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Surgery_Schwartz_4602 | Surgery_Schwartz | generating antibodies leading either to interference with neurologic function or to immune neurologic destruction. Up to 16% of lung cancer patients have neuromuscular dis-ability, and, of these, half have grade IV NEC (small cell) and 25% have squamous cell carcinomas. In patients with neurologic or muscular symptoms, central nervous system (CNS) metastases must be ruled out with CT or magnetic resonance imaging (MRI) of the head. Other metastatic dis-ease leading to disability must also be excluded.6. Lambert-Eaton syndrome. This myasthenia-like syndrome is caused by tumor secretion of immunoglobulin G (IgG) antibodies targeting voltage-gated calcium channels, which causes a neuromuscular conduction defect by decreasing the amount of acetylcholine released from presynaptic sites at the motor end plate. Symptoms, including gait abnormali-ties from proximal muscle weakness and impaired coordi-nation, may actually precede radiographic evidence of the tumor. Therapy is directed at the | Surgery_Schwartz. generating antibodies leading either to interference with neurologic function or to immune neurologic destruction. Up to 16% of lung cancer patients have neuromuscular dis-ability, and, of these, half have grade IV NEC (small cell) and 25% have squamous cell carcinomas. In patients with neurologic or muscular symptoms, central nervous system (CNS) metastases must be ruled out with CT or magnetic resonance imaging (MRI) of the head. Other metastatic dis-ease leading to disability must also be excluded.6. Lambert-Eaton syndrome. This myasthenia-like syndrome is caused by tumor secretion of immunoglobulin G (IgG) antibodies targeting voltage-gated calcium channels, which causes a neuromuscular conduction defect by decreasing the amount of acetylcholine released from presynaptic sites at the motor end plate. Symptoms, including gait abnormali-ties from proximal muscle weakness and impaired coordi-nation, may actually precede radiographic evidence of the tumor. Therapy is directed at the |
Surgery_Schwartz_4603 | Surgery_Schwartz | motor end plate. Symptoms, including gait abnormali-ties from proximal muscle weakness and impaired coordi-nation, may actually precede radiographic evidence of the tumor. Therapy is directed at the primary tumor with resec-tion, radiation, and/or chemotherapy. Many patients have dramatic improvement after successful therapy. For patients with refractory symptoms, treatment consists of guanidine Brunicardi_Ch19_p0661-p0750.indd 68201/03/19 7:00 PM | Surgery_Schwartz. motor end plate. Symptoms, including gait abnormali-ties from proximal muscle weakness and impaired coordi-nation, may actually precede radiographic evidence of the tumor. Therapy is directed at the primary tumor with resec-tion, radiation, and/or chemotherapy. Many patients have dramatic improvement after successful therapy. For patients with refractory symptoms, treatment consists of guanidine Brunicardi_Ch19_p0661-p0750.indd 68201/03/19 7:00 PM |
Surgery_Schwartz_4604 | Surgery_Schwartz | CHAPTER 19683CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAhydrochloride, immunosuppressive agents such as predni-sone and azathioprine, and occasionally plasma exchange. Unlike with myasthenia gravis patients, neostigmine is usu-ally ineffective.Symptoms Associated with Metastatic Lung Cancer. Lung cancer metastasizes most commonly to the CNS, vertebral bod-ies, bone, liver, adrenal glands, lungs, skin, and soft tissues. CNS metastases are present at diagnosis in 10% of patients; another 10% to 15% will develop CNS metastases following diagnosis. Focal symptoms, including headache, nausea, vom-iting, seizures, hemiplegia, and dysarthria, are common. Lung cancer is the most common cause of spinal cord compression, either by primary tumor invasion of an intervertebral foramen or direct extension of vertebral metastases. Bony metastases are identified in 25% of lung cancer patients. They are primar-ily lytic and produce pain locally; thus, any new and localized skeletal symptoms must be | Surgery_Schwartz. CHAPTER 19683CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAhydrochloride, immunosuppressive agents such as predni-sone and azathioprine, and occasionally plasma exchange. Unlike with myasthenia gravis patients, neostigmine is usu-ally ineffective.Symptoms Associated with Metastatic Lung Cancer. Lung cancer metastasizes most commonly to the CNS, vertebral bod-ies, bone, liver, adrenal glands, lungs, skin, and soft tissues. CNS metastases are present at diagnosis in 10% of patients; another 10% to 15% will develop CNS metastases following diagnosis. Focal symptoms, including headache, nausea, vom-iting, seizures, hemiplegia, and dysarthria, are common. Lung cancer is the most common cause of spinal cord compression, either by primary tumor invasion of an intervertebral foramen or direct extension of vertebral metastases. Bony metastases are identified in 25% of lung cancer patients. They are primar-ily lytic and produce pain locally; thus, any new and localized skeletal symptoms must be |
Surgery_Schwartz_4605 | Surgery_Schwartz | of vertebral metastases. Bony metastases are identified in 25% of lung cancer patients. They are primar-ily lytic and produce pain locally; thus, any new and localized skeletal symptoms must be evaluated radiographically. Liver metastases and adrenal metastases are typically asymptomatic and usually discovered by routine CT scan. Adrenal metastasis may lead to adrenal hypofunction. Skin and soft tissue metas-tases occur in 8% of patients dying of lung cancer and gener-ally present as painless subcutaneous or intramuscular masses. Occasionally, tumor erodes through overlying skin; excision may then be necessary for both mental and physical palliation.Nonspecific Cancer-Related Symptoms. Lung cancer often produces a variety of nonspecific symptoms such as anorexia, weight loss, fatigue, and malaise and their presence raises con-cern for metastatic disease.Lung Cancer ManagementRole of Histologic Diagnosis and Molecular Testing. Establishing a clear histologic diagnosis early in the | Surgery_Schwartz. of vertebral metastases. Bony metastases are identified in 25% of lung cancer patients. They are primar-ily lytic and produce pain locally; thus, any new and localized skeletal symptoms must be evaluated radiographically. Liver metastases and adrenal metastases are typically asymptomatic and usually discovered by routine CT scan. Adrenal metastasis may lead to adrenal hypofunction. Skin and soft tissue metas-tases occur in 8% of patients dying of lung cancer and gener-ally present as painless subcutaneous or intramuscular masses. Occasionally, tumor erodes through overlying skin; excision may then be necessary for both mental and physical palliation.Nonspecific Cancer-Related Symptoms. Lung cancer often produces a variety of nonspecific symptoms such as anorexia, weight loss, fatigue, and malaise and their presence raises con-cern for metastatic disease.Lung Cancer ManagementRole of Histologic Diagnosis and Molecular Testing. Establishing a clear histologic diagnosis early in the |
