Current surgical treatment of nonsmall cell lung cancer.docx

Current surgical treatment of nonsmall cell lung cancer.docx

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Currentsurgicaltreatmentofnonsmallcelllungcancer

EurRespirJ2002;19:

61S-70S

Copyright©ERSJournalsLtd2002

Currentsurgicaltreatmentofnonsmallcelllungcancer2001

J.Deslauriers

CORRESPONDENCE:

J.Deslauriers,Centredepneumologiedel'HôpitalLaval,2725cheminSainte-Foy,Sainte-FoyQC,G1V4G5,Canada

Keywords:

 lungcancer,resectability,surgery,survival

Received:

August10,2001

AcceptedAugust13,2001

  Abstract

Recognizingthatsurgicaltreatmentisstillthebestoptionforcontrollinglungcancer,surgeonswantanoperationtobeperformedwhenthebenefitsclearlyoutweighthepossiblerisks,andwhenithasbeendeterminedthatcancerresectionisthemostappropriatecourseofmanagement.Thenecessityforacompulsiveattitudetowardpreoperativeassessmentisthereforetobeemphasized.

Approximately45%ofalllungcancersarelimitedtothechest,wheresurgicalresectionisthemosteffectivemethodofcontrollingthedisease.Patientswithtumour（T）1,node（N）0andT2N0tumourshaveearlylungcancer,andmostarecurablebyresection,with5-yrsurvivalratesintherange75–80%forpatientswithT1N0status.The"goldstandard"ofsurgeryremainslobectomy.StageT1N1andT2N1carcinomasrepresentagroupofpatientsinwhomthediseaseinvolveshilarandbronchopulmonarynodes.Thisgroupisbesttreatedbycompleteresectionandmediastinallymphadenectomy.

SurvivaldatafollowingsurgicalresectionofT3tumoursclearlyshowbettersurvivalinpatientswithT3N0diseasethaninthosewithT3N1–2disease.Five-yearsurvivalratesforcompletelyresectedT3N0lesionsareintherange30–50%.OnceN1diseaseispresent,survivaldecreasesto15–20%.IncompleteresectionsfailtocureandsurgeryisnotindicatedifN2diseaseisdocumentedpreoperatively.Onoccasion,T4tumoursinvolvingthecarinaorvertebralbodycanbecompletelyresectedbutT4N1–2lesionsarevirtuallyincurablebysurgery.

Thepresenceofmediastinallymphnodemetastasis（N2/N3disease）isanominousprognosticsignandstageIII-bdisease,byvirtueofmetastaticcontralateralnodes,isanabsolutecontraindicationtosurgicalresection.Inductiontreatmentswithchemoradiationhaveshownprolongationofsurvivalandthreerandomizedtrialshavedemonstratedasurvivaladvantageoversurgeryalone.

Lungcancerisasignificanthealthproblem,with

170,000newcasesbeingdiagnosedannuallyintheUSA.Ofthese,

45%arelimitedtothethorax,wheresurgeryisthemosteffectivemethodofcontrollingthedisease.Recognizingthisconcept,surgeonswantanoperationtobeperformedwhenthebenefitsclearlyoutweighthepossiblerisks,andwhenithasbeendeterminedthatcancerresectionisthemostappropriatecourseofmanagement.

Thenecessityforacompulsiveattitudetowardspreoperativeassessmentisthereforetobeemphasizedsincerationaltreatmentandprognosisdependlargelyonthestageofthediseaseatthetimeofdiagnosis.Inthepreoperativesetting,thetechniquesusedshouldbesequentialandlogicalandhelptoidentifypatientssuitablefortreatmentwithcurativeintent.Theyshoulddefinethepatientsmostlikelytobenefitfrompulmonaryresectionwhileensuringthatnoindividualisdeniedthechanceofcurativeresectionbasedonradiologicalorclinicalfindingsalone1.Theyshouldalsohelpintheselectionofpatientseligibleforinductiontherapyprogrammes.Ifproperpretreatmentstagingisaccomplished,therateofexploratorythoracotomyorincompleteresectionshouldnotexceed8–10%.Ultimately,theprognosisoftheresectedpatientwithlungcancerisbasedoncompleteintraoperativestaging,whichcanbeperformedbyeithersystematicnodesamplingorcompletelymphadenectomy.Atpresent,neitherofthesetechniqueshasbeenshowntoimprovesurvival.

Patientswithtumour（T）1,node（N）0andT2N0tumourshaveearlylungcancers,andmostarecurablebyresection,with5-yrsurvivalratesintherange75–80%forpatientswithT1N0status.StageT1N1andT2N1carcinomasrepresentagroupofpatientsinwhomthediseaseinvolveshilarandbronchopulmonarynodes.Thisgroupisbesttreatedbycompleteresectionandmediastinallymphadenectomy.SurvivaldatafollowingsurgicalresectionofhigherstageprimarytumoursclearlyshowbettersurvivalinpatientswithN0diseasethaninpatientswithnodalmetastasis.

ThepresenceofN2diseaseisanominousprognosticfactor,althoughinductiontherapiesinvolvingchemotherapyorchemoradiationappeartoprolongsurvivalversussurgeryaloneinthegroupofpatientsthatisamenabletocompleteresection.

Thisreviewsummarizesthesurvivalinformationavailableforthevarioussubsetsofnonsmallcelllungcancer（NSCLC）.Itisacknowledgedthatnearlyallofthesedatacomefromsurgicalseriesinwhichresectionoftheprimarytumourwasthemainstayoftreatment.

