Transcript SURGICAL MANAGEMENT OF LUNG CANCER

Surgical Management of Lung
Cancer
By
Mr A Soorae
LUNG CANCER
- Commonest cancer
- 40,000 cases on year
- Mean survival rate
< 6 months
- 80% die within one year of diagnosis
- overall five year survival 5.5%
- Resection best hope for cure
1881 – Experimental Lung Resection –
(Block & Gluck)
1895 – Pneumonectomy for Pyogenic
infection - (Macewen)
1912 - Dissection lobectomy - (davies)
1933 – Pneumonectomy for Lung Cancer –
(Graham)
Principles of evaluation
-
Diagnosis
-
Local Extent
- Distant Metastases
- General Condition
Clinical presentation of lung cancer
1.
2.
Asymptomatic
Symptomatic
(a) Local
- Cough
(b)
- Haemoptysis
- Wheeze
- Stridor
- Chest pain
- Dyspnoea
Metastatic
- Effusion
- Liver
-
-
Diaphragmatic paralysis
Pancoast/Horner’s syndrome
SVC Obstruction
Hoarseness
3.Paraneoplastic Syndromes
Brain
Adrenal
Bone
Other
Diagnosis
- SPUTUM CYTOLOGY
- BRONCHOSCOPY
- FNA
- NODAL BIOPSY
- VAT
- THORACOTOMY
- Biopsy
- BAL
- Brushings
- Needle
Staging
- BRONCHOSCOPY
- Proximal Extent
- Second Lesion
- IMAGING
- CXR
- CT
- MRI
- Ultrasound
- Nuclear
V/Q
Bone scan/Liver scan
Gallium/Thallium
P.E.T
- MEDIASTINOSCOPY/MEDIASTINOTOMY
TNM Staging system for NSCL
PRIMARY TUMOURS (T)
TX
T0
Tis
T1
T2
T3
T4
NODES (N)
NO
N1
N2
N3
Occult
No primary
In-situ
< 3 cm, Lobar bronchus, surrounded by lung
> 3 cm, visceral pleura, atelectasis < entire lung
> 2 cm from carina
Any size, extension to chest wall, diaphragm, mediastinal pleura,
pericardium
Invasion mediastinum, heart, great vessels,trachea, oesophagus,
vertebra and effusions
No nodes
Ipsilateral, peribronchial and hilar
Ipsilateral mediastinal and sub-carinal
Contralateral mediastinal – supraclavicular
DISTANT
METASTASIS (M)
MO
No Metastasis
M1
Distant Metastases
Staging based on TNM
OCCULT
STAGE 0
STAGE I
STAGE II
STAGE III A
STAGE III B
STAGE IV
TX
Tis
T1 – 2
T1 – 2
T1–3
T4
ANY T
ANY T
NO
MO
NO
N1
NO - 2
ANY N
N3
ANY N
MO
MO
MO
MO
MO
M1
The questions to be answered before
surgery
- Is is cancer?
- Is it resectable?
- Is there adequate cardio-respiratory reserve?
- Is there a major medical contra-indication?
- Is the patient agreeable to surgery?
>70% NSCLC – Stage IIIB & IV at presentation
hence, inoperable
RESECTION – possible in Stage I, II AND IIIA only
Resectability rate in the UK
- 10%
Pre-operative pulmonary evaluation
1.
2.
3.
4.
5.
Spirometry & Lung Volumes
Gas Exchange
Exercise testing
e.g. walking or stair climbing
Split Lung Function Studies
Rarely
-
Bronchospirometry
-
Vascular Studies - TUPAO
Pre-operative non-pulmonary risk factors
• Smoking
• Obesity
• Pre-existing disease
(a) Cardiac
• MI within six months
• é JVP
• arrhythmias
• > 5 premature ventricular ectopics
• Severe aortic stenosis
• Severe angina
(b) Non-cardiac
• Severe liver and renal impairment
• Age
Controversial
Physiology of thoracotomy
- Work of breathing é
- Chest wall compliance ê
- Vital capacity ê
- F.R.C ê
Hence
Alveolar hypoventilation
Respiratory acidosis
Hypoxia
- Impaired cough
Hence
Retained secretions
Atelectasis
Hypoxia
Peri-operative respiratory management
Aimed at preventing
By
• Atelectasis
• Bronchitis
• Bronchospasm
• Cessation of smoking
• Bronchodilators
• Cortico-steroids
• Pneumonia
• Pulmonary thromboembolus
• Hypoxaemic and
hypercapnic respiratory
failure
•
•
•
•
Antibiotics
Physiotherapy
D.V.T prophylaxis
Pain control
Goal of resection
“Complete removal of all gross and microscopic tumour
within the hemithorax”
Can be achieved by :•
•
•
•
•
Pneumonectomy
Lobectomy/Bilobectomy
Bronchoplastic procedures
Segmentectomy
Wedge resection
• Extended resections
Resection rate
UK
HOLLAND
USA
<10%
24%
25%
Resection for lung cancer
UK
1998-1999
1999-2000
2000-2001
C.T.C
3612
3378
3765
1998-1999
1999-2000
2000-2001
282
253
313
Reasons for low resection rate
in the UK
• Advanced disease
• Co-morbidity
• Elderly population
• Lack of resources
• Lack of surgeons
Complications I
1. Pulmonary
2. CARDIAC
• Atelectasis
• Arrhythmias
• MI
•
•
•
•
•
•
Lobar collapse
Infection
Aspiration
Pulmonary embolism
ARDS
Lobar torsion
• Respiratory insufficiency
• LVF
• Herniation
Complications II
3. Others
• Airleaks and spaces
• Empyema
• B.P.F
•
•
•
•
•
•
Haemorrhage/haemothorax
Oesophago-pleural fistula
Chylothorax/pleural effusions
Tumour embolus
Wound infection/dehiscence
Pain
Role of surgery in palliation
Pleural Effusion
• VAT and pleurodesis
• Pleuro-peritoneal shunt
Major airway obstruction
• Endoscopic resection
• Stents
• Rarely pleurectomy
Pericardial effusion
• Pericardiocentesis
• Pericardial window
SVC Obstruction
• Reconstruction
• Bypass
Results
• Overall operative mortality
• 5 year survival
Stage I
Stage II
Stage IIIA
Stage IIIB
Stage IV
5%
27%
65% - 75%
40% - 50%
10% - 30%
< 5%
< 5%
Surgical controversies
N2 disease
• Radical node dissection V’s sampling
• Segmentectomy V’s lobectomy
• Peripheral nodules
• Synchronous/Metachronous tumours
• VAT V’s open
• Small cell carcinoma
• Metastatic lung cancer
•