380 likes | 539 Views
Surgical Management of Lung Cancer. Mike Poullis CTC Liverpool. 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.
E N D
Surgical Management of Lung Cancer Mike Poullis CTC Liverpool
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
Overview • Diagnostic (Full Hx and examination 1st ) • CXR • CT • PET • Bronchoscopy • VATS • Mediasteinoscopy • Mediasteinotomy • Treatment • Wedge • Lobectomy • Combined wedge and lobectomy • Pneumonectomy • Palliation • Effusions
CXR • Previous CXR • Bony erosion if has chest pain • Rate of growth • Cardiac Status • Physiological status
CT • T Stage • Lobectomy • Pneumonectomy • N Stage • ? Need mediastinoscopy or mediasteinotomy • M stage • Liver • Adrenals • Other Nodules, Bronchiectasis, Previous CABG, Cardiac, Vascular
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
PET +Ve -Ve
Diagnostic: Bronchoscopy • Rigid and flexible scope • Biopsy and selective washings • Larger samples than flexible scope • Exact location • Lobectomy • Pneumonectomy • Unresectable • Sleeve
Diagnostic: VATS (Video Assisted Thoracic Surgery) • Diagnosis of pleural disease
Mediasteinoscopy & Mediasteinotomy Different lymph node stations
Mediasteinoscopy & Mediasteinotomy • Diagnosis of unresectable disease • Eliminate N2 disease from surgical resection
Mediasteinoscopy & Mediasteinotomy • Different surgical cuts
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 ?
How Fit Is the Patient ? • Performance status • Pulmonary function tests • Age • Medical and surgical conditions • What operation do they need
Stage • Assuming fit patient • Can and should you take it out • N2 or N3 disease • T4 disease
Histology • Eliminate benign disease • Beware false negative biopsy • Beware scar cancers • Eliminate small cell patients
Exact size and location ? All T1N0 non small cell carcinoma
Treatment • Wedge • Lobectomy • Combined wedge and lobectomy • Pneumonectomy
Thoracotomy • Posterolateral • Anterolateral • Anterior • Posterior • Lateral • Mini • Muscle sparing
Treatment: Wedge • Small nodules in poor pulmonary function patients
Treatment: Lobectomy • Gold standard • Left LUL, LLL, • Right RUL+/-RML, RLL+/-RML, RML • Never RUL and RLL
Treatment: Pneumonectomy • Extensive tumours only • Intrapericardial or extrapericardial
Chemotherapy and Radiotherapy • Adjuvant • Neoadjuvant • Down staging • Unexpected N2, or positive margins • All small cell • NICE recommends referring all postoperative lung cancer patients
Small Cell • Small nodule needle biopsy shows small cell • If bone scan, and CT head negative refer • If mediasteinoscopy negative then ? Surgical resection
Palliation • Pleural effusions • Drainage, and pleurodesis • Pleurectomy • Talc • Noxious chemotherapeutic agent • Decortication • Removal of tumour mass surrounding lung in pleural space • BENIGN DISEASE DIFFERENT