DIAGNOSIS AND STAGING OF LUNG CANCER

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DIAGNOSIS AND STAGING OF LUNG CANCER

• Angeliki Rapti Chief of the 2nd Pulmonogy Deptm.
  Hospital of Chest Diseases of Athens
• MD, Phd, FCCP

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TOPICS

• Screening of lung cancer
• Symptoms
• Diagnostic methods
• Staging

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LUNG CANCERMORTALITY

• 214.000 patients 2007 - 169.400 2002 (US)
• Lung cancer causes more deaths than the four more
  common cancers combined (colon breast, pancreas,
  prostate)
• 1.2 million people worldwide died of LC in 2002

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LUNG CANCER

• Early diagnosis
• Good staging

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EALRY DIAGNOSIS

• Diagnosis of lung cancer in asymptomatic patients
• Resectable tumor

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Lung cancer screeningWhich of the following is
correct

• CXR
• Sputum cytology
• Low-dose spiral CT
• Biomarkers
• None of the above

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NONE OF THEM
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ACCP Guidelines

• Randomized controlled trials in the
  1970s-1980s showed that CXR and sputum cytology
  didnt change the mortality rates of lung cancer

• IT IS NOT RECOMMENTED
• The use of serial CXRs
• The use of single or serial sputum cytology
• To screen the presence of lung cancer

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Low-Dose
Spiral CT
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SCREENING WITH Low-Dose Spiral CT (LDSCT)

• LDSCT , compared with CXR, detects three times as
  many small lung nodules, of those that are
  diagnosed as cancer.
• 15- 30 of the nodules biopsies are negative

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Low-Dose Spiral CT

• The impact on mortality remains unknown
• Overdiagnosis of cancers
• High rates of benign nodule detection
• Uncertainty
• about how to assess nodule growth rates

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ELCAP TRIAL

• Diagnosis of stage I lung cancer
• 412 subjects of 31.567 ( 1.3) who had been
  screened by LDSCT

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SCREENING WITH Low-Dose Spiral CT (LDSCT)

• Two large trials using LDSCT as screening tool
• Mayo Clinic ELCAP
• Found the same lung cancer incidence and
  mortality compared with the Mayo Clinic Project
  (CXR)

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LUNG CANCER MORTALITY RATES

• Mayo Clinic Project (CXR)
• 4.4 deaths per 1,000 person-year in the CXR arm
• 3.9 deaths per 1,000 person-year in the control
  arm
• LDSCT
• 4.1 deaths per 1,000 person-year in the
• Mayo Clinic CT trial
• 5.5 deaths per 1,000 person-year
• in the ELCAP trial

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ACCP Guidelines

• IT IS NOT RECOMMENDED
• Low dose spiral CT in screening for lung cancer
  except in the context of a well designed clinical
  trial

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Screening with biomarkers

• Several promising biomarker tests for the early
  detection of lung cancer are under investigation
• Remains unclear the sensitivity and specificity
  of these tests
• Screening with biomarkers requires further
  clinical evaluation before any recommendation may
  be made.

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Which of the following is true

• 15 of patients with lung cancer are
  asymptomatic at presentation
• 35 of patients with lung cancer are
  asymptomatic at presentation
• 6 of patients with lung cancer are
  asymptomatic at presentation

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Which of the following is true

• 15 of patients with lung cancer are
  asymptomatic at presentation
• 35 of patients with lung cancer are
  asymptomatic at presentation
• 6 of patients with lung cancer are
  asymptomatic at presentation

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Which of the following symptoms is the most
common in lung cancer

• Sputum
• Chest pain
• Cough
• Hemoptysis
• dyspnoea

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Common symptoms of lung cancer

• Chest pain
• Cough
• Hemoptysis
• dyspnoea

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Which is true

• Patients with lung cancer usually present with
  respiratory symptoms
• With non specific systemic symptoms
• With multiple symptoms, respiratory and
  constitutional

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Symptoms of lung cancer

• Patients with lung cancer usually present with
  respiratory symptoms
• With non specific symptoms
• With multiple symptoms, respiratory and
  constitutional

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Shoulder and arm pain is present in which of the
following

• Arthritis
• Superior vena cava syndrome
• Pancoast syndrome
• Metastatic disease

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Shoulder and arm pain

• Arthritis
• Superior vena cava syndrome
• Pancoast syndrome
• Metastatic disease

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Pancoast syndrome

• Ipsilateral Horner syndrome
• ptosis-meiosis-anhydrosis
• Related to paravertebral extension sympathetic
  nerve involvement of the tumor

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Symptoms of intrathorasic disease

