Surgical Approach to NSCLC

7/23/2019 Surgical Approach to NSCLC

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Surgical approach to NSPunnarerk Thongcharoen, MD

Department of Surgery

Faculty of Medicine Siriraj Hospital



Disclosure

• No confict o interest



Surgery or lung cancer

• For diagnosis and staging

• For curative treatment

• For palliative treatment



Based on guidelines such as …

• ACCP !"#

• $S%& !"'

• NCCN !"(



Surgery or diagnosis and stagin

• N assessment• Cervical mediastinoscopy ) ormer *+old staninvasive test

• -as .een replaced .y $B/S as initial invasivemediastinal assessment

• Primary tumor tissue diagnosis• 0edge e1cision 2ith ro3en section or undiaglesion ater less4invasive test has .een attem



Cervical mediastinoscopy5s role

•

$1tensive in6ltration o the mediastinum7 no ev

o e1trathoracic metastatic disease

• 8he diagnosis o lung cancer should .e esta.lish

the least invasive and saest method• Bronchoscopy 2ith 8BNA

• $B/S4NA

• $/S4NA

• 88NA

•

mediastinoscopy







N staging approach .y C8 imaresult•

Bul9y N on C8 no need ro invasive con6rmatio

• Discrete N on C8 invasive staging regardless

result• NA over S1

• Normal mediastinum C8• Positive P$8 invasive staging

• Negative P$87 : peripheral : Stage ;A ) No invasive needed



;nvasive mediastinal staging

•

<ecommend needle techni=ue >$B/S7 $/S? o

surgical7 e1cept• L/L lesion AP0 assessment .y mediastinotom

mediastinoscopy@ A8S i other LN station are ne

• ; clinical suspicion o N involvement remain

ater a negative result using NA7 surgical sta

ediastinoscopy7 A8S? should .e perormed



Surgery or curative treatment

•$arly lung cancer

• Locally advanced lung cancer



$arly lung cancer

•Stage ;7 ;;

• Surgery is the mainstay o treatment

• Future o neoaduvant@ aduvant treatmen



Surgery or early NSCLC

•

Standard procedure• Anatomical resection and lymph node assessm

• <esection• Pneumonectomy Sleeve lo.ectomy

• Lo.ectomy EEE

• Segmentectomy

• 0edge resection



Sleeve lo.ectomy

•

; technically easi.le >ade=uate ree margsleeve lo.ectomy should al2ays considere

pneumonectomy



Less than lo.ectomy or earlyNSCLC

•

Poor lung reserved patients

• Severe co4mor.idities

• ;n our e1perience7 most are lingular

segmentectomies in elderly 2ith concomit

PD





Su.lo.ar resection ACCP !"#• For stage ; NSCLC patient 2ho may not tolerate a lo.ar re

due to decreased pulmonary unction or comor.id disease

r resection is recommended over nonsurgical therapy

• ;n patients 2ith maor increased ris9 o perioperative mort

competing causes o death >due to age related or other co

ies?7 an anatomic su.lo.ar resection >segmentectomy? ov

ctomy is suggested

• For stage ; predominantly ++& lesion cm7 a su.lo.ar r

2ith negative margins is suggested over lo.ectomy



•

During su.lo.ar resection o solid tumors compromised patients7 it is recommended

de=uate margins should .e achieved > cm

• Su.lo.ar resection should include sample

N



Su.lo.ar resection $S%& !"'

•

For early stage 8"N! lung cancer7 anatomsegmentectomy or 2ide 2edge resection

rently reconsidered or small7 non4invasive

nimally invasive lesions7 especially those 2

ound4glass opacity >++&? characteristics



Su.lo.ar resection NCCN !"(

•

Appropriate in selected patients• Poor pulmonary reserve7 severe co4mor.iditie

• Small >cm?7 peripheral nodule 2ith• Pure A;S histology or

• ++& >(!G? or

• Slo2 gro2ing >imaging con6rmed7 dou.ling time )days?



%ultiocal lung cancer >%FLC?

•

;n patients 2ith suspected or proven %FLCsuggested that su.lo.ar resection o all le

uspected o .eing malignant .e perormed

si.le



N disease

•

Hno2n N

S1 is not recommended as intherapy

• ;ncidental N >intraop 6nding?•

Continue resection as planned i ormal preopstaging is done ; not stopping completeging

• ;n A8S7 may considered stopping operation



%ediastinal LN assessment

•

Systematic LN dissection• <emoval o all node4.earing tissue 2ithin de6nedor a standard set o lymph node stations

• Systematic sampling•

$1plore and B1 o a standard set o lymph node seach case

• LN sampling• &nly selected suspicious or representative nodes



LN assessment $S%& !"'

