8/16/2019 Advance in Lung Cancer Surgery

1/108

Advance in Lung Cancer Management:

Surgeon’s View

Punnarerk Thongcharoen, MD

Division of Cardio-thoracic Surgery Department of Surgery

Faculty of Medicine Siriraj ospital

Mahidol !niversity, Thailand

8/16/2019 Advance in Lung Cancer Surgery

2/108

8/16/2019 Advance in Lung Cancer Surgery

3/108

8/16/2019 Advance in Lung Cancer Surgery

4/108

8/16/2019 Advance in Lung Cancer Surgery

5/108

8/16/2019 Advance in Lung Cancer Surgery

6/108

8/16/2019 Advance in Lung Cancer Surgery

7/108

8/16/2019 Advance in Lung Cancer Surgery

8/108

• Lung cancer

 incidence/100000

8/16/2019 Advance in Lung Cancer Surgery

9/108

8/16/2019 Advance in Lung Cancer Surgery

10/108

Lets fght against lung

cancer• Reduce revalence o! lung cancer

• "mrove treatment outcome o! lung

cancer

8/16/2019 Advance in Lung Cancer Surgery

11/108

Lung cancer treatment

e#uation• $arl% case & Relativel% good outcome

• $arl% case & Surger% is a mainsta% o!

treatment •  'hus

• Surger% is a (e% to good outcome)

• And* o! course*

• A surgeon is a (e% to good outcome+

8/16/2019 Advance in Lung Cancer Surgery

12/108

 'o imrove outcome o!

lung cancer treatment

•  'o increase the num,er o! surgicall%

curative candidate

•  'o ma-imi.e the survival a!ter surger%

and minimi.e the mor,idit% and mortalit

% during erioerative eriod

8/16/2019 Advance in Lung Cancer Surgery

13/108

 'o increase the num,er o!

surgicall% curative candidate

• etect more earl% case among general/ high

cancer ris( oulation  lung cancer screening 

• iagnose lung cancer among atient resenting

with ulmonar% lesion that might ,e cancer

S2* mass3)4 more e5ectivel%

• irect those surgical candidates to thoracic

surgical service as much as ossi,le and ASA

8/16/2019 Advance in Lung Cancer Surgery

14/108

 'o ma-imi.e the goods and

minimi.e the ,ads

• evelo surgical techni#ue that

rovide the ,est oncologic outcome

• 2eoad6uvant/ ad6uvant thera%*

integrated holistic care

• Minimall% invasive era

8/16/2019 Advance in Lung Cancer Surgery

15/108

8/16/2019 Advance in Lung Cancer Surgery

16/108

Lung cancer screening

• Recommend onl% !or high cancer ris(

oulation

• Low dose C' chest

8/16/2019 Advance in Lung Cancer Surgery

17/108

7ow to 33 e5ectivel% diagnose lung

cancer in atient resenting with ul

monar% lesion that might ,e cancer

8/16/2019 Advance in Lung Cancer Surgery

18/108

 'issue diagnosis is the (e%+

• Lung cancer is still ossi,le8*  

tissue diagnosis confrmed that it is d

efnitel% CA2C$R or 29' cancer

• $-cision ,ios% is the last answer)

• 2o more 'R"AL and error4 with anti

t,c regimen

8/16/2019 Advance in Lung Cancer Surgery

19/108

Recommend

• Chest s%mtom  ;wee(

8/16/2019 Advance in Lung Cancer Surgery

20/108

atient with ulm nodule/

mass• Review revious imaging stud%  –Most lung cancer are not

•

>etting ,igger within less than amonth

• Sta,le !or more than  %ears

8/16/2019 Advance in Lung Cancer Surgery

21/108

 'in% solid nodule ? @ mm4

'i , lid d l  @

8/16/2019 Advance in Lung Cancer Surgery

22/108

• revalence o! malignanc% is higher)

