1. To understand how to carry out an accurate diagnosis of lung cancer.
2. To learn about the actual therapeutic approach to lung cancer in the era of "personalised treatment".
3. To appreciate how a multidisciplinary team can make the difference in effectively managing lung cancer.
Lung cancer is the leading cause of cancer-related mortality worldwide. Non-small cell lung cancer (NSCLC), the most common subtype, has an overall 5-year survival rate of 16%, which has not improved significantly for several decades. The poor prognosis could be attributed to the diagnosis of lung cancer at an advanced stage and the lack of a cure. Radiological imaging plays a crucial role in the diagnostic workup of lung cancer, from the early identification to the accurate staging. The new staging TNM system introduced relevant changes in order to better reflects different patient prognosis, even though with some limitations. It is mandatory when lung cancer is suspected, to obtain a tissue diagnosis to ascertain the tumour type. Imaging modalities represent effective tools to guide further investigative procedures for tissue sampling and, therefore, to adequately guide patient management and treatment planning. In the past decade, the therapeutic arsenal for NSCLCs has diversified significantly, with the emergence of targeted therapies and, more recently, immunotherapies. Personalised treatment has grown with the integration of predictive biomarkers, giving the potential to identify patients who may experience the lowest toxicity and/or derive the greatest benefit from these new treatments based on individual tumour profile. Lung cancer treatment planning is a complex process that involves multiple specialities. In the past two decades, multidisciplinary care has emerged as the standard of care in lung cancer management. This session will be focused on discussing the main aspects of lung cancer diagnosis and management.
1. To learn how to optimise the diagnostic algorithm of lung cancer.
2. To understand the evolving meaning of TNM classification.
3. To become familiar with key imaging criteria to manage lung cancer.
Lung cancer (LC) staging is mandatory to formulate effective treatment strategies and optimise patient outcomes. The staging has traditionally relied on the TNM system, for which the International Association for the Study of Lung Cancer (IASLC), which is now in his eighth edition (TNM-8). The TNM-8 is based on detailed analysis of a new large international database of lung cancer cases assembled by the IASLC. Fundamental cornerstones of TNM-8 include the modifications to the T classification on the basis of 1-cm increments in tumour size, the grouping of lung cancers that result in partial or complete lung atelectasis or pneumonitis, and grouping of tumours with involvement of a main bronchus irrespective of the distance from the carina. Furthermore, reassignment of diaphragmatic invasion was included in terms of T classification, whilst the mediastinal pleural invasion was removed from the T classification, and the M classification was divided into different descriptors on the basis of the number and site of extrathoracic metastases. In response to these revisions, established stage groups have been modified, and others have been created. In addition, recommendations for classifying patterns of disease that result in multiple sites of pulmonary involvement, including multiple primary lung cancers, lung cancers with separate tumour nodules, multiple ground-glass/lepidic lesions, and consolidation, as well as recommendations for lesion measurement, are addressed. Understanding the key revisions introduced in TNM-8 allows radiologists to accurately stage patients with lung cancer and optimise therapy.
1. To learn about the best way to obtain tumour tissue using different approaches.
2. To optimise tumour tissue management increasing the diagnostic yield in histologic subtyping and predictive molecular determinations.
3. To understand the correct information to relate to the oncologist as the first line of treatment.
The advent of effective targeted therapies in lung cancer has significantly changed the standard of care and contemporarily stressed the need for even more tumour tissue finalised at predictive biomarker determinations. Lung cancer presentation, patients characteristics, tumor location and stage profoundly impact on the better approach to maximize the amount of neoplastic material using conventional invasive methods, while liquid biopsy does represent a new source of tumour cells, particularly helpful in monitoring disease progression and in the comprehension of the mechanisms of drug resistance when using specific inhibitors in oncogenic driven malignancies. Actually, radiologists and bronchoscopists are both involved in the correct choice to sample lung cancer, but no universally perfect procedures do exist. The significant increase of adenocarcinoma histology, representing about 60% of all lung malignancies, led to a huge number of peripheral tumours with more frequent mediastinal lymph node involvement. Then, computed-tomography (CT)-guided and transbronchial (with/without endobronchial ultrasound guidance, EBUS) fine-needle aspiration (FNA) are the most common adopted techniques, equally allowing a fair-to-optimal tumour specimen. First line treatment initially requires a precise histological definition of lung cancer. Indeed, about 30% of non-small-cell carcinoma (NSCLC) are poorly-differentiated requiring immunostains with TTF-1 (quite specific for adenocarcinoma) and p40 (indicating squamous cell differentiation). Advanced/metastatic adenocarcinoma, squamous cell carcinoma arising in non-smokers and NSCLC not otherwise specified require a prompt determination of EGFR mutations, ALK and ROS1 rearrangements and PD-L1 expression, whereas conventional squamous cell carcinoma needs only PD-L1 investigation.
