advance in lung cancer surgery

8/16/2019 Advance in Lung Cancer Surgery

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Advance inLung Cancer Management:

Surgeon’s View

Punnarerk Thongcharoen, MD

Division of Cardio-thoracic SurgeryDepartment of Surgery

Faculty of Medicine Siriraj ospital

Mahidol !niversity, Thailand



• Lung cancer

incidence/100000



Lets fght against lung

cancer• Reduce revalence o! lung cancer

• "mrove treatment outcome o! lung

cancer



Lung cancer treatment

e#uation• $arl% case & Relativel% good outcome

• $arl% case & Surger% is a mainsta% o!

treatment• 'hus

• Surger% is a (e% to good outcome)

• And* o! course*

• A surgeon is a (e% to good outcome+



'o imrove outcome o!

lung cancer treatment

• 'o increase the num,er o! surgicall%

curative candidate

• 'o ma-imi.e the survival a!ter surger%

and minimi.e the mor,idit% and mortalit

% during erioerative eriod



'o increase the num,er o!

surgicall% curative candidate

• etect more earl% case among general/ high

cancer ris( oulation lung cancer screening

• iagnose lung cancer among atient resenting

with ulmonar% lesion that might ,e cancer

S2* mass3)4 more e5ectivel%

• irect those surgical candidates to thoracic

surgical service as much as ossi,le and ASA



'o ma-imi.e the goods and

minimi.e the ,ads

• evelo surgical techni#ue that

rovide the ,est oncologic outcome

• 2eoad6uvant/ ad6uvant thera%*

integrated holistic care

• Minimall% invasive era



Lung cancer screening

• Recommend onl% !or high cancer ris(

oulation

• Low dose C' chest



7ow to 33 e5ectivel% diagnose lung

cancer in atient resenting with ul

monar% lesion that might ,e cancer



'issue diagnosis is the (e%+

• Lung cancer is still ossi,le8*

tissue diagnosis confrmed that it is d

efnitel% CA2C$R or 29' cancer

• $-cision ,ios% is the last answer)

• 2o more 'R"AL and error4 with anti

t,c regimen



Recommend

• Chest s%mtom ;wee( <2o defnite

- can ,e made Chest -;ra%

• Chest -;ra% shows ulmonar% nodule/

mass alwa%s aim to '"SS=$ - – $-cet su,centimeter nodule with

estimated low ro,a,ilit% to ,e malignanc%

i i h l d l



atient with ulm nodule/

mass• Review revious imaging stud%

–Most lung cancer are not•

>etting ,igger within less than amonth

• Sta,le !or more than %ears



'in% solid nodule ? @ mm4

'i , lid d l @



• revalence o! malignanc% is higher)

• Recommended /= C' duration is

shorter

'in% su,solid nodule ? @

mm4

l d l



ulmonar% nodule:

aroach• irst* start with estimate the

ro,a,ilit% o! malignanc% ,% –

clinical 6udgment and/or – a validated model Ma%o 3 most

oular4



Solid nodule

• Second* customi.e diagnosis

aroach ,% si.e and retest li(eliho

od



Solitar% ulmonar% nodule

• $' availa,le – Ver% low C' surveillance

– Low to mod li(elihood $'

– 7igh Bios% S-/ nonS-4



Solitar% ulmonar% nodule

• $' ; 29' availa,le – Ver% low C' surveillance

– Low to mod* high li(elihood Bios%

S-/ nonS-4



Surgical role in - aroach

• rimar% lesion – edge resection : 9en/ VA'S

•Mediastinal L2 – Cervical mediastinosco%* anterior

mediastinotom%* VA'S

• leural metastasis – VA'S



ulmonar% nodule:

2on S- vs S- B-• hen clinical ro,a,ilit% and imaging are discordant

• Benign - re#uiring secifc medical R- is susected

•

Susect cancer with mediastinal invasion or distantmetastasis/ SCLC

• 7igh retest ro,a,ilit%

• Non Sx Bx result is non diagnostic and

suspicioun of malignancy remains

•$' strongl% ositive



Mediastinal B-

• irst choice is now $B=S

• Cervical mediastinosco% : indication –

$B=S: susicious – Re;assessment ost induction CM';R'



Surgical role in staging

• 2 disease: 'he line ,etween earl%

and advanced* good outcome and o

or outcome)

• "nvasive mediastinal staging is ver%

imortant)

