1) Surgery is still the mainstay of curative treatment for NSCLC, though diagnostic role has decreased with less invasive techniques preferred if doubt remains after needle biopsies. 2) Pre-operative assessment is key to determine operability and extent of surgery. N2 involvement means surgery is not recommended initially. 3) Lobectomy is the standard resection but sublobar options are available for selected patients based on cardiopulmonary reserve and disease characteristics like small GGO lesions. Pneumonectomy should be avoided with sleeve lobectomy preferred. 4) Minimally invasive surgery like VATS is becoming the preferred approach over thoracotomy for select patients when oncologic principles can be maintained

1. Surgical approach to NSCLC
Punnarerk Thongcharoen, MD
Department of Surgery
Faculty of Medicine Siriraj Hospital

2. Disclosure
• No conflict of interest

3. Surgery for lung cancer
• For diagnosis and staging
• For curative treatment
• For palliative treatment

4. Based on guidelines such as …
• ACCP 2013
• ESMO 2014
• NCCN 2015

5. Surgery for diagnosis and staging
• N2 assessment
• Cervical mediastinoscopy – former “Gold standard” invasive test
• Has been replaced by EBUS as initial invasive mediastinal assessment
• Primary tumor tissue diagnosis
• Wedge excision with frozen section for undiagnosed lesion after less-
invasive test has been attempted

6. Cervical mediastinoscopy’s role
• Extensive infiltration of the mediastinum, no evidence of extrathoracic
metastatic disease
• The diagnosis of lung cancer should be established by the least invasive and
safest method
• Bronchoscopy with TBNA
• EBUS-NA
• EUS-NA
• TTNA
• mediastinoscopy

9. N2 staging approach by CT imaging result
• Bulky N2 on CT no need fro invasive confirmation
• Discrete N2 on CT  invasive staging regardless of PET result
• NA over Sx
• Normal mediastinum CT
• Positive PET invasive staging
• Negative PET, + peripheral + Stage IA – No invasive staging needed

10. Invasive mediastinal staging
• Recommend needle technique (EBUS, EUS) over surgical, except
• LUL lesion  APW assessment by mediastinotomy/ mediastinoscopy/
VATS if other LN station are negative
• If clinical suspicion of N2 involvement remains high after a
negative result using NA, surgical staging (mediastinoscopy, VATS)
should be performed.

11. Surgery for curative treatment
• Early lung cancer
• Locally advanced lung cancer

12. Early lung cancer
• Stage I, II
• Surgery is the mainstay of treatment.
• Future of neoadjuvant/ adjuvant treatment???

13. Surgery for early NSCLC
• Standard procedure
• Anatomical resection and lymph node assessment
• Resection
• Pneumonectomy  Sleeve lobectomy
• Lobectomy ***
• Segmentectomy
• Wedge resection

14. Sleeve lobectomy
• If technically feasible (adequate free margin), sleeve
lobectomy should always considered over pneumonectomy.

15. Less than lobectomy for early NSCLC
• Poor lung reserved patients
• Severe co-morbidities
• In our experience, most are lingular segmentectomies in
elderly with concomitant COPD.

17. Sublobar resection: ACCP 2013
• For stage I NSCLC patient who may not tolerate a lobar resection due to
decreased pulmonary function or comorbid disease, sublobar resection is
recommended over nonsurgical therapy
• In patients with major increased risk of perioperative mortality or competing
causes of death (due to age related or other co-morbidities), an anatomic
sublobar resection (segmentectomy) over a lobectomy is suggested
• For stage I predominantly GGO lesion 2 cm, a sublobar resection with
negative margins is suggested over lobectomy .

18. • During sublobar resection of solid tumors in compromised
patients, it is recommended that adequate margins should
be achieved (2 cm)
• Sublobar resection should include sample of N1, N2

19. Sublobar resection: ESMO 2014
• For early stage T1N0 lung cancer, anatomical segmentectomy
or wide wedge resection are currently reconsidered for
small, non-invasive or minimally invasive lesions, especially
those with ground-glass opacity (GGO) characteristics

20. Sublobar resection: NCCN 2015
• Appropriate in selected patients
• Poor pulmonary reserve, severe co-morbidities
• Small (2cm), peripheral nodule with
• Pure AIS histology or
• GGO (50%) or
• Slow growing (imaging confirmed, doubling time – 400 days)

21. Multifocal lung cancer (MFLC)
• In patients with suspected or proven MFLC, it is suggested
that sublobar resection of all lesions suspected of being
malignant be performed, if feasible.

