Case Discussion (lung cancer)

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Case Discussion (lung cancer)

• Pinar Çelik
• TTS 15. Annual Congress
• 11-15 April 2012
• Antalya

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Conflict of interest

• I dont have any conflict of interest

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Synchronous lung cancer is determination of
second primary lung cancer in a patient with lung
cancer at diagnosis.

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Synchronous lung cancer

• Occurance rate 0.8 - 14.5
• 5-year survival rate 0-76
• Reasons of difference in survival Difficulties
  in diagnosis, BAC, inclusion of patients with
  carcinoid tumours and satellite noduls, few
  cases, second tumour is metastatic

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Synchronous lung cancer

• If the tumours histological types are different
  it is separate primary lung cancers
• If the tumours histological types are same
• One of them is primary, other one is
  metastase
• Synchronous lung cancer

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Martini-Melamed criteria

• 1. Tumours should be located distantly and
  separately
• 2. Histological types
• a. Different histology
• b. If same histology
• They should be located at different segment,
  lobe or lung and
• Originated from carcinoma insitu
• No presence of carcinoma at shared lymphatic
  drainage
• No extrapulmonary metastases at the diagnosis

Martini N, Melamed MR. J Thorac Cardiovasc Surg
1975
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Antakli criteria

• 1. Different histology
• 2. Same histology with two or more of the
  following
• a. Anatomically distinct
• b. Associated premalignant lesion
• c. No systemic metastases
• d. No mediastinal lymph node spread
• e. Different DNA ploidy

Antakli T. et al. Ann Thorac Surg 1995
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Staging ?

• There is no specific staging at synchronous lung
  cancer (TNM)
• Staging of each tumour should be done separately,
  advanced one should be recorded.
• Synchronous lung cancers was not discussed at
  last staging, their assessment was done as
  metastases of each other.

Pastorina U. Eur J Cancer 200137 75-90
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Staging

• When the synchronous lung cancer diagnosis is
  done distant metastases assessment and
  mediastineal staging should be done
• Mediastinal metastases should be proved
  invasively
• Cranial MR should be seen
• PET-CT should be done
• Pulmonary capacity should be evaluated

Detterbeck FC, Jones DR et al. Chest 2003 Bury T.
et al. Eur Resp J 1997
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PET-CT

• Standardized PET-CT has not true positive or
  negative rates in patients with nodule lt1 cm
• Spatial resolution of PET-CT is 6-8 mm
• PET-CT is not reliable in patients with lesion
  located at lower zone
• Duration of shot is longer than spiral CT
• Respiratory artefact

Allen-Auerbach M, Yeom K, Park J. et al. J Nucl
Med. 2006
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Staging (case)

• Evaluation of distant metastases and mediastinal
  staging was done with PET-CT
• Pulmonary capacity of patient was evaluated
• Invasive staging was not done
• Lesion at contralateral lung was not clarified at
  diagnosis (synchronous lung cancer, metastases,
  benign lesion?)

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Thorax CT(case)

A 40x25 mm lobulated, pleura based lesion with
malignant nature located at apical segment of
upper lobe of right lung was seen. Invasion to
chest wall or ribs was not observed. There was
no mediastinal, hilar or axillary pathological
lymphadenopathy.
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Thorax CT(case)

A 17x13 mm lesion with irregular border located
at laterobasal segment of lower lobe of left lung
was seen. This lesion was causing retraction at
major fissure. A 8 mm subpleural nodule at
laterobasal segment of lower lob of left lung was
seen.
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PET-CT (case)

• A pleura based lesion located at apical segment
  and posteromedial of posterior segment of upper
  lob of right lung was including posterolateral of
  right 3.rib (local invasion). The central of
  lesion was hypometabolic, border of lesion was
  hypermetabolic (SUV max 6.1),
• There was diffuse increase at right shoulder
  joint and muscle (SUV max 3.2), linear increase
  in sternum (SUV max 3.3).
• SUV value of nodule and mass located at lower
  lobe of left lung was not mentioned, probable due
  to low FDG value.

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PET-CT (case)

• A pleura based lesion located at apical segment
  and posteromedial of posterior segment of upper
  lob of right lung was including posterolateral of
  right 3.rib (local invasion). The central of
  lesion was hypometabolic, border of lesion was
  hypermetabolic (SUV max 6.1) (Malign lesion)
• There was diffuse increase at right shoulder
  joint and muscle (SUV max 3.2), linear increase
  in sternum (SUV max 3.3) (degeneration and
  by-pass)
• SUV value of nodule and mass located at lower
  lobe of left lung was not mentioned, probable due
  to low FDG value.

