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General Thoracic Surgery > Early Stage NSCLC > Flashcards

Early Stage NSCLC Flashcards

1
Q

Definition of early stage lung cancer

A

Stage I or Stage II

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2
Q

Percentage of patients diagnosed with NSCLC that are considered early stage

A

~15% (13%)

Early stage (Stage I or II)

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3
Q

Leading risk factors for development of NSCLC

A
  • Smoking (largest)
  • Radon gas exposure
  • Asbestos
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4
Q

Most patients with NSCLC present with __ stage disease

A

Locally advanced or metastatic disease

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5
Q

Primary results of National Lung Screening Trial (NLST)

A
  • 20% reduction in lung-cancer specific mortality with low-dose helical CT vs CXR
  • 7% reduction in all-cause mortality with low-dose helical CT vs CXR
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6
Q

NCCN Guidelines for Staging of Early-Stage biopsy proven NSCLC

A
  • CT (chest and abdomen through adrenals)
  • PET/CT
  • Brain MRI (stage > Ib)
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7
Q

Characteristics of suspicious appearing MLN on CT or PET/CT for lung cancer

A
  • MLN > 1cm in long-axis diameter
  • PET hypermetaboic (SUV >= 2.5)
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8
Q

Approach to adrenal masses detected on staging workup for NSCLC

A
  1. Assess for funcitoning tumor (pheo/cortisol/etc)
  2. FNA biopsy of mass if non-functioning
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9
Q

All primary tumor biopsy specimens should undergo pathologic review for what

A
  1. Histologic subtype
  2. Molecular markers (dictate adjuvant treatment)
    1. EGFR
    2. K-ras
    3. ELM4/ALK
    4. ERCC1
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10
Q

MLN biopsy techniques and respective accessability patterns

A
  1. Cervical mediastinoscopy (stations 2,4,7)
  2. EBUS-TBNA (stations 1,2,3,4,7,10,11)
  3. EUS-FNA (stations 2R,2L,4L,7,8,9 + left adrenal masses)
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11
Q

Comparision of efficacy between mediastioscopy and EBUS-TBNA for MLN biopsy

A

Likely similar sensitivity, specificiy and diagnostic accuracy

(no direct head-to-head comparisons)

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12
Q

POC (Standard of Care) for early-stage lung cancer

A

Lobectomy (vs. sublobar resection)

  • Lower 5-year overall and cancer-specific mortality (67-90%)
  • Lower local recurrence rate (1-12%)
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13
Q

Approximate Local Recurrence (LR) and 5-year Survival (5-S) Rates for:

Lobectomy

Segmentectomy

Wedge Resection

A
  • Lobectomy (1-12% LR, 65-90% 5-S)
  • Segmentectomy (2-23% LR, 40-90% 5-S)
  • Wedge Resection (15-30% LR, 25-70% 5-S)
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14
Q

Evidence comparing lobectomy to sublobar resection for stage I NSCLC

A

Lung Cancer Study Group (1995)

  • Multi-institution RCT
  • Lobectomy vs. Sublobar resection
  • Results:
    • No differnece in morbidity or PFTs
    • 3x increase in local recurrance after wedge resection
    • 2.4x increase in local recurrence after segmentectomy
    • Tumor size (even if < 1cm) did not affect local recurrence
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15
Q

Surgical option for early stage NSCLC patients with poor cardiopulmonary fitness or other medical comorbidities precluding lobectomy

A

Segmentectomy with margins equal to size of primary tumor

(Preferable to wedge resection)

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16
Q

Surgical option for proximal tumors

A

Sleeve resection (key is tension-free repair)

  • Sleeve prefereable to pneumonectomy
  • Anastomosis should be buttressed
    • Intercostal muscle
    • Omentum
    • Pericarium
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17
Q

Benefits of buttressing bronchial anastomosis after sleeve resection

A
  1. Improved anastomoic healing
  2. Decreased risk of fistula formation (PA and bronchus)
18
Q

Characteristics of BAC

A
  • originates from type II pneumocytes (Clara cells)
  • presentation:
    • solitary peripheral nodule
    • pulmonary infiltrate
    • multi-focal disease
19
Q