  Clinicalandsurgicalstagingofnonsmallcelllungcancer

References

TheUnionInternationaleContreleCancerandAmericanJointCommitteeonCancerStaginghaverecentlyestablishednewcriteriafortumour,node,metastasis（TNM）stagingoflungcancer,andtheprognosisforthevariousTNMsubsetshasalsobeenredefined（table 1

）2.

Table1Revisedstagegroupingoftumour,node,metastasis（TNM）subsets

Stage

TNMsubset

Cumulative5-yrsurvived%

I-a

T1N0M0

61

67

I-b

T2N0M0

38

57

II-a

T1N1M0

34

55

II-b

T2N1M0

24

39

T3N0M0

22

38

III-a

T1–3N2M0

13

23

T3N1M0

9

25

III-b

T4N0–2M0

7

T1–4N3M0

3

IV

AnyT,anyNM1

1

cTNM:

clinicalTNMstage

pTNM:

pathologicalTMNstage

（From2.）

InthisrevisedTNMclassification,thedescriptorshavegenerallyremainedthesameasthosedescribedin19863.TumoursclassifiedasT3areneoplasmsthathavegrownbeyondthelungparenchymatoinvolvestructuresstillamenabletoresection,whereasT4definesthosetumourswithextensiveextrapulmonaryextension,usuallyprecludingcurativeorcompleteresection.TheT4descriptoralsoincludestumourswithsatellitenoduleslocatedwithinthesamelobe.Satellitenoduleslocatedintheipsilateralnonprimarytumourlobe（s）ofthelungaredesignatedM1.

TheclassificationofregionallymphnodestationshasbeenaddressedbyMountainandDressler4,whotriedtocombinethefeaturesofthetwosystemsthathavebeeninusefor>30 yrs,thefirstonebasedontheworkofT.NarukeandadvocatedbytheAmericanJointCommitteeonCancerStaging5andthesecondbeingthenodalmapproposedbytheAmericanThoracicSociety6.IntheproposalofMountainandDressler4,allN2nodesarecontainedwithinthemediastinalpleuralenvelopeandarenumbered1–9.Itisunderstood,althoughnotclearlystated,that,inmanycases,themediastinalpleuralreflectionisdifficulttoidentify,evenonsurgery,andsothedistinctionbetweenhilarnodes（N1）andlowtracheobronchialnodes（N2）maybedifficulttomake.Anatomically,thepleuralenvelopebeginsjustproximaltotheoriginoftheupperlobebronchus,andsoalllymphnodescephaladtothispointshouldbedesignatedasmediastinal.

Preoperativediagnosis

Althoughsomesurgeonscontinuetoadvocatethoracotomoywithoutdiagnosisbecause"youaregoingtooperateanyway",adequatetreatmentplanningbeginswithaproperdiagnosisoftheunderlyingdiseaseprocess7.Thisinformationallowsforacleardiscussionwiththepatientastowhatwillbedoneatoperation,aswellasforstreamliningtheinvestigationofthelesion.Further,itavoidsrelianceonintraoperativefrozensectionresults,whichcanattimesbemisleading.

Withimprovedbiopsytechniques,oftenperformedundercomputedtomographicguidance,andwithrefinementsinthepathologicalinterpretationofsmallspecimens,thediagnosisoflungcancercanbemadepreoperativelyinvirtuallyallpatients.Flexiblebronchoscopyisreliableincentraltumours,whichrepresent30%ofalllungneoplasms,whereaspercutaneousfine-needleaspirationbiopsycanestablishthediagnosisinasmanyas90–95%ofperipheraltumours8.Itisimportanttounderstandthatanegativeresultdoesnotexcludemalignancy,especiallyifthecytologicalfindingsarereportedasunsatisfactoryornonspecific.Intheseindividuals,repeatbiopsymaybeofvalue.

Clinicalstagingofthenodefactor

ThepresenceofmetastasestoregionallymphnodessignificantlyinfluencesboththetreatmentandprognosisofpatientswithNSCLC.ThepresenceofN1nodes,althoughrarelyofcrucialimportanceexceptperhapsinpatientswithT3–T4tumours,meansmoreextensiveresectionwithincreasedsurgicalriskandreducedprospectsforcure.Atpresent,thetechniquesusedforpreoperativedocumentationofN1statusareimperfect,andcomputedtomography（CT）doesnotappeartobebetterthanchestradiographyorobliquetomography,especiallyincaseswherethehilumisofnormalsizeonroutineexamination.Hilarabnormalitiesmaybeeasiertodetectwithmagneticresonanceimaging（MRI）becausenodescanbemorereadilydistinguishedfromlocalbloodvesselsbythistechnique.

Thepresenceofmediastinallymphnodemetastases（N2,N3disease）isanominousprognosticsign.Physicalexaminationcandetectenlargedsupraclavicularnodes,butthistypeofexaminationisnotoriouslyinaccurateifperformedbyaninexperiencedexaminer.Carefulclinicalhistorytakingandphysicalexaminationcanalsodetectevidenceofsuperiorvenacavaobstructionorleftrecurrentnervepalsy,bothbeingnearlyabsolutesignsofN2disease.

Advancedinvasiveandnoninvasivetechniquesarecurrentlyusedtopreoperativelydeterminethestatusofmediastinalnodes.ImagingmodalitiessuchasCTandMRIcandemonstratenodalen