• $-tensive mediastinal invasion on C'

no !urther invasive staging



Video;mediastinosco%



iagnosed earl% lung cancer

• 'he most e5ective treatment should include

surgical resection as a mainsta% o! treatment)

• 'he rimar% concern !or B-;confrmed earl% 2SCLC

is ro,a,l% how to get the atient to the 9R)

• 'he surger% re!usals seem to ,e a considera,le

reserve in onconeumonolog% to raise the oera,ilit

% o! lung cancer and to imrove the results o! its sur

gical treatment)

! ili i h h ! 8



Are %ou !amiliar with these !acts8

Factors related withdecision

Yes(%

refuse)

No(%

refuse)

P

"ge # $% &' %' ()(*

+elief that D is .(/certain

&0 %* ()((0

+elieve eposure to air

during surgery spreadscancer

&$ %( ()((*

Faith alone curesdisease

&1 %( ()((*

Pra er 2ill cure cancer &% %' ()((

Reasons 29' a5ected



Reasons 29' a5ected

re!usal to S-Issues Yes

(%

refuse)

No

(%

refuse)

p

3ducation *% years %1 %4 5S+iopsy-con6rmed %1 %4 5S

Physician discusses prosand cons of S

%4 &( 5S

Family must approve S &% %& 5S



Lets do some e-ercise



Scenario

• An as%mtomatic woman* DE %ears old*

chec(ed u at a 7osital A)

• Chest -;ra% showed a ))cm S2 at RLL)

• C' showed irregular nodule susected

CA with !ew aratracheal L2 0)E;0)@ cm

• $'/C' was done

สร างจากเค าโครงเร องจรง โปรดใช วจารณญานในกา



Scenario

• $'/C' showed one ositive 0)@ cm

aratracheal L2* no other distant me

tastasis)

• hat do %ou thin(8

• hat is %our ne-t move8



i5erent mindsets: 'his atient has3)

") 2 disease & advanced case CM'/R'

B.Resectable 2 disease S-

C.Resectable 2 disease 2eoad6uvant

S-

D.Suspicious 2 disease $B=S;2A

E.Suspicious 2 disease mediastinosco%



hat guidelines sa%8

2CC2 01F ACC 01G



2CC2 01F* ACC 01G*

2"C$ 011



Susicious 2

,% imaging/ $' Hve4• Must ,e c%tologicall%/ histologicall%

confrmed ,% invasive mediastinal stag

ing 1C4

• UNLESS – resence o! distant metastasis



"nvasive staging

• If available * $B=S* $=S* $B=S/$=S <

2A is the frst choice) 1B4



So3

• 'he aroriate move seems to ,e

needle asiration !or mediastinal

staging $B=S4



Bac( to the case

• At 7os A)* a doctor suggested that she alread%

had 2 disease* so this is an inoera,le case )

Curative chemoradiation was recommended)

• t went to 7os B) !or the second oinion where

she got the second di5erent oinion+

• A surgeon suggested lo,ectom% right awa%)

Because the ositive aratracheal L2 was small

er than 0)@ cm)

o %ou agree with this



o %ou agree with this

suggestion8") Ies

+) 2o

C) "’m not sure



hat evidences sa%8

• or atients with discrete mediastinal L2

enlargement and no distant metastases4*

invasive conrmation o! the radiograhic stage is recommended regardless of a PET

scan nding on the mediastinal nodes4

• ACC 01G >rade o! recommendation* 1C



• She then went to 7osital C !or the

third oinion where* again* she got a

nother di5erent oinion)

• 'he surgeon suggested re!erring to

intervention ulmonologist !or $B=S;

2A



• er!ormed $B=S negative

• "nteresting+))))$' Hve* $B=S <ve

• hat is %our suggestion then8



hat evidence sa%s8

• or atients with discrete mediastinal L2

enlargement and no distant metastases4*

a nonmalignant result !rom a needle techni#ue eg, $=S;2A* 'B2A* $B=S;2A* or ''2

A4 should e further conrmed y mediast

inoscopy regardless o! a $' scan fnding

on the mediastinal nodes4)

•

ACC 01G* >rade o! recommendation* 1C



• er!ormed cervical mediastinosco%

adenoCA



hat will %ou do ne-t8



'han( %ou



i5erent mindsets

") t has 2 disease* & advanced case &inoera,le efnitive chemoradiation

+) t has resecta,le 2 disease S-

C) "t is resecta,le 2 disease 2eoad6uvantchemothera% !ollowed ,% S-

D) "t is resecta,le 2 disease 2eoad6uvant

chemoradiation !ollowed ,% S-3) 2one o! a,ove



hat guidelines sa%8

• 'his atient defnitel% had discrete

2 disease)