Surgery_Schwartz_4606 | Surgery_Schwartz | and malaise and their presence raises con-cern for metastatic disease.Lung Cancer ManagementRole of Histologic Diagnosis and Molecular Testing. Establishing a clear histologic diagnosis early in the evaluation and management of lung cancer is critical to effective treat-ment. Molecular signatures are also key determinants of treat-ment algorithms for adenocarcinoma and will likely become important for squamous cell carcinoma as well. Currently, differentiation between adenocarcinoma and squamous cell carcinoma in cytologic specimens or small biopsy specimens is imperative in patients with advanced stage disease, as treat-ment with pemetrexed or bevacizumab-based chemotherapy is associated with improved progression-free survival in patients with adenocarcinoma but not squamous cell cancer. Further-more, life-threatening hemorrhage has occurred in patients with squamous cell carcinoma who were treated with bevacizumab. Finally, EGFR mutation predicts response to EGFR tumor kinase | Surgery_Schwartz. and malaise and their presence raises con-cern for metastatic disease.Lung Cancer ManagementRole of Histologic Diagnosis and Molecular Testing. Establishing a clear histologic diagnosis early in the evaluation and management of lung cancer is critical to effective treat-ment. Molecular signatures are also key determinants of treat-ment algorithms for adenocarcinoma and will likely become important for squamous cell carcinoma as well. Currently, differentiation between adenocarcinoma and squamous cell carcinoma in cytologic specimens or small biopsy specimens is imperative in patients with advanced stage disease, as treat-ment with pemetrexed or bevacizumab-based chemotherapy is associated with improved progression-free survival in patients with adenocarcinoma but not squamous cell cancer. Further-more, life-threatening hemorrhage has occurred in patients with squamous cell carcinoma who were treated with bevacizumab. Finally, EGFR mutation predicts response to EGFR tumor kinase |
Surgery_Schwartz_4607 | Surgery_Schwartz | Further-more, life-threatening hemorrhage has occurred in patients with squamous cell carcinoma who were treated with bevacizumab. Finally, EGFR mutation predicts response to EGFR tumor kinase inhibitors and is now recommended as first-line therapy in advanced adenocarcinoma. Because adequate tissue is required for histologic assessment and molecular testing, each institution should have a clear, multidisciplinary approach to patient evalu-ation, tissue acquisition, tissue handling/processing, and tissue analysis (Fig. 19-18). In many cases, tumor morphology differ-entiates adenocarcinoma from the other histologic subtypes. If no clear morphology can be identified, then additional testing for one immunohistochemistry marker for adenocarcinoma and one for squamous cell carcinoma will usually enable differentiation. Immunohistochemistry for neuroendocrine markers is reserved for lesions exhibiting neuroendocrine morphology. Additional molecular testing should be performed on all | Surgery_Schwartz. Further-more, life-threatening hemorrhage has occurred in patients with squamous cell carcinoma who were treated with bevacizumab. Finally, EGFR mutation predicts response to EGFR tumor kinase inhibitors and is now recommended as first-line therapy in advanced adenocarcinoma. Because adequate tissue is required for histologic assessment and molecular testing, each institution should have a clear, multidisciplinary approach to patient evalu-ation, tissue acquisition, tissue handling/processing, and tissue analysis (Fig. 19-18). In many cases, tumor morphology differ-entiates adenocarcinoma from the other histologic subtypes. If no clear morphology can be identified, then additional testing for one immunohistochemistry marker for adenocarcinoma and one for squamous cell carcinoma will usually enable differentiation. Immunohistochemistry for neuroendocrine markers is reserved for lesions exhibiting neuroendocrine morphology. Additional molecular testing should be performed on all |
Surgery_Schwartz_4608 | Surgery_Schwartz | usually enable differentiation. Immunohistochemistry for neuroendocrine markers is reserved for lesions exhibiting neuroendocrine morphology. Additional molecular testing should be performed on all adenocarcinoma specimens for known predictive and prognostic tumor mark-ers (e.g., EGFR, KRAS, and EML4-ALK fusion gene). Ideally, use of tissue sections and cell block material is limited to the minimum necessary at each decision point. This emphasizes the importance of a multidisciplinary approach; surgeons and radiologists must work in direct cooperation with the cytopa-thologist to ensure that tissue samples are adequate for morpho-logic diagnosis as well as providing sufficient cellular material to enable molecular testing. With adoption of endobronchial and endoscopic ultrasound, electromagnetic navigational bronchos-copy, VATS, and even transthoracic image-guided fine-needle and core-needle biopsy, surgeons are increasingly involved in the acquisition of diagnostic tissue for | Surgery_Schwartz. usually enable differentiation. Immunohistochemistry for neuroendocrine markers is reserved for lesions exhibiting neuroendocrine morphology. Additional molecular testing should be performed on all adenocarcinoma specimens for known predictive and prognostic tumor mark-ers (e.g., EGFR, KRAS, and EML4-ALK fusion gene). Ideally, use of tissue sections and cell block material is limited to the minimum necessary at each decision point. This emphasizes the importance of a multidisciplinary approach; surgeons and radiologists must work in direct cooperation with the cytopa-thologist to ensure that tissue samples are adequate for morpho-logic diagnosis as well as providing sufficient cellular material to enable molecular testing. With adoption of endobronchial and endoscopic ultrasound, electromagnetic navigational bronchos-copy, VATS, and even transthoracic image-guided fine-needle and core-needle biopsy, surgeons are increasingly involved in the acquisition of diagnostic tissue for |
Surgery_Schwartz_4609 | Surgery_Schwartz | navigational bronchos-copy, VATS, and even transthoracic image-guided fine-needle and core-needle biopsy, surgeons are increasingly involved in the acquisition of diagnostic tissue for primary, metastatic, and recurrent intrathoracic disease, and a thorough understanding of key issues is necessary to ensure optimal treatment and patient outcomes.Patient Evaluation. Pretreatment evaluation encompasses three areas: diagnosis and assessment of the primary tumor, assessment for metastatic disease, and determination of func-tional status (the patient’s ability to tolerate the prescribed treatment regimen). A discrete approach to each area allows the surgeon to systematically evaluate the patient, perform accurate clinical staging, and determine the patient’s functional suitabil-ity for therapy (Table 19-9).Assessment of the Primary Tumor Primary tumor assessment begins with directed history questions regarding the presence or absence of pulmonary, nonpulmonary, thoracic, and | Surgery_Schwartz. navigational bronchos-copy, VATS, and even transthoracic image-guided fine-needle and core-needle biopsy, surgeons are increasingly involved in the acquisition of diagnostic tissue for primary, metastatic, and recurrent intrathoracic disease, and a thorough understanding of key issues is necessary to ensure optimal treatment and patient outcomes.Patient Evaluation. Pretreatment evaluation encompasses three areas: diagnosis and assessment of the primary tumor, assessment for metastatic disease, and determination of func-tional status (the patient’s ability to tolerate the prescribed treatment regimen). A discrete approach to each area allows the surgeon to systematically evaluate the patient, perform accurate clinical staging, and determine the patient’s functional suitabil-ity for therapy (Table 19-9).Assessment of the Primary Tumor Primary tumor assessment begins with directed history questions regarding the presence or absence of pulmonary, nonpulmonary, thoracic, and |
