Wu C-Y, et. al. Ann. Thorac. Surg. 2013 Feb;95(2):405–11. Gonzalez-Rivas D, et al. Multimedia Manual of Cardiothoracic Surgery. 2012 Mar 23;2012(0):mms007–7.
LUNG CANCER- TREATMENT RECENT ADVANCES
Presenter- Dr.Jyotindra singh
Non Small Cell Lung Cancer
• Most common malignancy in males
around the world.
• Leading cause of cancer related
• Lung cancer recently surpassed
heart disease as the leading cause
of smoking-related mortality!
• In India accounts for the
commonest cancer in 3 leading
cancer registries – Bhopal, Delhi &
Incidence & Prevalence
Incidence per 100,000
Primary Lung Cancer
Small Cell type (20% – 30%)
Non Small cell type (70% - 80%)
Bronchial surface epithelial type
Squamous cell (30 - 50%)
Goblet cell type
Adenocarcinoma (20 - 40%)
Clara cell type
Large Cell (10 – 15%)
Type II alveolar cell type
Bronchial gland type
Carcinomas with sarcomatous elements
Squamous cell carcinoma
Incidence of SCC appears to be
decreasing relative to adenocarcinoma.
• Arise centrally –(two third) within
the main, lobar, segmental or
• Grow slow,metastasize late
• Extends both intrabronchially &
• Because there is exfoliation of the
malignant cells from the bronchial
surface, squamous cell carcinoma
can be detected by cytologic
examination at its earliest stage.
• Peripherally located-undergo central
necrosis with resultant cavitation
Squamous cell carcinoma
• Better prognosis than
• The more necrosis – the
worse the prognosis
• Well differentiated SCC –
more locoregional spread
• Poorly differentiated SCC
– early metastases to
• Alveolar filling of
peripheral SCC – more
CAVITATTION DUE TO TUMOUR NECROSIS
Usually arise in the smaller
peripheral airways (as distinct
from the cartilage bearing
Detected earlier by radiology.
Most common in non-smokers
Rising incidence associated with
different pattern of tobacco
More frequently associated with
pleural effusions and distant
Premalignant leison is known as
atypical alveolar hyperplasia.
On routine medical examination, the chest film of
a 64-year-old man shows bilateral primary lung
tumours in the upper lobes; the lesion on the left
side is partly obscured by the clavicle. (b) CT scan
clearly defines the irregularly shaped primary
lesions (arrows). Synchronous primary lung cancers
occur in about 3-5% of patients and can be of
different histologic subgroups.
Scar carcinoma- poor
Central fibrosis<5mmexcellent,>15mm – worst
Ground glass opacity <3 mm on
HRCT –Better prognosis.
Incidence of lymph node
involvement is less or even
absent when greater percentage
of ground glass appearance.
Central tumours- higher incidence
of LN metastasis.
BAC (variant)- higher incidence of
LN involvement .
• Genetic predisposition
– Genetic trait : Li Fraumeni syndrome
– Gene polymorphisms:
• DNA repair genes : XRCC1
• COX 2
• Interleukin 6
• Occupational & Environmental
– Asbestos exposure: Occupational or
residential (silicate type fibers)
– Foundry workers and welders: Ni,
– Uranium mine workers: Inhaled
– Air pollution:
• Diesel exhaust
• Metal fumes
• Air sulfate and PAH content
• Dietary influence
– Folate & B12 deficiency
– Inadequate antioxidant consumption
A cigarette is a euphemism for a
cleverly crafted product that
delivers just the right amount of
nicotine to keep its user addicted
for life before killing the person.''
World Health Organization
director-general Gro Harlem
• Signs directly caused by tumor
invasion or compression:
Limitation of chest movement
Vocal cord palsy
Engorged veins in the chest
wall and face
• Signs due to metastasis
– Bony tenderness
– Adrenal insufficiency
Eaton Lambert syndrome
Pure red cell aplasia
• Paraneoplastic syndromes:
– Cancer cachexia (MC)
– HPOA & clubbing
VIP induced diarrhea
• Investigations to confirm the disease
Sputum cytology (sensitivity 65% - 75%)
Transthoracic FNAC (sensitivity 87% - 91%)
Bronchoscopic biopsy (70% - 80%)
TT-FNAC associated with
• Pneumothorax (27%)
• Hemoptysis (5%)
• Local bleeding (11%)
• Investigations to assess the stage
• Investigations to assess fitness for treatment
– Renal and liver function tests
– Pulmonary function tests
• Plain X rays
– A tumor visible in a chest X ray has usually completed 75% of
it’s natural history.
