Lung CancerAn Overview

Wake Forest Baptist Medical CenterRadiation Oncology Department

John T. Lucas Jr. MD, MSCR PGY2

- Epidemiology- Prognosis- Etiology- Screening - Pathogenesis- Workup - Pathology- Staging - Pattern of Spread- Management

Outline

• In 2009, there were 219,000 newly diagnosed cases of lung cancers in the ∼ U.S., accounting for >160,000 deaths. >850,000 worldwide

• This > deaths from colorectal, breast, & prostate ca combined

• The overall 5-yr survival rate for NSCLC is 15%

• Most common stage @ dx ~ Metastatic (30%)– Stage 1 ~ 10% 5 yr OS 50-80%– Stage 2 ~ 20% 5 yr OS 30-70%– Stage 3 ~ 30% 5 yr OS 5-30%– Stage 4 ~ 40% MS 3-6 mo

Best supportive care 8-10mo

Epidemiology

Worldwide

• Blacks have the highest incidence of lung cancer.

• Lung Cancers in smokers– M>F

– Minimal variation in regional incidence

• Lung Cancers in never smokers have different

high risk groups– F>M

– Wide variation in regional incidence

Epidemiology

Is there a role for screening?

-Early Trials – NCI, Mayo-Trial design complicated by lead time, length time bias-Patient selection problems

Lead time bias

• No screening

Signs or symptomsDEATH

SURVIVAL

Screening

Positive test

DEATH

SURVIVAL

• 53,454 persons randomized to either low-dose spiral CT or conventional PA chest radiograph

• Prevalence screen, and two annual incidence screens

• Follow-up through 2009

• High Risk defined as: – age 55 – 74– current or former smoker (quit within the

last 15 years)– at least 30 pack years smoking history

Is there a role for screening?- NLSTDesign

Radiographic Classification

• Benign: benign calcification pattern, fat attenuation, linear morphology, stable for > 2 years

• Abnormal: new nodules > 10 mm diameter, or enlarging nodules > 7 mm not meeting benign criteria or unrelated to neoplastic process

• Indeterminate: new solitary or multiple nodules 4 -10 mm in diameter, or enlarging nodules < 7 mm

• Nodules < 4 mm

Is there a role for screening? - NLST

• If new abnormal nodule was observed

w/u bx etc.

• If new benign appearing lesion

continue screening

• If new benign appearing lesion that is enlarging

w/u bx etc.

Is there a role for screening?- NLSTDesign

Is there a role for screening?- NLSTResults

Is there a role for screening?- NLSTResults

Is there a role for screening?- NLSTResults

- 20% reduction in lung cancer–specific deaths in the LDCT group,

- 247 deaths due to lung cancer per 100 000 person-years in the LDCT group

- 309 deaths per 100 000 person-years in the chest radiography group

Is there a role for screening?- NLSTDiscussion – Risks?

So it works but is it worth it- i.e. is this PSA all over again?

-Overdiagnosis and intervention is a very real risk-60% of cases dx’d by PSA are not likely to result in a (-) in OS

-LDCT is unlikely to occur w/out regulation

-27% of LDCT arm had abnormal finding 96.4% were false positives

-60 days into NLST, 21 patients died 2/2 invasive eval for a abnl finding- 6 of these didn’t have lung ca

-Variation in how nodules are managed could yield excessive risk-CT guided FNA has 15% pneumothorax rate, 6% require chest tube

-Surgery for Lung Ca in trial done at academic centers, known to have >2 fold increase in @ 5yr compared to community centers

Is there a role for screening?- NLSTDiscussion – If applied?

- Informal dividing line b/n cost-effective & not cost-effective is around $50,000/ QALY

- 39.1% of patients screened would have a + finding, -e.g., a nodule 4 mm or larger, and each patient who was positive at baseline screening would undergo two follow-up chest CTs based on current practice standards.

- A 20% mortality reduction would work out to about a 0.04 increase in life-years when divided across the NLST cohort

-Previous estimates of COST/QALY were on the order of $150,000

- Preliminary estimates show additional cost of screening would work out to about $38,000 per QALY

- Alternative?