Surgery_Schwartz_4610 | Surgery_Schwartz | for therapy (Table 19-9).Assessment of the Primary Tumor Primary tumor assessment begins with directed history questions regarding the presence or absence of pulmonary, nonpulmonary, thoracic, and paraneo-plastic symptoms. Because patients often present to the surgeon with a CXR or CT scan demonstrating the lesion, tumor location can guide the history and physical examination.A routine chest CT scan should be performed; this should include intravenous contrast to enable assessment of the pri-mary tumor, delineation of mediastinal lymph nodes relative to normal mediastinal structures, and the tumor’s relationship to surrounding and contiguous structures. Recommendations for treatment and options for obtaining tissue diagnosis require a thorough understanding and assessment of CT findings.Concern for contiguous invasion of adjacent structures is often raised in response to a combination of symptom history, location of the primary tumor, and CT imaging. It is common to see the primary | Surgery_Schwartz. for therapy (Table 19-9).Assessment of the Primary Tumor Primary tumor assessment begins with directed history questions regarding the presence or absence of pulmonary, nonpulmonary, thoracic, and paraneo-plastic symptoms. Because patients often present to the surgeon with a CXR or CT scan demonstrating the lesion, tumor location can guide the history and physical examination.A routine chest CT scan should be performed; this should include intravenous contrast to enable assessment of the pri-mary tumor, delineation of mediastinal lymph nodes relative to normal mediastinal structures, and the tumor’s relationship to surrounding and contiguous structures. Recommendations for treatment and options for obtaining tissue diagnosis require a thorough understanding and assessment of CT findings.Concern for contiguous invasion of adjacent structures is often raised in response to a combination of symptom history, location of the primary tumor, and CT imaging. It is common to see the primary |
Surgery_Schwartz_4611 | Surgery_Schwartz | for contiguous invasion of adjacent structures is often raised in response to a combination of symptom history, location of the primary tumor, and CT imaging. It is common to see the primary tumor abutting the chest wall without clear radiographic evidence of rib destruction. In this circumstance, localized pain can indicate parietal pleural, rib, or intercostal nerve involvement. Similar observations apply to tumors abut-ting the recurrent laryngeal nerve, phrenic nerve, diaphragm, vertebral bodies, and chest apex. Thoracotomy should not be denied because of presumptive evidence of invasion of the chest wall, vertebral body, or mediastinal structures; proof of invasion may require thoracoscopy or even thoracotomy.MRI of pulmonary lesions and mediastinal nodes, over-all, offers no real advantages over CT scanning. It is an excel-lent modality, however, for defining a tumor’s relationship to a major vessel, given its excellent imaging of vascular structures. This is especially true if | Surgery_Schwartz. for contiguous invasion of adjacent structures is often raised in response to a combination of symptom history, location of the primary tumor, and CT imaging. It is common to see the primary tumor abutting the chest wall without clear radiographic evidence of rib destruction. In this circumstance, localized pain can indicate parietal pleural, rib, or intercostal nerve involvement. Similar observations apply to tumors abut-ting the recurrent laryngeal nerve, phrenic nerve, diaphragm, vertebral bodies, and chest apex. Thoracotomy should not be denied because of presumptive evidence of invasion of the chest wall, vertebral body, or mediastinal structures; proof of invasion may require thoracoscopy or even thoracotomy.MRI of pulmonary lesions and mediastinal nodes, over-all, offers no real advantages over CT scanning. It is an excel-lent modality, however, for defining a tumor’s relationship to a major vessel, given its excellent imaging of vascular structures. This is especially true if |
Surgery_Schwartz_4612 | Surgery_Schwartz | over CT scanning. It is an excel-lent modality, however, for defining a tumor’s relationship to a major vessel, given its excellent imaging of vascular structures. This is especially true if the use of iodine contrast material is contraindicated. Thus, use of MRI in lung cancer patients is reserved for those with contrast allergies or suspected mediasti-nal, vascular, or vertebral body invasion.Options for Tissue Acquisition The surgeon must have an evidence-based algorithm for diagnosis and treatment of a pul-monary nodule and masses (Fig. 19-19).24 Depending on nodule size, bronchial tree proximity, and the population prevalence of lung cancer, bronchoscopy has a 20% to 80% sensitivity for detecting neoplastic processes within a pulmonary lesion. Brunicardi_Ch19_p0661-p0750.indd 68301/03/19 7:00 PM 684SPECIFIC CONSIDERATIONSPART IISTEP 1STEP 2POSITIVE BIOPSY (FOB,TBBx, Core, SLBx)POSITIVE CYTOLOGY(effusion, aspirate, washings,brushings)Histology: Lepidic, papillary, and/oracinar | Surgery_Schwartz. over CT scanning. It is an excel-lent modality, however, for defining a tumor’s relationship to a major vessel, given its excellent imaging of vascular structures. This is especially true if the use of iodine contrast material is contraindicated. Thus, use of MRI in lung cancer patients is reserved for those with contrast allergies or suspected mediasti-nal, vascular, or vertebral body invasion.Options for Tissue Acquisition The surgeon must have an evidence-based algorithm for diagnosis and treatment of a pul-monary nodule and masses (Fig. 19-19).24 Depending on nodule size, bronchial tree proximity, and the population prevalence of lung cancer, bronchoscopy has a 20% to 80% sensitivity for detecting neoplastic processes within a pulmonary lesion. Brunicardi_Ch19_p0661-p0750.indd 68301/03/19 7:00 PM 684SPECIFIC CONSIDERATIONSPART IISTEP 1STEP 2POSITIVE BIOPSY (FOB,TBBx, Core, SLBx)POSITIVE CYTOLOGY(effusion, aspirate, washings,brushings)Histology: Lepidic, papillary, and/oracinar |
