Balloons vs. Puddles: Can We Do Smaller Surgeries after Induction Therapy for NSCLC?

Howard (Jack) West, MD, Founder and President

In my thoracic oncology tumor board today, we discussed a situation that comes up fairly often: a patient has a collapsed lung lobe from a tumor near the middle of the chest, with some regional lymph nodes involved, and the surgeon thinks he's likely to need the whole lung removed because the location of the tumor is nestled in just the wrong place.  The patient has enough lung function to undergo surgery, but losing an entire lung (pneumonectomy) is a big loss, and he's already only a debatable candidate to be able to undergo surgery safely.  So the question emerges, "Can we give pre-operative chemotherapy specifically with the intent of shrinking a cancer enough to enable a less extensive surgery than would be needed if no pre-operative therapy is done?"

It's a question that doesn't have a clear answer.  The concept of "downstaging" a cancer with neoadjuvant (pre-operative) chemotherapy or chemo/radiation is an appealing potential appeal of the strategy, but there isn't clear evidence that it really works.  In the ChEST trial that has been recently published that compared pre-operative cisplatin/gemcitabine chemotherapy followed by surgery to surgery alone, the recipients of neoadjuvant therapy were less likely to have undergone a pneumonectomy (17% vs. 25%) and more likely to have received a lobectomy (70% vs. 60%) .  On the other hand, the SouthWest Oncology Group (SWOG) ran a similar neoadjuvant chemotherapy trial and found that there were no differences in the pneumonectomy rates with or without pre-op chemo -- 17% in both arms.  What gives?

Part of the challenge is that surgeons have different styles: some have come to believe that a cancer is like a balloon, and if it appears to shrink, you presume that the new borders of the cancer don't have any additional cancer around them.  Therefore, it's OK to do a smaller surgery than you would have originally done.  On the other hand, some surgeons see a cancer as a puddle drying up, so that even though the main borders are smaller on repeat scans, and maybe even when directly visualized by the surgeon, you can't be confident that there aren't little satellite areas of cancer outside of the main borders.  Therefore, they feel that if someone needed a pneumonectomy originally, you can't do a smaller surgery after pre-operative therapy, even if it looks as if the cancer is now small enough to enable a more limited surgery.

So the question of which patients receive a larger or smaller surgery depend only in part on what their tumor requires, and in part on the philosophy of the medical team (but usually especially the surgeon, who tends to get more votes in such matters).   We can't rely on the rates of pneumonectomy vs. lobectomy to tell us whether all of the pneumonectomies were clearly needed or not.  What would be most helpful would be to determine if the patients who were deemed to require a pneumonectomy that was then converted to a lobectomy do just as well as the patients who were anticipated to require a lobectomy from the beginning.  But to my knowledge, we don't have any such data.

In the end, let me give you a sense of how variable these styles are. I work with four board-certfied, excellent thoracic surgeons who get along amazingly well, even if they don't all do things the same way. Two of them favor revising the surgery after pre-operative therapy, and two favor doing the original surgery that would have been required.  And the one who presented the case today? He favored pre-operative therapy for a patient we shared a few months ago (but who ended up requiring a pneumonectomy after neoadjuvant chemo/radiation anyway), but for this particular patient, he favored up front surgery with a pneumonectomy.  In the more recent case, he wasn't at all optimistic that the operative options would be better after chemo or chemo/radiation.  It just goes to show how individualized patients and their cancers can be, with no "right way" for everyone, even with the same surgeon and team.

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