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Surgical Approach in NSC Lung Cancers-2006

Surgical Approach in NSC Lung Cancers-2006. Levent ELBEYLİ MD Gaziantep University Faculty of Medicine Department of Thoracic Surgery. HOW PREVALENT IS THE CANCER?. There are estimated 20.000.000 patients with cancer in the world. Each year 10 million people get cancer.

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Surgical Approach in NSC Lung Cancers-2006

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  1. Surgical Approach in NSC Lung Cancers-2006 Levent ELBEYLİ MD Gaziantep University Faculty of Medicine Department of Thoracic Surgery

  2. HOW PREVALENT IS THE CANCER? • There are estimated 20.000.000 patients with cancer in the world. • Each year 10 million people get cancer. • In the year 2020, this number will increase to 16 million. • In the year 2020, 60% of them will be in developing countries. • Each year 7 million people die of cancer. • In the year 2020, it will be 10 million. • The most common cause of death! • 12% of all deaths in the world • Twice more common than death due to ADIS in the year 2004

  3. Risk of developing cancer throughout life span (Based on location, Males, USA, 1999-2001) Risk Location All locations 1 in 2 Prostate 1 in 6 Lung and bronchi 1 in 13 Colon and Rectum 1 in 17 Bladder1 in 28 Non-Hodgkin lymphoma 1 in 46 Melanoma 1 in 53 Kidney 1 in 67 Leukemia1 in 68 Mouth cavity 1 in 73 Gastric 1 in 81 Source: DevCan: Probability of Developing or Dying of Cancer Software, Version 5.2 Statistical Research and Applications Branch, NCI, 2004. http://srab.cancer.gov/devcan

  4. The number of cases in 2005 in USA Women662,870 Men710,040 Prostate33% Lung and bronchi 13% Colon and rectum 10% Bladder 7% Melanoma, skin 5% Non-Hodgkin 4% lymphoma Kidney 3% Leukemia 3% Mouth cavity 3% Pancreas 2% All other 17% 32% Breast 12% Lung and bronchi 11% Colon and rectum 6% Uterinecorpus 4% Non-Hodgkin lymphoma 4% Melanoma, skin 3% Ovary 3% Thyroid 2% Bladder 2% Pancreas 21% All other *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2005.

  5. Cancer related deaths* in USA in 2005 Men295,280 Women275,000 Lung and bronchi 31% Prostate 10% Colon and rectum 10% Pancreas 5% Leukemia 4% Esophagus 4% Liver and intrahepatic 3% Bile ducts Non-Hodgkin 3% lymphoma Bladder 3% Kidney 3% All other 24% 27% Lung and bronchi 15% Breast 10% Colon and rectum 6% Ovary 6% Pancreas 4% Leukemia 3% Non-Hodgkinlymphoma 3% Uterine corpus 2% Multiple myeloma 2% Brainand other CNS 22% All other ONS=Other nervous system. Source: American Cancer Society, 2005.

  6. Epidemiology LUNG CANCER • Leading cause of death due to cancer both in men and women in Japan. • In 2003, 41615 men (22%) and 15086 women (12%) died of lung cancer.

  7. Epidemiology • Adenocarcinoma is the most common in Western countries and Japan • Squamous cell carcinoma is the most common histopathological type in Asian countries and Turkey (45%).

  8. Lung Stomach Bladder Colorectal Larynx Prostate Leukemia Bra’n/CNS NHL Other Cancer Incidence in Turkey, MenTotal: 38041

  9. Breast Colorectal Stomach Ovary Lung Leukemia Endometrium/c.u. Cervix Brain/CNS Other Cancer Incidence in Turkey, WomenTotal: 27755

  10. Frequency of cancer (incidence) Expected cancer incidence150-300 per 100,000 Cancer incidence according to 55.77 per 100,000 Turkish Ministry of Health, (1998) Evaluation of Cancer Reports, 1995-1999 Ministry of Health,2002 Izmir Cancer Registry Center (1993-1996) In children (0-14 years) 115.6 / million In adults 145.4 / 100,000 EJC, 37:83-92,2001

  11. RelativeSurvival rates* (%) (According to the location of the cancer in 3 different time periods) • All locations 50 53 64 • Breast (women) 75 78 88 • Colon 50 58 63 • Leukemia 34 41 46 • Lung and bronchi 13 14 15 • Melanoma, skin 80 85 91 • Non-Hodgkin lymphoma 47 54 59 • Ovary 37 41 44† • Pancreas 3 3 4 • Prostate 67 75 99 • Rectum 49 55 64 • Bladder 73 78 82 Location 1974-1976 1983-1985 1995-2000 *5-year relative survival rates based on follow up of patients through 2001. †Recent changes in classification of ovarian cancer have affected 1995-2000 survival rates Source: Surveillance, Epidemiology, and End Results Program, 1975-2001, Division of Cancer Control and Population Sciences, National Cancer Institute, 2004.

