Matthew Kilmurry, M.D.

St. Marys General Hospital

Grand River Hospital

I have no conflicts of
interest
The problem
2003 numbers for Ontario
7500 new cases
6300 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 mets
Other primaries
Resection of pulmonary
mets
Several prognostic factors
Disease free interval
Number of mets
Resectability
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 method
Studies using CT, CXR and sputum
High index of suspicion
smokers

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
PFTs
Cardiac investigations
2D echo
Stress test
Nuclear 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
surgery
Solitary brain mets
Treatment
Lobectomy preferred approach
Limited resection has higher recurrence and
worse long term suvival
Stage survival, 5 years
Stage 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 LUL
Small 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 effusions
Endobronchial 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. Marys
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