Lung CancerRole of SurgeryRicardo M. TerraAssociate Professor of Thoracic SurgeryUniversity of Sao Paulo Medical School

Disclosure

• Scientific Consultant/Advisory Board: Johnson&Johnson

• Educational grants:

– Medtronic

– Pfizer

General ObjectivesSurgery for Lung Cancer• Local treatment– Tissue for pathology– Margins– Surgical staging

Outline• Role of of surgery in Lung Cancer:– Stage 1 and 2– Stage 3

• Technical aspects– Type of resection– Lymphadenectomy– Minimally invasive surgery

Stage 1 and 2

• California Cancer Registry• 19702 patients Stage I• 1432 no treatment

Chest. 2007 Jul;132(1):193-9.

Operated X not treated

Chest. 2007 Jul;132(1):193-9.

Therapeutic Alternatives• Surgery• Lobectomy• Segmentectomy

• Stereotaxic Radiotherapy• Percutaneous Ablation

Guidelines• Resection is the gold-standard treatment

ACCP, 2013

ESMO, 2013

Lung Cancer Stage in Brazil (Sao Paulo Registry)Registro Hospitalar de Câncer do Estado de São Paulo2000 a 2010 (n=20850)

FOSP, 2015

Lung Cancer Stage in Brazil (Sao Paulo Registry)Registro Hospitalar de Câncer do Estado de São Paulo2000 a 2010 (n=20850)

FOSP, 2015

45% underwent surgery

0%

20%

40%

60%

80%

100%

CTPE

T-CT

Bron

chos

copy

CT gu

ided b

iopsy

VATS

biop

syPa

tholog

y rep

ort

CTPE

T-CT

Bron

chos

copy

CT gu

ided b

iopsy

VATS

biop

syPa

tholog

y rep

ort

PRIVATE PUBLIC

% of

Res

pond

ents

Access to Healthcare Resources in the Private and Public Systems

Easily available

Somewhat difficult, requires some effort

Moderately difficult, requires moderate effort

Very difficult, requires a lot of effort

Available but far away

Available but very expensive for patient

Not Available

n= 461 respostas (cirurgia torácica, pneumologia, radiologia)Access to diagnostic resources

JTD,2018

European Journal of Cardio-Thoracic Surgery 47 (2015) e19–e24, 2014

Stage 3 (N2)

N2 Disease – Imprecise termHeterogeneous population

pN1 /N2 Stations 8th RevisionPathologic - R0

Pathologic - any R

N1a vs N1b vs N2a1 vs N2a2 vs N2b Comparisons Adjusted for Histology (adeno vs others), Sex, Age

60+ , and Region. (Cox PH regression on R0 cases)

comparison HR PN1b vs N1a 1.39 0.0005

N2a1 (skip) vs N1b 0.89 0.2863

N2a2 vs N2a1 (skip) 1.35 0.0007

N2b vs N2a2 1.26 0.0028

N2a2 vs N1b 1.21 0.064

N1 Single = N1aN1 Multiple = N1bN Si gle N skip ets = N aN2 Single N2 + N1 = N2a2N2 Multiple N2 = N2bN1a vs N1b vs N2a1 vs N2a2 vs N2b Comparisons Adjusted for Histology (adeno vs others), Sex, Age

60+ , R0 Resection, and Region. (Cox PH regression on All cases)