– Guides local radiotherapy
• CT scans:
– Accurate assessment of primary disease.
– Best for detection of mediastinal and chest wall invasion.
• Nodal size < 1 cm : 8% chance of occult nodal metastasis
• Nodal size > 2 cm : 70% chance of occult or overt metastasis
– Assessment of abdominal disease esp. of adrenal involvement.
• PET CT has a greater degree of sensitivity for detection of
nodal disease that would be missed by size based criteria
Most valuable invasive investigation as it allows:
– Confirmation of diagnosis:
Biopsy and brushings 80% accurate
Low false positive rates 0.8%
Transbronchial forceps biopsy positive in 70%
Visualization of tumor done in 60% - 75%
– Staging of the tumor:
• Extent of bronchial and carinal involvement.
– Symptom alleviation:
• Bleeding control
• Importance in brachytherapy
– Response assessment
– Detection of preinvasive malignancy (screening):
• Autoflurosecence bronchoscopy.
– 3 cm or less,
completely covered by
pleura, does not involve
– > 3cm size.
– Visceral pleura
– Main bronchus invasion
but > 2cm from carina.
– Atelectasis / obstructive
extends to the hilar
region but does not
involve the entire lung.
Main bronchus <2cm to
– Complete atelectasis /
of entire lung
nodule in same lobe
– MALIGNANT pleural /
Staging: AJCC 2002
5 yr overall survival
IB IIA IIB IIIA IIIB IV
Chart illustrates the descriptors from the 7th edition of the TNM staging system for lung
• Tumor size cutoff of 3 cm.
– Several authors have demonstrated the prognostic value of size
> 5 cm and recommend it be incorporated in T3 disease.
• T3N0M0 is lumped into stage IIB
– Prognosis of patients with chest wall disease significantly better
than other T3 category tumors even after complete resection.
– Even those T3 patients who have rib destruction have a
significantly poorer prognosis as compared to those with soft
• Normal lymphatic drainage of the lung doesn't obey
– Right sided lymphatics extend to the left border of the trachea
across the midline.
– Survival of patients with level 3 and 7 nodal involvement is
Small cell lung carcinoma
• 15 – 25 % of all lung cancers
• Almost exclusively in smokers
• Distinguished from NSCLC by:
– Rapid doubling time
– High growth fraction
– Early development of widespread metastasis
• Typically arise centrally
• Most common presentation is a large
hilar mass with bulky mediastinal
• Commonly spread to
liver, adrenals, bone and brain.
• produces paraneoplastic Syndrome.
• Tumour markers-3 main groups:
Neural, Epithelial, Neuroendocrine.
VALG STAGING SYSTEM
Very-limited disease: confined to one
hemithorax without mediastinal lymph
Limited disease: confined to one
hemithorax including the contralateral
lymph nodes (all within radiation field).
Extensive disease: beyond these
SCLC without treatment
< 3 months
The host factors of poor
performance status and weight
Stage (limited versus extensive).
In extensive disease, the number
of organ sites involved is
inversely related to prognosis
Metastatic involvement of the
central nervous system, the
marrow, or the liver is
unfavorable compared to other
In most trials, women fare better
than men, although the reasons
for this are not known.
The presence of paraneoplastic
syndromes is generally
Combination of chemo & radiation
combination chemotherapy is the
backbone of treatment
thoracic radiotherapy significantly
improves long term survival
Early thoracic radiotherapy gives better
results than late radiotherapy.
Cisplatin and etoposide are most easily
combined within concurrent chemoradiation
protocols (Turrisi et al )
BID radiotherapy gives better local control and
better long term survival than QD (5y survival
%: 26% Turrisi et al, NEJM 99 )
PCI significantly improves survival by 4-5 % at
5 years when given to complete responders
(Auperin et al )
SCLC LD Standard of treatment
Cisplatin 80 mg/m2 d1
Etoposide 120 mg/m2 d1-3
Q3wk x 4
Thoracic Radiotherapy 45 Gy 1.5
Gy/fraction bid 3 wk
Turrisi et al. NEJM 1999
EXTENSIVE STAGE DISEASE
• Primary treatment is chemo
Cisplatin or Carboplatin plus
– Median survival approx. 11
– 5 year survival approx 0%
Second line therapy> 95 % relapse
after first-line treatment
Topotecan for chemo sensitive
Role of PCI
No improvement achieved by
– Novel agents (taxanes, topo 1
P = 0.0104
Surgical Aspects in Lung Cancer
• How fit is the patient ?
