Locally Advanced Lung Cancer

Question 1

Definition of locally advanced lung cancer

Answer 1

NSCLC that has invaded adjacent structures

T3 or T4 cancers

Question 2

Prevalence of locally advanced lung ca

Answer 2

5-10% of newly diagnosed lung ca

Question 3

Presentation of locally advanced lung ca

Answer 3

• Chest pain (chest wall invasion)
• Obstructive sx (compression of airways or great vessels [ie SVC syndrome])
• Asymptomatic (25%)

Question 4

Cross sectional imaging used for locally advanced lung ca

Answer 4

• CT (evaluation of chest wall invasion, ribs, and intercostal m)
• MRI (preferred for spinal cord and vascular involvment)
• No good imaging for pleural involvement

Question 5

Definition of T3 locally advanced lung ca

Answer 5

• Local invasion:
  
  • chest wall
  • diaphragm
  • phrenic nerve
  • parietal pleura
  • pericardium
  • main stem bronchus (< 2cm from carina, no involvment of carina)
• Tumors >5- 7 cm with obstructive atelectasis or pneumonitis of entire lung
• 2 or more tumors within same lobe

Question 6

Definition of T4 locally advanced lung cancer

Answer 6

• Local invasion:
  
  • Mediastinal structures
    
    • heart
    • great vessels
    • trachea/carina
    • recurrent LN
    • esophagus
  • Vertebral body
• 2 or more tumors in different ipsilateral lobes

Question 7

Spectrum of stages defined as locally advanced lung ca

Answer 7

Stages IIb - IIIb

• IIb (T3N0)
• IIIa (T3N1-2 or T4N1)
• IIIb (T3-4N3 or T4N2)

Question 8

Essential in surgical w/u of locally advanced lung ca

Answer 8

Rule out presence of metastatic disease

• Surgical staging of mediastinum
• PET/CT (chest and abdomen thru adrenals)
• Head CT/MRI (r/o brain mets)

Question 9

Key elements to determine treatment for locally advanced lung ca

Answer 9

• Resectiability
• Patient fitness
• Nodal Status
• Any tumor specific circumstances:
  
  • Chest wall invasion
  • Spinal invasion
  • Superior sulcus tumors
  • Need for bronchoplastic procedure
  • Ipsilateral mets

Question 10

Definition of resectibility for locally advanced lung ca

Answer 10

• Ability to obtain R0 resection
• T4 lesions classically unresectable
  
  • Tx: palliative chemoradiation
  • Exception:
    
    • Invasion of carina (carinal pneumonectomy) or vertebral bodies
    • Highly selected patients with invasion of SVC, PA and Ao have been treated surgically with multimodality therapy.

Question 11

Important determinants of patient fitness for surgical resection of locally advanced lunc ca

Answer 11

• Pulmonary function
• Cardiac evaluation
• Nutritional assessment

Question 12

Significance of LN status for management of locally advanced lung ca

Answer 12

Treatment strategy for locally advanced lung cancer depends upon extent of LN involvment.

Surgical staging of mediastinum (mediastinoscopy) gold standard

Question 13

Methods to determine LN status for localy advnaced lung ca

Answer 13

• Gold standard: mediastinoscopy with LN biopsy
• Alternate:
  
  • CT
  • PET/CT
  • MRI
  • EBUS
• LUL tumors have most inconsistency in LN positivity

Question 14

Mangement algorithm for locally advanced lung cancer

Answer 14

• N1 disease: sugical resection
• N2 disease:
  
  • induction chemoXRT
  • re-stage with cross-sectional imaging
  • surgical resection of positive response to induction therapy
    
    • single N2 node demonstrates superior prognosis to multinodal involvement
• N3 disease:
  
  • palliative chemoradiation only

Question 15

Management of chest wall invasion

Answer 15

• posterolateral thoracotomy (1 rib above and below tumor)
• en bloc resection tumor with overlying structures and chest wall
  
  • remove 1 uninvolved rib above and below
  • 2 cm margin
• chest wall reconstruction for defects > 5 cm
  
  • unnecessary if defect covered entirely by scapula
  • Tissue flaps (latissimus, serratus, rectus flap)
  • Synthetics
    
    • PTFE (Gortex) mesh
    • Polypropylene mesh with methyl methacrylate
    • Vicryl mesh

Question 16

Managment of locally advanced lung ca with spinal invasion

Answer 16

• Induction chemoXRT
• Vertebral involvement: partial or complete vertebrectomy with spinal reconstruction
• Intervertebral foramen invovlemetn: laminectomy and/or rib disarticulation
• Potential complication: CSF leak with meningitis or subarachnoid or ventricular air leak

Question 17

Locally advanced lung ca tumor located at uppermost aspect of costovertebral gutter

