surgical approach to nsclc
TRANSCRIPT
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
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Disclosure
• No confict o interest
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Surgery or lung cancer
• For diagnosis and staging
• For curative treatment
• For palliative treatment
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Based on guidelines such as …
• ACCP !"#
• $S%& !"'
• NCCN !"(
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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
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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
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7/23/2019 Surgical Approach to NSCLC
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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$87 : peripheral : Stage ;A ) No invasive needed
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;nvasive mediastinal staging
•
<ecommend needle techni=ue >$B/S7 $/S? o
surgical7 e1cept• L/L lesion AP0 assessment .y mediastinotom
mediastinoscopy@ A8S i other LN station are ne
• ; clinical suspicion o N involvement remain
ater a negative result using NA7 surgical sta
ediastinoscopy7 A8S? should .e perormed
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Surgery or curative treatment
•$arly lung cancer
• Locally advanced lung cancer
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$arly lung cancer
•Stage ;7 ;;
• Surgery is the mainstay o treatment
• Future o neoaduvant@ aduvant treatmen
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Surgery or early NSCLC
•
Standard procedure• Anatomical resection and lymph node assessm
• <esection• Pneumonectomy Sleeve lo.ectomy
• Lo.ectomy EEE
• Segmentectomy
• 0edge resection
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Sleeve lo.ectomy
•
; technically easi.le >ade=uate ree margsleeve lo.ectomy should al2ays considere
pneumonectomy
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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
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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
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•
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
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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
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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?
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%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
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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
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%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
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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
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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
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•
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
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•
For stage ;; NSCLC7 mediastinal lymph noddissection may provide additional survival
t over mediastinal lymph node sampling a
uggested
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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
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&pen vs A8S
•
&pen is standard A8S is alternative
• <ecently7 NCCN !"(• %;S >A8S? should .e considered in selected p
• No oncologic compromised
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• 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%& !"' $ither open or A8S access can .e uas appropriate to the e1pertise o the surgeon
• NCCN !"( A8S@ %;S@ <A8S should .e strongly
considered as long as there is no compromise o d oncologic and dissection principles ;n high A8e center7 A8S is .etter than open regarding
• Pain7 hospital stay7 time return to unction7 complicatoccured
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Bene6t o A8S
•
Direct .ene6t to the patients• Pain
• Cosmetic
• -ospital stay
• 8ime or return to 2or9
• 8ime or starting aduvant therapy
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Bene6t o A8S
•
For hospital• Shorter hospital stay more patients admittetreatment
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$volution o A8S
• Standard A8S lo.ectomy• ' ports@ # ports
• Single port A8S lo.ectomy
• <A8S
• %A+S %agnetic4anchored guidance system
• N&8$S Natural ori6ce transluminal endoscopic s
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<A8S
•
No clear .ene6t or lo.ectomy• %ay .e useul or lo.ectomy 2ith .roncho
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N&8$S
•
8ranstracheal• 8ransum.ilical
N&8$S
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N&8$S/se natural ori6ce ) No incision
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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
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Surgery or locally advanced NS
•
Local invasion• Chest 2all7 pericardium7 verte.ral .ody7 atriuPancoast tumor
• ; NI7 consider en .loc surgery
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Surgery or palliation
•
%alignant pleural eusion• Pleurectomy
• Pleurodesis ) mechanical@ medical
• Shunt
• -emoptysis@ o.structive pneumonitis
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Sirira Lung Cancer 8eam
Surgical approach to NSCLC
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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 NSCLC
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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 NSCLC
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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 NSCLC
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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
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