Treatment options for BAC

A
  • Lobectomy (Standard of Care [SOC], if PFTs will tolerate)
  • Mutilple wedge resections (multifocal, disease burdon not extensive)
  • Chemotherapy (EGFR inhibitors [25% pts with EGFR mutations] for extensive disease)
20
Q

Critical adjunct to all lobectomies

A

Mediastinal lymph node evaluation (dissection preferable)

  • Right sided nodules
    • Stations (2R, 4R, 7, 8, 9, 10R and 14L)
  • Left sided nodules
    • Stations (2L, 4L, 5, 6, 7, 8, 9, 10L and 14L)
21
Q

Comparison of VATS to Open lobectomy

A

Meta-analyses suggest that VATS (vs Open) associated with:

  • Lower morbidity
  • Improved QOL
  • Improved survival
22
Q

Overall complication rate associated with early-stage lung cancer pulmonary resection

23
Q

MC compliations after pulmonary resection

A
  • Prolonged air leak
  • Arrhythmia (atrial fibrillation)
  • PNA
  • Respiratory failure
  • Wound infection
  • Altered mental status
24
Q

Unique complication after RUL lobectomy

A

RML torsion

  • Diagnosis:
    • RML atelectasis on postop CXR
    • Immediate bronchoscopy (CT if diagnosis in doubt)
  • Treatment: Immediate reoperation (detorsion + RML staples pexy to RLL)
  • Prevention: Stapled pexy of RML to RLL
25
Q

NCCN adjuvant treatment guidelines for Stage Ib NSCLC with R0 resection

A

Not indicated

R0 resection alone is adequate SOC

26
Q

NCCN treatment guidelines for early-stage (I or II) NSCLC with R1 resection

A
  1. Re-resection (preferred)
  2. Adjuvant radiation therapy
27
Q

NCCN guideline indications for adjuvant chemotherapy following early-stage NSCLC resection

A
  • High-risk stage Ib tumors
  • Stage II tumors
28
Q

First-line chemotherapy for adjuvant treatment of early stage NSCLC

A

Cisplatin-based regimen

  • Alternative: carboplatin + paclitaxol
    • unable to tolerate cisplatin rx
    • medical combidities preclude cisplatin rx
29
Q

NCCN treatment guidelines for medically inoperable early-stage NSCLC patients

A

Definitive chemoradition therapy

Cisplatin-based chemotherapy

30
Q

Indications for RFA in early-stage NSCLC

A

Patients lacking sufficient cardiopulmonary reserve to tolerate any pulmonary resection

31
Q

NCCN surviellence guidelines following surgical resection for early-stage NSCLC

A

H&P + non-contrast chest CT

(Q4-6 months x 2 years, then annually)

*PET/CT not indicated for routine followup

32
Q

Prognosis for untreated early-stage NSCLC

A

Median survival ~ 17 months (0% 5-year survival)

(5-year survival following R0 lobectomy: ~55-90%)

33
Q

Description of Stage I NSCLC

A

Tumors confined to lung without any local extension or metastases

34
Q

Description of Stage II NSCLC

A

Tumors associated with hilar or peribronchial lymph node involvement (N1) or with extension to the chest wall, mediastinum, or diaphrgam (T3, adjacent resectable structures)

35
Q

Description of Stage II NSCLC

A

Locally advanced tumors with mediastinal lymph node mets (N2 or N3), malignant pleural effusion, or invastion of adjacent non-resectable structures (T4)

36
Q

Description of Stage IV NSCLC

A

Tumors with distant mets (M1) or synchronous tumors in different lobes

37
Q

Main determinant of resectability for patients without distant metastatic disease

A

Mediastinal staging

38
Q

Most common methods of staging mediastinum

A
  • CT scan
  • PET scan
  • Mediastinoscopy
  • EBUS
39
Q

Primary results of ACOSOG Z0050 trial

(Reed et al, 2003)

A

PET scan prevented nontherapeutic thoracotomy in 6.3% of patients with NSCLC considered resectable by standard staging procedures.

40
Q

Postitive Predicted Value of PET for medistinal disease

41
Q

Rationale for performance of mediastinoscopy for patients with T2,T3,or T4 tumors with negative mediastinal staging by CT or PET

A

15% of patients will have positive mediastinal node involvent that werould preclude curative surgery.

General Thoracic Surgery (36 decks)

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