Lung Cancer Non-Small Cell Staging/Prognosis/Treatment

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Lung CancerNon-Small CellStaging/Prognosis/Treat
ment

• Oncology Teaching
• October 14, 2005
• Lorenzo E Ferri

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Lung Cancer
Highest cancer death rate for men and women
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Canadian Cancer Statistics 2004
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Lung Cancer Pathology

• Non-Small Cell
• Squamous Cell Carcinoma
• Adenocarcinoma
• BAC
• Large Cell
• Small Cell
• Neuroendocrine (Carcinoid, Large cell NE, small)

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Staging

• Staging should provide prognosis and dictate
  management
• TNM Classification universally accepted

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T status T1

• 3 cm or less, completely covered by pleura, does
  not involve main bronchus

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T Status T2

• gt 3cm
• Visceral pleura
• Main bronchus but gt 2cm from carina
• Atelectasis but not complete lung

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T status T3

• Chest wall
• Diapragm
• Mediastinal pleura
• Pericardium
• Main bronchus lt2cm to carina
• Complete atelectasis

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T Status T4

• Carina
• Vertebrae
• Great Vessel
• Esophagus
• Heart
• Separate tumour nodule in same lobe
• MALIGNANT pleural effusion

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Lymph Node Mapping
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N Status

• N0 no regional LN metastases
• N1 LN mets in ipsilateral peribronchial and/or
  intrapulmonary
• N2 ipsilateral mediastinal or subcarinal
• N3 contralat mediastinal or supraclavicular
  nodes

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M Status

• Common distant sites sites include
• Brain, bone, liver, adrenal
• Two nodules in same lung

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Stage I

• 1A T1 N0
• 1B T2 N0

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Stage IIA

• T1 N1

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Stage IIB

• T2 N1
• T3 N0

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Stage IIIA

• T1-3 N2
• T3 N1

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Stage IIIB

• T0-3 N3
• T4 N0-3

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5 Year Survival

• Overall 5 year survival 15 (no change in 3
  decades)

• IA
• IB
• IIA
• IIB
• IIIA
• IIIB
• IV

• 60-75
• 50-60
• 50-60
• 40-50
• 15-30
• 5-10
• 0-5

Mountain 1997, Rami-Porta 2000, Naruke 1988
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Survival
Survival by Pathologic Stage
Survival by Clinical Stage
MD Anderson 1975-1988
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Is all Stage IIIA (N2) the same?

• Single vs multiple station
• Bulky vs non-bulky
• Station 5/6 in LUL cancer
• Nodal vs extra-nodal disease

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Staging Investigations non invasive

• History and Physical! hoarseness (T3 or N2)
  supraclavicular nodes (N3)
• CXR Size (rough), chest wall (T3), effusion
  (T4)
• CT Chest/upper Abdo
• T status accurate
• N status (gt1 cm 70 , lt1cm7 )
• M status adrenal, liver, lung, bone

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Staging Investigations non invasive

• MR for T4 and M1
• thorax not routine for Pancoast
• Brain asymptomatic patients have brain mets in
  less than 3 Hillers et al Thorax 1994
• Bone Scan asymptomatic patients have mets in
  less than 5

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PET/CT

• Technology is evolving
• Allows for one step extrathoracic staging
• Independent predictor for survival (low SUV)
• What about mediastinum?
• NPP must be very high if invasive staging is to
  be avoided
• NPP98 in a recent study (Pozo-Rodriguez JSO
  2005)

Not good for BAC, small lesions lt0.5 cm
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PET/CT
Does this need pathologic confirmation?
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Invasive Staging Bronchial, Mediastinal and
Pleural

• Bronchial ? Bronchoscopy for proximal lesions
  (T3 vs T4)
• Pleural ?
• Throracentesis 60-65 accurate
• Pleuroscopy and biopsy more than 95

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Are all effusions associated with known lung
cancer malignant?
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Mediastinal Staging - Invasive

• CT and PET/CT better but not perfect for
  mediastinal nodes
• Mediastinoscopy is the gold standard!
• Assesses N2 and N3

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Endoscopic Biopsy EUS FNA TBNA
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What is really needed?

• Do we need to invasively assess N2 disease in
  everyone?
• Small peripheral lesion (esp SCC and BAC) have a
  low rate of mediastinal mets (1 cm10, 3 cm
  25)
• CT/PET accuracy is improving
• TBNA and EUS often obviate the need for M-scope

Institution specific U of T everyone gets a
M-scope McGill and rest of N.A. -
selective
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Treatment

• Stage IA Lobectomy (VATS vs Thoracotomy)
• Stage IB-IIB - Lobectomy adjuvant Cx
• Pancoast (T3N1) neoadjuvant chemorads (EP
  2cycles with 45 Gy)
• Stage IIIA
• T3N1 (resected) adjuvant Cx
• N2 disease ? ???
• Traditionally a non-surgical disease BUT..
• Neoadjuvant (Int 0139) - no Difference, but 27
  vs 20 5-yr survival - Albain et al ASCO 2005

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Treatment

• Stage IIIB definitive CxTx, BUT.
• Not all T4s are equal
• T4N0-1 aorta, vertebra, all other major vessels
  have been resected with reasonable 5 year
  survival (20-30) Rendina JTCVS 1999

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Treatment

• Stage IV
• Palliative median survival approx 6 months
• Malignant effusion if symptomatic
• Thoracentesis ?
• if no improvement think lymphangetic spread, PE,
  etc
• If symptomatically improved
• if lung expands ? Pleurodesis
• If lung trapped ? pleural drainage (tenkhoff vs
  repeated taps)

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