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Surgical Approach to Non Small Cell Lung Cancer

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Surgical Approach to Non Small Cell Lung Cancer. Dr Punnaruck Thongcharoen

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Surgical Approach to Non Small Cell Lung Cancer

  1. 1. Surgical approach to NSCLC Punnarerk Thongcharoen, MD Department of Surgery Faculty of Medicine Siriraj Hospital
  2. 2. Disclosure • No conflict of interest
  3. 3. Surgery for lung cancer • For diagnosis and staging • For curative treatment • For palliative treatment
  4. 4. Based on guidelines such as … • ACCP 2013 • ESMO 2014 • NCCN 2015
  5. 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for diagnosis and staging • N2 assessment • Cervical mediastinoscopy – former “Gold standard” invasive test • Has been replaced by EBUS as initial invasive mediastinal assessment • Primary tumor tissue diagnosis • Wedge excision with frozen section for undiagnosed lesion after less-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. 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
  7. 7. 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
  8. 8. 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.
  9. 9. Surgery for curative treatment • Early lung cancer • Locally advanced lung cancer
  10. 10. Early lung cancer • Stage I, II • Surgery is the mainstay of treatment. • Future of neoadjuvant/ adjuvant treatment???
  11. 11. Surgery for early NSCLC • Standard procedure • Anatomical resection and lymph node assessment • Resection • Pneumonectomy  Sleeve lobectomy • Lobectomy *** • Segmentectomy • Wedge resection
  12. 12. Sleeve lobectomy • If technically feasible (adequate free margin), sleeve lobectomy should always considered over pneumonectomy.
  13. 13. 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.
  14. 14. 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 .
  15. 15. • 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
  16. 16. 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
  17. 17. 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)
  18. 18. 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.
  19. 19. 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)
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. • 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.
  24. 24. • For stage II NSCLC, mediastinal lymph node dissection may provide additional survival benefit over mediastinal lymph node sampling and is suggested.
  25. 25. 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)
  26. 26. Open vs VATS • Open is standard. VATS is alternative. • Recently, NCCN 2015 • MIS (VATS) should be considered in selected patients • No oncologic compromised
  27. 27. • 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
  28. 28. Benefit of VATS • Direct benefit to the patients • Pain • Cosmetic • Hospital stay • Time for return to work • Time for starting adjuvant therapy
  29. 29. Benefit of VATS • For hospital • Shorter hospital stay  more patients admitted for treatment
  30. 30. 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
  31. 31. RATS • No clear benefit for lobectomy • May be useful for lobectomy with bronchoplasty
  32. 32. NOTES • Transtracheal • Transumbilical
  33. 33. NOTES Use natural orifice – No incision
  34. 34. 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
  35. 35. Surgery for locally advanced NSCLC • Local invasion • Chest wall, pericardium, vertebral body, atrium, Pancoast tumor • If N<2, consider en bloc surgery
  36. 36. Surgery for palliation • Malignant pleural effusion • Pleurectomy • Pleurodesis – mechanical/ medical • Shunt • Hemoptysis/ obstructive pneumonitis
  37. 37. Siriraj Lung Cancer Team
  38. 38. 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.
  39. 39. 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.
  40. 40. 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
  41. 41. 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.

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