A. Tfayli - Head and neck - Guidelines and clinical case presentation (2-3 ca...
MON 2011 - Slide 22 - W. Weder - Surgery
1. 10th ESO-ESMO Masterclass in Clinical Oncology
02-07 April 2011, Ermatingen
NSCLC:
Surgery
Walter Weder MD
Professor of Surgery
University Hospital Zurich
2. Case 1
59 y, female, 40 py,
incidental finding on
chest X-ray
3. Questions
• What is your diagnosis?
• Further staging?
• Lobectomy or sublobar resection?
• Radiotherapy
• Adjuvant therapy indicated?
4. NSCLC - stages at presentation
7%
Stage II 31%
Stage III
24%
Stage I
38%
Stage IV
Fry, Cancer 1996
5. Stage-dependent survival for NSCLC
5-y survival after state-of-the-art treatment
• Stage I 54-80%
• Stage II 38-60%
• Stage IIIA 10-30%
• Stage IIIB <10%
• Stage IV <5%
Tsuboi, World Conference IASLC 2009
6. Personalized therapy
• Local extension
Surgery
TNM • Timing
Radiotherapy
• Undetermined
Paradigm shift from empiric to integrated therapy
adapted from D. Gandara, World Conference IASLC 2009
7. Lung cancer - treatment concepts
T 1- 3 N 0 Curative surgery
± adjuvant therapy
T 1 -3 N 1
T 1 -3 N2 Chemo-/(radio-)therapy
and surgery
T 4 N 0-1
T 1 -2 N 3
T 4 N3 M1 Palliative therapy
9. Minimally invasive (VATS) resections
2-4 incisions
30 – 70% of all lobectomies
in experienced centers
may preserve immunologic response and
better compliance for adjuvant therapy
10. Limited resection vs lobectomy
„Limited“
Resections Lobectomy
n=122 (%) n=125 (%) p-value
Recurrence 38 (31.1) 23 (18.4) 0.02
Locoregional 21 (17.2) 8 (6.4) 0.01
recurrence
Distant 17 (13.9) 15 (12.0) 0.67
metastases
Death 48 (39.3) 38 (30.4) 0.08
Lung Cancer Study Group: Ann. Thorac. Surg., 60, 615, 1995
11. Limited resection vs lobectomy
Nakamura H. et al. Brit. J. Cancer 2005; 92, 1033
12. The role of Tumor size
5-Year-survival
according to tumor diameter
< 20mm 21-30 mm > 30 mm
Lobectomy 92% 87% 81%
Segmentectomy 96% 85% 63%
Wedge resection 86% 39% 0%
Okada et al. J. Thorac. Cardiovasc. Surg. 2005; 129, 87
14. Consequences of limited resection
• Small functional advantage after
limited resection (<10 %)
• More local recurrences after sublobar
resections
• Small survival disadvantage (3.6%)
19. Chest wall infiltration
• important only for planning of the
surgical procedure
• 5-year survival up to 40% in T3N1with
adjuvant chemotherapy Burkhardt, JTCVS 2002
• similar success rates in pancoast tumors
following induction radio-chemotherapy
and complete resection Rusch, JCO 2007
20. Pancoast tumors
(superior sulcus tumors)
Tumor of the apex of the lung
with possible infiltration of the
chest wall brachial plexus,
stellate ganglion, ribs, vertebae
< 5% of all bronchogenic
carcinoma
PET/CT for staging
(mediastinum,
distant metastases)
Determination of the
radiation field
24. Incidental (occult) N2 disease
adjuvant treatment
• adjuvant cisplantin – based chemotherapy is
recommended
• adjuvant postoperative radiotherapy should
be considered to reduce local recurrence
ACCP Guidelines, Chest 2007
32. 65 year old obese (BMI 25) female of RLL with metastases to
lymph nodes # 10, 7, 4 R (tracheal infiltration)
Patient received 2 cycles of induction with CDDP/GEM. Tolerated
chemotherapy very poorly
Restaging with PET/CT SD (± PD)
MRI of brain without metastasis
33. Patient is alive after 5 years with
NED, assessed clinically and by CT
34. ‘Resectable N2‘ – which questions
have to be answered?
• Is ‘N2‘ technically resectable?
• Is surgery complete?
• Is surgery indicated from an oncological point
of view?
• What is the risk for the patient?
• Does the patient tolerate pulmonary resection?
risk-benefit ratio
38. Take home message I
• NSCLC remains to be the cancer with the highest
cancer related mortality
• Appropriate clinical and pathological staging
(including tissue diagnosis) is key to an
“individualized“ treatment
• Lobectomy with systematic mediastinal lymph node
dissection is the standard surgical procedure for
most T1 – T3, N0 – N1 tumors
• Minimal invasive lobectomy by VATS is performed
more and more frequent in specialized centers since
morbidity and mortality is reduced and adjuvant
therapy better tolerated
39. Take home message II
• Adjuvant chemotherapy is indicated for “fit patients“
with stages ≥ T2, N1
• Patients with ipsilateral mediastinal lymph node
metastasis (N2 disease) are best treated with
neaoadjuvant chemo(-radio)therapy followed by
surgery preferentially as part of “clinical trial“
• surgical resection after induction
chemoradiotherapy should be limited to a lobectomy
- whenever possible
• surgical resection for NSCLC should be complete
and the treatment related mortality within an
acceptable range.