• Hoarseness
• Dysphagia
• Superior vena- cava syndrome
• plethoric appearance, distension of the venous
  drainage of the arm and neck - edema of the face,
  neck, arms
• Pleuritic pain
• Chest wall pain
• Cardiac tamponade

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Which of the following are most common in lung
cancer ( extrathoracic disease )

• Abdominal pain
• Weight loss
• Flank pain
• Anorexia
• Fatigue
• Headache
• Bone pain

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Which of the following are most common in lung
cancer ( extrathoracic disease )

• Abdominal pain
• Weight loss
• Flank pain
• Anorexia
• Fatigue
• Headache
• Bone pain

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Paraneoplastic syndromeswhich of the following
are most common in lung cancer

• Ectopic adrenocorticotropic hormone secretion
• Inapropriate production of antidiuretic hormone
• Hypertrophic osteoarthropathy
• Lambert - Eaton syndrome
• Clubbing of the fingers

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Paraneoplastic syndromeswhich of the following
are most common in lung cancer

• Ectopic adrenocorticotropic hormone secretion
• Inapropriate production of antidiuretic hormone
• Hypertrophic osteoarthropathy
• Lambert - Eaton syndrome
• Clubbing of the fingers

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ACCP Recommendations

• Patients with known or suspected lung cancer
  receive timely and efficient care. Grade of
  recommendation, 1B
• All patients with known or suspected lung cancer
  give a thorough history, and undergo a thorough
  physical examination and standard laboratory
  tests as a screen for metastatic disease. Grade
  of recommendation, 1C
• Patients with lung cancer and a paraneoplastic
  syndrome not be precluded from potentially
  curative therapy on the basis of these symptoms
  alone. Grade of recommendation, 2C

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Laboratoty findings which of the following is
most common in lung cancer

• Anemia
• Elevated ALP levels
• Hypercalcemia
• Hyponatremia
• Elevated liver enzyme levels

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Laboratoty findings which of the following is
most common in lung cancer

• Anemia
• Elevated ALP levels
• Hypercalcemia
• Hyponatremia
• Elevated liver enzyme levels

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Psycological disorders
hyponatremia
SCLC
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DIAGNOSTIC METHODS

• The method of diagnosis depends on
• Type of lung cancer
• Size
• Location of the primary tumor
• Metastasis
• Clinical status of the patient

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Diagnosis of primary tumormain goals

• Maximize the yield of the procedure for diagnosis
  and staging
• Avoid unnecessary invasive tests for the patient

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DIAGNOSTIC METHODS

• Sputum cytology (sensitivity 66 specificity 99)
• Pleural fluid cytology
• CT- scan
• Flexible bronchoscopy
• FNB
• FDG-PET scan

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Which of the following are true for positive
sputum cytology

• Adenocarcinoma
• Blood sputum
• Mediastinal infiltration
• Large tumor
• Central location

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Which of the following are true

• Adenocarcinoma
• Blood sputum
• Mediastinal infiltration
• Large tumor
• Central location

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Which of the following is the first procedure

• Flexible bronchoscopy
• Pleural biopsy
• Thoracentesis
• FNB
• Sputum cytology

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Which of the following is the first procedure

• Flexible bronchoscopy
• Pleural biopsy
• Thoracentesis
• FNB
• Sputum cytology

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FLEXIBLE BRONCHOSCOPY

• Diagnostic yield depends on
• location
• extension of the tumor

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Flexible bronchoscopy
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Patient with dry cough
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Bronchoscopy
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FNA-FNB
Sensitivity 92 False negative 30
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Which of the following are true to diagnose
pleural metastasis

• Pleural fluid cytology
• Percutaneous pleural biopsy
• Thoracoscopic pleural biopsy

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Which of the following are true to diagnose
pleural metastasis

• Pleural fluid cytology
• Percutaneous pleural biopsy
• Thoracoscopic pleural biopsy

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Diagnosis of pleural metastasis

• Three separate pleural fluid specimens give a
  positive diagnosis in 80 of patients
• Percutaneous closed pleural biopsy is diagnostic
  in 50 of patients
• Thoracoscopic pleural biopsy sensitivity
  80-99
• specificity 93-100

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SINGLE PULMONARY NODULE
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Which of the following are true

• SPN gt 8 mm in diameter are suspicious for
  malignancy
• Doubling times for malignant SPN are usually lt
  100 days
• SPN gt 5 mm are suspicious for malignancy
• Doubling times for malignant SPN are usually lt
  300 days

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Which of the following are true

• SPN gt 8 mm in diameter are suspicious for
  malignancy
• SPN gt 5 mm are suspicious for malignancy
• Doubling times for malignant SPN are usually
• lt 100 days
• Doubling times for malignant SPN are usually lt
  300 days

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Which of the following are true