• Heavy smokers have a 20x excess of lung cancer (ACS cohort study).

• Risk of developing lung cancer in former smokers is around 1/2 (9x vs. 20x) that of current smokers (ACS cohort study).

• There is an RR of 1.2–1.3 for developing lung cancer from passive smoke exposure.

• Nicotine-derived nitrosoaminoketone (NNK)

• <20% of smokers actually develop lung cancer (in the Carotene and Retinol Efficacy Trial, 10-yr cancer risk was 1%–15%).

• Adenocarcinoma is the histologic subtype that is least associated with smoking.

Etiology

Pathogenesis-Smokers vs NonSmokers

Etiology - Nonsmokers

             

Lung Cancer Herbst, Heymach, and Lippman, M.D. N Engl J Med 2008; 359:1367-1380 

Etiology - Genetics

Source: Grace

Etiology - Genetics

• EGFR mut are more sensitive

than WT in vivo & in vitro

• 500-1000 fold compared to WT– 2/2 +apoptosis, cell cycle arrest

• Erlotinib & Gefitinib resistance

was overcome by IR

Pathogenesis- Why do I care? - EGFR

Cancer Res. 2006 Oct 1;66(19):9601-8. Non-small-cell lung cancers with kinase domain mutations in the epidermal growth factor receptor are sensitive to ionizing radiation. Das AK, Sato M, Story MD, Peyton M, Graves R, Redpath S, Girard L, Gazdar AF, Shay JW, Minna JD, Nirodi CS.

• Ras mut are more resistant

than WT in vivo & in vitro

• 2/2 constitutive Raf/MEK/ERK

• Can be overcome by

farnesyltransferase inhibitors

& KSR1 inhibitors

Pathogenesis- Why do I care? - Ras

Bernhard EJ, Stanbridge EJ, Gupta S, et al. Direct evidence for the contribution of activated N-ras and K-ras oncogenes to increased intrinsic radiation resistance in human tumor cell lines. Cancer Res 2000;60:6597–600

Cancer Ther. 2010 Oct;9(10):2724-36. 2010 Sep 28. Pharmacologic inactivation of kinase suppressor of Ras1 sensitizes epidermal growth factor receptor and oncogenic Ras-dependent tumors to ionizing radiation treatment.Xiao H, Zhang Q, Shen J, Bindokas V, Xing HR.

Pathogenesis(80%) NSCLC- Histologic Subtypes:50% Adenocarcinoma-Progenitor: BASC• Bronchoalveolar• Acinar• Papillary

(35%) SCC-Progenitor: Basal Cell

(15%) Large cell-Progenitor: NE Cell• Giant Cell• Clear Cell

(16%) SCLC-Progenitor: NE Cell

- H & P - ROS: PS, weight loss, baseline dyspnea- Physical Exam: note +/- clubbing, hoarseness, pain, palsy,

sympathetic deficit- (SH: Tobacco, Work/Home exposure)

- CBC, CMP, +/- ABG, +/- Alk Phos, LDH- FDG-PET, CT C/A/P

- Eval tumor, nodes, distant sites, & r/o other pathology (i.e. PNA)

- MRI Brain if:- LN+ Nonsquamous histology- All Stage 3-4

- ECOG PS - PFTs (DLCO, FEV1)- Tissue

Workup

• Pancoast Tumor: Apical Tumor + Chest wall inv

• Pancoast Syndrome: – Apical tumor + shoulder pain/brachial plexus palsy– +/- Horner’s Syndrome

Workup – Pancoast Tumor

• Endocrine – If diffuse complaints (N/V/lethargy) & not yet on tx

• CBC, CMP further w/u pending former

• Neurologic– If weakness that is focal & improves w/steroids

• C/T/L spine MRI

– If multifocal consider• r/o Steroid myopathy – Check CK• Neuro c/s

– Nerve conduction studies, EMG CSF, Neuro/Immune Ab panel

Workup – Paraneoplastic d/o’s

Workup- Paraneoplastic- Endocrine

Workup- Paraneoplastic- Neurologic

Workup- Paraneoplastic- Neurologic

Pathology

Pathology - AdenocarcinomaDiffuse TTF1+Focal p63+CK7+/CK20(-)

