Surgical Management of Lung Cancer

1. Surgical Management of Lung Cancer Mike Poullis CTC Liverpool

2. Surgical Management of Lung Cancer • Is the patient for • Diagnosis • Treatment • Palliation • How fit is the patient ? • What is the stage, histology, and exact size and location ? • Remember NOT ALL PATIENTS HAVE PROVEN LUNG CANCER

3. Overview • Diagnostic (Full Hx and examination 1st ) • CXR • CT • PET • Bronchoscopy • VATS • Mediasteinoscopy • Mediasteinotomy • Treatment • Wedge • Lobectomy • Combined wedge and lobectomy • Pneumonectomy • Palliation • Effusions

4. Diagnostic Tests

5. CXR • Previous CXR • Bony erosion if has chest pain • Rate of growth • Cardiac Status • Physiological status

6. CT • T Stage • Lobectomy • Pneumonectomy • N Stage • ? Need mediastinoscopy or mediasteinotomy • M stage • Liver • Adrenals • Other Nodules, Bronchiectasis, Previous CABG, Cardiac, Vascular

7. PET • Tumour • >1cm • Beware Carcinoid and alveolar cell carcinoma • Mediastinum • If –Ve then probably normal • If +Ve then needs biopsy • Metastasis not brain or heart

8. PET +Ve -Ve

9. Diagnostic: Bronchoscopy

10. Diagnostic: Bronchoscopy • Rigid and flexible scope • Biopsy and selective washings • Larger samples than flexible scope • Exact location • Lobectomy • Pneumonectomy • Unresectable • Sleeve

11. Diagnostic: Bronchoscopy

12. Diagnostic: VATS

13. Diagnostic: VATS (Video Assisted Thoracic Surgery) • Diagnosis of pleural disease

14. VATS

15. Mediasteinoscopy & Mediasteinotomy Different lymph node stations

16. Mediasteinoscopy & Mediasteinotomy • Diagnosis of unresectable disease • Eliminate N2 disease from surgical resection

17. Mediasteinoscopy & Mediasteinotomy • Different surgical cuts

18. Mediasteinoscopy & Mediasteinotomy

19. Mediasteinoscopy & Mediasteinotomy

20. Treatment

21. Surgical Assessment • How fit is the patient ? • What is the • stage, • histology, • exact size and • location ? • Basically is the patient fit enough for the operation you think they need ?

22. How Fit Is the Patient ? • Performance status • Pulmonary function tests • Age • Medical and surgical conditions • What operation do they need

23. Stage • Assuming fit patient • Can and should you take it out • N2 or N3 disease • T4 disease

24. Histology • Eliminate benign disease • Beware false negative biopsy • Beware scar cancers • Eliminate small cell patients

25. Exact size and location ? All T1N0 non small cell carcinoma

26. Treatment • Wedge • Lobectomy • Combined wedge and lobectomy • Pneumonectomy

27. Thoracotomy • Posterolateral • Anterolateral • Anterior • Posterior • Lateral • Mini • Muscle sparing

28. Incision

29. Treatment: Wedge

30. Treatment: Wedge • Small nodules in poor pulmonary function patients

31. Treatment: Lobectomy • Gold standard • Left LUL, LLL, • Right RUL+/-RML, RLL+/-RML, RML • Never RUL and RLL

32. Treatment: Lobectomy

33. Treatment: Pneumonectomy • Extensive tumours only • Intrapericardial or extrapericardial

34. Outcomes After Surgery

35. Chemotherapy and Radiotherapy • Adjuvant • Neoadjuvant • Down staging • Unexpected N2, or positive margins • All small cell • NICE recommends referring all postoperative lung cancer patients

36. Small Cell • Small nodule needle biopsy shows small cell • If bone scan, and CT head negative refer • If mediasteinoscopy negative then ? Surgical resection

37. Palliation • Pleural effusions • Drainage, and pleurodesis • Pleurectomy • Talc • Noxious chemotherapeutic agent • Decortication • Removal of tumour mass surrounding lung in pleural space • BENIGN DISEASE DIFFERENT

38. Any Questions ?