Surgical approach to NSCLC

Punnarerk Thongcharoen, MD
Department of Surgery
Faculty 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Has been replaced by EBUS as initial invasive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 mediastinoscopys 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 (m
ediastinoscopy, 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 CO
PD.

Sublobar resection: ACCP 2013

For stage I NSCLC patient who may not tolerate a lobar resection
due to decreased pulmonary function or comorbid disease, subloba
r 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-morbidit
ies), an anatomic sublobar resection (segmentectomy) over a lobe
ctomy 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 a
dequate 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 cur
rently reconsidered for small, non-invasive or mi
nimally invasive lesions, especially those with gr
ound-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 s
uspected of being malignant be performed, if fea
sible.

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 sta
ging
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 m
aximum standardised uptake value on PET scann
ing 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 recommen
ded over selective or no sampling for accurate p
athologic staging

 For stage I NSCLC who have undergone

systematic hilar and mediastinal lymph node sta
ging showing intraoperative N0 status, the additi
on of a mediastinal lymph node dissection does
not provide a survival benefit and is not suggest
ed.

 For stage II NSCLC, mediastinal lymph node

dissection may provide additional survival benefi
t over mediastinal lymph node sampling and is s
uggested.

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 experi
enced 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 standar
d oncologic and dissection principles. In high VATS volum
e 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

NOTES
Use 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 sel
ected 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.