PET Scanning and Lung Cancer- A Surgeon s Perspective

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1 PET Scanning and Lung Cancer- A Surgeon s Perspective

2 Disclaimer Member of advisory board Pfizer

3 Changing Environment Incidence Biology Detection Technology/treatment options

4 Canadian Cancer Statistics 2015

5 Canadian Cancer Statistics 2015

6 LUNG CANCER MORTALITY Canadian Cancer Statistics 2015

7 NEW CASES LUNG CA Canadian Cancer Statistics 2015

8 Biology Peripheral tumours Multiple ground glass opacities Lung cancer in non-smokers Molecular testing important treatable mutations

9 CT scanning Fast inexpensive Low dose Screening Detection

10 Technology Minimally invasive surgery safer, less painful EBUS Per oral lymph node biopsy SBRT non-surgical treatment option Combined radiotherapy/chemotherapy for cure Aggressive surgery in previously inoperable patients Treatment of oligomets Molecular testing personalized medicine

11 Related to cell type Staging Patient factors Prognosis

12 Staging Lung Cancer extremely stage dependent Treatment decisions driven by staging information Treatment options for primary curative treatment very dependent of best staging information possible

13 Staging Survival in lung cancer very sensitive to staging 5-year survival: Stage % Stage % Stage % Stage 4 1-2%

14 Staging-nodes N1 Hilar and intrapulmonary nodes N2 Ipsilateral mediastinal nodes N3 Contralateral mediastinal nodes Supraclavicular nodes 16/05/

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23 Treatment for cure Diagnosis Palliation Role of Surgery

24 Treatment for Cure Surgery Surgery + Chemotherapy SBRT XRT + Chemotherapy

25 Surgical Treatment VATS resection Well tolerated Extends indications Extent of resection Wedge/segment- 1% Lobectomy 1.5% Pneumonectomy 5% Lymph nodes resected for staging Re-resection increasingly common

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27 Decision PALLIATION CURE 27

28 Timing of Treatment 2009 Staging data indicates that size of tumour has a significant effect on cure rates The strategy of serial CT scans less attractive

29 Decision making Cell type Stage Patient factors-age, medical conditions, motivation Treatment decisions Pre-operative/intraoperative tumour biopsy Pre-operative lymph node biopsies SBRT - Surgery 29

30 PET in Lung Cancer Diagnosis Characterization of lung nodules treatment vs. observation vs. discontinue follow-up Definitive in certain circumstances Staging Unsuspected metastatic disease Lymph node status Chest wall involvement

31 PET in Definitive Diagnosis of Lung Cancer Poor condition patient with failure of needle biopsy Poor condition patient with typical radiological appearance not a candidate for biopsy VATS candidate with deep located nodule Discussion at tumour board

32 Conditions for PET diagnosis Typical radiological appearance Serial radiological changes typical of cancer No endemic inflammatory conditions Histo, Coccidio, TB Mutual agreement for PET only diagnosis

33 Clinical Situations aided by PET 1. Indeterminate pulmonary nodule 2. Lymph node assessment 3. Multiple Pulmonary Nodules 4. Metastatic disease

34 STAGE 1 RUL NODULE

35 TWO LUNG NODULES

36 TWO LUNG NODULES

37 LLL MASS AND HILAR LN

38 HILAR LN

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45 EBUS

46 Specific Situations Solitary brain met in otherwise operable cancer Questionable regional lymphatic metastatic disease and choice of primary treatment in poor risk patient Difficulty in obtaining a diagnosis in a very poor risk patient Locally advanced disease appropriate for concurrent chemo-radiotherapy Highly symptomatic patient with unsuccessful biopsy

47 CHALLENGES Atelectasis with a central tumour Large GGO s Carcinoid tumours Incidental positive findings

48 Treatment potentially curative Non small cell stage 1 Surgery/SBRT 65-80% Stage 2 - Surgery/Chemo 40-55% Stage 3 Chemo/XRT- 20%, rarely surgery Small cell limited stage Chemotherapy/Radiotherapy - 20% 48

49 Males 15% Females 18% Prognosis - cure Almost all surgical/chemo patients, occasional chemoradiotherapy Stage % Stage % Stage % Stage 4 1-2% 49

50 Conclusions PET scanning is of major importance in surgical decision making Aggressive potentially curable therapies are now rational with the additional staging information from PET Fewer futile therapies are used with the addition of PET scanning Future possibility of stratifying response to chemotherapy with PET

51 CONCLUSIONS Potentially increased numbers of nodules to assess with CT screening Tumour board review extremely important

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57 Diagnosis Bronchoscopy Mediastinoscopy EBUS Interventional radiology needle biopsy PET

58 Palliation Major surgery done only for potential cure Laser, malignant pleural effusions

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65 Squamous cell carcinoma 65

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67 Adenocarcinoma 67

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70 Lepidic carcinoma 70

71 Carcinoid 71

72 Stage 1 72

73 Stage 2B 73

74 Stage 3A 74

75 Stage 3B 75