Surgery_Schwartz_4613 | Surgery_Schwartz | 7:00 PM 684SPECIFIC CONSIDERATIONSPART IISTEP 1STEP 2POSITIVE BIOPSY (FOB,TBBx, Core, SLBx)POSITIVE CYTOLOGY(effusion, aspirate, washings,brushings)Histology: Lepidic, papillary, and/oracinar architecture(s)Cytology: 3-D arrangements, delicatefoamy/vacuolated (translucent)cytoplasm,Fine nuclear chromatin and oftenprominent nucleoliNuclei are often eccentrically situatedClassic morphology:ADCADC markerand/orMucin +ve;SQCCmarker –ve(or weak insame cells)NSCLC, favor ADCNE morphology, large cells,NE IHC+No clear ADC orSQCC morphology:NSCLC-NOSNSCLC, favor SQCCSQCC marker +veADC marker –ve/orMucin –veApply ancillary panel ofOne SQCC and one ADC marker+/OR MucinIHC –ve andMucin –veNSCLC NOSADC marker or Mucin +ve;as well as SQCC marker +vein different cellsMolecular analysis:e.g., EGFR mutation†NSCLC, NOS,possibleadenosquamous caIf tumor tissue inadequate for molecular testing,discuss need for further sampling — back to Step 1NE morphology, small cells, nonucleoli, NE IHC+, TTF-1 | Surgery_Schwartz. 7:00 PM 684SPECIFIC CONSIDERATIONSPART IISTEP 1STEP 2POSITIVE BIOPSY (FOB,TBBx, Core, SLBx)POSITIVE CYTOLOGY(effusion, aspirate, washings,brushings)Histology: Lepidic, papillary, and/oracinar architecture(s)Cytology: 3-D arrangements, delicatefoamy/vacuolated (translucent)cytoplasm,Fine nuclear chromatin and oftenprominent nucleoliNuclei are often eccentrically situatedClassic morphology:ADCADC markerand/orMucin +ve;SQCCmarker –ve(or weak insame cells)NSCLC, favor ADCNE morphology, large cells,NE IHC+No clear ADC orSQCC morphology:NSCLC-NOSNSCLC, favor SQCCSQCC marker +veADC marker –ve/orMucin –veApply ancillary panel ofOne SQCC and one ADC marker+/OR MucinIHC –ve andMucin –veNSCLC NOSADC marker or Mucin +ve;as well as SQCC marker +vein different cellsMolecular analysis:e.g., EGFR mutation†NSCLC, NOS,possibleadenosquamous caIf tumor tissue inadequate for molecular testing,discuss need for further sampling — back to Step 1NE morphology, small cells, nonucleoli, NE IHC+, TTF-1 |
Surgery_Schwartz_4614 | Surgery_Schwartz | mutation†NSCLC, NOS,possibleadenosquamous caIf tumor tissue inadequate for molecular testing,discuss need for further sampling — back to Step 1NE morphology, small cells, nonucleoli, NE IHC+, TTF-1 +/–,CK+Keratinization, pearlsand/or intercellular bridgesNSCLC,LCNECClassic Morphology:SQCCSCLCSTEP 3Figure 19-18. Algorithm for adenocarcinoma diagnosis in small biopsies and/or cytology. Step 1: When positive biopsies (fiberoptic bronchos-copy [FOB], transbronchial [TBBx], core, or surgical lung biopsy [SLBx]) or cytology (effusion, aspirate, washings, and brushings) show clear adenocarcinoma (ADC) or squamous cell carcinoma (SQCC) morphology, the diagnosis can be firmly established. If there is neuroendocrine (NE) morphology, the tumor may be classified as small cell carcinoma (SCLC) or non–small cell lung carcinoma (NSCLC), probably large cell neuroendocrine carcinoma (LCNEC) according to standard criteria (+ = positive, – = negative, and ± = positive or negative). If there is no clear | Surgery_Schwartz. mutation†NSCLC, NOS,possibleadenosquamous caIf tumor tissue inadequate for molecular testing,discuss need for further sampling — back to Step 1NE morphology, small cells, nonucleoli, NE IHC+, TTF-1 +/–,CK+Keratinization, pearlsand/or intercellular bridgesNSCLC,LCNECClassic Morphology:SQCCSCLCSTEP 3Figure 19-18. Algorithm for adenocarcinoma diagnosis in small biopsies and/or cytology. Step 1: When positive biopsies (fiberoptic bronchos-copy [FOB], transbronchial [TBBx], core, or surgical lung biopsy [SLBx]) or cytology (effusion, aspirate, washings, and brushings) show clear adenocarcinoma (ADC) or squamous cell carcinoma (SQCC) morphology, the diagnosis can be firmly established. If there is neuroendocrine (NE) morphology, the tumor may be classified as small cell carcinoma (SCLC) or non–small cell lung carcinoma (NSCLC), probably large cell neuroendocrine carcinoma (LCNEC) according to standard criteria (+ = positive, – = negative, and ± = positive or negative). If there is no clear |
Surgery_Schwartz_4615 | Surgery_Schwartz | cell lung carcinoma (NSCLC), probably large cell neuroendocrine carcinoma (LCNEC) according to standard criteria (+ = positive, – = negative, and ± = positive or negative). If there is no clear ADC or SQCC morphology, the tumor is regarded as NSCLC—not otherwise specified (NOS). Step 2: NSCLC-NOS can be further classified based on (a) immunohistochemical stains, (b) mucin (DPAS or mucicarmine) stains, or (c) molecular data. If the stains all favor ADC-positive ADC marker(s) (i.e., TTF-1 and/or mucin positive) with negative SQCC markers, then the tumor is classified as NSCLC, favor ADC. If SQCC markers (i.e., p63 and/or CK5/6) are positive with negative ADC markers, the tumor is classified as NSCLC, favor SQCC. If the ADC and SQCC markers are both strongly positive in different populations of tumor cells, the tumor is classified as NSCLC-NOS, with a comment it may represent adenosquamous carcinoma. If all markers are negative, the tumor is classified as NSCLC-NOS. †EGFR mutation | Surgery_Schwartz. cell lung carcinoma (NSCLC), probably large cell neuroendocrine carcinoma (LCNEC) according to standard criteria (+ = positive, – = negative, and ± = positive or negative). If there is no clear ADC or SQCC morphology, the tumor is regarded as NSCLC—not otherwise specified (NOS). Step 2: NSCLC-NOS can be further classified based on (a) immunohistochemical stains, (b) mucin (DPAS or mucicarmine) stains, or (c) molecular data. If the stains all favor ADC-positive ADC marker(s) (i.e., TTF-1 and/or mucin positive) with negative SQCC markers, then the tumor is classified as NSCLC, favor ADC. If SQCC markers (i.e., p63 and/or CK5/6) are positive with negative ADC markers, the tumor is classified as NSCLC, favor SQCC. If the ADC and SQCC markers are both strongly positive in different populations of tumor cells, the tumor is classified as NSCLC-NOS, with a comment it may represent adenosquamous carcinoma. If all markers are negative, the tumor is classified as NSCLC-NOS. †EGFR mutation |
Surgery_Schwartz_4616 | Surgery_Schwartz | of tumor cells, the tumor is classified as NSCLC-NOS, with a comment it may represent adenosquamous carcinoma. If all markers are negative, the tumor is classified as NSCLC-NOS. †EGFR mutation testing should be performed in (1) classic ADC, (2) NSCLC, favor ADC, (3) NSCLC-NOS, and (4) NSCLC-NOS, possible adenosquamous carcinoma. In NSCLC-NOS, if EGFR mutation is positive, the tumor is more likely to be ADC than SQCC. Step 3: If clinical management requires a more specific diagnosis than NSCLC-NOS, additional biopsies may be indicated. CD = cluster designation; CK = cytokeratin; DPAS = diastase-periodic acid Schiff; DPAS +ve = periodic-acid Schiff with diastase; EGFR = epidermal growth factor receptor; IHC = immunohistochemistry; NB = of note; TTF-1 = thyroid transcription factor-1; –ve = negative; +ve = positive. (Reproduced with permission from Travis WD, Brambilla E, Noguchi M, et al: Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International | Surgery_Schwartz. of tumor cells, the tumor is classified as NSCLC-NOS, with a comment it may represent adenosquamous carcinoma. If all markers are negative, the tumor is classified as NSCLC-NOS. †EGFR mutation testing should be performed in (1) classic ADC, (2) NSCLC, favor ADC, (3) NSCLC-NOS, and (4) NSCLC-NOS, possible adenosquamous carcinoma. In NSCLC-NOS, if EGFR mutation is positive, the tumor is more likely to be ADC than SQCC. Step 3: If clinical management requires a more specific diagnosis than NSCLC-NOS, additional biopsies may be indicated. CD = cluster designation; CK = cytokeratin; DPAS = diastase-periodic acid Schiff; DPAS +ve = periodic-acid Schiff with diastase; EGFR = epidermal growth factor receptor; IHC = immunohistochemistry; NB = of note; TTF-1 = thyroid transcription factor-1; –ve = negative; +ve = positive. (Reproduced with permission from Travis WD, Brambilla E, Noguchi M, et al: Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International |