Multiple Histologic Subtypes: mixed, acinar, papillary, nonmucinous, mucinous, solid, fetal, signet, clear cell

Each w/varying genetics of unclear significance

NonsmokerEGFR mutations +f

SmokerKRAS mutations +f

BothTP53 mutations >70%Smokers>Nonsmokers

ALK mut 7%

Pathology – Squamous Cell Carcinoma CK5/6+

Keratin +<25% TTF1<25% CK7+

EGFR amp in 30%(-) f of KDR mutKRAS (-)p53 mut + in >60%

Pathology – Large Cell NE Carcinoma

Chromograninor Synaptophysin or NCAM +

50% TTF1+<25% CK1/5/10/14/20

*High propensity for CNSmetastasis

-PathologySmall Cell Carcinoma

EMA+TTF1+

+/- (25%) ChromograninSynaptophysinNCAMNeuron specific Enolase

Amp in c-Metp53 mut in >75%Rare:EGFR,ALK,KRAS

 - TNM Staging in 1972 for NSCLC

- Updated by Cliff Mountain in 1987 (4th)- Previously just MD Anderson data used for validation

- Updated by Cliff Mountain in 1997 (5th)

- The 6th Ed project started in 1998

- Two workshops in Brompton Hospital in 1998

- Committee reformed in 2002

- Revised by Sobin in 2002 NY (6th)

- New Staging by IASLC in 2009 (7th)

Lung Cancer Staging History

Changes to T Staging from 6th Ed.

T1 broken into T1a, Tb

T2 broken into T2a, T2bT2 given upper limit of 7cm

T3 now >7cm

Multiple tumor nodules in same lobe changed from T4 T3

Multiple tumor nodules in same lung but different lung from M1 T4

• Nodal staging was once divergent

in classification

• Naruke (Japan) & ATS/LCSG

had separate systems which

were reconciled in the AJCC in 1996

• Conflict: – ATS 10L & 10R vs. Naruke 10 (hilar) &

4 (lower paratracheal, including azygos nodes)

• Resolution: LN drainage

& anatomy is simplified w/zones– All nodes w/in mediastinal pleural reflection

= N2 nodes

– All LN stations distal to mediastinal pleural

reflection & w/in visceral pleura = N1 nodes

Changes to N Staging form 6th Ed.

Regional Lymph Node Classification for Lung Cancer Staging Clifton F. Mountain and Carolyn M. Dresler CHEST June 1997 vol. 111 no. 6 1718-1723

• Historically Stage 3 disease has been heterogenous based on TNM

• Widely regarded to have a uniformly poor prognosis based on OS

Controversies in Staging

• None were made to Nodal staging, however the N2 grouping remains a heterogeneous Stage grouping

• Staging LN by # Chains may be more useful than regions

Changes to Staging

Re-appraisal of N2 disease by lymphatic drainage pattern for non-small-cell lung cancers: By terms of nodal stations, zones, chains, and a composite. Zheng H, Wang LM, Bao F, Jiang GN, Xie HK, Ding JA, Hu XF, Chen C. Lung Cancer. 2011 Apr 27.

Changes to M Staging

Multiple tumor nodules in same lung M1 T4

M1 subdivided into M1a, M1b

Malignant pleural effusion reclassified from T4 M1a

Separate nodules in contralateral lung M1a

M1b = distant metastases

Staging- Role for Molecular Markers- Multiple Markers have been suggested in several Metanalyses

Favorablebcl-2EGFR Mut

AdverseTTF1Cox2EGFR AmpRasKi67HER2VEGFMicrovascular Densityp53Aneuploidy

- Many are being used to stratify treatment, none are being used for staging

7th Edition AJCC Staging – T Stage• Tx: No gross dz, but +cytology

• T1: <3cm• T1a: <2cm in greatest dimension

• T1b: >2cm, <3cm in greatest dimension

• T2: if 3-7cm and involves: main bronchus, 2cm or more distal to carina, invades visceral pleura, associated w/partial atelectasis or obstructive pneumonitis

