Main.SurgeryForLungCancer History

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-->4)  close follow up is required since up to 45 % of patients will develop a second primary, most of which will be airway carcinomas
to:
-->4)  close follow up is required since up to 45 % of patients will develop a second primary, most of which will be airway carcinomas

'''2. Surgical Treatment of stage I (T1 N0 M0, T2 N0 M0) Non-Small Cell Lung Carcinoma'''
->'''A.''' 20% of patients
->'''B.''' includes patients with tumors:
-->1) 3 cm size or less surrounded by lung or visceral pleura, without extension proximal to a lobar bronchus
-->2) tumors > 3 cm, or tumor of any size that invades visceral pleura or has associated
atelectasis extending to the hilum, and is >2 cm distal to carina (T2)
-->3) Have no nodal metastases (N0 M0)
->'''C.''' Staging
-->1) Patients should be preoperatively and intraoperatively staged
-->2) Pre-op includes H&P, LFT’s, CXR, CT scan
-->3) Controversy exists over pre-op routine bone and brain scans for asymptomatic patients
-->4) Intra-op node dissection
-->5) Prior to 1986, the TNM classification included T1N1 tumors under stage 1, therefore reported overall survival was lower
->'''D.''' Results of surgery
-->1) Overall reported 5 year survival is 50-85% (82-85% T1, 67-68% T2)
-->2) Histology not a prognostic factor in survival
-->3) Close follow up required since recurrence rate is 27-39%
--->a) 60% recur within 2 years and 91% in 5 years
--->b) 34% develop second primaries:  33% lung, 16% breast, 13% head and neck, 8% colorectal, 7% bladder
-->4) Adjuvant therappy not warranted
-->5) Some evidence to suggest Vitamin A supplementation may have an effect on lowering the incidence of second primary tumors

'''3. Surgical Treatment of Stage II (T1N1M0, T2N1M0) Non-Small Cell Lung Carcinoma'''
->'''A.''' 10% of patients
->'''B.''' Includes patients with tumors:
-->1) Primary tumors confined to the lung and >2 cm distal to carina, with metastases to peribronchial or ipsilateral hilar lymph nodes
-->2) Treatment is lobectomy, bilobectomy or pneumonectomy with MLND
->'''C.''' Results of surgery
-->1) Overall survival is 39-49% 5 year
-->2) Prognostic factors include size of primary and number of metastatic lymph nodes
-->3) Recurrence rate in one study (Martini et al) was 55% with 21% loco-regional and 79% distant
-->4) No adjuvant therapy has improved survival
-->5) Postoperative radiotherapy has been shown to decrease locoregional recurrence rate
-->6) Adenocarcinoma tends to recur distally more often while SCCA tends to recur locally

'''4. Surgical Treatment of Stage IIIA (T3 N0-1 M0, T1-3 N2 M0) Non-Small Cell Lung Cancer'''
->'''A.''' Includes patients with tumors:
-->1) With limited, circumscribed extrapulmonary extension of the primary tumor (T3)
-->2) And/or  metastases confined to the ipsilateral mediastinal of subcarinal lymph nodes (N2)

'''5. Surgical Treatment of T3 (Chest Wall Invasion) Non-Small Cell Lung Carcinoma (exclusive of superior sulcus tumors)'''
->'''A.''' 5% tumors invade parietal pleura and chest wall
->'''B.''' Surgical treatment
-->1) Includes pulmonary resection with contiguous soft tissue and rib resection and chest wall reconstruction
-->2) When peripheral tumors is attached to parietal pleura, extrapleural resection can be attempted with good success or en bloc resection will be required
-->3) Marlex mesh and methylmethacrylate can be utilizied for reconstruction
-->4) Overall operative mortality is 4-12%
-->5) Overall 5 year survival is 26-40%
-->6) Lymph node status and depth of invasion correlates with survival
-->7) Most important prognostic factor is whether a complete resection can be performed