Surgery_Schwartz_4617 | Surgery_Schwartz | = negative; +ve = positive. (Reproduced with permission from Travis WD, Brambilla E, Noguchi M, et al: Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification, Arch Pathol Lab Med. 2013 May;137(5):668-684.)Brunicardi_Ch19_p0661-p0750.indd 68401/03/19 7:00 PM | Surgery_Schwartz. = negative; +ve = positive. (Reproduced with permission from Travis WD, Brambilla E, Noguchi M, et al: Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification, Arch Pathol Lab Med. 2013 May;137(5):668-684.)Brunicardi_Ch19_p0661-p0750.indd 68401/03/19 7:00 PM |
Surgery_Schwartz_4618 | Surgery_Schwartz | CHAPTER 19685CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATable 19-9Evaluation of patients with lung cancer PRIMARY TUMORMETASTATIC DISEASEFUNCTIONAL ASSESSMENTHistoryPulmonaryWeight lossAbility to walk up two flights of stairsNonpulmonary thoracicMalaiseAbility to walk on a flat surface indefinitelyParaneoplastic New bone painNeurologic signs or symptomsSkin lesionsPhysical examination VoiceSupraclavicular node palpationAccessory muscle usage Skin examinationAir flow by auscultation Neurologic examinationForce of coughRadiographic examinationChest CTChest CT, PETChest CT: tumor anatomy, atelectasisTissue analysisBronchoscopyBone scan, head MRI, abdominal CTQuantitative perfusion scanTransthoracic needle aspiration and biopsy Bronchoscopic lymph node FNAEndoscopic ultrasoundMediastinoscopyBiopsy of suspected metastasisOtherThoracoscopy—Pulmonary function tests (FEV1, Dlco, O2 consumption)Abbreviations: CT = computed tomography; Dlco = carbon monoxide diffusion capacity; FEV1 = forced | Surgery_Schwartz. CHAPTER 19685CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATable 19-9Evaluation of patients with lung cancer PRIMARY TUMORMETASTATIC DISEASEFUNCTIONAL ASSESSMENTHistoryPulmonaryWeight lossAbility to walk up two flights of stairsNonpulmonary thoracicMalaiseAbility to walk on a flat surface indefinitelyParaneoplastic New bone painNeurologic signs or symptomsSkin lesionsPhysical examination VoiceSupraclavicular node palpationAccessory muscle usage Skin examinationAir flow by auscultation Neurologic examinationForce of coughRadiographic examinationChest CTChest CT, PETChest CT: tumor anatomy, atelectasisTissue analysisBronchoscopyBone scan, head MRI, abdominal CTQuantitative perfusion scanTransthoracic needle aspiration and biopsy Bronchoscopic lymph node FNAEndoscopic ultrasoundMediastinoscopyBiopsy of suspected metastasisOtherThoracoscopy—Pulmonary function tests (FEV1, Dlco, O2 consumption)Abbreviations: CT = computed tomography; Dlco = carbon monoxide diffusion capacity; FEV1 = forced |
Surgery_Schwartz_4619 | Surgery_Schwartz | of suspected metastasisOtherThoracoscopy—Pulmonary function tests (FEV1, Dlco, O2 consumption)Abbreviations: CT = computed tomography; Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second; FNA = fine-needle aspiration; MRI = magnetic resonance imaging; O2 = oxygen; PET = positron emission tomography.Diagnostic tissue from bronchoscopy can be obtained by one of four methods:1. Brushings and washings for cytology2. Direct forceps biopsy of a visualized lesion3. Endobronchial ultrasound-guided fine-needle aspiration (FNA) of an externally compressing lesion without visual-ized endobronchial tumor4. Transbronchial biopsy with fluoroscopy to guide forceps to the lesion or electromagnetic navigational bronchoscopyElectromagnetic navigation bronchoscopy is a recent addi-tion to the surgeon’s armamentarium for transbronchial biopsy of peripheral lung lesions. Using electromagnetic markers that create a three-dimensional image and align the recorded CT images | Surgery_Schwartz. of suspected metastasisOtherThoracoscopy—Pulmonary function tests (FEV1, Dlco, O2 consumption)Abbreviations: CT = computed tomography; Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second; FNA = fine-needle aspiration; MRI = magnetic resonance imaging; O2 = oxygen; PET = positron emission tomography.Diagnostic tissue from bronchoscopy can be obtained by one of four methods:1. Brushings and washings for cytology2. Direct forceps biopsy of a visualized lesion3. Endobronchial ultrasound-guided fine-needle aspiration (FNA) of an externally compressing lesion without visual-ized endobronchial tumor4. Transbronchial biopsy with fluoroscopy to guide forceps to the lesion or electromagnetic navigational bronchoscopyElectromagnetic navigation bronchoscopy is a recent addi-tion to the surgeon’s armamentarium for transbronchial biopsy of peripheral lung lesions. Using electromagnetic markers that create a three-dimensional image and align the recorded CT images |
Surgery_Schwartz_4620 | Surgery_Schwartz | addi-tion to the surgeon’s armamentarium for transbronchial biopsy of peripheral lung lesions. Using electromagnetic markers that create a three-dimensional image and align the recorded CT images to the patient’s true anatomy, a transbronchial catheter is advanced, and brushings, FNA, cup biopsy, and washings can be performed. Diagnostic yield using electromagnetic naviga-tion bronchoscopy as an adjunct to standard bronchoscopy is reported as high as 80%. The approach can also be used for placement of fiducial markers for subsequent stereotactic body radiation therapy and for tattooing the perilesional region to guide subsequent video-assisted thoracoscopic resection.Pneumothorax rates are approximately 1% to 3.5%.For peripheral lesions (roughly the outer half of the lung), transbronchial biopsy is performed first, followed by brushings and washings. This improves diagnostic yield by disrupting the lesion with the biopsy forceps and mobilizing additional cells. For central lesions, | Surgery_Schwartz. addi-tion to the surgeon’s armamentarium for transbronchial biopsy of peripheral lung lesions. Using electromagnetic markers that create a three-dimensional image and align the recorded CT images to the patient’s true anatomy, a transbronchial catheter is advanced, and brushings, FNA, cup biopsy, and washings can be performed. Diagnostic yield using electromagnetic naviga-tion bronchoscopy as an adjunct to standard bronchoscopy is reported as high as 80%. The approach can also be used for placement of fiducial markers for subsequent stereotactic body radiation therapy and for tattooing the perilesional region to guide subsequent video-assisted thoracoscopic resection.Pneumothorax rates are approximately 1% to 3.5%.For peripheral lesions (roughly the outer half of the lung), transbronchial biopsy is performed first, followed by brushings and washings. This improves diagnostic yield by disrupting the lesion with the biopsy forceps and mobilizing additional cells. For central lesions, |
