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Surgery Options for Smaller, Slow-Growing Lung Cancers

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GCVL_LU-D03_Sublobectomy_Surgery_Options

 

Dr. Eric Vallieres, thoracic surgeon, discusses the potential to do smaller lung surgeries on patients with a lung cancer that poses a minimal risk of recurrence.

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The standard of care in 2015 for an early stage lung cancer is surgery, and that surgery had been established in the early ‘90s as being a lobectomy. The way that was done back then is that we took tumors that were less than 3 cm in size, we went to the operating room,

GCVL_LU-D03 Figures 1a ML.001

made sure all the lymph nodes were okay, flipped a coin — half of the patients got a lobectomy, and the other half got less than lobectomy, and that could have been either a wedge resection, or a segmentectomy.

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When they analyzed the results of that study, and the first author on that was Ginsberg, they noticed that patients who had had a lobectomy did better: they lived cancer-free longer, they had less recurrence, it was a better operation. So, back in the early ‘90s, that study established lobectomy as a standard of care.

Now, that was 20 years ago, and 20 years ago we were treating tumors that were larger than what we are seeing today, because today people are getting CAT scans — either screening CAT scans, or for-other-reason CAT scans, and we’re picking up on a lot of little, little tumors that we never knew existed before because the x-rays were not good enough. As a result of that, we are now seeing tumors that are 1 cm in size, 8 mm, 12 mm, that we rarely, if ever, saw before. The Ginsberg trial — most of those tumors were over 2 cm in size, so the question is, do we really need to do a lobectomy for those little tumors that we’re now picking up today? Those 8 mm tumors, 9 mm tumors, first question; the second question is, we’re also seeing a different type of cancer today that we never saw when I was in training — I never knew these things existed, and they were so-called, for a while, bronchioloalveolar carcinomas, and now the term is more early, well-differentiated adenocarcinomas,

GCVL_LU-D03 Figures 1a ML.003

either in situ or minimally invasive, or invasive, adenocarcinoma — it’s a field that’s evolving. But these tumors are small, not very aggressive, don’t metastasize, and there is certainly a fair amount of evidence, mainly out of Japan, to show that you do not need to do a lobectomy for these particularly not very aggressive, early adenocarcinomas that have not invaded. 

As a result of that, those new tumors, and the fact that we’re seeing smaller tumors in general, has brought back the concept that maybe we don’t need to do a lobectomy for all of the lung cancers that we’re seeing today. And in fact, there is a study in North America right now that is ongoing, looking at the role of lobectomy, or less, in tumors of 2 cm or less in size; that study is accruing, it’s been accruing for many years, but it’s getting there. In Japan, they’ve already closed a thousand patient study addressing the same question — we don’t have the results yet. So, it’s the same design as the Ginsberg trial, 20 years later, just with smaller tumors to see whether or not we need to do a lobectomy.

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The one thing we have to understand though, is that not every 10 mm tumor has the same biology, and there are 10 mm (or 1 cm) tumors that can be fairly aggressive. That’s particularly true when the tumor is a solid tumor, not just one of those, what we call in radiological terms, a ground-glass opacity, which tend to be more of a not very aggressive type of tumor, and we have to be careful that we cannot — I don’t think, personally, not having seen the results of those two trials, but I don’t think that we can just across the board say every tumor under 1 cm should be treated or can be treated with less than a lobectomy, and I think we have to realize that there are some of those tumors where more of a bigger operation may still be warranted.

But, there are a lot of these less aggressive types of tumors, those adenocarcinoma in  situ (or AIS), or minimally invasive adenocarcinoma where the focus of invasion that is only 5 mm or less in size, where you can do a very small operation, a wedge, and you get away with it. Similarly, if you elect to treat these patients with focal radiation therapy, you probably will do very well — these tumors don’t metastasize, and you can limit your field of radiation for those tumors, just as we can limit our field of surgery, and you’ll probably do very, very well for these particularly biologically favorable tumors, which are new.


GRACE Video

Types of Lung Surgery: From Wedge Resection to Pneumonectomy

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GRACE Cancer Video Library - Lung

GCVL_LU-D02_Lung_Cancer_Surgery_Types

 

There are multiple different types of lung cancer surgery. Dr. Eric Vallières, thoracic surgeon, reviews the different forms of lung surgery, include wedge resection, segmentectomy, lobectomy, and pneumonectomy.

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So, in lung cancer surgery, there are different types of operations that one can perform. The smallest amount of lung that one would consider removing is called a wedge resection, which is the equivalent of taking a bite into the lung without looking at boundaries and anatomy.

GCVL_LU-D02_Figs for Lung_Cancer_Surgery_Types ML.001

As you move up into the magnitude of the surgery, the next operation in line would be called a segmentectomy, which relates to the smallest anatomical division that the pulmonary lobes have. Those who have not had surgery — we all have five lobes in our two lungs, so three on the right, two on the left, and each lobe is divided into a number of segments. So, if you will remove only a segment, it’s called a segmentectomy, two segments would be a bisegmentectomy, and so on.

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Beyond the segmentectomy, is the next amount of lung we would remove, consider removing — is a lobectomy, meaning one lobe, and as I’ve said just a few minutes ago, there are five of those: three on the right, two on the left. On the right side, sometimes, we will remove two lobes — the middle lobe, and either the upper lobe, or the lower lobe, and that is called a bilobectomy.

