ES 05.05 Lung Cancer Surgery for High Risk Patients

Abstract

High risk lung cancer patients represent a challenge in thoracic oncology, they are often related to heavy smoke habit with increased cardiovascular or respiratory diseases that prevents for getting optimal results in their lung cancer treatment. In the other hand it is widely accepted that lobectomy and lymphadenectomy is the standard treatment for younger patients with adequate cardiopulmonary function, especially in solid lung cancer patients.1 High risk patients with early stage lung cancer, often undergo sublobar resections, regardless of histology or tumor size, which increases the risk of local recurrence and may decrease long-term survival. However, a significant group of these patients have a good prognosis, either because their histology or tumor size are favorable, they present slow growing tumors or because they can undergo anatomical sublobar resections and a lymphadenectomy that provides an adequate disease control. In patients without respiratory or cardiovascular impairment it is accepted that sublobar resections have the same possibility of controlling the disease than lobectomy for ground glass opacity lesions, partially solid lesions (<50%) or with invasion area less than 5mm.2-4 The biggest problem appears in high-risk patients with solid lesions, in whom sublobar resections have not demonstrated the same oncological performance compared to lobectomy. This group will face the dilemma of decreasing operative morbimortality and the risk of postoperative respiratory disability versus decreased global and disease-free survival.5 Reports and our own experience with the treatment of T1 and T2 patients with segmentectomies and wedge resections suggests that it is appropriate to try these patients with economical resections to improve the quality of life and survival in a group of patients whose survival curve does not depend only on cancer, but it is also important the competitive causes of mortality (ex. cardiovascular disease, pulmonary fibrosis, emphysema).5 In our group, we evaluate cardiovascular risk with echocardiography and provocative test for myocardial ischemia, preferably exercise stress test. Respiratory risk is evaluated with spirometry, DLCO and cardiopulmonary exercise testing (peak VO2 and ventilatory equivalent VE/VCO2).6,7 If ppoFEV1 <60%, ppoDLCO <60%, V02 <10-15ml/kg/min and/or CO2 equivalent >35, values that show that the patient is high-risk or inoperable, we incorporate the patient to an exercise training program. Our protocol considers 1-1.5 hours/day of training, with progressive load to improve muscular strength, cardiovascular and respiratory capacity, associated with full medical treatment (LABA/LAMA inhalers plus inhaled and eventually systemic corticosteroids). After completing the training period, the patient is reevaluated and the treatment plan is defined: 1. If he leaves the high-risk group (VO2 >15ml/kg/min with VE/VCO2 <35), he will receive standard oncological surgery, according to tumor size and radiological/histological findings (TNM, GGO vs solid component, invasion). 2. If the surgical contraindication persists (VO2 <10ml/kg/min with VE/VCO2 >35), we prefer non-surgical treatments (like SBRT). In our institution, less than 5% of patients that enter the training program remain inoperable. 3. If the patient persists in the high or moderate-risk group (VO2 10-15ml/kg/min with VE/VCO2 <35), we prefer sublobar resections. In patients where the tumor is pure GGO or predominantly GGO (<50% solid) and measure less than 2 cms, we perform a VATS wide wedge resection plus hilar and mediastinal sampling. Frozen section must confirm that less than 50% is invasive or invasion area is smaller than 5mm. Margins should be larger than 1cm to persevere with wedge resection. If these requirements are not met: solid tumors larger than 10mm or mostly solid/GGO tumors, or GGO tumors greater than 2 cm with >25% solid, or has an invasive component larger than 5mm, we perform an anatomic segmental resection, by VATS or thoracotomy, associated with hilar and mediastinal lymphadenectomy.2,8-10 4. Even in larger tumors, we will attempt segmental resection in high-risk patients. We consider that although the risk of local recurrence is high, the lower morbidity and mortality rate of sublobar resections justifies this approach in high-risk patients. We believe that a sublobar resection with margins larger than 1 cm, grant better quality of life than a patient who becomes oxygen dependent, dies in the postoperative period or has not been resected due to the impossibility of lobectomy. In our institution, we have a prospective registry of morbidity that allows us to evaluate M&M rate and the relation with VO2 in patients with lobar and sublobar resections (Fig 1).5,9 Finally, in those patients with solid tumors and lymphovascular invasion, that are staged as clinically an pathological N0, the problem is that the intralobar lymph nodes are not completely accessible or evaluable. This implies that actually the N1 barrier is not adequately studied with sublobar resections, especially in those patients undergoing a training program and become candidates to wedge or even anatomical segmental resections as a treatment choice. This lack of information may be acceptable in AIS or MIA tumors, but constitute a greater risk in patients with solid or partially solid tumors, and even greater risk in those with lymphovascular invasion in the paraffin section. Should we consider these patients as potential N1 and add treatment to avoid the risk of relapse? There is no evidence to support this approach yet, but we feel it should be considered. 1.De Zoysa MK et al. Is limited pulmonary resection equivalent to lobectomy for surgical management of stage I non-small-cell lung cancer? Interactive CardioVascular and Thoracic Surgery 14(2012) 816-20 2.Asamura H et al. Radiographically determined noninvasive adenocarcinoma of the lung: Survival outcomes of Japan Clinical Oncology Group 0201. J Thorac Cardiovasc Surg 2013;146:24-30 3. Sakurai H, Asamura H. Sublobar resection for early stage lung cancer. Transl Lung Cancer Res 2014;3(3):164-172 4. Suzuki K, Asamura H et al. “Early” peripheral lung cancer: prognostic significance of Ground Glass Opacity on thin-section computed tomographic scan. Ann thorac Surg 2002;74:1635-9 5. Nakamura H et al. Comparison of the surgical outcomes of thoracoscopic lobectomy, segmentectomy, and wedge resection for clinical stage I non-small-cell lung cancer. 2011 Apr;59(3):137-41. 6. Shafiek et al. Risk of postoperative complications in chronic obstructive lung disease patients considered fit for lung surgery: beyond oxygen consumption. Eur J Cardiothorac Surg 2016; http://dx.doi.org/10/1093/ejcts/ezw104 7. Salati M, Brunelli A. Risk stratification in lung resection. Curr Surg Rep. 2016; 4:37 8. Hattori A et al. Prognostic impact of the findings on thin section computed tomography in patients with subcentimetric non-small cell lung cancer. JTO 2017;12(6):954-962 9. Valenzuela R et al. Long term survival of lung cancer in Chile. JTO2017;12(1):S745-S746 10. Aokage K et al. Limited resection for early-stage non-small cell lung cancer as function-preserving radical surgery: a review. Jpn J Clin Oncol,2017,47(1):7-11. High risk patients, lung cancer