• $nsure that it is not more than 2)

istant metastasis8



iscrete 2 ; Surgical case8

• RC's comaring multimodalit%

treatment with or without surger% h

ave shown e#uivalent results)

• CM' H SJ K CM' H R'



"nvasive staging

• If available * $B=S* $=S* $B=S/$=S <

2A is the frst choice) 1B4

• "! the clinical susicion remains high

a!ter a negative result o! 2A* surgical

staging eg* mediastinosco%* VA'S*

etc4 should ,e er!ormed)



Clear ,eneft8

• "n overall su,grou* a treatment strateg%

with induction thera% and surger% is neithe

r clearl% ,etter nor clearl% worse than chem

oradiothera% alone)

• the 2orth American "ntergrou 01G stud%

suggested ,etter rogression;!ree survival a

nd atter survival curves in the induction th

era% and surger% arm



ACC 01G < discrete 2

• $ither defnitive CM;R' or induction

thera% !ollowed ,% surger% is recommend

ed over either surger% or radiation alone >rade 1A4 )

• rimar% surgical resection !ollowed ,%

ad6uvant thera% is not recommended e-c

et as art o! a clinical trial4 >rade 1C4 )



Surger%: hen to

•"! surger% is to la% a role* it should ,e

done a!ter neoad6uvant thera%)

•

Currentl%* NSurvival o! atients withreoerativel% identifed 2 disease is

oor with rimar% surger%O until !urthe

r studies rove otherwise)



An% su,grou with ,eneft8

• Single micrometastasis 2

• Continental e5ect



2 H less than 'G invasion

3clude distant metastasis



2 less than 'G invasion

5o "pparentProgression



i5erent mindsets

") t has 2 disease* & advanced case &inoera,le efnitive chemoradiation

+) t has resecta,le 2 disease S-

C) "t is resecta,le 2 disease 2eoad6uvantchemothera% !ollowed ,% S-

D) "t is resecta,le 2 disease 2eoad6uvant

chemoradiation !ollowed ,% S-3) 2one o! a,ove



urther recommendation !rom 2CC2

• Restaging a!ter induction CMR' – C' H/; $'

– Re;mediastinosco% is ossi,le* ,ut

diPcult) 7ow a,out attemt $B=S/$=S at retreatrment stage to reserve mediastinosco% !or restaging8



Surve% 010

• S- !or one station 2* ? G cm))))))))))))0)EQ

• S- !or K 1 station 2* ? G cm)))))))))))))F)DQ

• =se $B=S/$=S)))))))))))))))))))))))))))))))))))@0Q

• =se athologic evaluation a!ter neoad6 thera%

to ma(e a surgical decision))))))))))))))))))))F0)EQ

• Consider neoad6 H S- i! li(el% to re#uire

neumonectom%))))))))))))))))))))))))))))))))EF)@Q



hat did " do88

• ith discrete 2* " ersonall% re!er

neoad6uvant concurrent CMR' !ollow

ed ,% surger%)

• So neoad6uvant treatment was done)

'he t was sent ,ac( !or restaging)

• hat was restaging !or her8



• Surger% a!ter defnitive CMR'/CM'88



ACC 01G

• urther identifcation o! atients more

li(el% to ,eneft !rom surgical resection a!t

er induction thera% is not ossi,le ,aseduon retreatment characteristics)

• ecisions to ursue surgical resection

a!ter induction thera% should ,e made

rior to initiation o! an% thera%)

$vidence regarding surger% a!ter neoad6uvant



$vidence regarding surger% a!ter neoad6uvant

CMR'

• Beneft – Are there clear ,enefts8

•

7arm – 7igher mor,idit% and mortalit%8

• An% su,grou with less ,eneft and/

or higher MM8



Restaging

• Clinical evaluation was done) 2o other

distant metastasis is susected)

• C' scan was done and showed unchanged

rimar% tumor as well as aratracheal L2)

• 'hen RLL lo,ectom% with s%stematic

mediastinal l%mh node dissection was done)

, i h , f



Su,grou with ,enefts

• 2onenlarged 2 nodes* non,ul(% nodes * and

single;node;station involvementT

• atients with nodal downstaging or other signs o!