• T2a: >3cm, <5cm in greatest dimension

• T2b: >5cm, <7cm in greatest dimension

• T3: >7cm or invades: – parietal pleura, CW, diaphragm, phrenic n, mediastinal pleura, parietal pericardium, <2cm

from carina, associated w/obstruction/atelectasis of entire lung

• T4: Any Size byt invades:– mediastinum, heart, great vessels, trachea, recurrent laryngeal n., esophagus, vertebral body,

carina, separate tumor nodule in different ipsilateral lobe

7th Edition AJCC Staging – N&M Stage• N Stage

– Nx: Regional LN cannot be assessed

– N0: No LN mets

– N1: Ipsilateral peribronchial, hilar, intrapulmonary LNs (>Lvl 10)

– N2: Ipsilateral mediastinal (< Lvl 7) &/or subcarinal LNs

– N3: Contralateral mediastinal, hilar, or contralateral scalene/SCV LNs

• M Stage– M0: No distant metastasis

– M1: Distant metastasis• M1a: Separate tumor nodule in contralateral lobe or malignant pleural effusion

• M1b: Distant Metastasis

7th Edition AJCC Staging – SCLC• 25-35% Limited Stage

– Confined to one hemithorax and regional nodes (conventionally one RT field)

• 65-75% Extensive Stage – -10% bave brain metastases at presentation

– Any disease not fitting into the above

Current Consensus Nodal Map

Regional Lymph Node Classification for Lung Cancer Staging Clifton F. Mountain and Carolyn M. Dresler CHEST June 1997 vol. 111 no. 6 1718-1723

Regional Lymph Node Classification for Lung Cancer Staging Clifton F. Mountain and Carolyn M. Dresler CHEST June 1997 vol. 111 no. 6 1718-1723

Stage Grouping

Patterns of Spread•Nodal

–Zones

–Stations

–Chains

•Distant–Brain

–Bone

–Adrenal Nodule

–Contralateral Lung

–Liver

–Pericardium

–Kidneys

–Subcutaneous

RU Mediastinum - R pre/paratracheal LN chain (4R, 2R, Sup 10R) - Tracheo-esophageal chain (LN Lvl 3p) - R. Phrenic n. chain (LN Lvl 3a)LU Mediastinum - Preaorto-carotid chain (LN Lvl 5,6) - L. Superior bronchial recurrent chain (Lvl 10L, 4L, 2L) - L. Phrenic n. Chain (Lvl 3a)Lower Mediastinum - Common inter-tracheobronchial chain (Lvl 7, 8, 10R, 10L) - Inf Pulm l. chain (LN not relevant-not pictured)

M. Riquet, A. Arame, C. Foucault and F. Le Pimpec Barthes, Prognostic classifications of lymph node involvement in lung cancer and current International Association for the Study of Lung Cancer descriptive classification in zones. Interact Cardiovasc Thorac Surg,  11  (2010), pp. 260–264.

Pattern of Spread

Re-appraisal of N2 disease by lymphatic drainage pattern for non-small-cell lung cancers: By terms of nodal stations, zones, chains, and a composite. Zheng H, Wang LM, Bao F, Jiang GN, Xie HK, Ding JA, Hu XF, Chen C. Lung Cancer. 2011 Apr 27.

Patterns of Spread

RUL (black nodes)RML (dark gray nodes)RLL (striped nodes)LUL (crosshatched nodes)LLL (dotted nodes)

Radiographics. 2004 Mar-Apr;24(2):419-34. Patterns of lymphadenopathy in thoracic malignancies. Sharma A, Fidias P, Hayman LA, Loomis SL, Taber KH, Aquino SL.

• No Accepted LN # for sampling• ATS recs sampling reachable nodal stations• AJCC recs

– R. Lung: 2R, 4R, 7, 10R, 11R– L. Lung: 5, 6, 7, 10L, 11L– Lower Lobe: Sample Lvl 9

• Ideal exploration (for staging) would include >= 1 LN node from the R & L, Superior & Inf paratracheal & subcarinal stations.