• What is the stage,
histology, and exact size
and location ?
• Is the patient for
– Combined wedge
Surgery : PFT based algorithm
FEV1 > 1.5 L
DLCO > 60%
FEV1 > 2 L
DLCO > 60%
•Calculated Post operative FEV1 & DLCO
V02 max < 15 ml/kg/min
V02 max > 15 ml/kg/min
NSCLC: Stage at Diagnosis
Stage I and II
– Surgery as primary treatment
– Multimodality Therapy
– Neoadjuvant therapy
(chemo/radiation) followed by
surgery & additional therapy
– Combination chemotherapy
& radiation therapy.
– Palliative chemotherapy and/or
radiation ,best supportive care
Ettinger et al. Oncology. 1996;10:81-111.
SEGMNENTECTOMY WEDGE RESECTION
Small peripheral tumour confined to
an anatomic segment.
Non anatomic and definitive
therapy only in poor risk patients.
Patient has limited pulmonary
CRITERIA FOR WEDGE RESECTION
A tumor < 3cm in diameter
Location in outer third of lung
Absence of endobronchial
Clear margins by frozen section
negative mediatinal & hilar node
Low grade tumour under
Lingulectomy( encompassing 2
segments)- peripheral NSCLC.
LCSG report Ginsberg- limited
resection for T1N0 NSCLC- local
recurrence 3 fold higher than for
lobectomy although ultimate
survival not significantly different,
CALBG ( cancer & leukemia
Group B ) - Trial of lobectomy vs
ACOSOG – Trial sublobar resection
vs sublobar resection + implanted
Segmentectomy vs wedge rxn
– Better deep margin (El Sharif et al Ann Surg Onc 2007)
– Better nodal evaluation/clearance
• Wedge resection
– Adequate for peripheral (subpleural), small
(1 cm) lesions when margin is wide
(diameter of lesion or more)
– If lesion straddles segmental boundary (i.e.
between lingula and upper division)
Resection of a lung cancer confined to
parenchyma of a single lobe.
Removal of tumour + peripheral
(pleural ) & central lymphatic drainage
Leaves sufficient lung volume to fill the
Ginsberg reported operative mortality –
2% vs 4 % for pneumonectomy.
• Involves resection of right
upper and middle lobe or of
the right middle & lower lobe• when a tumour located in
anterior segement of RUL
Tumour in RML has spread
across the minor fissure or
approximates an incomplete
• When tumour in RML is centralproximity of the origins of
superior segmental and middle
• Interlobar vascular vascular or
• Inability to achieve complete resection
–T3 or T4 tumors
–N2 or N3 disease
• Inability to obtain single lung ventilation
• Large Tumor > 5 cm (too large to remove
through utility incision)
• Conditions that compromise the safety of
-- Pre-op chemotherapy / radiation therapy or
-- Presence of hilar lympnadenopathy
-- Presence of extensive adhesions
Invasion of extra-pulmonary structure
1281 Propensity matched patients
(945 VATS, 857 thoracotomy)
Fewer overall complications
(35.7% vs. 26.2% p <.0001)
– Decreased arrhythmias
– Fewer pulmonary complications
– Fewer Blood transfusions
Shorter Hospital Stay (4 vs. 5
Equal operative mortality (1%)
Better quality of life
Easier for octogenarians
• Resection of lobe along with a
circumferential segment of
• Indicated for endobronchial
tumours at the origins of right
or upper lobe bronchi.
Tumour should be limited to
• Pts. With negative mediastinal
node has the best survival.
• Anastomotic complications
The indications are central tumors
that involve the main bronchus
Large parenchymal cancers that
violate the fissures or invade the
interlobar vessels, or hilar lymph node
Pneumonectomy in the latter situation
should be reserved for cases in which
higher stations are benign and a
complete resection is possible.
The operative mortality for
pneumonectomy is about twice that of
Patients with N2 disease or
centrally locally invasive tumours
are treated by induction therapydue to extent of their disease
they need pneumonectomy
Supra aortic pneumonectomy
CHEST WALL INFILTRATION
Tumors invading the chest wall are
The involved ribs should be
transected several centimeters beyond
the margin of gross involvement.