'''6. Surgical Treatment of T3 (Proximity to carina) Non-Small Cell Lung Cancer'''
->'''A.''' Lesion within 2 cm of carina
->'''B.''' Treatment includes
-->1) Pneumonectomy
-->2) Sleeve lobectomy
-->3) Sleeve pneumonectomy
->'''C.''' Most important diagnostic procedure is bronchoscopy in order to determine proximity of the tumor to the carina
->'''D.''' Results of surgical treatment
-->1) Sleeve lobectomy
--->a) Overall mortality 0-%
--->b) Overall 5 year survival is 30-64%
-->2) Sleeve pneumonectomy
-->a) Overall mortality 4-27%
-->b) Overall 5 year survival 16-23%
-->c) Indication is for bulky tumors in proximity to or involving the carina or tracheobronchial angle
-->d) Major complication is anastamotic dehiscence with a mortality of 100%

'''7. Surgical Treatment of N2 Disease (Mediastinal Lymph Node Metastases) in Patients with Non-Small Cell Lung Cancer'''
->'''A.''' 45% of presenting patients
->'''B.''' Overall 5 year survival is 20-30%
->'''C.''' Memorial Sloan Kettering experience (1974-1981 with 1598 patients)
-->1) 151 cases completelly resectable
-->2) Post-operative XRT used in 90% patients
-->3) Mediastinoscopy not routinely performed
-->4) 79% underwent lobectomy, 17% pneumonectomy and 4% segmentectomy
-->5) Overall 5 year survival was 30%
-->6) No difference in survival between SCCA or adenocarcinoma
-->7) Patients presenting with obviouos N2 disease had poorer survival
-->8) Number of nodes affected survival, upper paratracheal nodes affected survival with an overall 5 year survival of 20%
-->9) 73% patients developed recurrent disease
->'''D.''' Adjuvant therapy
-->1) Lung Cancer Study Group
--->a) Stage II and III patients
--->b) Found that post-operative radiotherapy significantly decreased local recurrence but no affect on survival
--->c Also randomized patients with adenoca and large cell ca to receive postop BCG and levamisole vs. Chemotherapy and found increased disease free survival in those patients that received chemotherapy
-->2) Stage IIIA patients
--->a) Three randomized trials of preoperative chemotherapy plux surgery vs. Surgery alone revealed survival benefit in patients receiving preoperative chemotherapy with a response rate 60%

'''8. Surgical Treatment of Stage IIIB Non- Small Cell Lung Cancer'''

'''9. Surgical Treatment of T4 (pleural Effusion) Non-Small Cell Cancer'''
->'''A.''' patients with malignant pleural effusions
->'''B.''' if cytologically negative, the effusion is excluded as staging element and is staged asT1, T2 or T3 lesion
->'''C.''' evaluation of patients with pleural effusions
-->1) Thoracentesis
-->2) thoracoscopy- perform if thoracentesis cytologically negative fluid
--->a) if pleural metastases is found then patient is non-operable (T4)
--->b) if no pleural metastases are found then the patient is an operable candidate (only 6 % of patients)
->'''C.''' median survival for patients with malignant pleural effusions is 6 months
->'''D.''' tube thoracostomy , pleurodesis, VATS may be required to control recurrent pleural effusions

'''10. Surgical Treatment of T 4 (Mediastinum) Non-Small Cell Lung Cancer'''
->'''A.''' patients with tumors of any size invading heart, great vessels, trachea, esophagus, vertebral body or carina
->'''B.''' most patients are considered inoperable if biopsied pre-operatively or are found unresectable intra-operatively
->'''C.'''  MSKCC experience
-->1) 225 patients in their review
-->2) overall survival 22% at 2 years, 13% at 3 years and 7% at 5 years
-->3) therapy  was either complete resection, incomplete resection with brachytherapy,
brachytherapy alone of incomplete resection alone
-->4) 5 year survival for patients that underwent complete resection was 9 %
->'''D.''' patients should receive pre-op chemotherapy if possible in attempt to down stage the tumor
->'''E.''' a small study by Macchiarini (23 patients) utilizing induction chemotherapy with patients with T4 tumors demonstrated a 3 year survival of 54%