good resonse to neo; ad6uvant thera% eg*

tumor shrin(age* decrease in intensit% o! uta(e

on uorodeo-%glucose $' scan4T

• atients in whom a neumonectom% is not neces

sar%)

S i l ,



Secial su,grou

• $lderl% atients higher mor,idit%*

more severe mor,idit%* e#ual mortalit%

•

Broncholastic rocedure sleeveresection4 e#ual MM* long term

survival

• neumonectom% worse E;%ear survival

= ! l



=n!ortunatel%

• athological reort revealed Hve

aratracheal L2)

• "! we (new this ,e!orehand* should

we do the oeration8



'he Southwest 9ncolog% >rou S9>4



g% 4

stud% @@0E

• 1E

• trimodalit% aroach in atients with ,ul(% stage """ 2SCLC:

– induction chemoradiation with concurrent cislatin* etooside*

and radiothera% !ollowed ,% surgical resection)

• 'he G;%ear survival rate was 26% )

• atients who were downstaged node;negative at the time

o! surger%4 had a G;%ear survival rate o! 41%.

• "denti!%ing this grou rior to surger% ma% not ,e ossi,le)

Anal%sis o! a ;%ear e-erience in



% %

1E atients 001;4

• or G c%cles o! latinum;,ased

chemothera%

• Resonse rate was DQ

• 9erations included D lo,ectom%/

,ilo,ectom%* neumonectom%)

• Comlete resection rate was FQ*

• 9erative mortalit% was F)EQ



'rial o!



accelerated multimodalit% thera%

• 'he induction regimen: 1;da% course o!

concurrent cislatin* aclita-el* and radiothera%

• 10E atients

– @ were candidates !or surgical treatment

– @Gcurative resections

• lo,ectom% FT neumonectom% GDT ,ilo,ectom% E

– Surgical mortalit% Q

– neumonia or ARS GQT B GQT wound in!ection QT

reoeration !or ,leeding 1Q



010

'G invasion 2 2o surger%



'G invasion 2 < 2o surger%



Restaging strateg%



Restaging strateg%

• 7%othesis – "n the conte-t o! a multimodalit%

treatment lan* ma6or ulmonar% resecti

on !or atients not e-eriencing athologic resonse e-oses them to oerativeris( without hoe !or ,eneft)

•

>oal < identi!% the nonresonders



• 2oninvasive means o! restaging ,%

$' or C' scan4 have not ,een !ound

to have suP cient negative redictiv

e value a!ter neoad6uvant thera%)



• oor correlation o! ,oth noninvasive

and invasive methods o! restaging ot

her than a thorough f rst;time media

stinosco% done at the time o! restag

ing

hich ones will ,eneft !rom CMR' S-



hich ones will ,eneft !rom CMR' S-

• atient re!erences and values*

• a demonstrated a,ilit% to accomlish

surger% with low oerative mortalit%

• !actors inuencing the a,ilit% to

achieve local control ie* radiothera

% dose and volume vs R0 resection4)



• 'he a,ilit% to achieve a comlete

resection through lo,ectom% is the o

nl% area !or which there is an% evi; d

ence suggesting a ossi,le ,enef t t

o multimodalit% treatment that includes surger%*



• Resection !ollowing induction thera%

rovides !or suerior local control

and is clearl% the most accurate met

hod to assess resonse to treatment

and thus redict survival)

rognostic !actors



rognostic !actors

• Comleteness o! surgical resection

• $-tent o! resection neumonectom% ? lo,ectom%4

• ownstaging o! mediastinal L2’s

• Lower ' stage

• Single L2 station involvement

•

egree o! athologic resonse in the rimar%tumour



Revised $S'S guidelines !or reoerative mediastinal l%mh node staging !ornon;small cell lung cancer

Uul% 01G



9ther surgical role !or



staging• or isolated A window L2* staging

should ,e er!ormed via Cham,erlai

n* VA'S* or e-tended cervical medias

tinosco%)

Surger%: diagnostic role



Surger%: diagnostic role

here and when



here and when•

hen: – susicious o! non ,ul(%/ infltrative 2

disease a!ter ositive imaging/$' and with negative invasive staging ,% 2A or without 2A

– Susicious o! isolated A window involvement

• here: – aratracheal < cervical mediastinosco%

– A < e-tended cervical med)* VA'S

advance in lung cancer surgery

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