Upload
spa718
View
1.050
Download
5
Embed Size (px)
Citation preview
Surgical approach to NSCLCPunnarerk Thongcharoen, MD
Department of SurgeryFaculty of Medicine Siriraj Hospital
Disclosure
• No conflict of interest
Surgery for lung cancer
• For diagnosis and staging
• For curative treatment
• For palliative treatment
Based on guidelines such as …
• ACCP 2013
• ESMO 2014
• NCCN 2015
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• Has been replaced by EBUS as initial invasive mediastinal assessment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
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
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
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.
Surgery for curative treatment
• Early lung cancer
• Locally advanced lung cancer
Early lung cancer
• Stage I, II
• Surgery is the mainstay of treatment.
• Future of neoadjuvant/ adjuvant treatment???
Surgery for early NSCLC
• Standard procedure
• Anatomical resection and lymph node assessment
• Resection
• Pneumonectomy Sleeve lobectomy
• Lobectomy ***
• Segmentectomy
• Wedge resection
Sleeve lobectomy
• If technically feasible (adequate free margin), sleeve
lobectomy should always considered over pneumonectomy.
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.
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 .
• 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
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
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)
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.
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)
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
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
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
• 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.
• For stage II NSCLC, mediastinal lymph node dissection may
provide additional survival benefit over mediastinal lymph
node sampling and is suggested.
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)
Open vs VATS
• Open is standard. VATS is alternative.
• Recently, NCCN 2015
• MIS (VATS) should be considered in selected patients
• No oncologic compromised
• 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
Benefit of VATS
• Direct benefit to the patients
• Pain
• Cosmetic
• Hospital stay
• Time for return to work
• Time for starting adjuvant therapy
Benefit of VATS
• For hospital
• Shorter hospital stay more patients admitted for treatment
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
RATS
• No clear benefit for lobectomy
•May be useful for lobectomy with bronchoplasty
NOTES
• Transtracheal
• Transumbilical
NOTESUse natural orifice – No incision
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
Surgery for locally advanced NSCLC
• Local invasion
• Chest wall, pericardium, vertebral body, atrium, Pancoast tumor
• If N<2, consider en bloc surgery
Surgery for palliation
•Malignant pleural effusion
• Pleurectomy
• Pleurodesis – mechanical/ medical
• Shunt
• Hemoptysis/ obstructive pneumonitis
Siriraj Lung Cancer Team
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.
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.
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
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.