Surgery_Schwartz_4621 | Surgery_Schwartz | biopsy is performed first, followed by brushings and washings. This improves diagnostic yield by disrupting the lesion with the biopsy forceps and mobilizing additional cells. For central lesions, direct forceps biopsy is often possible. For central lesions with external airway compression but no visible endobronchial lesions, endobronchial ultrasound (EBUS) is highly accurate and safe for transbronchial biopsies of both the primary tumor (when it abuts the central airways) as well as the mediastinal lymph nodes.33Image-guided transthoracic FNA (ultrasound or CT FNA) biopsy can accurately diagnose appropriately selected peripheral pulmonary lesions in up to 95% of patients. Three biopsy results are possible after image-guided biopsy procedures: malignant, a specific benign process, or indeterminate. Because falsenegative rates range from 3% to 29%, further diagnostic efforts are warranted in the absence of a specific benign diagnosis (such as granulomatous inflammation or hamartoma) | Surgery_Schwartz. biopsy is performed first, followed by brushings and washings. This improves diagnostic yield by disrupting the lesion with the biopsy forceps and mobilizing additional cells. For central lesions, direct forceps biopsy is often possible. For central lesions with external airway compression but no visible endobronchial lesions, endobronchial ultrasound (EBUS) is highly accurate and safe for transbronchial biopsies of both the primary tumor (when it abuts the central airways) as well as the mediastinal lymph nodes.33Image-guided transthoracic FNA (ultrasound or CT FNA) biopsy can accurately diagnose appropriately selected peripheral pulmonary lesions in up to 95% of patients. Three biopsy results are possible after image-guided biopsy procedures: malignant, a specific benign process, or indeterminate. Because falsenegative rates range from 3% to 29%, further diagnostic efforts are warranted in the absence of a specific benign diagnosis (such as granulomatous inflammation or hamartoma) |
Surgery_Schwartz_4622 | Surgery_Schwartz | Because falsenegative rates range from 3% to 29%, further diagnostic efforts are warranted in the absence of a specific benign diagnosis (such as granulomatous inflammation or hamartoma) because malig-nancy is not ruled out.34 The primary complication is pneumo-thorax in as many as 30% of cases. Intrapulmonary bleeding occurs, but it rarely causes clinically significant hemoptysis or respiratory compromise.Some groups advocate use of video-assisted thoracoscopic biopsy as the first option for diagnosis, citing superior diagnostic accuracy and low surgical risk. With VATS, the nodule can be excised with a wedge or segmental resection, if less than 3 cm, or a core-needle biopsy can be performed under direct vision for larger lesions. VATS can also provide valuable staging informa-tion, including sampling/dissection of mediastinal lymph nodes and assessing whether the primary tumor has invaded a contigu-ous structure (such as the chest wall or mediastinum).Lesions most suitable for VATS | Surgery_Schwartz. Because falsenegative rates range from 3% to 29%, further diagnostic efforts are warranted in the absence of a specific benign diagnosis (such as granulomatous inflammation or hamartoma) because malig-nancy is not ruled out.34 The primary complication is pneumo-thorax in as many as 30% of cases. Intrapulmonary bleeding occurs, but it rarely causes clinically significant hemoptysis or respiratory compromise.Some groups advocate use of video-assisted thoracoscopic biopsy as the first option for diagnosis, citing superior diagnostic accuracy and low surgical risk. With VATS, the nodule can be excised with a wedge or segmental resection, if less than 3 cm, or a core-needle biopsy can be performed under direct vision for larger lesions. VATS can also provide valuable staging informa-tion, including sampling/dissection of mediastinal lymph nodes and assessing whether the primary tumor has invaded a contigu-ous structure (such as the chest wall or mediastinum).Lesions most suitable for VATS |
Surgery_Schwartz_4623 | Surgery_Schwartz | sampling/dissection of mediastinal lymph nodes and assessing whether the primary tumor has invaded a contigu-ous structure (such as the chest wall or mediastinum).Lesions most suitable for VATS are those that are located in the outer one-third of the lung. The surgeon should avoid direct manipulation of the nodule or violation of the visceral pleura overlying the nodule. In addition, the excised nodule must be extracted from the chest within a bag to prevent seeding of the chest wall. If the patient’s pulmonary reserve is adequate, the surgeon can proceed to lobectomy (either VATS or open) after frozen section diagnosis.Brunicardi_Ch19_p0661-p0750.indd 68501/03/19 7:00 PM 686SPECIFIC CONSIDERATIONSPART IIA thoracotomy is occasionally necessary to diagnose and stage a primary tumor. Although this occurs rarely, two circum-stances may require such an approach: (a) a deep-seated lesion that yielded an indeterminate needle biopsy result or that could not be biopsied for technical | Surgery_Schwartz. sampling/dissection of mediastinal lymph nodes and assessing whether the primary tumor has invaded a contigu-ous structure (such as the chest wall or mediastinum).Lesions most suitable for VATS are those that are located in the outer one-third of the lung. The surgeon should avoid direct manipulation of the nodule or violation of the visceral pleura overlying the nodule. In addition, the excised nodule must be extracted from the chest within a bag to prevent seeding of the chest wall. If the patient’s pulmonary reserve is adequate, the surgeon can proceed to lobectomy (either VATS or open) after frozen section diagnosis.Brunicardi_Ch19_p0661-p0750.indd 68501/03/19 7:00 PM 686SPECIFIC CONSIDERATIONSPART IIA thoracotomy is occasionally necessary to diagnose and stage a primary tumor. Although this occurs rarely, two circum-stances may require such an approach: (a) a deep-seated lesion that yielded an indeterminate needle biopsy result or that could not be biopsied for technical |
Surgery_Schwartz_4624 | Surgery_Schwartz | Although this occurs rarely, two circum-stances may require such an approach: (a) a deep-seated lesion that yielded an indeterminate needle biopsy result or that could not be biopsied for technical reasons; or (b) inability to determine inva-sion of a mediastinal structure by any method short of palpation. In the circumstance of a deep-seated lesion without a diagnosis, tissue can be obtained via thoracotomy using FNA, core-needle biopsy, or excisional biopsy. Intraoperative frozen-section analysis is required; if the open biopsy frozen-section result is indetermi-nate, a lobectomy may be necessary in extremely rare situations. If a pneumonectomy is required to remove the lesion, a tissue diag-nosis of cancer must be made before proceeding.Assessment for Metastatic Disease Approximately 40% of patients with newly diagnosed lung cancer present with distant metastasis. The presence of lymph node or systemic metastases may imply inoperability. As with the primary tumor, assess-ment for | Surgery_Schwartz. Although this occurs rarely, two circum-stances may require such an approach: (a) a deep-seated lesion that yielded an indeterminate needle biopsy result or that could not be biopsied for technical reasons; or (b) inability to determine inva-sion of a mediastinal structure by any method short of palpation. In the circumstance of a deep-seated lesion without a diagnosis, tissue can be obtained via thoracotomy using FNA, core-needle biopsy, or excisional biopsy. Intraoperative frozen-section analysis is required; if the open biopsy frozen-section result is indetermi-nate, a lobectomy may be necessary in extremely rare situations. If a pneumonectomy is required to remove the lesion, a tissue diag-nosis of cancer must be made before proceeding.Assessment for Metastatic Disease Approximately 40% of patients with newly diagnosed lung cancer present with distant metastasis. The presence of lymph node or systemic metastases may imply inoperability. As with the primary tumor, assess-ment for |