• Recommended /= C' duration is

shorter

 'in% su,solid nodule ? @

mm4

 l d l

8/16/2019 Advance in Lung Cancer Surgery

23/108

ulmonar% nodule:

aroach• irst* start with estimate the

ro,a,ilit% o! malignanc% ,%  –

clinical 6udgment and/or  – a validated model Ma%o 3 most

oular4

8/16/2019 Advance in Lung Cancer Surgery

24/108

8/16/2019 Advance in Lung Cancer Surgery

25/108

8/16/2019 Advance in Lung Cancer Surgery

26/108

Solid nodule

• Second* customi.e diagnosis

aroach ,% si.e and retest li(eliho

od

8/16/2019 Advance in Lung Cancer Surgery

27/108

8/16/2019 Advance in Lung Cancer Surgery

28/108

8/16/2019 Advance in Lung Cancer Surgery

29/108

Solitar% ulmonar% nodule

• $' availa,le  – Ver% low  C' surveillance

 – Low to mod li(elihood  $'

 – 7igh  Bios% S-/ nonS-4

8/16/2019 Advance in Lung Cancer Surgery

30/108

Solitar% ulmonar% nodule

• $' ; 29' availa,le  – Ver% low  C' surveillance

 – Low to mod* high li(elihood  Bios%

S-/ nonS-4

8/16/2019 Advance in Lung Cancer Surgery

31/108

Surgical role in - aroach

• rimar% lesion  – edge resection : 9en/ VA'S

• Mediastinal L2  – Cervical mediastinosco%* anterior

mediastinotom%* VA'S

• leural metastasis  – VA'S

8/16/2019 Advance in Lung Cancer Surgery

32/108

ulmonar% nodule:

2on S- vs S- B- • hen clinical ro,a,ilit% and imaging are discordant

• Benign - re#uiring secifc medical R- is susected

•

Susect cancer with mediastinal invasion or distant metastasis/ SCLC

• 7igh retest ro,a,ilit%

• Non Sx Bx result is non diagnostic and

suspicioun of malignancy remains 

• $' strongl% ositive

8/16/2019 Advance in Lung Cancer Surgery

33/108

Mediastinal B-

• irst choice is now $B=S

• Cervical mediastinosco% : indication  –

$B=S: susicious  – Re;assessment ost induction CM';R'

8/16/2019 Advance in Lung Cancer Surgery

34/108

Surgical role in staging

• 2 disease: 'he line ,etween earl%

and advanced* good outcome and o

or outcome)

• "nvasive mediastinal staging is ver%

imortant)

• $-tensive mediastinal invasion on C'

 no !urther invasive staging

8/16/2019 Advance in Lung Cancer Surgery

35/108

Video;mediastinosco%

8/16/2019 Advance in Lung Cancer Surgery

36/108

8/16/2019 Advance in Lung Cancer Surgery

37/108

iagnosed earl% lung cancer

•  'he most e5ective treatment should include

surgical resection as a mainsta% o! treatment)

•  'he rimar% concern !or B-;confrmed earl% 2SCLC

is ro,a,l% how to get the atient to the 9R)

•  'he surger% re!usals seem to ,e a considera,le

reserve in onconeumonolog% to raise the oera,ilit

% o! lung cancer and to imrove the results o! its sur

gical treatment)

! ili i h h ! 8

8/16/2019 Advance in Lung Cancer Surgery

38/108

Are %ou !amiliar with these !acts8

Factors related with decision

 Yes (%

refuse)

No (%

refuse)

P

"ge # $% &' %' ()(*

+elief that D is  .(/ certain

&0 %* ()(( 0

+elieve eposure to air

during surgery spreads cancer

&$ %( ()( (*

Faith alone cures disease

&1 %( ()( (*

Pra er 2ill cure cancer &% %' ()((

Reasons 29' a5ected

8/16/2019 Advance in Lung Cancer Surgery

39/108

Reasons 29' a5ected

re!usal to S-Issues Yes (%

refuse)

No

(%

refuse)

 p

3ducation  *% years %1 %4 5S +iopsy-con6rmed %1 %4 5S

Physician discusses pros and cons of S

%4 &( 5S

Family must approve S &% %& 5S

8/16/2019 Advance in Lung Cancer Surgery

40/108

Lets do some e-ercise

8/16/2019 Advance in Lung Cancer Surgery

41/108

Scenario

• An as%mtomatic woman* DE %ears old*

chec(ed u at a 7osital A)

• Chest -;ra% showed a ))cm S2 at RLL)

• C' showed irregular nodule susected

CA with !ew aratracheal L2 0)E;0)@ cm

• $'/C' was done

 

สร  างจากเค  าโครงเร องจรง