Surgical Management of Lung Cancer

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Surgical Management of Lung Cancer

• Mike Poullis
• CTC Liverpool

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Surgical Management of Lung Cancer

• Is the patient for
• Diagnosis
• Treatment
• Palliation
• How fit is the patient ?
• What is the stage, histology, and exact size and
  location ?
• Remember NOT ALL PATIENTS HAVE PROVEN LUNG CANCER

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Overview

• Diagnostic (Full Hx and examination 1st )
• CXR
• CT
• PET
• Bronchoscopy
• VATS
• Mediasteinoscopy
• Mediasteinotomy
• Treatment
• Wedge
• Lobectomy
• Combined wedge and lobectomy
• Pneumonectomy
• Palliation
• Effusions

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Diagnostic Tests
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CXR

• Previous CXR
• Bony erosion if has chest pain
• Rate of growth
• Cardiac Status
• Physiological status

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CT

• T Stage
• Lobectomy
• Pneumonectomy
• N Stage
• ? Need mediastinoscopy or mediasteinotomy
• M stage
• Liver
• Adrenals
• Other Nodules, Bronchiectasis, Previous CABG,
  Cardiac, Vascular

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PET

• Tumour
• gt1cm
• Beware Carcinoid and alveolar cell carcinoma
• Mediastinum
• If Ve then probably normal
• If Ve then needs biopsy
• Metastasis not brain or heart

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PET
Ve
-Ve
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Diagnostic Bronchoscopy
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Diagnostic Bronchoscopy

• Rigid and flexible scope
• Biopsy and selective washings
• Larger samples than flexible scope
• Exact location
• Lobectomy
• Pneumonectomy
• Unresectable
• Sleeve

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Diagnostic Bronchoscopy
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Diagnostic VATS
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Diagnostic VATS (Video Assisted Thoracic
Surgery)

• Diagnosis of pleural disease

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VATS
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Mediasteinoscopy Mediasteinotomy

• Different
• lymph node
• stations

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Mediasteinoscopy Mediasteinotomy

• Diagnosis of unresectable disease
• Eliminate N2 disease from surgical resection

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Mediasteinoscopy Mediasteinotomy

• Different surgical cuts

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Mediasteinoscopy Mediasteinotomy
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Mediasteinoscopy Mediasteinotomy
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Treatment
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Surgical Assessment

• How fit is the patient ?
• What is the
• stage,
• histology,
• exact size and
• location ?
• Basically is the patient fit enough for the
  operation you think they need ?

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How Fit Is the Patient ?

• Performance status
• Pulmonary function tests
• Age
• Medical and surgical conditions
• What operation do they need

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Stage

• Assuming fit patient
• Can and should you take it out
• N2 or N3 disease
• T4 disease

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Histology

• Eliminate benign disease
• Beware false negative biopsy
• Beware scar cancers
• Eliminate small cell patients

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Exact size and location ?
All T1N0 non small cell carcinoma
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Treatment

• Wedge
• Lobectomy
• Combined wedge and lobectomy
• Pneumonectomy

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Thoracotomy

• Posterolateral
• Anterolateral
• Anterior
• Posterior
• Lateral
• Mini
• Muscle sparing

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Incision
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Treatment Wedge
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Treatment Wedge

• Small nodules in poor pulmonary function patients

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Treatment Lobectomy

• Gold standard
• Left LUL, LLL,
• Right RUL/-RML, RLL/-RML, RML
• Never RUL and RLL

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Treatment Lobectomy
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Treatment Pneumonectomy

• Extensive tumours only
• Intrapericardial or extrapericardial

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Outcomes After Surgery
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Chemotherapy and Radiotherapy

• Adjuvant
• Neoadjuvant
• Down staging
• Unexpected N2, or positive margins
• All small cell
• NICE recommends referring all postoperative lung
  cancer patients

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Small Cell

• Small nodule needle biopsy shows small cell
• If bone scan, and CT head negative refer
• If mediasteinoscopy negative then ? Surgical
  resection

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Palliation

• Pleural effusions
• Drainage, and pleurodesis
• Pleurectomy
• Talc
• Noxious chemotherapeutic agent
• Decortication
• Removal of tumour mass surrounding lung in
  pleural space
• BENIGN DISEASE DIFFERENT

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Any Questions ?