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Surgery For Lung Cancer

Sugery for Lung Cancer

1 .Introduction

A. Lung carcinoma is the second most common form of cancer in the U.S. and is the leading cause of death in men
1) (33% of cancer related deaths)
2) Lung cancer is the most common cause of death in women (23%) breast ca (18%)
3) Overall cure rate is 10-13 % of patients at 5 years
4) 1909 intratracheal anesthesia was introduced
5) Graham and Singer in 1933 reported the first successful pneumonectomy for lung carcinoma
6) In 1950, Churchill proposed that a lobectomy could be effective in the resection of lung carcinomas
7) Lung Cancer Study Group randomized 247 patients to compare segmentectomy versus lobectomy in the treatment of lung cancer
a) for segmentectomy the local recurrence rate was 17.2 % versus 6.4 % for lobectomy
b) 5 year survival was 50 % for segmentectomy versus 68 % for lobectomy
8) for incomplete resection for bronchogenic carcinoma the 5 year survival is 4 %
9) mediastinal lymph node dissection should be included in the resection
a) important for pathological staging
b) adds minimal time and morbidity to the procedure
c) compartments include :
(1) superior mediastinal
(2) A-P window
(3) subcarinal and inferior mediastinal

1. Surgical Treatment of Occult (TX NO MO) Non- Small Cell Lung Carcinoma

A. Low incidence, 1.5% in Memorial Hospital experience
B. these are individuals who participate in early screening programs and submit sputum for cytological analysis on a routine basis, or have hemoptysis with normal CXR
C. 33 % of patients with positive sputum cytology and negative CXR will have head and neck cancer
D. detailed head and neck examination is important in the diagnosis
E. bonchoscopy
1) careful examination required
2) endobronchial brushing of each segmental bronchus required
3) fluorescent staining is possible with parenterally administered hematoporphyrin derivative
F. Treatment
1) photoablation has been described (3 yr survival 50- 70 %)
2) surgical resection is the treatment of choice
3) local recurrence is low, median survival is 9 years
4) close follow up is required since up to 45 % of patients will develop a second primary, most of which will be airway carcinomas

2. Surgical Treatment of stage I (T1 N0 M0, T2 N0 M0) Non-Small Cell Lung Carcinoma

A. 20% of patients
B. includes patients with tumors:
1) 3 cm size or less surrounded by lung or visceral pleura, without extension proximal to a lobar bronchus
2) tumors > 3 cm, or tumor of any size that invades visceral pleura or has associated

atelectasis extending to the hilum, and is >2 cm distal to carina (T2)

3) Have no nodal metastases (N0 M0)
C. Staging
1) Patients should be preoperatively and intraoperatively staged
2) Pre-op includes H&P, LFT’s, CXR, CT scan
3) Controversy exists over pre-op routine bone and brain scans for asymptomatic patients
4) Intra-op node dissection
5) Prior to 1986, the TNM classification included T1N1 tumors under stage 1, therefore reported overall survival was lower
D. Results of surgery
1) Overall reported 5 year survival is 50-85% (82-85% T1, 67-68% T2)
2) Histology not a prognostic factor in survival
3) Close follow up required since recurrence rate is 27-39%
a) 60% recur within 2 years and 91% in 5 years
b) 34% develop second primaries: 33% lung, 16% breast, 13% head and neck, 8% colorectal, 7% bladder
4) Adjuvant therappy not warranted
5) Some evidence to suggest Vitamin A supplementation may have an effect on lowering the incidence of second primary tumors

3. Surgical Treatment of Stage II (T1N1M0, T2N1M0) Non-Small Cell Lung Carcinoma

A. 10% of patients
B. Includes patients with tumors:
1) Primary tumors confined to the lung and >2 cm distal to carina, with metastases to peribronchial or ipsilateral hilar lymph nodes
2) Treatment is lobectomy, bilobectomy or pneumonectomy with MLND
C. Results of surgery
1) Overall survival is 39-49% 5 year
2) Prognostic factors include size of primary and number of metastatic lymph nodes
3) Recurrence rate in one study (Martini et al) was 55% with 21% loco-regional and 79% distant
4) No adjuvant therapy has improved survival
5) Postoperative radiotherapy has been shown to decrease locoregional recurrence rate
6) Adenocarcinoma tends to recur distally more often while SCCA tends to recur locally

4. Surgical Treatment of Stage IIIA (T3 N0-1 M0, T1-3 N2 M0) Non-Small Cell Lung Cancer

A. Includes patients with tumors:
1) With limited, circumscribed extrapulmonary extension of the primary tumor (T3)
2) And/or metastases confined to the ipsilateral mediastinal of subcarinal lymph nodes (N2)

5. Surgical Treatment of T3 (Chest Wall Invasion) Non-Small Cell Lung Carcinoma (exclusive of superior sulcus tumors)

A. 5% tumors invade parietal pleura and chest wall
B. Surgical treatment
1) Includes pulmonary resection with contiguous soft tissue and rib resection and chest wall reconstruction
2) When peripheral tumors is attached to parietal pleura, extrapleural resection can be attempted with good success or en bloc resection will be required
3) Marlex mesh and methylmethacrylate can be utilizied for reconstruction
4) Overall operative mortality is 4-12%
5) Overall 5 year survival is 26-40%
6) Lymph node status and depth of invasion correlates with survival
7) Most important prognostic factor is whether a complete resection can be performed