Mediastinal Staging

• NonInvasive– PET– CT– MRI

• Invasive– Trans Thoracic Needle Aspiration – EUS FNA– EBUS w/TBNA – Cervical Mediastinoscopy– Extended Cervial Mediastinoscopy– Thoracoscopy – Mediastinoscopy + Ant

Mediastinotomy – Radical Video-Assisted

Mediastinoscopic Lymphadenectomy

– Transcervical Extended Mediastinal Lymphadenectomy- TEMLA

Mediastinal Staging

 Summary ROC curve for imaging mediastinal lymph nodes that are > 1 cm diameter w/standard CT scanning

Chest. 2003 Jan;123(1 Suppl):137S-146S. Noninvasive staging of non-small cell lung cancer: a review of the current evidence. Toloza EM, Harpole L, McCrory DC.

Mediastinal Staging - Noninvasive

Summary ROC curve for imaging mediastinal lymph nodes that are > 1 cm diameter w/FDG PET

Chest. 2003 Jan;123(1 Suppl):137S-146S. Noninvasive staging of non-small cell lung cancer: a review of the current evidence. Toloza EM, Harpole L, McCrory DC.

Mediastinal Staging - Noninvasive

Sensitivity ~ 100% & Specificity ~ 84% for USPIO in predicting LAD

J Magn Reson Imaging. 2000 Dec;12(6):899-904. MR imaging of mediastinal lymph nodes: evaluation using a superparamagnetic contrast agent. Pannu HK, Wang KP, Borman TL, Bluemke DA.

Mediastinal Staging - Noninvasive

• Invasive Staging Techniques– Trans Thoracic Needle Aspiration – EUS FNA – EBUS w/TBNA – Cervical Mediastinoscopy– Extended Cervical Mediastinoscopy– Thoracoscopy – Mediastinoscopy + Ant Mediastinotomy – Transcervical Extended Mediastinal Lymphadenectomy- TEMLA

Mediastinal Staging - Invasive

Mediastinal Staging - Invasive

• Invasive Staging Techniques – Summary of Nodal Accessibility

= least invasive way of staging LN station

 

Surgical Assessment and Intraoperative Management of Mediastinal Lymph Nodes in Non-Small Cell Lung Cancer Review Article. The Annals of Thoracic Surgery, Volume 84, Issue 3, September 2007, Pages 1059-1065

Mediastinal Staging – Invasive - Utility

Mediastinal Staging – Invasive - TBNA

Chest. 2011 Feb;139(2):395-401. 2010 Oct 28. Rapid on-site evaluation of transbronchial aspirates in the diagnosis of hilar and mediastinal adenopathy: a randomized trial. Trisolini R, Cancellieri A, Tinelli C, Paioli D, Scudeller L, Casadei GP, Parri SF, Livi V, Bondi A, Boaron M, Patelli M.

 

Mediastinal Lymph Node Sampling

Complication rate 10.1%

Possible Complications-Hematoma-Recurrent Laryngeal n. injury-Infection-Pneumothorax

Mediastinal Staging – Invasive - Mediastinoscopy

 Mediastinal Staging – Invasive

J Thorac Cardiovasc Surg. 2011 Sep 30. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, da Cunha Santos G, Geddie W, Boerner S, Le LW, Keshavjee S.

EBUS & mediastinoscopy concordance rate for staging in 136 patients (91%; Kappa, 0.8; 95% confidence interval, 0.7-0.9).

No significant differences were found between EBUS-TBNA & mediastinoscopy in determining the true pathologic N stage (McNemar's test, P = .78).

EBUS Med

Complications 0% 2.6%%

EBUS Med

Sensitivity 81% 79%

Spec 100% 100%

NPV 91% 90%

PPV 100% 100%

Accuracy 93% 93%

153 NSCLC patients

EBUS TBNA

Mediastinoscopy

Prospective Trial EBUS vs. Mediastinoscopy

• Neuro

• Abdominal

• MSK

Staging Distant Disease

• Clinical Neuro Eval

• Clinical Abdominal Eval

• Clinical MSK Eval

Chest. 2003 Jan;123(1 Suppl):137S-146S. Noninvasive staging of non-small cell lung cancer: a review of the current evidence. Toloza EM, Harpole L, McCrory DC.