  12. NSCLC’de • Previous studies have shown that: • Resectability of the tumor • Mean survival rates • Deaths due to cancer

  13. NSCLC andMetastasis screening • In patients with suspected pleural involvement (Pleural effusion) VATS is recommended if cytology comes negative twice. • Conventional pleura biopsy is not conclusive if there is no diffuse involvement. • Because the results of blind biopsy from pleural nodulations are not satisfactory. • Whereas with VATS, it is possible get samples from the nodules under direct visualization

  14. PET and lung cancer • Evaluation of solitary pulmonary nodules • Staging • Evaluating the response to treatment • Demonstration of focus of recurrent cancer • Assessment of prognostic data.

  15. Due to disappointments in long term survival after surgery as well as postoperative complications and high mortality, there are still ongoing attempts to select patients to have pulmonary resection in NSCLC Preoperative evaluation EJSO 32 (2006) 12–23

  16. Preoperative evaluation • Accompanying disorders of the patients: • Chronic Obstructive Pulmonary Disease • Heart diseases • Diabetes • Venous system disorders affect the operative morbidity and mortality

  17. Preoperative evaluation Pulmonary function tests Blood gases Perfusion-ventilation scintigraphy of the lung DLCO Cardiopulmonary exercise tests

  18. Preoperative evaluation • The results of the tests should be evaluated together with the localization of the tumor. • For instance: • Tumor with hilar localization, obstructing the main bronchus and main pulmonary artery (Autopneumonectomy) • Peripherally located tumor that invaded more than one lobe via the fissure.

  19. Treatment of the elderly patients Even though the age of 70 is taken as the threshold, the exact definition of “old patient” is yet to be determined. Biological age is more important than the chronological age of the patient. Age only is an obscure prognostic criteria in terms of tolerability to treatment or outcome. The performance of the patient and accompanying diseases are more important.

  20. Preoperative evaluation • Mean FEV1 of 14 cases who had pneumonectomy due to advanced lung cancer in our clinic in 2005 was 62.7%. • Postoperative mortality among these cases was 7.14% (n:1). • The cause of mortalite was postpneumonectomic bronchopleural fistula and consequent empyema following neoadjuvant treatment.

  21. Treatment • It is important to differentiate NSCLC from SCLC for prognosis and determination of treatment strategies. • For long term survival; • Morbidity • Pulmonary functions • Smoking • Socil support is important

  22. Treatment • In NSCLC, especially in early stage tumors first coice of treatment is SURGERY. • Why? • Is the aim to prolong survival?

  23. Surgical treatment • The principle objective in early stage tumors: • Anatomical pulmonary resection. This can be achieved by: • Lobectomy • Bilobectomy • Pneumonectomy • Extended resections Sleeve Resections

  24. Surgical Objectives • Primary tumor and all lymphatic drainage of it should be excised with lobectomy or pneumonectomy. • During the dissection, the integrity of the tumor should not be compromised to prevent the dissemination of the tumor cells in the operative field. • Neighboring tissues or tissues with tumor invasion should be removed en-block. Lung Cancer (2005) 49, 25—33

  25. Surgical Objectives • Margins of resection should be checked with frozen section during the operation and resection should be extended when positive. • Mediastinal lymph nodes should be removed in an order and numbered. Lung Cancer (2005) 49, 25—33

  26. Our N2 staging strategy Contrast Thoracic CT Bulky N2 N2 (+) N2 (-) PET Inoperable Risk (+) Risk (-) (+) (-) Surgery Mediastinoscopy Surgery

  27. Surgical treatment • Mediastinal lymph node dissection: • No statistically significant difference was observed between sampling and systematic dissection with respect to survival and regional recurrence. • Some clinical trials showed that SND is better than nodal sampling for long survival • Watanabe use Naruke’s lenf node map + extended LND alternative to Cahan’s study. Long survival seems is better.

  28. Surgical Treatment • Extended resections: • When thoracic wall is involved, there is no need for RT when margin of resection is negative. • Superior sulcus tumors; Though neoadjuvant treatment has been advocated by some, others disagree due to operative difficulties and risks.