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If we remove the entire lung, that is called a pneumonectomy, and that’s the magnitude — that’s the highest amount of lung that you can remove from one side, for obvious reasons.

GCVL_LU-D02_Figs for Lung_Cancer_Surgery_Types ML.004

In 2015, for a tumor that has still localized to the lung itself, for a tumor that has not spread anywhere, and in a patient who has the adequate cardiac and pulmonary reserves to tolerate the operation that is required, surgery is considered the standard of care — that’s the main option. There are other options, but at this stage in the game, they’re considered secondary, or less than standard of care options.

Now, when someone is evaluated for lung cancer surgery, not only do we evaluate whether the tumor is still localized, meaning it hasn’t spread anywhere, meaning that it’s a tumor that should be considered for surgery — that’s called resectability, but we also have to evaluate whether someone can handle that operation — that’s called operability, and that usually means, mainly, that we evaluate whether they have enough lung reserves to lose part of their lung, and that’s how we decide whether or not someone can handle, for example, a lobectomy.


Dr West

The Importance of the OLIGO in Oligometastatic or Oligoprogression

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There is a principle in management of lung cancer that some patients who have a very limited degree of metastatic disease or progression after a good response may do unusually well with local treatment, such as radiation or surgery, for the isolated area(s) of disease that are metastatic or growing. The idea for this stems from the concept of the “precocious metastasis”, which is essentially the idea of “the one that got away” — perhaps if there is just a very limited metastatic deposit of cancer or one area progressing and everything else is well contained, that area of escape can be obliterated without other areas of escape popping up elsewhere.

In the last few years, approaches like video assisted surgeries with wedge resections and focal radiation (stereotactic body radiation therapy, or SBRT) are now also making it more feasible to do additional local treatments with fewer side effects than in the past. This has led to a huge trend toward more and more surgeries or radiation treatments to areas of metastatic disease.  The question is whether this is really beneficial or whether it’s done largely because it’s easy to mislead patients and even ourselves as doctors that more is better, especially when it’s a profitable thing to do and someone else is paying for it. But I fear that these principles are being applied far beyond where they make good sense.

The term “oligometastatic” comes from the Greek root “oligo”, meaning few, along with metastases, and that fits when there is just one area of metastatic spread, or perhaps two. The problem is when local treatments are applied for 3 or 4 or more areas of disease. An isolated area of metastatic spread or progression may well represent a rogue area with its own biology, and there is an arugable reason to hope that we can resect or ablate that area and not have other areas of disease crop up. On the other hand, 5 areas of metastatic disease isn’t oligometastatic disease — it’s frankly metastatic disease, and it is unfathomably unlikely that the underlying cancer process can be controlled by just treating the areas you can see today. It would be like picking off a bunch of dandelions from the stems in your lawn and presuming your job is done. If you see 5 dandelions, you can be sure that eradicating those 5 won’t end the problem, and that plenty more will follow. Unfortunately, whether it’s a poor understanding of biology or an economic motivation to treat people in situations where it’s not oligometastatic at all, far too many practitioners of local therapies are all too eager to encourage patients to pursue treatments that cannot be reasonably expected to be helpful. 

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Dr West

I think I’m too old for a big lung surgery: What can you do for my lung cancer?

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For early stage NSCLC, the historic standard of care is a lobectomy.  But the reality is that with the median age of patients with new lung cancer a little over 70 and many patients quite sick from their lung cancer, COPD, and/or other medical problems, not every patient is a great candidate for surgery.

An 86 year old retired fireman I saw in clinic for the first time this past week illustrates the challenge and provides an opportunity for us to consider the options for him.  He has no smoking history (ironically, the other firefighters all smoked and made fun of him for not smoking), but he “ate smoke” in his work with no protective mask for decades and now has COPD as well as significant heart disease, with a first heart attack nearly 30 years ago, a triple bypass, a pacemaker now, and he walks with a walker.  He was involved in a motor vehicle accident a month ago (not his fault, mind you), went to an ER, and had some imaging that incidentally revealed an asymptomatic 2.5 cm mass in the apex (top) of his left lung, with no enlarged lymph nodes.  Of note, this is how most early stage lung cancers are detected: rather than being related to symptoms, they are found incidentally when someone undergoes pre-operative imaging for gall bladder surgery, goes to the ER for chest pain, etc., or now increasingly has a chest CT for lung cancer screening. Continue reading


Dr West

Dr. David Harpole on Advances in Lung Cancer Surgical Techniques

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Harpole Lung Cancer Surgery Advances FigureThe second part of the webinar by Dr. David Harpole of Duke University reviews advances in lung cancer surgery, covering techniques ranging from video-assisted thoracic surgery to robotic surgery to sub-lobar resections and other developments offering new promising alternatives.covered several of the new advances in the techniques used for lung surgery, ranging from minimally invasive lung surgeries through a dime-sized hole to robotic-assisted surgery and other developments.  

 

 

 

Harpole Adv Lung Surg Pt 2 Surg Techniques Audio Podcast

Harpole Adv Lung Surg Pt 2 Surg Techniques Transcript

Harpole Adv Lung Surg Pt 2 Surg Techniques Figs

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