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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
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• Lung cancer
incidence/100000
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Lets fght against lung
cancer• Reduce revalence o! lung cancer
• "mrove treatment outcome o! lung
cancer
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Lung cancer treatment
e#uation• $arl% case & Relativel% good outcome
• $arl% case & Surger% is a mainsta% o!
treatment• 'hus
• Surger% is a (e% to good outcome)
• And* o! course*
• A surgeon is a (e% to good outcome+
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'o imrove outcome o!
lung cancer treatment
• 'o increase the num,er o! surgicall%
curative candidate
• 'o ma-imi.e the survival a!ter surger%
and minimi.e the mor,idit% and mortalit
% during erioerative eriod
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'o increase the num,er o!
surgicall% curative candidate
• etect more earl% case among general/ high
cancer ris( oulation lung cancer screening
• iagnose lung cancer among atient resenting
with ulmonar% lesion that might ,e cancer
S2* mass3)4 more e5ectivel%
• irect those surgical candidates to thoracic
surgical service as much as ossi,le and ASA
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'o ma-imi.e the goods and
minimi.e the ,ads
• evelo surgical techni#ue that
rovide the ,est oncologic outcome
• 2eoad6uvant/ ad6uvant thera%*
integrated holistic care
• Minimall% invasive era
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Lung cancer screening
• Recommend onl% !or high cancer ris(
oulation
• Low dose C' chest
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7ow to 33 e5ectivel% diagnose lung
cancer in atient resenting with ul
monar% lesion that might ,e cancer
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'issue diagnosis is the (e%+
• Lung cancer is still ossi,le8*
tissue diagnosis confrmed that it is d
efnitel% CA2C$R or 29' cancer
• $-cision ,ios% is the last answer)
• 2o more 'R"AL and error4 with anti
t,c regimen
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Recommend
• Chest s%mtom ;wee( <2o defnite
- can ,e made Chest -;ra%
• Chest -;ra% shows ulmonar% nodule/
mass alwa%s aim to '"SS=$ - – $-cet su,centimeter nodule with
estimated low ro,a,ilit% to ,e malignanc%
i i h l d l
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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
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'in% solid nodule ? @ mm4
'i , lid d l @
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• revalence o! malignanc% is higher)
• Recommended /= C' duration is
shorter
'in% su,solid nodule ? @
mm4
l d l
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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
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Solid nodule
• Second* customi.e diagnosis
aroach ,% si.e and retest li(eliho
od
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Solitar% ulmonar% nodule
• $' availa,le – Ver% low C' surveillance
– Low to mod li(elihood $'
– 7igh Bios% S-/ nonS-4
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Solitar% ulmonar% nodule
• $' ; 29' availa,le – Ver% low C' surveillance
– Low to mod* high li(elihood Bios%
S-/ nonS-4
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Surgical role in - aroach
• rimar% lesion – edge resection : 9en/ VA'S
•Mediastinal L2 – Cervical mediastinosco%* anterior
mediastinotom%* VA'S
• leural metastasis – VA'S
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ulmonar% nodule:
2on S- vs S- B-• hen clinical ro,a,ilit% and imaging are discordant
• Benign - re#uiring secifc medical R- is susected
•
Susect cancer with mediastinal invasion or distantmetastasis/ SCLC
• 7igh retest ro,a,ilit%
• Non Sx Bx result is non diagnostic and
suspicioun of malignancy remains
•$' strongl% ositive
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Mediastinal B-
• irst choice is now $B=S
• Cervical mediastinosco% : indication –
$B=S: susicious – Re;assessment ost induction CM';R'
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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
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Video;mediastinosco%
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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
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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
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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
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Lets do some e-ercise
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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
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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
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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 $B=S;2A
E.Suspicious 2 disease mediastinosco%
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hat guidelines sa%8
2CC2 01F ACC 01G
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2CC2 01F* ACC 01G*
2"C$ 011
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Susicious 2
,% imaging/ $' Hve4• Must ,e c%tologicall%/ histologicall%
confrmed ,% invasive mediastinal stag
ing 1C4
• UNLESS – resence o! distant metastasis
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"nvasive staging
• If available * $B=S* $=S* $B=S/$=S <
2A is the frst choice) 1B4
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So3
• 'he aroriate move seems to ,e
needle asiration !or mediastinal
staging $B=S4
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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
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o %ou agree with this
suggestion8") Ies
+) 2o
C) "’m not sure
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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
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• 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
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• er!ormed $B=S negative
• "nteresting+))))$' Hve* $B=S <ve
• hat is %our suggestion then8
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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
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• er!ormed cervical mediastinosco%
adenoCA
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hat will %ou do ne-t8
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'han( %ou
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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
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hat guidelines sa%8
• 'his atient defnitel% had discrete
2 disease)
• $nsure that it is not more than 2)
istant metastasis8
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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'
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"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)
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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
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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 )
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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)
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An% su,grou with ,eneft8
• Single micrometastasis 2
• Continental e5ect
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2 H less than 'G invasion
3clude distant metastasis
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2 less than 'G invasion
5o "pparentProgression
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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
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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
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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
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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
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• Surger% a!ter defnitive CMR'/CM'88
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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%)
$vidence regarding surger% a!ter neoad6uvant
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$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
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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
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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 ,
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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
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=n!ortunatel%
• athological reort revealed Hve
aratracheal L2)
• "! we (new this ,e!orehand* should
we do the oeration8
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'he Southwest 9ncolog% >rou S9>4
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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
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% %
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
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'rial o!
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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
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010
'G invasion 2 2o surger%
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'G invasion 2 < 2o surger%
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Restaging strateg%
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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
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• 2oninvasive means o! restaging ,%
$' or C' scan4 have not ,een !ound
to have suP cient negative redictiv
e value a!ter neoad6uvant thera%)
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• 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-
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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)
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• '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%*
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• 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
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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
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Revised $S'S guidelines !or reoerative mediastinal l%mh node staging !ornon;small cell lung cancer
Uul% 01G
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9ther surgical role !or
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staging• or isolated A window L2* staging
should ,e er!ormed via Cham,erlai
n* VA'S* or e-tended cervical medias
tinosco%)
Surger%: diagnostic role
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Surger%: diagnostic role
here and when
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here and when•
hen: – susicious o! non ,ul(%/ infltrative 2
disease a!ter ositive imaging/$' 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