'''11. Surgical Treatment of Stage IV (T1-4, No-2, M1) Non-Small Cell Cancer'''
->'''A.''' this includes any patient with distant metastatic disease (M1)
->'''B.''' small role for surgical therapy limited to patients with solitary brain metastases
-->1) if both lesions are resectable (brain metastases and lung tumor) then craniotomy should be performed followed by thoracotomy
-->2) patients who receive post-operative whole brain radiation  have an improved  median survival 9.2 months vs. 3.4 months

'''12. The Problems of Surgical Therapy For Small Cell Carcinoma'''
->'''A.''' in general is not a surgical disease
->'''B.''' surgery indicated in only a small number of patients
->'''C.''' it is usually discovered  intra-operatively in a patient with presumed non-small cell cancer
->'''D.''' if at thoracotomy the diagnosis of stage I small cell cancer is made, then complete resection should be attempted
->'''E.''' the VA Surgical Oncology Group demonstrated 5 year survival rates of 60% for T1N0 and 31% for T1N1 disease (54% received post-op chemotherapy)
->'''F.''' post-operative chemotherapy is recommended
->'''G.''' patients with stage II or III are best served by chemotherapy and radiation
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%center%%blue%''''+Sugery for Lung Cancer+''''


'''1 .Introduction'''
->'''A.''' Lung carcinoma is the second most common form of cancer in the U.S. and is the leading cause of death in men
-->1) (33% of cancer related deaths)
-->2) Lung cancer is the most common cause of death in women (23%) breast ca (18%)
-->3) Overall cure rate is 10-13 % of patients at 5 years
-->4) 1909 intratracheal anesthesia was introduced
-->5) Graham and Singer in 1933 reported the first successful pneumonectomy for lung carcinoma
-->6) In 1950, Churchill proposed that a lobectomy could be effective in the resection of lung carcinomas
-->7) Lung Cancer Study Group randomized 247 patients to compare segmentectomy versus lobectomy in the treatment of lung cancer
--->a) for segmentectomy the local recurrence rate was 17.2 % versus 6.4 % for lobectomy
--->b) 5 year survival was 50 % for segmentectomy versus 68 % for lobectomy
-->8) for incomplete resection for bronchogenic carcinoma the 5 year survival is 4 %
-->9) mediastinal lymph node dissection should be included in the resection
--->a) important for pathological staging
--->b) adds minimal time and morbidity to the procedure
--->c) compartments include :
---->(1) superior mediastinal
---->(2) A-P window
---->(3) subcarinal and inferior mediastinal

'''1. Surgical Treatment of Occult (TX NO MO) Non- Small Cell Lung Carcinoma'''
->'''A.'''  Low incidence, 1.5% in Memorial Hospital experience
->'''B.'''  these are individuals who participate in early screening programs and submit sputum for cytological analysis on a routine basis, or have hemoptysis with normal CXR
->'''C.'''  33 % of patients with positive sputum cytology and negative CXR will have head and neck cancer
->'''D.'''  detailed head and neck examination is important in the diagnosis
->'''E.'''  bonchoscopy
-->1) careful examination required
-->2) endobronchial brushing of each segmental bronchus required
-->3) fluorescent staining is possible with parenterally administered hematoporphyrin derivative
->'''F.''' Treatment
-->1)  photoablation has been described (3 yr survival 50- 70 %)
-->2)  surgical resection is the treatment of choice
-->3)  local recurrence is low, median survival is 9 years
-->4)  close follow up is required since up to 45 % of patients will develop a second primary, most of which will be airway carcinomas