SURGICAL PERSPECTIVE IN LUNG CANCER

Dr.Harilal V Nambiar MS, MCh, FIACS

Senior Consultant CTVS Surgeon

BMH, Calicut

AIM OF SURGERY IN NSCLC

Complete removal of primary tumor with no residual macro or microscopic tumor left behind(R0)

Accurate intra operative staging needed to decide extent of resection

Systematic nodal dissection (Hilar & mediastinal nodes) for a better outcome

Resectability also depends on the functional capacity of the patient especially in the elderly(>70 yrs)

Tailored, personalized therapy with quality of life parameters is important determining short & long term results of Sx.

TNM CLASSIFICATION

T1 Tumor

T2 Tumor

Previously T4

Previously M1

N0 and N1

• N1 means at least stage IIa

N2

• N2 means at least stage IIIa

N3

• N3 means at least stage IIIb

M1a M1b

Putting it all Together

New category adenocarcinoma(Broncho alveolar Ca.)

Adenocarcinoma insitu(AIS) Solitary adenocarcinoma <3cm, purely

of lepedic growth without invasion.

Minimally invasive adenocarcinoma (MIA) <3cm size & <0.5cm invasion

Non Invasive investigations Plain X ray chest

PA & lateral

High voltage (<125Kv will ensure adequate penetration through tumor & mediastinum.

CT Scan - Identifies enlarged

mediastinal lymphnodes >10mm max short axis dia.

Identifies metastasis in the chest, Liver & Adrenals.

CT scan N staging sensitivity 65%, Specificity 75%).

CT over/under stage the lesions by 40% compared to OT findings.

MRI – Not superior to CT in staging

Useful in clarifying the degree of invasion of mediastinum, root of neck, chest wall & diaphragm.

Isotope Scan for distant metastasis – More useful in SCLC.

Not indicated if there are no symptoms suggestive metastasis.

PET CT scan – Most accurate imaging test in confirming lymphnode metastasis.

Sensitivity 88%, Specificity 93%

Invasive investigations Percutaneous

needle biopsy – High diagnostic rate, low morbidity.

Invaluable in patients with peripheral lesions & are unfit for Sx for tissue diagnosis.

Bronchoscopy – Gives direct evidence of T stage & indirect evidence of N stage (Blunt carina) in some cases.

Vocal cord paralysis implies extra capsular spread to mediastinal nodes & inoperability.

Position of the tumor endobronchially will determine the stage & type of resection needed .

EBUS, EUS (Medical Mediastinoscopy)

• Can be done under LA

• If positive invasive

surgical staging avoided.

• EBUS has negative

predictive value of EBUS

79%, EUS 80%.

EUS

• False negative EBUS

28%, EUS 22%.

• In EBUS negative

cases 28% of N2

disease was

mediastinoscopy

positive.

Mediastinoscopy

Cervical M.scopy Anterior

Mediastinotomy Extended M.scopy

(Cervical + Anterior)

Video assisted mediastinal lymphadenectomy (VAMLA)

Done under GA Low morbidity(2%) Low

mortality(0.08%) PPV 100% NPV 96% Currently may be

chosen for EBUS negative N2 cases.

Pre op primary staging

Re-staging

FITNESS FOR SURGERY

Age – Mortality ↑ in the elderly(>70)

Elderly patients undergoing lung Sx needs intense peri op ICU support.

Pneumonectomy has higher mortality in elderly.

Stage I, II diseases may be managed by lobectomy or wedge resection in the elderly.

Recent weight loss - >10% weight loss in the recent past has over all poor prognosis.

Performance status patients with WHO 2 or worse likely to have advanced disease & needs to careful assessment

Poor nutrition status has shown by <90% of ideal body weight, low BMI(<18.5), grade I mal nutrition, triceps skin fold thickness <25th centile.

Low albumin level can lead to poor wound healing, higher infection rate & morbidity.

Such patients who are anatomically suitable for resection, but with > 1 co morbidities should be discussed in a multi disciplinary meeting.

Strategy of surgery

Stage I (cT1N0, cT2N0), Stage II (cT1N1, cT2N1, cT3N0) Should be Operable.

Stage I tumors have a high chance & stage II tumors reasonable chance of being cured by surgery alone.

Stage III a (cT3N1, cT1-3N2) have low chance of being cured by surgery alone and may need adjuvant chemotherapy.

Stage III b, Stage IV – Inoperable

OPERATIONS AVAILABLE Group -I (Standard)

Lobectomy Bi-Lobectomy Pneumonectomy

Group II (Lung Parenchymal Saving Sx) Proximal

Rotating bronchoplasty Bronchial/Tracheal wedge resectionBronchial / Tracheal sleeve resection

Distal Anatomical Segmentectomy Wedge excision.