Staging Distant Disease

• Staging

• Target Delineation

• Prognosis

• Follow-up Imaging

• Technique

• Investigational Agents

Role for PET

Role for PET – Staging

Int J Radiat Oncol Biol Phys. 2004 May 1;59(1):78-86. Impact of FDG-PET on radiation therapy volume delineation in non-small-cell lung cancer. Bradley J, Thorstad WL, Mutic S, Miller TR, Dehdashti F, Siegel BA, Bosch W, Bertrand RJ.

Role for PET – Target Delineation

Int J Radiat Oncol Biol Phys. 2004 May 1;59(1):78-86. Impact of FDG-PET on radiation therapy volume delineation in non-small-cell lung cancer. Bradley J, Thorstad WL, Mutic S, Miller TR, Dehdashti F, Siegel BA, Bosch W, Bertrand RJ.

• Sensitivity and specificity of FDG-PET/CT for detecting recurrence has historically been estimated to range from 93% to 100% and 82% to 92%, respectively

Mac Manus MP, Ding Z, Hogg A, et al. Association between pulmonary uptake of fluorodeoxyglucose detected by positron emission tomography scanning after radiation therapy for nonsmall-cell lung cancer and radiation pneumonitis. Int J Radiat Oncol Biol Phys. [Epub ahead of print July 31, 2010].

Role for PET in follow-up

• Hoopes et al demonstrated that moderate HM activity may persist for up to 2 yrs after completion of SBRT w/out definite evidence of recurrence. – Validated prospectively

Mac Manus MP, Ding Z, Hogg A, et al. Association between pulmonary uptake of fluorodeoxyglucose detected by positron emission tomography scanning after radiation therapy for nonsmall-cell lung cancer and radiation pneumonitis. Int J Radiat Oncol Biol Phys. [Epub ahead of print July 31, 2010].

Role for PET in follow-up for SBRT

• A study from the University of Pittsburgh demonstrated a significant correlation with mean SUV and treatment response. (mean SUV decreases)– Complete responders, 94%, – Partial responders 48%, – Stable disease 28%– Patients with progressive disease had an SUV decrease of only 0.4%.

• However this study only had once LR, so their definition of CR, PR, SD is arbitrary and w/out clinical relevance

Clin Lung Cancer. 2008 Jul;9(4):217-21. Fractionated stereotactic body radiation therapy in the treatment of primary, recurrent, and metastatic lung tumors: the role of positron emission tomography/computed tomography-based treatment planning. Coon D, Gokhale AS, Burton SA, Heron DE, Ozhasoglu C, Christie N.

Role for PET in follow-up

• “Degree of post-treatment FDG uptake in patients receiving conventional radiation therapy for NSCLC has also been demonstrated to be a predictor of radiation pneumonitis”

- Albert Chang, Jeffrey Bradley PRO 2011

Mac Manus MP, Ding Z, Hogg A, et al. Association between pulmonary uptake of fluorodeoxyglucose detected by positron emission tomography scanning after radiation therapy for nonsmall-cell lung cancer and radiation pneumonitis. Int J Radiat Oncol Biol Phys. [Epub ahead of print July 31, 2010].

Role for PET in follow-up

• Used multivariate ordinal regression to look for covariates that would predict for pneumonitis

• No interactions tested for, data didn’t fit test assumptions• Radiation Pneumonitis is still a clinical diagnosis

• Reduces tumor vol (14-34%), & results in + SUVmax

Role for PET in Target Delineation: Technique

Med Phys. 2004 Dec;31(12):3179-86. Four-dimensional (4D) PET/CT imaging of the thorax. Nehmeh SA, Erdi YE, Pan T, Pevsner A, Rosenzweig KE, Yorke E, Mageras GS, Schoder H, Vernon P, Squire O, Mostafavi H, Larson SM, Humm JL.

