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• Has been replaced by EBUS as initial invasive mediastinal assessment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.