Group III (Extended Procedures) Intra pericardial Pneumonectomy Diaphragm Chest wall(Ribs ,Vertebrae) Superior sulcus(pancoast tumor)

Segmentectomy/Wedge excision

May be considered for very early lesions detected through large screening Programmes

May be a useful option in patients with impaired lung reserve.

But has high local recurrence rate(14-23%)

Long term survival ↓ by 5-10%

Management of AIS & MIA

Lesions <10mm / <500mm³ solid / GGO with standard uptake value on PET CT <2 can be observed.

GGO Lesions 11-15mm – Segmentectomy + Lymphnode sampling.

Solid lesions 11-15mm & GGO lesion 16-20mm – Segmentectomy + Lymphnode dissection.

Solid lesion 16-20mm – Lobectomy + Lymphnode dissection

Standard surgery Lobectomy – (Procedure of choice)

5 year survival T1-2N0 (50-70%) T1-2N1 (35-50%) T3N0 (45%) T3N1 (37%)

Mortality (<4%) / Morbidity 28%

Bi-Lobectomy Increased morbidity due to post op residual space, Mortality – 5%

Pneumonectomy

Mortality 6-8% / Morbidity 32%

Increased risk with Elderly, IHD, Poor performance status, COPD

Lymphnode management Random sampling

Systematic dissection of each mediastinal node station

Radical block dissection of all mediastinal lymphatic vessels(uncertain therapeutic value)

Sleeve Lobectomy Sleeve Pneumonectomy

Lung parenchyma saving Sx

Bronchoplastic resection(Sleeve lobectomy, sleeve Pneumonectomy)

Indicated in tumor involving RUL orifice

Indicated to preserve the lung Parenchyma Indicated for Carcinoid, highly selected

localized Br.Ca, Predominantly endo bronchial or carinal location.

Local recurrence rate 17%, Mortality 12%

Extended operationsChest wall resection 5% of lung tumors extend locally.

CT & MRI 90% accurate in showing rib erosion & soft tissue involvement.

Tumor removed enbloc with portion of chest wall & reconstructed.

Overall 5 year survival 30-40%, in N0 cases maybe up to 85%.

Post op radiotherapy is logical to prevent local recurrence.

Tumors adherent to vertebral column

Resection generally not appropriate because of poor prognosis.

They are designated as a T4 cases on staging

Superior sulcus (Pancoast Tumors) Involves brachial plexus, subclavian

vessels, ribs and vertebrae, stellate ganglion.

Poor prognosis even with aggressive Rx Correct selection of patients especially

NSLC with involvement of lateral wall only may be a surgical candidate. Complete resection with vascular reconstruction has achieve survival rates up to 30%

No role for surgery if mediastinal nodes are involved.

Radiotherapy is a better option.

Thorocoscopy (VATS)

Pleural effusion with malignant cells shows inoperability

It can assess pleural deposits, chest wall infiltration, sampling of nodes at station

8 & 9.

VATS May be a good option for wedge

resection of early peripheral lesion(T1aN0)

VATS Lobectomy rarely utilized in malignancy(<2%)

Limited data available Less post op pain More time consuming

5 Year Survival Rates – By Stage

IA 58-73%

IB 43-58%

IIA 36-46%

IIB 25-36%

IIIA 19-24%

IIIB 7-9%

IV 2-13%

AIS & MIA lesions

are completely

resectable with

100% 5 yr

survival

Small Cell Lung Cancer (SCLC)

Aggressive

Most patients present with wide

spread metastasis at the time of

diagnosis.

Pre op staging has to be more

rigorous involving brain & bone scan,

mediastinoscopy.

Chemotherapy is the standard line of management.

Unfortunately patients with limited disease on primary chemotherapy experience early relapse in the Ipsi lateral lung or mediastinal nodes.

Hence there is a renewed interest for surgery in early cases (stage I)

Recommendations

All patients should be staged by CT scan,

Mediastinoscopy & Screening of bones & brain

with iliac crest bone marrow sampling due to

high micro metastasis rate.

Surgery may be appropriate in stage I SCLC.

(<5% SCLC are operable).

Patients with small peripheral nodules should

not be denied surgery on basis of needle

biopsy showing SCLC.

5 year survival after Sx

T1N0 – 59.5%

T1N1 – 31.3%

T2N0 – 27.9%

T2N1 – 9%

T3N2 – 3.6%