In most cases, one rib and intercostal
tissue above and below the tumor
should also be included in the
For posterior defects, support by the
remaining chest wall muscles and
scapula is usually sufficient.
Anterior and lateral defects more
often require reconstruction.
For isolated chest wall invasion with
N0 or N1 positive nodes, there is no
known role for neoadjuvant therapy.
There is controversy regarding the
necessity of chest wall resection when
invasion is confined to the parietal
When invasion occurs, that portion of the
diaphragm should be resected with a wide
margin of normal tissue without regard to
the extent of the defect.
If the defect is small and can be closed
primarily without tension- Prosthetic
When a large area of diaphragm has been
resected or when the phrenic nerve has
been resected- diaphragmatic
When the defect is peripheral, it may be
possible to reinsert the remaining cut
edge at a higher level on the chest wall
Total resection of the pericardium on the
left can be performed without
Partial defects should be closed to
prevent herniation and strangulation of
the left ventricle.
On the right side, all pericardial defects,
regardless of size, require repair.
Large defects can be closed with the
pericardial fat pad, a pleural flap, or
nonautologous material such as
bovine pericardium or
A small opening be left in the repair or
that the prosthetic material be
fenestrated to prevent cardiac
Vertebral body invasion is considered T4
disease and thus unresectable.
DeMeester and colleagues described a
technique of partial vertebral resection
for tumors fixed to the paravertebral
They use a through the transverse
process, costotransverse foramen, and
superficial vertebral body
En bloc pulmonary resection and
complete vertebrectomy with
reconstruction by a combined anterior
and posterior approach.
Used when - tumor extent is
completely delineated, nodenegative, totally resectable, and,
after careful evaluation with MRI,
does not involve the spinal canal.
―Pancoast Tumor‖ is a
neoplasm located at the apical
adjacent to the subclavian
Symptoms arise as a result of
neoplastic involvement of the
brachial plexus, nerve roots,
sympathetic chain, ribs, and
Ptosis of the left eyelid, miosis
of the pupil and decreased
sweating of the left face, arm
and upper chest (Horner's
chest film- large tumour of the
right upper lobe that has
destroyed the adjacent rib.
CT scan reveals rib and soft
tissue involvement as well as
destruction of an adjacent
Lymph node dissection
• Lobe specific
dissection in NSCLC:
– Right Side:
• Upper lobe (1,2,3,4,7)
• Middle lobe (1,2,3,4,7)
• Lower lobe (1,2,3,4,7,8,9)
– Left Side:
• Upper lobe (4,5,6,7)
• Lower lobe (4,5,67,8,9)
Technique of Mediastinal Lymph Node
• Right Paratracheal – clear
all tissue from SVC to
trachea and from upper
lobe bronchus to the
• Left Aorto-Pulmonary
Window –clear all tissue
from phrenic nerve to the
descending aorta and from
the left upper lobe
bronchus to the subclavian
• Subcarinal- clear out all
tissue bordered by the
right and left bronchi and
Video Assisted Mediastinoscopic Lymphadenectomy (VAMLA)
• Free resection margins proved
• At least a lobe specific mediastinal
nodal dissection with complete hilar and
intrapulmonary nodal dissection.
• At least 6 nodes should have been
removed with 3 from mediastinal nodes.
• No extracapsular extension in the
• Highest mediastinal node removed should
be microscopically free.
Ramon et al Lung Cancer (2005) 49, 25—33
Criteria for inoperability
• Tumor based criteria:
Cytologically positive effusions.
Vertebral body invasion.
Invasion or in casement of great vessels.
Extensive involvement of Carina or trachea.
Recurrent laryngeal nerve paralysis.
Extensive mediastinal lymph node metastasis.
Extensive N2 or any N3 disease.
Patterns of failure
• In stage I tumors:
– Local recurrence rate = 7%
– Distant failure rate = 20%
– Second primary cancer = 34%
Martini et al, J Thor Cardiov Surg 1995; 109: 95 – 110.
• In stage II / III tumors:
Intrathoracic failure rate: 31%
5 yr survival in clinical N2 negative nodes: 27%
5 yr survival in clinical N2 positive nodes : 8%
Tumors measuring 1-2 cm have a mediastinal nodal metastasis rate
of 17% as compared to those measuring 2 to 3 cm, when the rate
• Patients who fail after surgery, present with extrathoracic
disease 70% of the time, local recurrence in 20% and local
and distant metastasis in 10%.