  29. Watanabe Y, Lung Cancer,2003 • Operative N2 cases n=218 • Complet. res. %70 (%30) • Uncomplet. res. %30 (%5) • cN0-1 (%36) • cN2 (%27) • Tumor wide <2cm (%48) • 2-3 cm (%31) • 3-5 cm (%27) • >5 cm ( %17) • T1-2 N2 (%34) • T3N2 (%9) • Single station. (%37) • Multiple stat. (%24)

  30. Surgery in N2 disease • Following Neoadjuvant treatment: • Mean 5-year survival is 25-30% after surgery when the tumor is downstaged • 5-8% when the stage is not changed • Continue with postoperative supplementary treatment in responsive cases…

  31. Neoadjuvant treatment • 60-75% of cases respond to Neoadjuvant treatment. • Full pathological clearance can be achieved in 20-25% of the cases • 5-year survival in N0 cases is 35% and 9% in residual nodal disease. • Decision on surgery should be made according to a new staging after neoadjuvant treatment. • CT scan is insufficient for assessment in Neoadjuvant cases. PET and mediastinoscopy are advised where possible. • In such cases, re-mediastinoscopy and operation is quite difficult. Risk of intraoperative complications are high. Usually intrapericardial pneumonectomy is required.

  32. Proposal for N2 In conclusion; Observation of a “Down-stage” after neoadjuvant chemotherapy or chemotherapy/radiotherapy in N2 cases is an important clue for the decision of surgery. The place of surgery in cases not “Down staging” is disputed and surgery should be avoided in cases requiring pneumonectomy due to high risk of mortality. The most suitable treatment modality in cases with bulky N2 is chemotherapy. Postoperative thoracic RT should be used to reduce the risk of local recurrence in completely resected cases. Cases who responded to neoadjuvant chemotherapy and were operated, same protocol should be continued in the adjuvant setting for 2-3 courses more

  33. Surgery in Stage IIIB • Requires totally patient oriented approach. • Sleeve pneumonectomy yields successful results in cases with trachea and/or carina invasion. • There is a debate on major vessel invasions: • Surgery can be performed for palliation if there is SVC invasion. • Resection can be tried in selected cases with aortic invasion.

  34. H.H 62 year-old maleSquamous epithelial carcinomaT4N1M0Left pneumonectomy + aortic resectionPostoperative 6 months, healthy

  35. Sağ kalım oranları(T4) • Left atrium %23 • SVC %20 • Carina %23 • Aort • Vertebral body %0

  36. T4 tumors • To eliminate confusions encountered as a result of frequent changes in TNM staging, more data would be required to confirm staging criteria. • Satellite nodules, would be regarded as an advanced regional disease, rather than systemic disease, and patients should be given the chance of surgery.

  37. T4 tumors • Combined resections should be performed in selected cases . • The outcome is quite satisfactory when full resection can be accomplished. European Journal of Cardio-thoracic Surgery 26 (2004) 652–654

  38. M.U. 40 Year-old male pT4N0M0 Right sleeve Pneumonectomy 54 months healthy

  39. T4 tumors • Pitz CM (2003) n=89 (Complete Res.: % 36.1) • 5 year survival 19,1% • 5 year sağ survival (complete) 46,2% • 5 year sağ survival (incomplete) 10,9% • Major vessel invasion 35,7% • Carina and trachea 50,8% • Vertebra 14.7% • N stage not important • Mortality 19,1% • Carina involvement n=11

  40. 65 Year-old male Epidermoid CA Mediastinoscopy (-) Stage IIIB (T4N0M0) Right sleeve pneumonectomy 56 months healthy

  41. T4 Tumors • Osaki T (2003) n= 76 (Complete Res: 61,8%) • 5 year survival 19,1% • Mediastinal group 18,2% • Satellite node group 26,7% • Pleural group 0% • N0-1 26,6% • N2 10,9% • Complete 29,8% • Incomplete 0% • Carina involvement n=5

  42. 63 year-old female L. Cell CA Right sleeve pneumonectomy T4N2M0 T4N1M0 12 months heart failure

  43. T4 Tumors n Mort. (%) 5 year survival (%) Maeda (1993) 31 16 40 Roviaro (1994) 28 4 20 Dartevelle (1996)60 6,6 43 Mitchell (2000) 60 15 42

  44. 50 year-old male (Y.Ç.) Epidermoid Ca Right sleeve pneumonectomy T4N0M0 Exitus after 20 months due to recurrence

  45. T4 tumors • In a multi-center study: • Wide mediastinal dissection or sampling, • Negative mediastinal nodal stations • Negative pleural fluid cytology Fulfills full resection criteria. European Journal of Cardio-thoracic Surgery 28 (2005) 622–628

  46. Surgery in Stage IV • Solitary brain metastasis • Solitary adrenal metastasis • Metastasis in the brain is removed first. • Adrenal metastases can be removed concurrently. Patchel RA. N Eng J Med 1990; 332:494-500

  47. Survival data:Locicero III J, Ponn RB, Daly BDT. Surgical Treatment of Non-Small Cell Lung Cancer. General Thoracic Sırgery. In eds Shields TW, Locicero III J and Ponn RB. 5th ed. Lippincott Williams and Wilkins, Philedelphia, 2000; 1311-1343

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