1. SURGERY FOR NSCLC GREG CHRISTODOULIDES MD, FACS, FCCP, FESTS
THORACIC SURGEON
Mar. L. March 9-11, 2012

2. General Remarks
Surgical excision of NSCLC gives the best chance for cure
Unfortunately <20% of lung cancers are diagnosed in early stage
In Cyprus there are about 200 cases of lung cancer recorded every year and about thoracotomies performed in general (Cancer Registry)

3. Surgical risks in elective lung resection
Major complications occur in 9%
Minor events in 19% (J.Martin 2004)
Mortality is 3% for lobectomies and 6% for pneumonectomies
Our mortality in Cyprus is 2% for the last 10y and the complications around 15%
Most complications are related to cardio – pulmonary problems
COPD is the most common risk factor

4. STAGING OF DISEASE Pre-op L.N. staging – WHY?
It will direct the surgical choices
Pts with positive mediastinal L.N. are not good candidates for resection as they yield bad results
staging is necessary for determining the prognosis
To compare various studies

5. Mediastinal L.Nodes Anatomical mapping

6. New staging for NSCLC

7. Staging of Mediastinal L.Nodes
Non invasive CT
MRI
PET
Integrated PET-CT
Invasive
Non surgical
TTNA-TBNA
EBUS-FNA
EUS-FNA
Surgical
Mediastinoscopy +Ant.M
VATS
Intra-op sampling or Complete dissection

8. Techniques of L.N staging
Mediastinoscopy
is the most valuable but is the most invasive
Level 2, 4, and 7, should always be included

9. Mediastinoscopy should be done (ESTS guidelines)
In all centrally located lung tumors
In all positive PET-scan L.N.
In all low uptake L.N. on PET-scan
In L.N. bigger than 16mm on CT (21% probability of N2 disease, De langer 2006)
Can be omitted in peripheral lesion with negative PET scan L.N

10. Transbronchial and transesophageal needle aspiration
TBNA (EBUS-FNA)
U/S guided bronchoscopy with FNA
EU/S - FNA

12. Intra-operative Staging
Systematic L.N. sampling: is the routine biopsy of representative nodes from all L.N. stations
Mediastinal L.N. dissection: removal of all L.N. bearing tissue in each nodal station (radical)

13. Radical Lymphadenectomy V Sampling
Is a matter of debate
Radical Lymph/ctomy can get more metastatic L.N. (Keller et al, Ann.Surg. 2000)
some randomised studies showed survival benefit with radical Lymph/tomy
(Whitson et al: Ann. Th. Surg. Sept. 2007,
Mancer et al: Cochrane Syst.Rev. Jan. 2005)

14. Stage I Includes IA and IB (tumors <3cm and <5cm)
No L.N. involved
Tumor > than 2cm from carina

15. Surgical management of stage I NSCLC
Best treated with surgery
Lobectomy with mediastinal L.N. dissection is the preferred procedure
If the LN are neg. no further post-op treatment is needed
The 5y survival is 70% (60-80%) for stage IA and 60% for stage IB

16. Stage I RX: Lobectomy & L.N. Dissection

17. Surgery for stage II NSCLC
Stage II includes T1 & T2 with N1
Lobectomy or pneumonectomy with L.N. dissection is the preferred Rx
Occasionally sleeve lobectomy is an option for centrally located small tumors in pulmonary compromised pts
Overall 5y survival is 45% for IIA and
33% for IIB

18. Stage II NSCLC

19. Surgery for stage IIIA NSCLC
It includes T1-(T4) with N2(N1) involvement
MLN mets is the most important factor affecting treatment and prognosis
Pts with cN2 yield bad results with surgery (Rush pts 5y survival 16% and Mountain 540 pts, 5y survival 23%)
pN2 disease yield better results 40% (Pearson J.Th.Cardiovasc.S % versus 15%, Martini 34% versus 9%)

20. Surgery for stage IIIA NSCLC
Bx of mediastinal L.N. should always be done pre-op
We operate pts with neg. mediastinal L.N.
Pts with stage IIIB or IIIA-N2 should have pre-op chemo-radiation and re-stage
The overall 5y survival (review 12 large studies with complete resection after Ch/R)
44% for T3 N0
26% for T3 N1

21. Surgery or NO Surgery for N2 ?
Most thoracic oncologist and surgeons agreed that N2 disease in multiple levels should be treated with chemoradiation (Ch/R)
Most surgeon also believe that downstaged or minimal stage N2 disease, if considered resectable after Ch/R, surgery is beneficial

22. The role of surgery after neoadjuvant treatment
For responders, surgical resection is beneficial and increase the survival
Restaging to identify responders (EBUS- FNA, CT-PET, re-mediastinoscopy)
No surgery for N2 disease but 25% 5y survival for N0 (Cerfolio Ann.Thor. Surg. 2008, and Detterberk Thor. S. Clin.2008, report up to 40% 5y.surv.)
Morbidity & mortality is slightly increased especially in Rt pneumonectomy

23. Surgical techniques

24. Rt Pneumonectomy

25. Surgery for T3 with chest wall involvement
If surgical candidates, complete resection is the aim
The resection should be un-block with clear margine of the infiltrated chest wall

26. CONCLUSIONS
Surgery is the best Rx for stage I & II (lobectomy – pneumonectomy – segmentectomy )
Accurate staging – Localized disease - and Complete Resection are the requirements for cure
Pts with pre-op detected N2 disease have poor surgical prognosis
Re-evaluation after Ch/R for possible surgical excision is an important option