• 2nd primary lung cancers are known to occur at a rate of 1%
per year in survivors.
Role of Radiotherapy
• Plays an important role in the management of
approx 85% of patients with non small cell lung
• RT can be applied in the following settings:
– With curative intent
– With Palliative intent
• RT is the most common treatment modality in
majority of patients in India as:
– Majority of the patients present with hilar or mediastinal
– Disease bulk prevents the use of surgical techniques.
– Associated comorbidities and poor lung function make
patients not suitable for surgery.
– Advanced age and poor socioeconomic status make RT an
attractive treatment option.
RT: Advanced Disease
– To achieve local
control due to high
probability of death due
to progression of
– T3 disease
– N1 or small N2 disease
– No evidence of distant
– Weight loss < 12% of
– < 50% of normal
working time spend in
– To achieve relief of
symptoms only when
disease is too advanced
for local control
– T4 disease
– Extensive N2 or N3
– Distant metastasis
– Weight loss > 12% of
– > 50% of normal
working time spend in
• Recent innovations
– 3 DCRT
• Respiratory gating:
– Tumors in lung may move by as much as 5-10 mm
during normal quiet breathing.
– The PTV may be effectively doubled if this is taken into
– Two techniques of respiratory gating are:
• Breathhold techniques:
– Active : Using valves and spirometers
– Passive: Voluntary breath holding
• Synchronized gating technique : Uses free breathing with
synchronized beam delivery.
Role of Postoperative Radiotherapy
– Advanced disease:
Margin positive (< 0.5 cm)
Microscopic or macroscopic residual disease
Hilar or mediastinal node positivity
Mediastinal or chest wall invasion.
• Dose : 30 – 40 Gy in 10-20 # over 2 weeks.
• Why is data regarding PORT inadequate?
– Unlike surgical series none of the studies have taken into
account the extent and site of nodal involvement which
have been found to be important prognostic variables.
– Many studies reported used inadequate doses .
• As far back as 1922, Yankauer placed capsules of
radium through a rigid bronchoscope into the
region of bronchogenic carcinoma.
• Brochoscopic afterloading flexible applicator based
technique first reported by Mendiondo et al.
– As a palliative measure
– Patients with clinically significant endobronchial
component who are not suitable for other forms of
– Life expectancy > 3 months.
– Ability to tolerate a bronchoscopy.
– Absence of bleeding diathesis.
Mostly used for
Stage IIIA disease
close or positive
• 3 radiation catheters
• Minimally invasive
• Radiation beads are
placed down the
• Then the beads are
• Very targeted – lung
motion is not an issue
• Based upon the premise that 70% - 80%
patients will have micrometastasis during
• Situations where CCT can be used:
Neoadjuvant CCT as an induction regimen
Adjuvant chemotherapy with or without
Palliative chemotherapy in systemic disease.
• No advantage of consolidation
chemotherapy has been established.
• Standard chemotherapy
– CAP regimen (q 3 weekly x 6
– CVP regimen
• 3 drug regimens have better
response rates but survival
benefit is absent.
• In a study by Schiller et al using
4 different platinum based CCT
regimens* failed to reveal any
benefit of a particular
Advanced Non-Small-Cell Lung Cancer: 2013 GUIDELINES
First-line Therapy: 2013
Option 1: choose 1 from column A and 1 from column B
Option 2: choose 2 from column B
Option 3: option 1 + column C (for certain patients)
Option 4: choose 1 from column D (for selected patients)
National Comprehensive Cancer Network clinical practice guidelines in oncology: Non-small-cell lung cancer
Contenders for Second Line and Beyond
• Non-small cell lung
• Small cell lung cancer
• EGFR Inhibitors
– Gefitinib (Iressa)
– Erlotinib (Tarceva)
• EGFR Monoclonal antibodies
– Cetuximab (Erbitux)
• VEGF Monoclonal antibodies
– Bevacizumab (Avastin)
• Many ongoing trials but what has emerged from already
concluded ones is:
Iressa does not prolong survival & no benefit from adding to
chemo also (IDEAL phase II trials, INTACT & ISEL phase III trials)
Erbitux may not show any benefit in combination with chemo
Avastin may show improved response in combination with chemo
but there is increased Grade III hemoptysis in squamous cell
Median time to progression increased by a mere 3 months.