comparison HR PN1b vs N1a 1.38 0.0005

N2a1 (skip) vs N1b 0.92 0.4331

N2a2 vs N2a1 (skip) 1.37 0.0002

N2b vs N2a2 1.21 0.0117

N2a2 vs N1b 1.26 0.0197

Location and Number of Pos Stations N1-N2 Any R

0%

20%

40%

60%

80%

100%

0 2 4 6YEARS AFTER RESECTION

1. N1 Single2. N1 Multiple3. N2 Single4. N2 Single+N15. N2 Multiple N2

Ev ents / N438 / 1135153 / 325261 / 602304 / 582462 / 796

MSTNR

60.967.043.938.0

60 Month 58% 50% 52% 41% 36%

Location and Number of Pos Stations N1-N2 R0

0%

20%

40%

60%

80%

100%

0 2 4 6YEARS AFTER RESECTION

1. N1 Single2. N1 Multiple3. N2 Single4. N2 Single+N15. N2 Multiple N2

Ev ents / N415 / 1089146 / 306230 / 549271 / 540403 / 711

MSTNR

60.970.946.040.0

60 Month 59% 50% 54% 43% 38%

Asamura H et al. J Thorac Oncol. 2015

ESMO 2013

2009

LobectomyPneumonectomy

SD: Stable diseaseOR: objective response

Technical Aspects

Type of Resection

• Lobectomy is the gold-standard

• Segmentectomy (preferred) or wedge resection in

patients with:

• Poor pulmonary reserve or major comorbidity

• Peripheral nodule < 2cm and:

• AIS histology

• >50% ground-glass appearance

• Long doubling time >400 days

Why Lobectomy?

Wedge resectionSegmentectomyLobectomy

Ann Thorac Surg 1995;60:615-622

• Clinical trial: 247 patients:• T1 N0 Lung Cancer (intraoperative staging)• Two Arms:

• Lobectomy• Sublobar resection

•Outcomes:• Local Recurrence• Disease-free survival

Ann Thorac Surg 1995;60:615-622

Limited Resection LobectomyEvent No. of Patients Rate (per person/y) No. of Patients Rate (per person/y) p Value Recurrence (excluding second primary) 38 0.101 23 0.057 0.02bRecurrence (including second primary) 42 0.112 32 0.079 0.079b

Locoregional recurrenced 21 0.060 8 0.020 0.008cNonlocal recurrenced 17 0.048 15 0.037 0.672 (NS)cDeath (with cancer) 30 0.073 21 0.049 0.094bDeath (all causes) 48 0.117 38 0.089 0.088b

Ann Thorac Surg 1995;60:615-622

Sublobar resection is associated with a higher rate of local recurrenceConclusion

Lobectomy is the gold-standard

Ann Thorac Surg 1995;60:615-622

• Enrollment: late 1980s, early 1990s• CT Scan• Staging methods

New challenges• Small nodules• Elderly patients• Ground-glass opacities

Is lobectomy really necessary?

Small nodules

N=2090 (688 sublobar resection)Propensity matched scores

• 4 Japanese Institutions• Retrospective 2005-2010• Stage IA (excluded R1/2 e multiple tumors)• GGO predominance (>50%)

3-year

RetrospectiveStage IAOrginal set: 800 (lobectomy)392 (sublobar)

Clinical trial ACOSOGZ4032

Segmentectomy vs. Wedge resection

Technical Aspects

Lymphadenectomy

No difference in complication rate

Randomized clinical trialLinfadenectomy X Sampling Resectable TNMc I-IIIA N= 471Resected Ly :SND: 9.45MLS: 3.63

Technical Aspects

Minimally InvasiveSurgery

Less invasive procedure

28771 cases, matching with Propensity-scores

European Journal of Cardiothoracic Surgery, 2018

Dexterity and lymph node dissection

Lung lobectomy in lung cancer patients VATS vs. Robotics: Randomized study

Ricardo Mingarini Terra, Pedro Henrique Xavier Nabuco de Araujo, Leticia Leone

Lauricella, Alberto Jorge Monteiro Del Vega, Paulo Manuel Pego-Fernandes, Fabio

Biscegli Jatene

Serviço de Cirurgia Torácica do Instituto do Câncer do Estado de São Paulo - ICESP

Disciplina de Cirurgia Torácica - Departamento de Cardiopneumologia – Faculdade

de Medicina da USP

Thank you!Ricardo M. Terrarmterra@uol.com.br