6. Surgical Treatment of T3 (Proximity to carina) Non-Small Cell Lung Cancer

A. Lesion within 2 cm of carina
B. Treatment includes
1) Pneumonectomy
2) Sleeve lobectomy
3) Sleeve pneumonectomy
C. Most important diagnostic procedure is bronchoscopy in order to determine proximity of the tumor to the carina
D. Results of surgical treatment
1) Sleeve lobectomy
a) Overall mortality 0-%
b) Overall 5 year survival is 30-64%
2) Sleeve pneumonectomy
a) Overall mortality 4-27%
b) Overall 5 year survival 16-23%
c) Indication is for bulky tumors in proximity to or involving the carina or tracheobronchial angle
d) Major complication is anastamotic dehiscence with a mortality of 100%

7. Surgical Treatment of N2 Disease (Mediastinal Lymph Node Metastases) in Patients with Non-Small Cell Lung Cancer

A. 45% of presenting patients
B. Overall 5 year survival is 20-30%
C. Memorial Sloan Kettering experience (1974-1981 with 1598 patients)
1) 151 cases completelly resectable
2) Post-operative XRT used in 90% patients
3) Mediastinoscopy not routinely performed
4) 79% underwent lobectomy, 17% pneumonectomy and 4% segmentectomy
5) Overall 5 year survival was 30%
6) No difference in survival between SCCA or adenocarcinoma
7) Patients presenting with obviouos N2 disease had poorer survival
8) Number of nodes affected survival, upper paratracheal nodes affected survival with an overall 5 year survival of 20%
9) 73% patients developed recurrent disease
D. Adjuvant therapy
1) Lung Cancer Study Group
a) Stage II and III patients
b) Found that post-operative radiotherapy significantly decreased local recurrence but no affect on survival
c Also randomized patients with adenoca and large cell ca to receive postop BCG and levamisole vs. Chemotherapy and found increased disease free survival in those patients that received chemotherapy
2) Stage IIIA patients
a) Three randomized trials of preoperative chemotherapy plux surgery vs. Surgery alone revealed survival benefit in patients receiving preoperative chemotherapy with a response rate 60%

8. Surgical Treatment of Stage IIIB Non- Small Cell Lung Cancer

9. Surgical Treatment of T4 (pleural Effusion) Non-Small Cell Cancer

A. patients with malignant pleural effusions
B. if cytologically negative, the effusion is excluded as staging element and is staged asT1, T2 or T3 lesion
C. evaluation of patients with pleural effusions
1) Thoracentesis
2) thoracoscopy- perform if thoracentesis cytologically negative fluid
a) if pleural metastases is found then patient is non-operable (T4)
b) if no pleural metastases are found then the patient is an operable candidate (only 6 % of patients)
C. median survival for patients with malignant pleural effusions is 6 months
D. tube thoracostomy , pleurodesis, VATS may be required to control recurrent pleural effusions

10. Surgical Treatment of T 4 (Mediastinum) Non-Small Cell Lung Cancer

A. patients with tumors of any size invading heart, great vessels, trachea, esophagus, vertebral body or carina
B. most patients are considered inoperable if biopsied pre-operatively or are found unresectable intra-operatively
C. MSKCC experience
1) 225 patients in their review
2) overall survival 22% at 2 years, 13% at 3 years and 7% at 5 years
3) therapy was either complete resection, incomplete resection with brachytherapy,

brachytherapy alone of incomplete resection alone

4) 5 year survival for patients that underwent complete resection was 9 %
D. patients should receive pre-op chemotherapy if possible in attempt to down stage the tumor
E. a small study by Macchiarini (23 patients) utilizing induction chemotherapy with patients with T4 tumors demonstrated a 3 year survival of 54%

11. Surgical Treatment of Stage IV (T1-4, No-2, M1) Non-Small Cell Cancer

A. this includes any patient with distant metastatic disease (M1)
B. small role for surgical therapy limited to patients with solitary brain metastases
1) if both lesions are resectable (brain metastases and lung tumor) then craniotomy should be performed followed by thoracotomy
2) patients who receive post-operative whole brain radiation have an improved median survival 9.2 months vs. 3.4 months

12. The Problems of Surgical Therapy For Small Cell Carcinoma

A. in general is not a surgical disease
B. surgery indicated in only a small number of patients
C. it is usually discovered intra-operatively in a patient with presumed non-small cell cancer
D. if at thoracotomy the diagnosis of stage I small cell cancer is made, then complete resection should be attempted
E. the VA Surgical Oncology Group demonstrated 5 year survival rates of 60% for T1N0 and 31% for T1N1 disease (54% received post-op chemotherapy)
F. post-operative chemotherapy is recommended
G. patients with stage II or III are best served by chemotherapy and radiation