• Shreve PD, Anzai Y, Wahl RL. Radiographics 1999
• Sarji SA. Biomed Imaging Interv J 2006
• Prabhakar HB, Sahani Dv et al. Radiographics 2007

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Which lesion firstly operated?

• In bilateral synchronous lung cancers,
  thoracotomy should be done to the one which has
  more advanced stage.
• In bilateral synchronous lung cancers, if one of
  the tumours has definite diagnosis and the other
  one has no histopathological diagnosis,
  thoracotomy should be done to the one which has
  no histopathological diagnosis.

• Kocaturk CI, Gunluoglu MZ, Cansever L. et al. Eur
  J Cardiothorac Surg 2010, Ferguson MK et al. J
  Thorac Cardiovasc Surg 1985

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Surgery and treatment(case)

• Right lung was oparated (the one has advanced
  stage, but lesion at left lung did not have
  diagnosis).
• Surgery Partial resection of right 2-3-4
  ribsright upper lobectomyMLND
• Postoperation pathology (pStageT3N0M0)
• Tumour exceeded visceral and parietal pleura and
  invaded to ribs.
• Tumour smooth tissue was close to the surgery
  border but ther was no continuity.
• Postoperation RT was applied
• Adjuvant KT?
• Follow up (3 month interval)

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Chest wall invasion (T3N0M0)

• Total resection
• Only parietal pleura invasion exstrapleural
  resection
• More deeper invasions en block resection
• MLND
• Surgical border negative ? no need for
  postoperative RT
• Surgical border positive ? postoperative RT

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Thorax CT (9. month of follow up)

• At the bronchial stubby location,
  residual-recurrent mass was observed.
• A 19x13 mm lesion with irregular border located
  at laterobasal segment of lower lobe of left lung
  was seen. This lesion was causing retraction at
  major fissure and had malignant nature. With the
  comparison of previous CT , there was minimal
  increase in dimension, evident increase in
  density of mass.
• Also 8.5x6.5 mm stable subpleural nodule at
  laterobasal segment of lower lob of left lung was
  seen.

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PET-CT (9.month of follow up)

• Increase in F-18 FDG at fibrotic area located at
  apical segment of upper lobe of right lung (SUV
  max 2.7).
• Moderate increase in F-18 FDG at 15.3x15.6 mm
  irregular lesion that was located at laterobasal
  segment of lower lobe of left lung (SUV max 2.2)
  and increase in SUV max value of this lesion was
  observed at respiratory gating imaging af late
  phase (SUV max 3.0).
• At rectosigmiod junction focal invrease in
  activity (SUV max 3.0).

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PET-CT ( 9. month of follow up)
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PET-CT (9.month of follow up)

• Increase in F-18 FDG at fibrotic area located at
  apical segment of upper lobe of right lung (SUV
  max 2.7) (RT)
• Moderate increase in F-18 FDG at 15.3x15.6 mm
  irregular lesion that was located at laterobasal
  segment of lower lobe of left lung (SUV max 2.2)
  and increase in SUV max value of this lesion was
  observed at respiratory gating imaging af late
  phase (SUV max 3.0) (malign lesion)
• At rectosigmiod junction focal increase in
  activity (SUV max 3.0). (GIS N uptake or malign
  lesion)

• Shreve PD, Anzai Y, Wahl RL. Radiographics 1999
• Sarji SA. Biomed Imaging Interv J 2006
• Prabhakar HB, Sahani Dv et al. Radiographics 2007

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ACCP Recommendations

• In patients who have two synchronous primary
  NSCLCs and are being considered for curative
  surgical resection, invasive mediastinal staging
  and extrathoracic imaging (head CT/MRI plus
  either whole-body PET or abdominal CT plus bone
  scan) are recommended. Involvement of mediastinal
  nodes and/or metastatic disease represents a
  contraindication to resection (1C).
• In patients suspected of having two synchronous
  primary NSCLCs, a thorough search for an
  extrathoracic primary cancer to rule out the
  possibility that both of the lung lesions
  represent metastases is recommended (1C).
• In patients (not suspected of having a second
  focus of cancer) who are found intraoperatively
  to have a second cancer in a different lobe,
  resection of each lesion is recommended, provided
  that the patient has adequate pulmonary reserve
  and there is no N2 nodal involvement (1C).

