Early Stage NSCLC

Question 1

Definition of early stage lung cancer

Answer 1

Stage I or Stage II

Question 2

Percentage of patients diagnosed with NSCLC that are considered early stage

Answer 2

~15% (13%)

Early stage (Stage I or II)

Question 3

Leading risk factors for development of NSCLC

Answer 3

• Smoking (largest)
• Radon gas exposure
• Asbestos

Question 4

Most patients with NSCLC present with __ stage disease

Answer 4

Locally advanced or metastatic disease

Question 5

Primary results of National Lung Screening Trial (NLST)

Answer 5

• 20% reduction in lung-cancer specific mortality with low-dose helical CT vs CXR
• 7% reduction in all-cause mortality with low-dose helical CT vs CXR

Question 6

NCCN Guidelines for Staging of Early-Stage biopsy proven NSCLC

Answer 6

• CT (chest and abdomen through adrenals)
• PET/CT
• Brain MRI (stage > Ib)

Question 7

Characteristics of suspicious appearing MLN on CT or PET/CT for lung cancer

Answer 7

• MLN > 1cm in long-axis diameter
• PET hypermetaboic (SUV >= 2.5)

Question 8

Approach to adrenal masses detected on staging workup for NSCLC

Answer 8

1. Assess for funcitoning tumor (pheo/cortisol/etc)
2. FNA biopsy of mass if non-functioning

Question 9

All primary tumor biopsy specimens should undergo pathologic review for what

Answer 9

1. Histologic subtype
2. Molecular markers (dictate adjuvant treatment)
   
   1. EGFR
   2. K-ras
   3. ELM4/ALK
   4. ERCC1

Question 10

MLN biopsy techniques and respective accessability patterns

Answer 10

1. Cervical mediastinoscopy (stations 2,4,7)
2. EBUS-TBNA (stations 1,2,3,4,7,10,11)
3. EUS-FNA (stations 2R,2L,4L,7,8,9 + left adrenal masses)

Question 11

Comparision of efficacy between mediastioscopy and EBUS-TBNA for MLN biopsy

Answer 11

Likely similar sensitivity, specificiy and diagnostic accuracy

(no direct head-to-head comparisons)

Question 12

POC (Standard of Care) for early-stage lung cancer

Answer 12

Lobectomy (vs. sublobar resection)

• Lower 5-year overall and cancer-specific mortality (67-90%)
• Lower local recurrence rate (1-12%)

Question 13

Approximate Local Recurrence (LR) and 5-year Survival (5-S) Rates for:

Lobectomy

Segmentectomy

Wedge Resection

Answer 13

• Lobectomy (1-12% LR, 65-90% 5-S)
• Segmentectomy (2-23% LR, 40-90% 5-S)
• Wedge Resection (15-30% LR, 25-70% 5-S)

Question 14

Evidence comparing lobectomy to sublobar resection for stage I NSCLC

Answer 14

Lung Cancer Study Group (1995)

• Multi-institution RCT
• Lobectomy vs. Sublobar resection
• Results:
  
  • No differnece in morbidity or PFTs
  • 3x increase in local recurrance after wedge resection
  • 2.4x increase in local recurrence after segmentectomy
  • Tumor size (even if < 1cm) did not affect local recurrence

Question 15

Surgical option for early stage NSCLC patients with poor cardiopulmonary fitness or other medical comorbidities precluding lobectomy

Answer 15

Segmentectomy with margins equal to size of primary tumor

(Preferable to wedge resection)

Question 16

Surgical option for proximal tumors

Answer 16

Sleeve resection (key is tension-free repair)

• Sleeve prefereable to pneumonectomy
• Anastomosis should be buttressed
  
  • Intercostal muscle
  • Omentum
  • Pericarium

Question 17

Benefits of buttressing bronchial anastomosis after sleeve resection

Answer 17

1. Improved anastomoic healing
2. Decreased risk of fistula formation (PA and bronchus)

Question 18

Characteristics of BAC

Answer 18

• originates from type II pneumocytes (Clara cells)
• presentation:
  
  • solitary peripheral nodule
  • pulmonary infiltrate
  • multi-focal disease

Question 19

Treatment options for BAC

Answer 19

• Lobectomy (Standard of Care [SOC], if PFTs will tolerate)
• Mutilple wedge resections (multifocal, disease burdon not extensive)
• Chemotherapy (EGFR inhibitors [25% pts with EGFR mutations] for extensive disease)