Gefitinib: Mechanism of Action
R, epidermal growth factor receptor
Stereotactic Radiation for Lung Cancer (SBRT)
• Relatively new treatment
• Established in early 1990s at
• Few fractions/high doses/steep
• Goal is tumor ablation
– Medical inoperability
• Improved therapeutic ratio over
fractionated RT courses
Stereotactic Body Radiotherapy VS Standard radiotheraypy
Standard radiotherapy – 6 weeks
5 year survival rates 10 – 30%
SBRT – 1 to 5 days
Local control rates 90%
3 year survival rates 56 – 60%
Results- Tumor Response After RFA
RFA is the use of high-frequency
electrical current to heat a
specific volume of tissue to
temperatures high enough to
cause destruction of undesired
• Lifting of the deflated lower lobe
off of the diaphragm and
sometimes with takedown of the
inferior pulmonary ligament in
cases where the tumor is located
in the lower lobe, is beneficial
during ablation to protect the
3 months post-RFA
• Randomized trial of ―sublobar resection‖ vs.
• Clinical stage IA(T1a) with PFTs adequate
– VATS or Thoracotomy
• Sublobar Resection
– Wedge resection or segmentectomy
– VATS or Thoracotomy
Lung Cancer Surgery: future
Wu C-Y, et. al. Ann. Thorac. Surg. 2013 Feb;95(2):405–11.
Gonzalez-Rivas D, et al. Multimedia Manual of Cardiothoracic Surgery. 2012 Mar
• Minimally Invasive Lobectomy is the new
standard for early stage lung cancer
Equivalent oncologic results
Improved completion of adjuvant therapy
• Thoracoscopic (VATS) Lobectomy is well
• The roles of sublobar resection and Robotic
surgery require further investigation
Wayne McLaren as the Marlboro man (1976)
Dying from Lung Cancer (1992)
Seminar on NSCLC, Department of
Radiotherapy, PGIMER. Moderator :
Dr. R. Kapoor
Surgical Resection of the Lung
Standard of Care For Peripheral Nodules
adjuvant local/systemic Rx)
Randomized Trial of Lobectomy Versus
Limited Resection for
T1 N0 Non-Small Cell Lung Cancer
(125 Lobectomy , 122 Limited Resection)
RJ Ginsberg, LV Rubinstein and Lung
Cancer Study Group
Ann Thorac Surg 1995;60:615-23
Lobectomy vs Limited Resection
logrank p=0.088 (one-tailed)
Time to death (from any cause) by treatment
Ginsberg and Rubinstein
Ann Thorac Surg
Wedge Resection Versus
Lobectomy for Stage I (T1 N0
M0) Non-Small Lung Cancer
J Thorac Cardiovasc Surg
Wedge vs Lobectomy for
Stage I NSCLC
Local Recur (%)
Op Mortality (%)
*- all WR (n=95) vs. Lobe (n=124) Statistical Methods: Life Table Analyses
Obtained by Log Rank and Wilcoxson Tests
J Thorac Cardiovasc Surg
Comparison Between Sublobar
Resection and 125Iodine Brachytherapy
After Sublobar Resection in High-Risk
Patients with Stage I Non–Small-Cell
R. Santos, A. Colonias, D. Parda, M. Trombetta, RH Maley,
R. Macherey, S. Bartley, T. Santucci, RJ Keenan,
Surgery 2003, Oct;134(4): 691-7
1 (1%) p=.0001
3 (3%) p=ns
8 days p=ns
93, 73, 68, 60%
96, 82, 70, 67%
22 (23%) p=ns
1, 2, 3 and 4 year
Pre-op FEV 1%
The FEV 1 did not change postoperatively in the sublobar
resection with brachytherapy group in the interval of follow-
Lobectomy vs Sublobar
“Effect of Tumor Size on Prognosis in Patients
with Non-Small Cell Lung Cancer: The Role of
Segmentectomy as a Type of Lesser
Okada M, Nishio W, Sakamoto T, Uchino K, Yuki T,
Nakagawa A, Tsubota N.
“J Thorac Cardiovasc Surg. 2005 Jan;129(1):87-93”
An evaluation of surgical resection in 1272 NSCLC
Lobectomy vs Sublobar
5 Year Cancer Specific Survival “Stage I”
20 mm or less
More than 30
“Okada, M, et al J Thorac Cardiovasc Surg. 2005