Post on 27-Jan-2016
description
Matthew Kilmurry, M.D.
St. Mary’s General Hospital
Grand River Hospital
I have no conflicts of interest
The problem
2003 numbers for Ontario7500 new cases6300 deaths
Only 25% of cases are surgically resectable
Breast cancer in 2007 was 8000 new cases and 2000 deaths
Causes
Smoking Radon exposure Asbestos exposure Second hand smoke Genetics
Types of Lung Cancer
Primary Secondary
Colonic metsOther primaries
Resection of pulmonary mets Several prognostic factors
Disease free intervalNumber of metsResectability
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
Primary lung cancer
Small cell Non small cell
Accounts for 75-80 % of primary lung tumors
Screening
No accepted screening methodStudies using CT, CXR and sputum
High index of suspicionsmokers
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
Nodal stations
Surgical Approach
Diagnosis: Is this cancer? Metastases: Is there spread? Suitability: Is the patient healthy enough
for surgery?
Diagnosis
History and physical Chest X-ray CT scan Percutaneous biopsy Bronchoscopy
Metastases
History and physical Upper abdominal imaging Bone scan and CT head PET scan Mediastinoscopy
Nodal stations
Suitability
History and physical PFT’s Cardiac investigations
2D echoStress testNuclear medicine
CPET Quantitative V/Q scan
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 surgerySolitary brain mets
Treatment
Lobectomy preferred approachLimited resection has higher recurrence and
worse long term suvival
Stage survival, 5 yearsStage I – 60-70%Stage II – 40-50%Stage III – 15-25%Stage IV – 0-10%
Case # 1
65 year old male previous smoking history
Chest X-ray done as part of annual health exam
CT confirmed mass in LULSmall lesion also noted in RUL
Case # 1
Case # 1
Bronchoscopy and mediastinoscopy showed no evidence of mets
Thoracotomy confirmed diagnosis and had lobectomy
Right upper lobe nodule unchanged over two years
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
Case # 2
Case # 2
CT chest showed large tumour with no evidence of mets
Biopsy shows NSCLC PET scan shows no evidence of
metastatic disease
Case # 2
Mediastinoscopy showed metastatic disease in lymph nodes
Referred for chemoradiotherapy Possible candidate for surgery
Palliation
Majority of work with chemo and radiotherapy
Pain and symptom management vital Surgery sometimes required
Pleural effusionsEndobronchial tumours
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
Thoracic Program
Combined thoracic surgery at St. Mary’s General Hospital
CCO pushing to eliminate low volume thoracic centers
Working to keep thoracic surgery in Kitchener-Waterloo
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