lung cancer lecture

8/10/2019 Lung Cancer Lecture

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Matthew Kilmurry, M.D.

St. Marys General Hospital

Grand River Hospital


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I have no conflicts ofinterest


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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 pulmonarynodules 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


Upper abdominal imaging

Bone scan and CT head

PET scan

Mediastinoscopy


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Nodal stations


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Suitability


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 surgeryusually 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 I60-70%

Stage II40-50%

Stage III15-25% Stage IV0-10%


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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

lung cancer lecture

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