Surgery_Schwartz_4625 | Surgery_Schwartz | 40% of patients with newly diagnosed lung cancer present with distant metastasis. The presence of lymph node or systemic metastases may imply inoperability. As with the primary tumor, assess-ment for the presence of metastatic disease should begin with the history and physical examination, focusing on new bone pain, neurologic symptoms, and new skin lesions. In addition, constitutional symptoms (e.g., anorexia, malaise, and unin-tentional weight loss of >5% of body weight) suggest either a large tumor burden or the presence of metastases. Physical examination focuses on overall appearance, noting any evi-dence of weight loss such as redundant skin or muscle wasting, and a complete examination of the head and neck, including NegativetestsPositivetestsNoNoNew SPN (8 mm to 30 mm)identified on CXR orCT scanBenign calcificationpresent or 2-year stabilitydemonstrated?Surgical risk acceptable?Assess clinicalprobability of cancer Low probabilityof cancer(<5%)Intermediateprobability of | Surgery_Schwartz. 40% of patients with newly diagnosed lung cancer present with distant metastasis. The presence of lymph node or systemic metastases may imply inoperability. As with the primary tumor, assess-ment for the presence of metastatic disease should begin with the history and physical examination, focusing on new bone pain, neurologic symptoms, and new skin lesions. In addition, constitutional symptoms (e.g., anorexia, malaise, and unin-tentional weight loss of >5% of body weight) suggest either a large tumor burden or the presence of metastases. Physical examination focuses on overall appearance, noting any evi-dence of weight loss such as redundant skin or muscle wasting, and a complete examination of the head and neck, including NegativetestsPositivetestsNoNoNew SPN (8 mm to 30 mm)identified on CXR orCT scanBenign calcificationpresent or 2-year stabilitydemonstrated?Surgical risk acceptable?Assess clinicalprobability of cancer Low probabilityof cancer(<5%)Intermediateprobability of |
Surgery_Schwartz_4626 | Surgery_Schwartz | on CXR orCT scanBenign calcificationpresent or 2-year stabilitydemonstrated?Surgical risk acceptable?Assess clinicalprobability of cancer Low probabilityof cancer(<5%)Intermediateprobability of cancer(>5%–60%)High probabilityof cancer(>60%)Establish diagnosis bybiopsy when possible.Consider XRT or monitorfor symptoms andpalliate as necessarySerial high-resolutionCT at 3, 6, 12 and24 monthsAdditional testing• PET imaging, if available• Contrast-enhanced CT, depending on institutional expertise• Transthoracic fine-needle aspiration biopsy, if nodule is peripherally located• Bronchoscopy, if airbronchogram present or if operator has expertise with newer guided techniques Video-assistedthoracoscopic surgery:examination of a frozensection, followed byresection if nodule ismalignantYesYesNo further interventionrequired except forpatients with pure groundglass opacities, in whomlonger annual follow-upshould be consideredFigure 19-19. Recommended management algorithm for patients with | Surgery_Schwartz. on CXR orCT scanBenign calcificationpresent or 2-year stabilitydemonstrated?Surgical risk acceptable?Assess clinicalprobability of cancer Low probabilityof cancer(<5%)Intermediateprobability of cancer(>5%–60%)High probabilityof cancer(>60%)Establish diagnosis bybiopsy when possible.Consider XRT or monitorfor symptoms andpalliate as necessarySerial high-resolutionCT at 3, 6, 12 and24 monthsAdditional testing• PET imaging, if available• Contrast-enhanced CT, depending on institutional expertise• Transthoracic fine-needle aspiration biopsy, if nodule is peripherally located• Bronchoscopy, if airbronchogram present or if operator has expertise with newer guided techniques Video-assistedthoracoscopic surgery:examination of a frozensection, followed byresection if nodule ismalignantYesYesNo further interventionrequired except forpatients with pure groundglass opacities, in whomlonger annual follow-upshould be consideredFigure 19-19. Recommended management algorithm for patients with |
Surgery_Schwartz_4627 | Surgery_Schwartz | further interventionrequired except forpatients with pure groundglass opacities, in whomlonger annual follow-upshould be consideredFigure 19-19. Recommended management algorithm for patients with solitary pulmonary nodules (SPNs) measuring 8 mm to 30 mm in diameter. CT = computed tomography; CXR = chest radiograph; PET = positron emission tomography; XRT = radiotherapy. (Adapted with permission from Gould MK, Fletcher J, Iannettoni MD, et al: Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):108S-130S.24)Brunicardi_Ch19_p0661-p0750.indd 68601/03/19 7:01 PM | Surgery_Schwartz. further interventionrequired except forpatients with pure groundglass opacities, in whomlonger annual follow-upshould be consideredFigure 19-19. Recommended management algorithm for patients with solitary pulmonary nodules (SPNs) measuring 8 mm to 30 mm in diameter. CT = computed tomography; CXR = chest radiograph; PET = positron emission tomography; XRT = radiotherapy. (Adapted with permission from Gould MK, Fletcher J, Iannettoni MD, et al: Evaluation of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):108S-130S.24)Brunicardi_Ch19_p0661-p0750.indd 68601/03/19 7:01 PM |
Surgery_Schwartz_4628 | Surgery_Schwartz | CHAPTER 19687CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAevaluation of cervical and supraclavicular lymph nodes and the oropharynx. This is particularly true for patients with a sig-nificant tobacco history. The skin should be thoroughly exam-ined. Routine laboratory studies include serum levels of hepatic enzymes (e.g., serum glutamic oxaloacetic transaminase and alkaline phosphatase), and serum calcium (to detect bone metas-tases or the ectopic parathyroid syndrome). Elevation of either hepatic enzymes or serum calcium levels typically occurs with extensive metastases.Mediastinal Lymph Nodes. Chest CT scanning facilitates assessment of mediastinal and hilar nodes for enlargement. How-ever, a positive CT result (i.e., nodal diameter >1.0 cm) predicts actual metastatic involvement in only about 70% of lung cancer patients. Thus, up to 30% of such nodes are enlarged from non-cancerous reactive causes (e.g., inflammation due to atelectasis or pneumonia secondary to the tumor). Patients | Surgery_Schwartz. CHAPTER 19687CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAevaluation of cervical and supraclavicular lymph nodes and the oropharynx. This is particularly true for patients with a sig-nificant tobacco history. The skin should be thoroughly exam-ined. Routine laboratory studies include serum levels of hepatic enzymes (e.g., serum glutamic oxaloacetic transaminase and alkaline phosphatase), and serum calcium (to detect bone metas-tases or the ectopic parathyroid syndrome). Elevation of either hepatic enzymes or serum calcium levels typically occurs with extensive metastases.Mediastinal Lymph Nodes. Chest CT scanning facilitates assessment of mediastinal and hilar nodes for enlargement. How-ever, a positive CT result (i.e., nodal diameter >1.0 cm) predicts actual metastatic involvement in only about 70% of lung cancer patients. Thus, up to 30% of such nodes are enlarged from non-cancerous reactive causes (e.g., inflammation due to atelectasis or pneumonia secondary to the tumor). Patients |
