SURGICAL

MANAGEMENT OF dr. Alan Seikka

NON SMALL CELL
LUNG CANCER
 EPIDEMIOLOGY
Lung cancer is the leading cause of cancer death worldwide. Non–small cell lung cancer (NSCLC) accounts
for 80% of newly diagnosed cased
The incidence of lung cancer is low among under 40s, but increases until the age of 70 years. The main risk
factor for lung cancer is smoking. Other risk factor including radiation exposure, occupational exposure to
carcinogens, familial history of cancer, and history of lung disease such as COPD or lung fibrosis.

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008

The leading cause of cancer death for men as much as 21.8% and is one of the main causes of
death for women as much as 9.1% (besides breast cancer).³
Persahabatan hospital : more than 50 percent of cases of all types of cancer diagnosed
Dharmais Hospital (2003-2007) tracheal cancer, bronchial cancer, and lung cancer are second
most neoplasma cases in men (13,4%), and caused mortality as many as 28,94%.³.
PNPK Kanker Paru – Komite Penanggulangan Kanker Nasional 2017
HISTORY Cahan:
Recommended
anatomical
Graham & lobectomy with
Allison: systemic
Adler Singer: first successful The first major
mediastinal
reported all First sleeve meeting on
lymphadenectomy
cases of successful VATS pulmonary
lobectomy for as “radical
lung cancer pneumectomy resection
bronchial cancer lobectomy”
1912 1933 1952 1960 1993

1800 1929 1939 1959 1986 1993

First Brunn Churchill and Carlens: TNM Lewis
discussed: 1st Basley: devised classification introduced
Lung succesfull segmentectomy mediastinoscopy firstly used the role of
cancer one stage in bronchiectasis VATS
lobectomy

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
PREOPERATIVE ASSESSMENT
Physiologic
Staging Accurate staging —> Prognostic factor Considerations
• Operability must be
Mediastinal staging is the main determinant of resectability for patients determined by careful
without distant metastatic disease —> CT scan/PET/Mediastinoscopy assessment of both the
medical risk of thoracotomy
PET (Sen 85%, Spec 88%) > CT scan (Sen 60%, Spec 81%), because better and the risk of removing the
detection of mediastinal and distant metastatic —> PET can prevent a involved lung parenchyma
nontherapeutic thoracotomy in a significant number of cases • Smoking-induced
cardiopulmonary disease is
the major cause of morbidity
PET has a positive predictive value for mediastinal disease of only and mortality
56%, needs confirmation of positif lymph node on imaging —> EBUS, • Pulmonary function testing
EUS, Mediastinoscopy and arterial blood gas
Mediastinoscopy is gold standard for locally advanced T2-T4 or suspected analysis help determine the
N1-N3. feasibility of pulmonary
resection

T1A by imaging —> no need mediastinoscopy

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
 Large clinical series demonstrate that 60% to 70% of patients with T1 N0 resected lung cancer survive 5 years

Eighty percent of these patients never have a recurrence. Between 15% and 20% die within 5 years after diagnosis from causes unrelated to
their NSCLC. At the other end of the spectrum, fewer than 10% of patients treated with surgical resection for stage IIIB NSCLC are cured of
their disease.

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
 Surgical Principles and Management Surgical Resections
Completely remove the tumor and all intrapulmonary lymphatic drainage. The
standard procedures for NSCLC resection are anatomic lobectomy, sleeve
resection, bilobectomy, and, uncommonly, pneumonectomy
Lobectomy
Take care not to transgress the tumor during resection in order to avoid tumor
spillage Pneumonectomy

Make an effort to perform enbloc resection of adjacent or invaded structures Segmentectomy

rather than discontinuous resection

Perform frozen section analysis on the bronchial margin and any other margins
Wedge Resection
in close proximity to the tumor.
VATS
Remove or sample all accessible mediastinal lymph node stations for pathologic
evaluation.
Lymph Node Dissection

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al.
Philadelphia: Elsevier; 2008
Frank C. Detterbeck. Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. ACCP
Guidelines 2012
Frank C. Detterbeck. Diagnosis and Management of
Lung Cancer, 3rd ed: American College of Chest
Physicians Evidence-Based Clinical Practice
Guidelines. ACCP Guidelines 2012
Frank C. Detterbeck. Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. ACCP
Guidelines 2012
 LOBECTOMY
Surgical standart for those who tolerance
NSCLC stage I  Minor Sugery increase recurance rate
30%  decrease survival rate 30%
Standart procedure for lobulated NSCLC.
The tumor extends accros the fissure  bilobectomy

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 SLEEVE LOBECTOMY
Sleeve lobectomy For solid mass close to
the main bronchus
Sleeve lobectomy  If the margin close to
the main bronchus is not tumor free.
Avoiding pneumonectomy
If undergoing the sleeve lobectomy achieve
the free tumor margin  the 5 year
survival rate is better than pneumonectomy
(52% vs 31%) perioperative
mortality(1,6% vs 5,3%).

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 PNEUMONECTOMY
Indication fot NSCLC with involving extensive
main bronchus and tolerance with the operational
procedure.