Answer 17

Superior sulcus tumor

• Can involve:
  
  • chest wall
  • spine
  • thoracic inlet structures (anterior, middle, posterior compartments)

Question 18

Thoracic inlet structures (anterior comparment) that can be invaded by superior sulcus tumors

Answer 18

• Anterior comparment:
  
  • platysma
  • SCM
  • subclavian vein

Question 19

Thoracic inlet structure (middle compartment) that can be invaded by superior sulcus tumors

Answer 19

• Middle compartment
  
  • phrenic nerve
  • anterior scalene m
  • subclavian artery
  • brachial plexus
  • middle scalene m
  • posterior scalene m

Question 20

Thoracic inlet structures (posterior compartment) that can be invaded by superior sulcus tumors

Answer 20

• Posterior compartment:
  
  • sympathetic ganglia
  • long thoracic nerve
  • external branch of spinal accessory nerve
  • scapular artery
  • vertebral artery

Question 21

Pancoasts syndrome (triad)

Answer 21

1. shoulder pain
2. atrophy of intrinsic hand muscles
3. Horner’s syndrome

• Superior sulcus tumors involving posterior compartment

Question 22

Treatment of superior sulcus tumors

Answer 22

• Proceed with neoadjuvant concurrent chemoradiation followed by planned surgical resection, followed by chemo or chemo/XRT.
• Induction chemoradiation in this situation comprises a platinum-based doublet (ideally cisplatin -etoposide, but cisplatin-vinblastine or carboplatin-pemetrexed (if adenocarcinoma) are also acceptable) administered concurrently with 45-50 Gy of radiation.
• A repeat PET-CT scan should be performed after induction therapy to determine:
  
  • if the patient has responded to the treatment -surgery
  • interval disease progression or development of metastases has occurred - no surgery
• Adjuvant therapy: a cisplatin-based doublet (options include cisplatin etoposide, cisplatin vinorelbine, cisplatin vinblastine; 2nd line for those who cannot take cisplatin = carboplatin paclitaxel/gemcitabine/pemetrexed). If the patient has mediastinal lymph node metastases identified on final pathology (missed by preoperative mediastinoscopy), a boost of mediastinal irradiation should be considered (if no prior RT; otherwise chemotherapy only).

Question 23

Contraindications to resection of superior sulcus tumors

Answer 23

Absolute contraindications to surgery because the tumor is not suitable for radical resection include:

1. the presence of extrathoracic metastases;
2. Invasion of the cervical trachea, esophagus, or brachial plexus above the C7 nerve root;
3. extensive vertebral invasion (2 or more); or
4. invasion of the spinal canal through the intervertebral foramina.
5. The presence of N2 disease.

Question 24

Surgical approach to superior sulcus tumors

Answer 24

• Upper lobectomy with en bloc resection of invovled structure
  
  • Brachial plexus T1 root alone ok, C8 (Klumpke paralysis, d/w pt)
  • Phrenic nerve should be preserved if possible
  • SC vein (resect and ligate)
  • SC artery (resect with primary anastomosis vs. PTFE interposition graft)

Question 25

Bronchoplastic procedure options for broncial/carinal involvement

Answer 25

• Broncial involement
  
  • sleeve lobectomy
  • bilobectomy
• Carinal involvement
  
  • sleeve resection
  • carinal pneumonectomy

Question 26

Results of comparison between pneumonectomy and sleeve lobectomy

Answer 26

Sleeve loectomy:

• Improved operative morbidity and mortality
• Comparable local recurrence rates
• Similar long-term survival rates

Question 27

Surgical option for lung cancer invading carina

Answer 27

• Sleeve pneumonectomy

Question 28

Key components for sleeve resections

Answer 28

• Negative proximal and distal bronchial margins
• Tension-free anastomosis
• Wrapping/butressing of anastomosis
  
  • pericaridial flap
  • pleural flap
  • pedicled intercostal flap

Question 29

Feared complication after broncoplastic procedure

Answer 29

Anastomotic dehiscence

• Initiate abx and tube thoracostomy.
• For dehiscence of 5 mm or less, simple chest tube drainage may be all that is needed, particularly if there was tissue coverage of the anastomosis and minimal air leakage.
• For larger segments of dehiscence and those with smaller defects but ongoing significant air leak or pleural contamination, completion pneumonectomy should be considered.
• Early dehiscence (not clearly defined but occurring in the early postoperative period) may be treated with debridement, additional mobilization of the remaining lung/hilum, and re-anastomosis with tissue coverage in select cases.

Question 30

Potenitial long-term complication of partial dehiscence or bronchial ischemia after bronchoplastic procedure and their management?