Shen KR, Meyers BF, Larner JM et al. ACCP
evidence-based clinical practice guidelines.
Chest 2007 Suppl
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Surgical approach to bilateral synchronous lung
cancer
Kocaturk CI, Gunluoglu MZ, Cansever L et al. Eur
J Cardiothorac Surg 2010
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Surgical approach to unilateral synchronous lung
cancer
Kocaturk CI, Gunluoglu MZ, Cansever L et al. Eur
J Cardiothorac Surg 2010
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Diagnosis and treatment (case)

• 1. Moderate differantial squamous cell carcinoma
• Right upper lobectomypartial resection of right
  2-3-4 ribsMLND
• Postoperative RT was given, KT was not.
• 2. Synchronous tumour, adenocarcinoma mix type
  after 9 month later
• Resected with wide surgery border, not added to
  lobectomy, postoperative RT or KT were not given.

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Survival

• Between 2001 and 2008, survival analysis of 26
  consecutive patients diagnosed with synchronous
  lung cancer
• 5 year survival 49.7
• Unilateral 40.6
• Bilateral 62.8
• Prognostic factors
• Pneumonectomy bad
• Adjuvant KT good

Kocaturk CI, Gunluoglu MZ, Cansever L et al. Eur
J Cardiothorac Surg 2010
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Survival

• Between 2001-2008 years survival analysis of
  multicentered 6 study that include 467 patient
  applied curative resection due to synchronous
  multiplelung cancers
• Mean survival was 52 month, postoperative
  mortality 1.9
• Prognostic factors
• Age
• Male gender
• N1, N2
• Unilateral tumours
• Different histopathological type, increase
  mortality

Tanvetyanon HT, Finley DJ, Fabian T, Voltolini L,
Kocaturk CI, Fulp WJ et al. ASCO 2012
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Prognosis (case)

• Good prognostic factors
• Bilateral tumours
• No presence of N1, N2
• Complete resection
• Pneumonectomy was not done
• Bad prognostic factors
• Male gender
• Different histology
• KT was not given

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Thank you
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Metachronous lung cancer is new lung cancer
development after curative surgery due to primary
lung cancer.
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Metachronous lung cancer

• Different histopathology
• If the tumours histopathology is same
• Disease free duration more than 2 years (ACCP 4
  years)
• Originated from carcinoma in situ
• Location of second cancer at different lobe or
  lung
• No presence of carcinoma at shared lymphatic
  drainage
• No extrapulmonary metastases at the diagnosis

Martini N, Melamed MR. J Thorac Cardiovasc Surg
1975 Shen KR, Meyers BF et al. ACCP
evidence-based clinical practice guidelines.
Chest. 2007 Suppl
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Metachronous lung cancer

• Different histology
• Same histology with two or more of the following
• Anatomically distinct
• Associated premalignant lesion
• No systemic metastases
• No mediastinal lymph node spread
• Different DNA ploidy

Antakli T. An Thorac Surg 1995
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ACCP recommendation

• In patients who have a metachronous NSCLC and are
  being considered for curative surgical resection,
  invasive mediastinal staging and extrathoracic
  imaging (head CT/MRI plus either whole-body PET
  or abdominal CT plus bone scan) are recommended.
• Involvement of mediastinal nodes and/or
  metastatic disease represents a contraindication
  to resection (1C).

Shen KR, Meyers BF et al. ACCP evidence-based
clinical practice guidelines. Chest. 2007 Suppl
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Treatment

• Treatment of metachronous lung cancer is complete
  resection like primary lung cancer.
• Presence of mediastinal and distant metastases
  shold be looked before surgical treatment.
• Patient respiratory capacity determines the
  surgical procedure.
• If lobectomy or segmentectomy was done for
  primary lung cacer before, complementary
  pneumonectomy can be done for tumours located
  same side.
• If right pneumonectomy was done before, only
  limited resection can be applied to the left
  lung.

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Survival

• 2 year survival 52
• 5 year survival 20

Antakli T et al. Ann Thorac Surg 1995 Pastorina
U. Eur J Cancer 2001.