgery at St. Marys General
  Hospital
• CCO pushing to eliminate low volume thoracic
  centers
• Working to keep thoracic surgery in
  Kitchener-Waterloo

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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