• IASLC meta-analysis showed that a high lesion SUV is a poor prognosticfactor for OS in patients w/locallyadvanced NSCLC

• If 1o w/ max SUV >15 (-) in OS &were more likely to have mediastinalLN involvement

• Reduction in SUVmax by >80% is 96% accurate for predicting pCR

• Reduction in SUVmax by >20% w/chemo portendsimproved PFS, and OS

Role for PET in Prognosis

J Thorac Oncol. 2010 May;5(5):612-9. Primary tumor SUV measured on FDGPET is of prognostic value for survival in NSCLC: update of a systematic review and meta-analysis by the European Lung Cancer Working Party for the IASLC Staging Project. Paesmans M, Berghmans T, Dusart M, Garcia C, Hossein-Foucher C, Lafitte JJ, Mascaux C, Meert AP, Roelandts M, Scherpereel A, Terrones Munoz V, Sculier JP

JCO, Vol 21, Issue 14 (July), 2003: 2651-2657 PET in NSCLC: Prediction of Response to Chemo by Quantitative Assessment of Glucose Use. Weber, Petersen, Schmidt, Tyndale-Hines, Link, Peschel, Schwaiger

• Early Stage- f/u visits– Post Tx: @ 2 mo then q4mo thereafter for 2 yrs

• 2 mo visit to establish baseline CT prior to tx change• q4mo visits: CT w/out contrast if no concerns

– 2 Yrs Post Tx: q6mo for 5 yrs w/CT– 5 yrs Post Tx: q1yr w/CT

• Advanced Stage- f/u visits– Post Tx: @ 2mo then q3 mo for 1 yr alternating w/MedOnc– 1 yr post Tx: q4mo w/CT (MedOnc orders scans)– 2yr post Tx: q6mo for 5yrs w/CT (usually MedOnc & RadOnc

same day)

Lung Cancer Management:

If new dyspnea while on treatment:- r/o Alternative Causes

- i.e. PE- Optimize Inhalers if not already done based on PFTs

If new dyspnea in f/u:-r/o Alternative Causes

- i.e. PE-Optimize Inhalers if not already done based on PFTs-Consider rpt PFTs-Review stability of patient’s COPD, i.e. would they benefit from prevention?

Lung Cancer Management- Dyspnea

The frequency of exacerbations (P=0.01):-Azithro: 1.48 per patient-yr -Placebo: 1.83 per patient-yr

-HR for having an acute COPD exacerbation per patient-yr in the azithromycin group was 0.73 (95% CI, 0.63 to 0.84) (P<0.001).

Lung Cancer Management- Dx & Tx of ExacerbationsProspective Trial-Azithromycin vs. Placebo for 1 yr

Endpoint: - # of exacerbations- QOL

Symptoms:- Nonproductive cough- Dyspnea w/exertion- Fever low grade- Pleuritic Chest pain- Malaise

Dx:- Low O2 Sat- A-a gradient on ABG- Depressed DLCO

Tx:- Prednisone 60mg/day for 2 wks w/taper over 3 wks- Consider antibiotics if prolonged taper & other risk factors for immunosuppression

Lung Cancer Management:- Radiation Pneumonitis

Lung Cancer Management: Resources

• MedOnc: – Petty

– Miller

– Ruiz

• CT Surg– Oaks

– Lata (VA)

• Trial Coordinator– Margaret Crowley

– Kathyrn Joesphs-Finlay

• Pulmonary Med: – Conforti– Bellinger

• TOPs Scheduling– Dee Cottrell

• CT Guided Lung Bx– MD - Clark

– Aaron Weldon/Helen Phelps

• VA Scheduling– Emy White

• Lodging etc.– Sally Benfield

European Journal of Cardio-Thoracic Surgery Vol 32, Issue 1, July 2007, Pages 1-8. ESTS guidelines for preoperative lymph node staging for non-small cell lung

cancer. Paul De Leyna, Didier Lardinoisb, Paul E. Van Schilc, Ramon Rami-Portad, Bernward Passlicke, Marcin Zielinskif, David A. Wallerg, Tony Leruta, Walter Wederb