•

Systematic nodal dissection can .e avoideearly4stage7 clinically N! lung cancer 2hen

a1imum standardised upta9e value on P$8

ing is I! and the pathological nodule si3"! mm



LN assessment ACCP !"#

•

For stage ; and ;; NSCLC7 systematic medialymph node sampling or dissection is reco

ded over selective or no sampling or accu

athologic staging



•

For stage ; NSCLC 2ho have undergonesystematic hilar and mediastinal lymph no

ging sho2ing intraoperative N! status7 the

on o a mediastinal lymph node dissection

not provide a survival .ene6t and is not su

ed



•

For stage ;; NSCLC7 mediastinal lymph noddissection may provide additional survival

t over mediastinal lymph node sampling a

uggested



Surgery or early NSCLC Surgictechni=ues

•

Conventional open thoracotomy• Standard posterolateral thoracotomy

• %ini4thoracotomy 2ith muscle sparing

• %inimally4invasive surgery• ideo4assisted thoracoscopic surgery >A8S?• <o.otic4assisted thoracoscopic surgery ><A8S



&pen vs A8S

•

&pen is standard A8S is alternative

• <ecently7 NCCN !"(• %;S >A8S? should .e considered in selected p

• No oncologic compromised



• 0hen is open vs A8S vs <A8S is preerred

early stage NSCLC• ACCP !"# For stage ; NSCLC7 %;S such as A8S

preerred over a thoracotomy and is suggested ienced centers

• $S%& !"' $ither open or A8S access can .e uas appropriate to the e1pertise o the surgeon

• NCCN !"( A8S@ %;S@ <A8S should .e strongly

considered as long as there is no compromise o d oncologic and dissection principles ;n high A8e center7 A8S is .etter than open regarding

• Pain7 hospital stay7 time return to unction7 complicatoccured



Bene6t o A8S

•

Direct .ene6t to the patients• Pain

• Cosmetic

• -ospital stay

• 8ime or return to 2or9

• 8ime or starting aduvant therapy



Bene6t o A8S

•

For hospital• Shorter hospital stay more patients admittetreatment



$volution o A8S

• Standard A8S lo.ectomy• ' ports@ # ports

• Single port A8S lo.ectomy

• <A8S

• %A+S %agnetic4anchored guidance system

• N&8$S Natural ori6ce transluminal endoscopic s





<A8S

•

No clear .ene6t or lo.ectomy• %ay .e useul or lo.ectomy 2ith .roncho



N&8$S

•

8ranstracheal• 8ransum.ilical

N&8$S



N&8$S/se natural ori6ce ) No incision



Preop cardiopulmonary evaluat

• For cardiac assessment7 use o the recali.rate

thoracic <C<; is recommended

• For unctional respiratory assessment7 F$" a

DLC& are re=uired• in case either one is IK!G7 use o e1ercise testing

split lung unction are recommended

• ;n these patients7 &ma1 can .e used to measure1ercise capacity and predict postoperative comp



Surgery or locally advanced NS

•

Local invasion• Chest 2all7 pericardium7 verte.ral .ody7 atriuPancoast tumor

• ; NI7 consider en .loc surgery



Surgery or palliation

•

%alignant pleural eusion• Pleurectomy

• Pleurodesis ) mechanical@ medical

• Shunt

• -emoptysis@ o.structive pneumonitis



Sirira Lung Cancer 8eam

Surgical approach to NSCLC



Surgical approach to NSCLCSummary ;

•

Surgery is still the mainstay o curativetreatment or NSCLC

• Diagnostic role has .een decreased7 repla

less invasive needle techni=ue procedures

• ; still in dou.t ater NA procedures7 surgic

staging is considered




Surgical approach to NSCLCSummary ;;

• N is the 9ey ; N is involved7 then S1 is no

recommended initial therapy

• Preoperative cardiopulmonary assessment is

mandatory to determine opera.ility7 respectand the e1tent o surgery

• Lo.ectomy is still the standard resection or




Surgical approach to NSCLCSummary ;;;

• Pneumonectomy should .e avoided slee

lo.ectomy

• Su.lo.ar resection is a good option in sele

patient• Patients actor cardiopulmonary reserve7 co4m

• Disease actor clinical ;A ++&




Surgical approach to NSCLCSummary ;• %inimally4invasive surgery >A8S? has .een introduced a

preerred surgical approach over conventional thoracotom

ected patients

• ;ntraop LN assessment is crucial• ; preer *lo.e4speci6c systematic dissection,

• %ore e1tensive surgery oers .ene6ts to locally advance

• Palliative role o surgery in NSCLC still e1ists



Documents

Surgical Approach to NSCLC