22. N2 disease
• Known N2  Sx is not recommended as initial therapy
• Incidental N2 (intraop finding)
• Continue resection as planned if formal preop med staging is done. If
not  stopping  complete med staging
• In VATS, may considered stopping operation. (NCCN)

23. Mediastinal LN assessment
• Systematic LN dissection
• Removal of all node-bearing tissue within defined landmarks for a standard set of
lymph node stations
• Systematic sampling
• Explore and Bx of a standard set of lymph node stations in each case
• LN sampling
• Only selected suspicious or representative nodes

24. LN assessment: ESMO 2014
• Systematic nodal dissection can be avoided in early-stage,
clinically N0 lung cancer when the maximum standardised
uptake value on PET scanning is <2.0 and the pathological
nodule size is ≤10 mm

25. LN assessment: ACCP 2013
• For stage I and II NSCLC, systematic mediastinal lymph node
sampling or dissection is recommended over selective or no
sampling for accurate pathologic staging

26. • For stage I NSCLC who have undergone systematic hilar and
mediastinal lymph node staging showing intraoperative N0
status, the addition of a mediastinal lymph node dissection
does not provide a survival benefit and is not suggested.

27. • For stage II NSCLC, mediastinal lymph node dissection may
provide additional survival benefit over mediastinal lymph
node sampling and is suggested.

28. Surgery for early NSCLC: Surgical techniques
• Conventional open thoracotomy
• Standard posterolateral thoracotomy
• Mini-thoracotomy with muscle sparing
• Minimally-invasive surgery
• Video-assisted thoracoscopic surgery (VATS)
• Robotic-assisted thoracoscopic surgery (RATS)

29. Open vs VATS
• Open is standard. VATS is alternative.
• Recently, NCCN 2015
• MIS (VATS) should be considered in selected patients
• No oncologic compromised

30. • When is open vs VATS vs RATS is preferred for early stage NSCLC?
• ACCP 2013: For stage I NSCLC, MIS such as VATS is preferred over a
thoracotomy and is suggested in experienced centers
• ESMO 2014: Either open or VATS access can be utilised as appropriate
to the expertise of the surgeon
• NCCN 2015: VATS/ MIS/ RATS should be strongly considered as long as
there is no compromise of standard oncologic and dissection principles.
In high VATS volume center, VATS is better than open regarding
• Pain, hospital stay, time return to function, complications occured

31. Benefit of VATS
• Direct benefit to the patients
• Pain
• Cosmetic
• Hospital stay
• Time for return to work
• Time for starting adjuvant therapy

32. Benefit of VATS
• For hospital
• Shorter hospital stay  more patients admitted for treatment

33. Evolution of VATS
• Standard VATS lobectomy
• 4 ports/ 3 ports
• Single port VATS lobectomy
• RATS
• MAGS: Magnetic-anchored guidance system
• NOTES: Natural orifice transluminal endoscopic surgery

35. RATS
• No clear benefit for lobectomy
• May be useful for lobectomy with bronchoplasty

36. NOTES
• Transtracheal
• Transumbilical

37. NOTES
Use natural orifice – No incision

38. Preop cardiopulmonary evaluation
• For cardiac assessment, use of the recalibrated thoracic RCRI is
recommended.
• For functional respiratory assessment, FEV1 and DLCO are required
• in case either one is <80%, use of exercise testing and split lung function are
recommended.
• In these patients, VO2max can be used to measure exercise capacity and
predict postoperative complications

39. Surgery for locally advanced NSCLC
• Local invasion
• Chest wall, pericardium, vertebral body, atrium, Pancoast tumor
• If N<2, consider en bloc surgery

40. Surgery for palliation
• Malignant pleural effusion
• Pleurectomy
• Pleurodesis – mechanical/ medical
• Shunt
• Hemoptysis/ obstructive pneumonitis

41. Siriraj Lung Cancer Team

42. Surgical approach to NSCLC: Summary I
• Surgery is still the mainstay of curative treatment for NSCLC
• Diagnostic role has been decreased, replaced by less invasive
needle technique procedures.
• If still in doubt after NA procedures, surgical staging is
considered.

43. Surgical approach to NSCLC: Summary II
• N2 is the key. If N2 is involved, then Sx is not a recommended
initial therapy.
• Preoperative cardiopulmonary assessment is mandatory to
determine operability, respectability and the extent of surgery.
• Lobectomy is still the standard resection for cure.

44. Surgical approach to NSCLC: Summary III
• Pneumonectomy should be avoided  sleeve lobectomy
• Sublobar resection is a good option in selected patient
• Patients factor: cardiopulmonary reserve, co-morbids
• Disease factor: clinical IA GGO

45. Surgical approach to NSCLC: Summary IV
• Minimally-invasive surgery (VATS) has been introduced as a preferred
surgical approach over conventional thoracotomy for selected patients
• Intraop LN assessment is crucial.
• I prefer “lobe-specific systematic dissection”.
• More extensive surgery offers benefits to locally advanced disease
• Palliative role of surgery in NSCLC still exists.