1. To learn about the meaning of personalised treatment and the evolution of lung cancer therapies in the last 10 years.
2. To understand the role of the newer targeted therapies.
3. To become familiar with the needs of the oncologist to optimise lung cancer treatment.
Lung cancer treatment has become a paradigmatic example of personalised medicine. Therapeutic management takes into consideration histology, molecular pathology, staging, patients’ characteristics. The identification of oncogenic driver alterations (EGFR activating mutations, ALK/ROS1 translocations) allowed the development of targeted therapies based on molecular profiling, enriching the previous ‘histology-directed treatment’ paradigm. These drugs, counteracting the deregulated pathways, improved outcomes substantially, quality of life and toxicity in molecular selected populations and represent today the standard of care in the oncogene-addicted advanced disease. Nevertheless, acquired resistance arises. Newer agents, overcoming cancer escape, showed remarkable outcomes. Unfortunately, the best sequence of the available treatments, in most cases, is not defined. The landscape is evolving, and other oncogenes are emerging as potential targets implementing personalised medicine algorithms. In the case of non-oncogene addiction and permissive comorbidities, immunotherapy demonstrated successful results in different settings. PDL-1 is the current biomarker to identify patients who may benefit from frontline immune checkpoint inhibitors. However, because of its high variability and dynamic expression, complementary predictive factors are exploring to maximise patients’ selection. In this scenario, tissue availability, after histologic definition, is necessary; non-invasive methods are emerging to overcome the potential limits of biopsies or aspirates. Lung cancer is an increasingly complex and heterogeneous disease. Understanding how to best sequence and combine therapies could represent another important step in treatment personalisation. Cooperation and multidisciplinary approaches are the keys for the shared vision of a precision medicine aimed to offer the best treatment to every single lung cancer patient.
1. To learn about the advances in the surgical approach for lung cancer treatment.
2. To understand how the clinical staging may affect surgical results in lung cancer.
3. To become familiar with the needs of the surgeon to define the appropriate surgical approach.
The optimal management of non-small cell lung cancer (NSCLC) requires multidisciplinary collaboration. The incidence of stage I and II NSCLC is likely to increase with the ageing population and the introduction of lung cancer screening for high-risk individuals. The surgical approach is to be tailored upon each individual case, and options are lobectomy, sublobar resections (SLR), sleeve resections, and minimally invasive techniques such as video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS). Furthermore, radiation therapy (especially stereotactic body radiation therapy - SBRT), is a valid alternative in compromised patients who are high-risk candidates for surgery. Minimally invasive techniques are suitable for a subset of patients who can be selected on the basis of a pre-surgical investigation by imaging and bronchoscopic sampling by ultrasonography. Stage III NSCLC is also treated surgically with curative purpose when specific conditions are fulfilled. A variable combination with neoadjuvant chemotherapy in specific cases is discussed by the lung cancer team before surgical resection, to improve long-term outcome. The synergistic collaboration of the lung cancer team is based on diagnostic cornerstones, which are demanded by the surgeon for the optimal planning of lung cancer resection (either minimally invasive or enlarged) with or without pre-surgical neo-adjuvant therapy, or for the definition of those subjects at high risk for surgical procedures (alternative treatment such as SBRT).
Lung cancer management and treatment planning are complex processes involving multiple specialities. In the past two decades, multidisciplinary care has emerged as the standard of care for lung cancer patients. Multidisciplinary care facilitates discussions between the different specialists involved in the diagnostic process to ensure that the site with the highest chance of obtaining tissue from is targeted ﬁrst, thereby minimising the risk to the patient of recurrent procedures. There is evidence that access to the most accurate staging investigations is improved by multidisciplinary care, helping to limit unnecessary surgery which does not appear to occur at the expense of patient undertreatment. The impact of multidisciplinary care on measures of quality lung cancer treatment includes staging accuracy, access to diagnostic investigations, improvements in clinical decision making, better utilisation of radiotherapy and palliative care services, and improved quality of life for patients. Multidisciplinary care reduces variation in care, overcomes barriers to treatment, promotes standardised treatment through adherence to guidelines, and allows the audit of clinical services and for these reasons is more likely to provide quality care for lung cancer patients. This presentation is a case-based review demonstrating the added role of the multidisciplinary discussion on lung cancer patient management.