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General Thoracic Surgery > Locally Advanced Lung Cancer > Flashcards

Locally Advanced Lung Cancer Flashcards

1
Q

Definition of locally advanced lung cancer

A

NSCLC that has invaded adjacent structures

T3 or T4 cancers

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2
Q

Prevalence of locally advanced lung ca

A

5-10% of newly diagnosed lung ca

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3
Q

Presentation of locally advanced lung ca

A
  • Chest pain (chest wall invasion)
  • Obstructive sx (compression of airways or great vessels [ie SVC syndrome])
  • Asymptomatic (25%)
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4
Q

Cross sectional imaging used for locally advanced lung ca

A
  • CT (evaluation of chest wall invasion, ribs, and intercostal m)
  • MRI (preferred for spinal cord and vascular involvment)
  • No good imaging for pleural involvement
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5
Q

Definition of T3 locally advanced lung ca

A
  • Local invasion:
    • chest wall
    • diaphragm
    • phrenic nerve
    • parietal pleura
    • pericardium
    • main stem bronchus (< 2cm from carina, no involvment of carina)
  • Tumors > 7 cm with obstructive atelectasis or pneumonitis of entire lung
  • 2 or more tumors within same lobe
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6
Q

Definition of T4 locally advanced lung cancer

A
  • Local invasion:
    • Mediastinal structures
      • heart
      • great vessels
      • trachea/carina
      • recurrent LN
      • esophagus
    • Vertebral body
  • 2 or more tumors in different ipsilateral lobes
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7
Q

Spectrum of stages defined as locally advanced lung ca

A

Stages IIb - IIIb

  • IIb (T3N0)
  • IIIa (T3N1-2 or T4N1)
  • IIIb (T3-4N3 or T4N2)
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8
Q

Essential in surgical w/u of locally advanced lung ca

A

Rule out presence of metastatic disease

  • Surgical staging of mediastinum
  • PET/CT (chest and abdomen thru adrenals)
  • Head CT/MRI (r/o brain mets)
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9
Q

Key elements to determine treatment for locally advanced lung ca

A
  • Resectiability
  • Patient fitness
  • Nodal Status
  • Any tumor specific circumstances:
    • Chest wall invasion
    • Spinal invasion
    • Superior sulcus tumors
    • Need for bronchoplastic procedure
    • Ipsilateral mets
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10
Q

Definition of resectibility for locally advanced lung ca

A
  • 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.
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11
Q

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

A
  • Pulmonary function
  • Cardiac evaluation
  • Nutritional assessment
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12
Q

Significance of LN status for management of locally advanced lung ca

A

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

Surgical staging of mediastinum (mediastinoscopy) gold standard

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13
Q

Methods to determine LN status for localy advnaced lung ca

A
  • Gold standard: mediastinoscopy with LN biopsy
  • Alternate:
    • CT
    • PET/CT
    • MRI
    • EBUS
  • LUL tumors have most inconsistency in LN positivity
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14
Q

Mangement algorithm for locally advanced lung cancer

A
  • 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
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15
Q

Management of chest wall invasion

A
  • 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
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16
Q

Managment of locally advanced lung ca with spinal invasion

A
  • 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
17
Q

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

A

Superior sulcus tumor

  • Can involve:
    • chest wall
    • spine
    • thoracic inlet structures (anterior, middle, posterior compartments)
18
Q

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

A
  • Anterior comparment:
    • platysma
    • SCM
    • subclavian vein
19
Q

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

A
  • Middle compartment
    • phrenic nerve
    • anterior scalene m
    • subclavian artery
    • brachial plexus
    • middle scalene m
    • posterior scalene m
20
Q

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

A
  • Posterior compartment:
    • sympathetic ganglia
    • long thoracic nerve
    • external branch of spinal accessory nerve
    • suscapular artery
21
Q

Pancoasts syndrome (triad)

A
  1. shoulder pain
  2. atrophy of intrinsic hand muscles
  3. Horner’s syndrome
  • Superior sulcus tumors involving posterior compartment
22
Q

Treatment of superior sulcus tumors

A

Induction chemoXRT followed by surgical resection

23
Q

Contraindications to resection of superior sulcus tumors

A
  • N2 or greater disease
  • Brachial plexus involement beyond C8-T1
    • Removal of C8
      • Klumpke paralysis: atrophy/paralysis of hand/forearm muscles
    • Removal of T1 alone: tolerated
  • Spinal cord invasion
24
Q

Surgical approach to superior sulcus tumors

A
  • 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)
25
Q

Bronchoplastic procedure options for broncial/carinal involvement

A
  • Broncial involement
    • sleeve lobectomy
    • bilobectomy
  • Carinal involvement
    • sleeve resection
    • carinal pneumonectomy
26
Q

Results of comparison between pneumonectomy and sleeve lobectomy

A

Sleeve loectomy:

  • Improved operative morbidity and mortality
  • Comparable local recurrence rates
  • Similar long-term survival rates
27
Q

Surgical option for lung cancer invading carina

A
  • Sleeve pneumonectomy
28
Q

Key components for sleeve resections

A
  • Negative proximal and distal bronchial margins
  • Tension-free anastomosis
  • Wrapping/butressing of anastomosis
    • pericaridial flap
    • pleural flap
    • pedicled intercostal flap
29
Q

Feared complication after broncoplastic procedure

A

Anastomotic dehiscence

  • Large or total dehiscnce with BPF/empyema: requires pneumonectomy
  • Small dehiscence without BPF: treated non-operatively with drainage
30
Q

Potenitial long-term complication of partial dehiscence or bronchial ischemia after bronchoplastic procedure

A

Anastomotic stricture

31
Q

Surgical approach for carinal pneumonectomy

A
  • 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)
32
Q

Technique to decrease tension on anastomosis during carinal pneumonectomy

A
  • preoperative mediastinoscopy (loosens tissue)
  • neck flexed position
  • intrapericardial release
33
Q

Approach to patients with ipsilateral lung ca mets

A
  • T3 (same lobe) or T4 (different lobe) disease
  • Surgical resection (if no N2 disease)
    • 40-50% 5-year survival (comparable to M1 disease)

General Thoracic Surgery (36 decks)

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