• Increase in SPN diameter of 25 doubling
  of SPN volume
• Increase in SPN diameter of 50 doubling
  of SPN volume
• SPN stable in imaging tests for 2 years does not
  require further evaluation
• SPN stable in imaging tests for 3 years does not
  require further evaluation

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Which of the following are true

• Increase in SPN diameter of 25 doubling
  of SPN volume
• Increase in SPN diameter of 50 doubling
  of SPN volume
• SPN stable in imaging tests for 2 years does not
  require further evaluation
• SPN stable in imaging tests for 3 years does not
  require further evaluation

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ACCP RECOMMENDATIONS

• In every patient with an SPN visible on CXR
  previous CXR or other relevant imaging should be
  reviewed
• In patients with SPN that shows clear evidence of
  growth in imaging tests, biopsy should be
  obtained
• When the SPN is stable on imaging tests for at
  least 2 years no further evaluation is
  recommended except ground glass opacities

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FDG-PET Scan
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SPN- FDG-PET- CT

• Sensitivity 90 - 95
• Specificity 80 - 100
• Detection of unsuspected disease in 11-14 of
  pts
• Less sensitive for SPN lt 8-10 mm

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SPN-FDG-PET

• False negative
• BAC
• Carcinoid
• Mucinous adenocarcinomas
• False positive
• Infections
• TB
• Sarcoidosis
• Reumatoid nodules

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ACCP RECOMMENDATIONS

• In patients with low clinical probability of
  malignancy and a SPN .8-10 mm in diameter
• FDG-PET should be performed
• In patients with a SPN of high clinical
  probability of malignancy or patients with
  nodules lt 8 mm
• FDG-PET is not recommended

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ACCP RECOMMENDATIONS OBSERVATION OF SPN

• Very low clinical probability of malignancy
• low clinical probability of malignancy and no
  hypermetabolic in FDG-PET
• No diagnostic FNB - lesion no hypermetabolic in
  FDG-PET
• Patient prefers observation

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70 years old man - 60 py

• FNB
• Bronchoscopy
• Surgical resection

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ACCP RECOMMENDATIONS

• In surgical candidates with an indeterminate SPN
  at least 8-10mm surgical diagnosis is preferred
• Moderate to high probability of malignancy
• Positive FDG-PET
• Patient prefers surgery

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CLINICAL STAGING

• Chest-CT including images through the adrenal
  glands
• Bone scan
• CT or MRI of the brain

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FDG-PET-Malignant pleural effusion

• sensitivity 89- 95
• specificity 67- 94
• accuracy 91- 92
• Great negative prognostic value

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FDG-PET Malignant pleural effusion
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FDG-PET bone metastases

• sensitivity
  specificity
• PET 98 90
• Bone Scanning 90 60

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FDG-PET bone metastases
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ACCP RECOMMENDATIONS

• For patients with extensive mediastinal
  infiltration of tumor and no distant metastases,
  radiographic (CT scan) assessment of the
  mediastinal stage is usually sufficient without
  invasive confirmation.

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STAGING OF MEDIASTINAL LYMPH NODES

• sensitivity
  specificity
• CT 52-69 69-71
• PET 84 89

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STAGING OF MEDIASTINAL LYMPH NODES

• FNA
• CT PET EUS

Specificity EUS FNA 90
PET FNA 72
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ACCP RECOMMENDATIONS

• . For patients with either a known or suspected
  lung cancer who are eligible for treatment, a CT
  scan of the chest with contrast including the
  upper abdomen (liver and adrenal glands) should
  be performed. Grade of recommendation, 1B
• 2. In patients with enlarged discrete mediastinal
  lymph nodes on CT scans (gt 1 cm on the short
  axis) and no evidence of metastatic disease,
  further evaluation of the mediastinum should be
  performed prior to definitive treatment of the
  primary tumor Grade of recommendation, 1B

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Patient with NSCLC positive PET- scan for N2
lymph nodes

• No surgical resection
• Surgical resection- adjuvant therapy
• Biopsy of the lymph nodes

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FDG-PET SCAN ACCP RECOMMENDATIONS

• PET scanning to evaluate for mediastinal and
  extrathoracic staging should be considered in
  patients with clinical 1A lung cancer being
  treated with curative intent. Grade of
  recommendation, 2C
• 4. Patients with clinical 1B-IIIB lung cancer
  being treated with curative intent, should
  undergo PET scanning for mediastinal and
  extrathoracic staging. Grade of recommendation,
  IB
• 5. In patients with an abnormal result on FDG-PET
  scans, further evaluation of the mediastinum with
  sampling of the abnormal lymph node should be
  performed prior to surgical resection of the
  primary tumor. Grade of recommendation, 1B

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Thank you