Answer 30

Anastomotic stricture

Anastomotic strictures may occur late and can typically be treated with balloon dilation. In rare cases, debridement of the stricture may be required with techniques such as laser therapy.

Question 31

Surgical approach for carinal pneumonectomy

Answer 31

• Right sided carinal pneumonectomy: right posterolateral thoracotomy
• Left sided carinal pneumonectomy:
  
  • median sternotomy
    
    • open posterior pericardium btw SVC and ascending Ao
  • left thoracotomy
  • bilateral (clamshell thoractomy)

Question 32

Technique to decrease tension on anastomosis during carinal pneumonectomy

Answer 32

• preoperative mediastinoscopy (loosens tissue)
• neck flexed position
• intrapericardial release

Question 33

Approach to patients with ipsilateral lung ca mets

Answer 33

• Same lobe (T3): lobectomy, followed by adjuvant chemotherapy.
• Different lobes, same lung (T4): lobectomy (for larger nodule) sublobar resection (for smaller nodule), as lung function permits.
• Surgical resection (if no N2 disease)
  
  • 40-50% 5-year survival (comparable to M1 disease)

Question 34

Surgical techniques for superior sulcus tumors?

Answer 34

1. Paulson-Shaw posterior thoracic inlet tumors
2. Dartevelle for tumors invading the subclavian vein or artery

Question 35

When should you perform a chest wall reconstruction?

Answer 35

• Must reconstruct:
  
  1. Posterior defects below 4th rib
  2. All anterior defects > 5 cm
  3. Resection of three or more ribs
  4. Removal of two or more ribs with baseline pulmonary compromise
  5. Resection of the manubrium
  6. Resection of the entire sternum
• Options include:
  
  • Biological acellular dermal substitute (e.g., Strattice, AlloDerm) -
  • PTFE (2 mm thickness, easy to handle) -
  • Prolene mesh alone -
  • Prolene with methylmethacrylate sandwich (rigid, but harder to handle/implant) -
  • Soft tissue flap with the help of plastic surgery (latissimus – for posterior/anterior locations, pectoralis/transverse rectus abdominis (TRAM) – for anterior locations only) may be necessary if the defect is very large or if there is local radionecrosis from neoadjuvant or prior radiotherapy.

Question 36

Approach to lung cancer lesions in different lungs?

(synchronous lesion Vs. M1a)

Answer 36

One strategy to manage these patients is to perform mediastinoscopy followed by resection of the smaller nodule in if the mediastinoscopy is negative.

• If the mediastinoscopy is positive, assume M1 disease (the mediastinal nodal disease means the disease is in transit and the contralateral lung nodule is more likely to be a metastasis rather than a primary) and treat with chemotherapy.
• If mediastinoscopy is negative, treat as two synchronous primaries and resect the smaller nodule. A second stage operation involves resection of the larger nodule. The amount of lung resected will depend on the patient’s lung function and which lobes are involved.

Question 37

“The tumor invades the chest wall, pericardium, adventitia of the aorta, superficial muscle of the esophagus, or focal area of SVC. How will you proceed?”

Answer 37

Tumor involving the chest wall, pericardium, focal vertebral body involvement and focal SVC involvement may be resected en bloc by surgeons with appropriate experience. Most surgeons would consider aortic or esophageal invasion a contraindication to proceeding. Clips should be placed to guide future radiotherapy if margins are close.

Question 38

“The tumor involves the proximal vagus nerve on the left. How will you manage this?”

Answer 38

The nerve should be resected en bloc with the specimen. The patient should then be considered for vocal cord medialization in the immediate postoperative period. Strict aspiration precautions should be considered for the immediate postoperative period.

Question 39

Common indications for sleeve resection include:

Answer 39

Common indications for sleeve resection include:

1. Lesions involving main bronchi or lobar bronchi close to the main bronchi
2. Benign or low-grade tumors (carcinoid being the most common)
3. Bulky peribronchial lymph node involvement
4. Tumors in the lateral aspect of the lower trachea or carina

Question 40

Contraindications for sleeve resection include:

Answer 40

1. Locally advanced T4 tumors
2. Patients with N2 or N3 disease
   
   • Note: the exception is in cases of carcinoid tumor, given that chemotherapy and radiation tend to be ineffective. The authors advocate proceeding with carcinoid resections despite advanced nodal disease for greatest chance of cure and for optimal management of existing and/or expected airway obstruction symptoms)
3. Inability to achieve negative margins

Question 41

“How do you handle a bronchial size mismatch during the end-to-end bronchial anastomosis?”

Answer 41

1. Traveling a further distance between bites on the larger sized bronchus should fix small size mismatches.
2. alternatively, a longitudinal wedge can be cut from the larger bronchus to allow tapering and better size match.
3. Telescoping is an advanced technique that can be considered by those with experience.