Locally Advanced Lung Cancer Flashcards
Definition of locally advanced lung cancer
NSCLC that has invaded adjacent structures
T3 or T4 cancers
Prevalence of locally advanced lung ca
5-10% of newly diagnosed lung ca
Presentation of locally advanced lung ca
- Chest pain (chest wall invasion)
- Obstructive sx (compression of airways or great vessels [ie SVC syndrome])
- Asymptomatic (25%)
Cross sectional imaging used for locally advanced lung ca
- CT (evaluation of chest wall invasion, ribs, and intercostal m)
- MRI (preferred for spinal cord and vascular involvment)
- No good imaging for pleural involvement
Definition of T3 locally advanced lung ca
- 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
Definition of T4 locally advanced lung cancer
- Local invasion:
- Mediastinal structures
- heart
- great vessels
- trachea/carina
- recurrent LN
- esophagus
- Vertebral body
- Mediastinal structures
- 2 or more tumors in different ipsilateral lobes
Spectrum of stages defined as locally advanced lung ca
Stages IIb - IIIb
- IIb (T3N0)
- IIIa (T3N1-2 or T4N1)
- IIIb (T3-4N3 or T4N2)
Essential in surgical w/u of locally advanced lung ca
Rule out presence of metastatic disease
- Surgical staging of mediastinum
- PET/CT (chest and abdomen thru adrenals)
- Head CT/MRI (r/o brain mets)
Key elements to determine treatment for locally advanced lung ca
- Resectiability
- Patient fitness
- Nodal Status
- Any tumor specific circumstances:
- Chest wall invasion
- Spinal invasion
- Superior sulcus tumors
- Need for bronchoplastic procedure
- Ipsilateral mets
Definition of resectibility for locally advanced lung ca
- 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.
Important determinants of patient fitness for surgical resection of locally advanced lunc ca
- Pulmonary function
- Cardiac evaluation
- Nutritional assessment
Significance of LN status for management of locally advanced lung ca
Treatment strategy for locally advanced lung cancer depends upon extent of LN involvment.
Surgical staging of mediastinum (mediastinoscopy) gold standard
Methods to determine LN status for localy advnaced lung ca
- Gold standard: mediastinoscopy with LN biopsy
- Alternate:
- CT
- PET/CT
- MRI
- EBUS
- LUL tumors have most inconsistency in LN positivity
Mangement algorithm for locally advanced lung cancer
- 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
Management of chest wall invasion
- 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
Managment of locally advanced lung ca with spinal invasion
- 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
Locally advanced lung ca tumor located at uppermost aspect of costovertebral gutter
Superior sulcus tumor
- Can involve:
- chest wall
- spine
- thoracic inlet structures (anterior, middle, posterior compartments)
Thoracic inlet structures (anterior comparment) that can be invaded by superior sulcus tumors
- Anterior comparment:
- platysma
- SCM
- subclavian vein
Thoracic inlet structure (middle compartment) that can be invaded by superior sulcus tumors
- Middle compartment
- phrenic nerve
- anterior scalene m
- subclavian artery
- brachial plexus
- middle scalene m
- posterior scalene m
Thoracic inlet structures (posterior compartment) that can be invaded by superior sulcus tumors
- Posterior compartment:
- sympathetic ganglia
- long thoracic nerve
- external branch of spinal accessory nerve
- suscapular artery
Pancoasts syndrome (triad)
- shoulder pain
- atrophy of intrinsic hand muscles
- Horner’s syndrome
- Superior sulcus tumors involving posterior compartment
Treatment of superior sulcus tumors
Induction chemoXRT followed by surgical resection
Contraindications to resection of superior sulcus tumors
- 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
- Removal of C8
- Spinal cord invasion
Surgical approach to superior sulcus tumors
- 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)
Bronchoplastic procedure options for broncial/carinal involvement
- Broncial involement
- sleeve lobectomy
- bilobectomy
- Carinal involvement
- sleeve resection
- carinal pneumonectomy
Results of comparison between pneumonectomy and sleeve lobectomy
Sleeve loectomy:
- Improved operative morbidity and mortality
- Comparable local recurrence rates
- Similar long-term survival rates
Surgical option for lung cancer invading carina
- Sleeve pneumonectomy
Key components for sleeve resections
- Negative proximal and distal bronchial margins
- Tension-free anastomosis
- Wrapping/butressing of anastomosis
- pericaridial flap
- pleural flap
- pedicled intercostal flap
Feared complication after broncoplastic procedure
Anastomotic dehiscence
- Large or total dehiscnce with BPF/empyema: requires pneumonectomy
- Small dehiscence without BPF: treated non-operatively with drainage
Potenitial long-term complication of partial dehiscence or bronchial ischemia after bronchoplastic procedure
Anastomotic stricture
Surgical approach for carinal pneumonectomy
- 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)
- median sternotomy
Technique to decrease tension on anastomosis during carinal pneumonectomy
- preoperative mediastinoscopy (loosens tissue)
- neck flexed position
- intrapericardial release
Approach to patients with ipsilateral lung ca mets
- T3 (same lobe) or T4 (different lobe) disease
- Surgical resection (if no N2 disease)
- 40-50% 5-year survival (comparable to M1 disease)
