PET Scanning and Lung Cancer- A Surgeon s Perspective
Disclaimer Member of advisory board Pfizer
Changing Environment Incidence Biology Detection Technology/treatment options
Canadian Cancer Statistics 2015
Canadian Cancer Statistics 2015
LUNG CANCER MORTALITY Canadian Cancer Statistics 2015
NEW CASES LUNG CA Canadian Cancer Statistics 2015
Biology Peripheral tumours Multiple ground glass opacities Lung cancer in non-smokers Molecular testing important treatable mutations
CT scanning Fast inexpensive Low dose Screening Detection
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
Related to cell type Staging Patient factors Prognosis
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
Staging Survival in lung cancer very sensitive to staging 5-year survival: Stage 1 60-80% Stage 2 40-55% Stage 3-10-15% Stage 4 1-2%
Staging-nodes N1 Hilar and intrapulmonary nodes N2 Ipsilateral mediastinal nodes N3 Contralateral mediastinal nodes Supraclavicular nodes 16/05/2016 14
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Treatment for cure Diagnosis Palliation Role of Surgery
Treatment for Cure Surgery Surgery + Chemotherapy SBRT XRT + Chemotherapy
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
Decision PALLIATION CURE 27
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
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
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
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
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
Clinical Situations aided by PET 1. Indeterminate pulmonary nodule 2. Lymph node assessment 3. Multiple Pulmonary Nodules 4. Metastatic disease
STAGE 1 RUL NODULE
TWO LUNG NODULES
TWO LUNG NODULES
LLL MASS AND HILAR LN
HILAR LN
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EBUS
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
CHALLENGES Atelectasis with a central tumour Large GGO s Carcinoid tumours Incidental positive findings
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
Males 15% Females 18% Prognosis - cure Almost all surgical/chemo patients, occasional chemoradiotherapy Stage 1 60-80% Stage 2 40-55% Stage 3 10-15% Stage 4 1-2% 49
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
CONCLUSIONS Potentially increased numbers of nodules to assess with CT screening Tumour board review extremely important
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Diagnosis Bronchoscopy Mediastinoscopy EBUS Interventional radiology needle biopsy PET
Palliation Major surgery done only for potential cure Laser, malignant pleural effusions
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Squamous cell carcinoma 65
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Adenocarcinoma 67
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Lepidic carcinoma 70
Carcinoid 71
Stage 1 72
Stage 2B 73
Stage 3A 74
Stage 3B 75