Matthew Kilmurry, M.D. St. Mary’s General Hospital Grand River Hospital.

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