Better to be avoided High perioperative

mortality (7%)  High cardiorespiration
complication

wherever possible do lobectomy  if the margin

of free tumor is hard to be achieved do
bronchoplasty

If reccurence after lobectomy  completion to

pneumonectomy High 30 day mortality rate
(20%) Bad 5 year survival rate(28%)
Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 SEGMENTECTOMY
• Anatomical Sublobar resection For patient with
bad tolerance undergoing lobectomy

• Inferior than lobectomy in reccurance rate and 5

year suvival rate, but better lung function

• More complicated technique than lobectomy or

wedge resection

• For T1 Case (<2cm), the 5 year surival rate 82%,

if N0 reccurance is equivalent with lobectomy)

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 WEDGE RESECTION
Non anatomical sublobar ressection.

For lobulated NSCLC patient but intolerance undergo

lobectomy.

Problem on wedge resection  High reccurance rate

even free tumor margin achieved

Worse 5 year survival rate than lobectomy (58% vs

70%)  High chance of death because of undergoing
the wedge resection, Not because of the tumor 
Patients who undergo wedge resection are significantly
older.

Post Operative radiation  minimize the reccurence 

decrease the already bad lung function

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 VAT Video Assisted thoracoscopic
Surgery  populer surgical
S approach
• Key points :
• for small, peripheral tumors state that it
decreases pain, preserves pulmonary
function,
• reduces the systemic inflammatory
response, and leads to an earlier return to
normal activities
• VATS is new approach, same indications.
• Absolute contraindications to VATS
lobectomy are inability to tolerate single-
lung ventilation, large tumor (>4 cm), a
fused pleural space, and established N2
disease.
Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 LYMPH NODE DISSECTION
Important for staging
Controversial  which one is needed complete
mediastinal node dissection vs sampling
mediastinal dissection?
stage I intraoperative N0 (smaller than 2 cm)  no
need mediastinal resection
The Eastern Cooperative Oncology Group (ECOG)
 stage II mediastinal lymph node dissection
sugested than sampling

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and
esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008
 SURGERY ON STAGE I (T1N0, T2N0)
• Stage I  surgery  best option

• Peripheral tumor location  controversial (Segmentectomy vs Lobectomy)

• Standard resection for stage I lung cancer in patients with adequate cardiopulmonary reserve
remains lobectomy because of the increased local recurrence rates of lesser resections
• controversy regarding the treatment of small (T1, N0) peripheral tumors remains. Some
authors have demonstrate excellent results with segmentectomy

• Traditionally, most patients with completely resected stage I or II NSCLC have not received adjuvant chemotherapy.
• Recent trial evaluated 482 patients with stage IB (T2 N0) and stage II completely resected NSCLC and demonstrated a
significant improvement in recurrence free and overall survival in the group of patients receiving adjuvant vinorelbine plus
cisplatin

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 SURGERY ON STAGE II (T1-2N1)
Lobectomy is the best choice
• Lobectomy is the procedure of choice for stage II disease and
was performed for 68% of the patients in this series.
Lobectomy resulted in complete resection for 34 of the 35 T1
N1 lesions. (Kettering Cancer Center Trial)

Post-operative radiation  decreasing reccurency on

stage II  not decreasing mortality

Survival Comparison of NSCLC Patient beetwen

adjuvant theraphy and Observation only.
• demonstrated that patients with stage II
completely resected NSCLC have a large survival
advantage when treated with postoperative
vinorelbine plus cisplatin

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 SURGERY ON STAGE II (T3N0)
T3 is the condition where the tumor already
invade through the chest wall, pericardium
parietal, mediastinal pleura, or 2cm from the
carina without involving the carina

Chest Wall Problem on closing the dissection deffect on

chest wall.
• For large defects with chest wall instability combination of Marlex and
methyl methacrylate
• For smaller defects, less than three ribs or less than 5 cm,  a taut Marlex
mesh or a Gore-Tex patch closure Chest computed tomographic scan of a T3
• Very small defects of one to two ribs, and defects located posteriorly beneath N0 left upper lobe non–small cell lung
the scapula,  do not require reconstruction cancer with chest wall invasion.

Superior sulcus tumors (Pancoast tumors) are apical bronchogenic

carcinomas with chest wall invasion. Undergo surgery 4-6 weeks
after the induction theraphy Contraindication for operation if N2
Or N3

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 SURGERY ON STAGE III
Low 5 year survival  15%

Stage IIIA
• N2 clinically undetected just found out intra-operatively ressection as clean as possible
• N2 clinically undetected If possible to be cut then do the surgery, if not then do
chemoradiation
Stage IIIB
• Basically has very bad outcome
• T4 involved carina  if N0/N1 5 year survival 53%, if N2/N3 the 5 year survival is 15%
• Satelite nodul Good survival if appear on the same lobe
• Involving mediastinal organ  able to undergo en block ressection 5 year survival 18%
• T4 Pleura  very bad difficult to do clean ressection 5 year survival close to 0
• N3  Worst prognosis  contraindication for operation
Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
 STAGE IV
The worst prognosis, if the far metastase has already found then the disease
cannot be cured by surgery

Brain metastasis  the worst (2-month life expectancy with steroid 6- months
whole brain radiation)

Adrenal Metastasis  detectable with CT/MRI

No surgical procedure is necessary

Kozower BD, Patterson GA. Surgical managemet of non small cell lung cancer. In: Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier;
2008
THANK YOU