SURGERY FOR NSCLC

GREG CHRISTODOULIDES

MD, FACS, FCCP, FESTS

THORACIC SURGEON

Mar. L. March 9-11, 2012

General Remarks

• Surgical excision of NSCLC gives the best chance for cure

• Unfortunately <20% of lung cancers are diagnosed in early stage

• In Cyprus there are about 200 cases of lung cancer recorded every year and about 100-120 thoracotomies performed in general (Cancer Registry)

Surgical risks in elective lung resection

• Major complications occur in 9%• Minor events in 19% (J.Martin 2004)

• Mortality is 3% for lobectomies and 6% for pneumonectomies

• Our mortality in Cyprus is 2% for the last 10y and the complications around 15%

• Most complications are related to cardio – pulmonary problems

• COPD is the most common risk factor

STAGING OF DISEASEPre-op L.N. staging – WHY?

• It will direct the surgical choices

• Pts with positive mediastinal L.N. are not good candidates for resection as they yield bad results

• staging is necessary for determining the prognosis

• To compare various studies

Mediastinal L.Nodes

Anatomical mapping

New staging for NSCLC

6th edition T/M descriptor

Revised T/M descriptor

N0 N1 N2 N3

T1 (<2cm) T1a IA IIA IIIA IIIB T1 (>2-3cm) T1b IA IIA IIIA IIIB T2 (>3-5cm) T2a IB IIA IIIA IIIB T2 (>5-7cm) T2b IIA IIB IIIA IIIB T2 (>7cm) T3 IIB IIIA IIIA IIIB T3 invasion T3 IIB IIIA IIIA IIIB T4 (same lobe nodule)

T3 IIB IIIA IIIA IIIB

T4 (extension) T4 IIIA IIIA IIIB IIIB M1 (ipsilateral lung)

T4 IIIA IIIA IIIB IIIB

T4 (pleural effusion) M1a IV IV IV IV M1 (controlateral lung)

M1a IV IV IV IV

M1 (distant) M1b IV IV IV IV

Staging of Mediastinal L.Nodes

Non invasive

• CT• MRI• PET• Integrated PET-CT

Invasive

Non surgical• TTNA-TBNA• EBUS-FNA• EUS-FNA

Surgical• Mediastinoscopy +Ant.M• VATS• Intra-op sampling or

Complete dissection

Techniques of L.N staging

Mediastinoscopy

is the most valuable but is the most invasive

Level 2, 4, and 7, should always be included

Mediastinoscopy should be done

(ESTS guidelines)

• In all centrally located lung tumors

• In all positive PET-scan L.N.

• In all low uptake L.N. on PET-scan• In L.N. bigger than 16mm on CT (21%

probability of N2 disease, De langer 2006)

• Can be omitted in peripheral lesion with negative PET scan L.N

Transbronchial and transesophageal needle aspiration

TBNA (EBUS-FNA) U/S guided

bronchoscopy with FNA

EU/S - FNA

Intra-operative Staging

• Systematic L.N. sampling: is the routine biopsy of representative nodes from all L.N. stations

• Mediastinal L.N. dissection: removal of all L.N. bearing tissue in each nodal station (radical)

Radical Lymphadenectomy V

Sampling

• Is a matter of debate• Radical Lymph/ctomy can get more

metastatic L.N. (Keller et al, Ann.Surg. 2000)

• some randomised studies showed survival benefit with radical Lymph/tomy

(Whitson et al: Ann. Th. Surg. Sept. 2007,

Mancer et al: Cochrane Syst.Rev. Jan. 2005)

Stage I

• Includes IA and IB (tumors <3cm and <5cm)

• No L.N. involved• Tumor > than 2cm from carina

Surgical management of stage I NSCLC

• Best treated with surgery

• Lobectomy with mediastinal L.N. dissection is the preferred procedure

• If the LN are neg. no further post-op treatment is needed

• The 5y survival is 70% (60-80%) for stage IA and 60% for stage IB

Stage IRX: Lobectomy & L.N. Dissection

Surgery for stage II NSCLC

• Stage II includes T1 & T2 with N1

• Lobectomy or pneumonectomy with L.N. dissection is the preferred Rx

• Occasionally sleeve lobectomy is an option for centrally located small tumors in pulmonary compromised pts

• Overall 5y survival is 45% for IIA and

33% for IIB

Stage II NSCLC

Surgery for stage IIIA NSCLC

• It includes T1-(T4) with N2(N1) involvement

• MLN mets is the most important factor affecting treatment and prognosis

• Pts with cN2 yield bad results with surgery (Rush 11600 pts 5y survival 16% and Mountain 540 pts, 5y survival 23%)

• pN2 disease yield better results 40% (Pearson J.Th.Cardiovasc.S. 1982 41% versus 15%, Martini 34% versus 9%)

Surgery for stage IIIA NSCLC

• Bx of mediastinal L.N. should always be done pre-op

• We operate pts with neg. mediastinal L.N.

• Pts with stage IIIB or IIIA-N2 should have pre-op chemo-radiation and re-stage

• The overall 5y survival (review 12 large studies with complete resection after Ch/R)

44% for T3 N0

26% for T3 N1

Surgery or NO Surgery for N2 ?

• Most thoracic oncologist and surgeons agreed that N2 disease in multiple levels should be treated with chemoradiation (Ch/R)

• Most surgeon also believe that downstaged or minimal stage N2 disease, if considered resectable after Ch/R, surgery is beneficial

The role of surgery after neoadjuvant treatment

• For responders, surgical resection is beneficial and increase the survival

• Restaging to identify responders (EBUS- FNA, CT-PET, re-mediastinoscopy)

• No surgery for N2 disease but 25% 5y survival for N0 (Cerfolio Ann.Thor. Surg. 2008, and Detterberk Thor. S. Clin.2008, report up to 40% 5y.surv.)

• Morbidity & mortality is slightly increased especially in Rt pneumonectomy

Surgical techniques

Rt Pneumonectomy

Surgery for T3 with chest wall involvement

• If surgical candidates, complete resection is the aim

• The resection should be un-block with clear margine of the infiltrated chest wall

CONCLUSIONS

• Surgery is the best Rx for stage I & II (lobectomy – pneumonectomy – segmentectomy )

• Accurate staging – Localized disease - and Complete Resection are the requirements for cure

• Pts with pre-op detected N2 disease have poor surgical prognosis

• Re-evaluation after Ch/R for possible surgical excision is an important option