Question 20

Critical adjunct to all lobectomies

Answer 20

Mediastinal lymph node evaluation (dissection preferable)

• Right sided nodules
  
  • Stations (2R, 4R, 7, 8, 9, 10R and 14L)
• Left sided nodules
  
  • Stations (2L, 4L, 5, 6, 7, 8, 9, 10L and 14L)

Question 21

Comparison of VATS to Open lobectomy

Answer 21

Meta-analyses suggest that VATS (vs Open) associated with:

• Lower morbidity
• Improved QOL
• Improved survival

Question 22

Overall complication rate associated with early-stage lung cancer pulmonary resection

Answer 22

30%

Question 23

MC compliations after pulmonary resection

Answer 23

• Prolonged air leak
• Arrhythmia (atrial fibrillation)
• PNA
• Respiratory failure
• Wound infection
• Altered mental status

Question 24

Unique complication after RUL lobectomy

Answer 24

RML torsion

• Diagnosis:
  
  • RML atelectasis on postop CXR
  • Immediate bronchoscopy (CT if diagnosis in doubt)
• Treatment: Immediate reoperation (detorsion + RML staples pexy to RLL)
• Prevention: Stapled pexy of RML to RLL

Question 25

NCCN adjuvant treatment guidelines for Stage Ib NSCLC with R0 resection

Answer 25

Not indicated R0 resection alone is adequate SOC

Question 26

NCCN treatment guidelines for early-stage (I or II) NSCLC with R1 resection

Answer 26

1. Re-resection (preferred) 2. Adjuvant radiation therapy

Question 27

NCCN guideline indications for adjuvant chemotherapy following early-stage NSCLC resection

Answer 27

* T2a-b (\>3-less than or equal to 5cm), N0; high risk patient * Stage IIb tumors ( T3[\>5cm] N0 or T1-2, N\>0)

Question 28

First-line chemotherapy for adjuvant treatment of early stage NSCLC

Answer 28

Cisplatin-based regimen * Alternative: carboplatin + paclitaxol * unable to tolerate cisplatin rx * medical combidities preclude cisplatin rx

Question 29

NCCN treatment guidelines for medically inoperable early-stage(T1-2,N0) NSCLC patients

Answer 29

Definitive radiation therapy: preferably with stereotactic ablative radiotherapy (SABR)

Question 30

Indications for RFA in early-stage NSCLC

Answer 30

Patients lacking sufficient cardiopulmonary reserve to tolerate any pulmonary resection

Question 31

NCCN surviellence guidelines following surgical resection for early-stage NSCLC

Answer 31

H&P + non-contrast chest CT (Q4-6 months x 2 years, then annually) \*PET/CT not indicated for routine followup

Question 32

Prognosis for untreated early-stage NSCLC

Answer 32

Median survival ~ 17 months (0% 5-year survival) (5-year survival following R0 lobectomy: ~55-90%)

Question 33

Description of Stage I NSCLC

Answer 33

Tumors confined to lung without any local extension or metastases

Question 34

Description of Stage II NSCLC

Answer 34

Tumors associated with hilar or peribronchial lymph node involvement (N1) or with extension to the chest wall, mediastinum, or diaphrgam (T3, *adjacent resectable structures*)

Question 35

Description of Stage II NSCLC

Answer 35

Locally advanced tumors with mediastinal lymph node mets (N2 or N3), malignant pleural effusion, or invastion of adjacent non-resectable structures (T4)

Question 36

Description of Stage IV NSCLC

Answer 36

Tumors with distant mets (M1) or synchronous tumors in different lobes

Question 37

Main determinant of resectability for patients without distant metastatic disease

Answer 37

Mediastinal staging

Question 38

Most common methods of staging mediastinum

Answer 38

* CT scan * PET scan * Mediastinoscopy * EBUS

Question 39

Primary results of ACOSOG Z0050 trial (Reed et al, 2003)

Answer 39

PET scan prevented nontherapeutic thoracotomy in 6.3% of patients with NSCLC considered resectable by standard staging procedures.

Question 40

Postitive Predicted Value of PET for medistinal disease

Answer 40

56%

Question 41

Rationale for performance of mediastinoscopy for patients with T2,T3,or T4 tumors with negative mediastinal staging by CT or PET

Answer 41

15% of patients will have positive mediastinal node involvent that werould preclude curative surgery.