Surgery_Schwartz_4629 | Surgery_Schwartz | about 70% of lung cancer patients. Thus, up to 30% of such nodes are enlarged from non-cancerous reactive causes (e.g., inflammation due to atelectasis or pneumonia secondary to the tumor). Patients should not be denied an attempt at curative resection just because of a posi-tive CT result for mediastinal lymph node enlargement; any CT finding of metastatic nodal involvement must be confirmed his-tologically. The negative predictive value of normal-appearing lymph nodes by CT (lymph nodes <1.0 cm) is better than the positive predictive value of a suspicious-appearing lymph node, particularly with small squamous cell tumors. With normal-size lymph nodes and a T1 tumor, the false-negative rate is less than 10%, leading many surgeons to omit mediastinoscopy. How-ever, the false-negative rate increases to nearly 30% with cen-trally located and T3 tumors. It has also been demonstrated that T1 adenocarcinomas or large cell carcinomas have a higher rate of early micrometastasis. Therefore, | Surgery_Schwartz. about 70% of lung cancer patients. Thus, up to 30% of such nodes are enlarged from non-cancerous reactive causes (e.g., inflammation due to atelectasis or pneumonia secondary to the tumor). Patients should not be denied an attempt at curative resection just because of a posi-tive CT result for mediastinal lymph node enlargement; any CT finding of metastatic nodal involvement must be confirmed his-tologically. The negative predictive value of normal-appearing lymph nodes by CT (lymph nodes <1.0 cm) is better than the positive predictive value of a suspicious-appearing lymph node, particularly with small squamous cell tumors. With normal-size lymph nodes and a T1 tumor, the false-negative rate is less than 10%, leading many surgeons to omit mediastinoscopy. How-ever, the false-negative rate increases to nearly 30% with cen-trally located and T3 tumors. It has also been demonstrated that T1 adenocarcinomas or large cell carcinomas have a higher rate of early micrometastasis. Therefore, |
Surgery_Schwartz_4630 | Surgery_Schwartz | increases to nearly 30% with cen-trally located and T3 tumors. It has also been demonstrated that T1 adenocarcinomas or large cell carcinomas have a higher rate of early micrometastasis. Therefore, all such patients should undergo mediastinoscopy.Mediastinal lymph node staging by PET scanning appears to have greater accuracy than CT scanning. PET staging of mediastinal lymph nodes has been evaluated in two meta-analyses. The overall sensitivity for mediastinal lymph node metastasis was 79% (95% confidence interval [CI] 76%–82%), with a specificity of 91% (95% CI 89%–93%) and an accuracy of 92% (95% CI 90%–94%).35In comparing PET with CT scans in patients who also underwent lymph node biopsies, PET had a sensitivity of 88% and a specificity of 91%, whereas CT scanning had a sensitivity of 63% and a specificity of 76%. Combining CT and PET scan-ning may lead to even greater accuracy.36 In one study of CT, PET, and mediastinoscopy in 68 patients with potentially opera-ble NSCLC, CT | Surgery_Schwartz. increases to nearly 30% with cen-trally located and T3 tumors. It has also been demonstrated that T1 adenocarcinomas or large cell carcinomas have a higher rate of early micrometastasis. Therefore, all such patients should undergo mediastinoscopy.Mediastinal lymph node staging by PET scanning appears to have greater accuracy than CT scanning. PET staging of mediastinal lymph nodes has been evaluated in two meta-analyses. The overall sensitivity for mediastinal lymph node metastasis was 79% (95% confidence interval [CI] 76%–82%), with a specificity of 91% (95% CI 89%–93%) and an accuracy of 92% (95% CI 90%–94%).35In comparing PET with CT scans in patients who also underwent lymph node biopsies, PET had a sensitivity of 88% and a specificity of 91%, whereas CT scanning had a sensitivity of 63% and a specificity of 76%. Combining CT and PET scan-ning may lead to even greater accuracy.36 In one study of CT, PET, and mediastinoscopy in 68 patients with potentially opera-ble NSCLC, CT |
Surgery_Schwartz_4631 | Surgery_Schwartz | of 63% and a specificity of 76%. Combining CT and PET scan-ning may lead to even greater accuracy.36 In one study of CT, PET, and mediastinoscopy in 68 patients with potentially opera-ble NSCLC, CT correctly identified the nodal stage in 40 patients (59%). It understaged the tumor in 12 patients and overstaged it in 16 patients. PET correctly identified the nodal stage in 59 patients (87%). It understaged the tumor in five patients and overstaged it in four. For detecting N2 and N3 disease, the combination of PET and CT scanning yielded a sensitivity, specificity, and accuracy of 93%, 95%, and 94%, respectively. CT scan alone yielded 75%, 63%, and 68%, respectively. Studies examining combined PET-CT consistently show improved accuracy compared to PET or CT alone; accuracy for PET-CT nodal positivity confirmed by medi-astinoscopy is approximately 75%, with a negative predictive value of approximately 90%. Right upper lobe lesions were more likely to have occult N2 disease than other | Surgery_Schwartz. of 63% and a specificity of 76%. Combining CT and PET scan-ning may lead to even greater accuracy.36 In one study of CT, PET, and mediastinoscopy in 68 patients with potentially opera-ble NSCLC, CT correctly identified the nodal stage in 40 patients (59%). It understaged the tumor in 12 patients and overstaged it in 16 patients. PET correctly identified the nodal stage in 59 patients (87%). It understaged the tumor in five patients and overstaged it in four. For detecting N2 and N3 disease, the combination of PET and CT scanning yielded a sensitivity, specificity, and accuracy of 93%, 95%, and 94%, respectively. CT scan alone yielded 75%, 63%, and 68%, respectively. Studies examining combined PET-CT consistently show improved accuracy compared to PET or CT alone; accuracy for PET-CT nodal positivity confirmed by medi-astinoscopy is approximately 75%, with a negative predictive value of approximately 90%. Right upper lobe lesions were more likely to have occult N2 disease than other |
Surgery_Schwartz_4632 | Surgery_Schwartz | positivity confirmed by medi-astinoscopy is approximately 75%, with a negative predictive value of approximately 90%. Right upper lobe lesions were more likely to have occult N2 disease than other lobes of the lung.37-40 PET-positive mediastinal lymph nodes require histologic verifica-tion of node positivity, either by EBUS-guided FNA or mediasti-noscopy, to minimize the risk of undertreatment, assuming node positivity without histologic confirmation relegates the patient to, at a minimum, induction chemotherapy. If there is a suggestion of TABLE 19-10Techniques for invasive mediastinal stagingEndoscopicEndobronchial ultrasound with transbronchial needle aspirationEndoscopic ultrasound with needle aspirationTransbronchial needle aspirationComputed tomography–guided transthoracic needle aspirationSurgicalVideo-assisted mediastinoscopyTranscervical extended mediastinal lymphadenectomy (TEMLA)Video-assisted mediastinal lymphadenectomy (VAMLA)Thoracoscopic transthoracic | Surgery_Schwartz. positivity confirmed by medi-astinoscopy is approximately 75%, with a negative predictive value of approximately 90%. Right upper lobe lesions were more likely to have occult N2 disease than other lobes of the lung.37-40 PET-positive mediastinal lymph nodes require histologic verifica-tion of node positivity, either by EBUS-guided FNA or mediasti-noscopy, to minimize the risk of undertreatment, assuming node positivity without histologic confirmation relegates the patient to, at a minimum, induction chemotherapy. If there is a suggestion of TABLE 19-10Techniques for invasive mediastinal stagingEndoscopicEndobronchial ultrasound with transbronchial needle aspirationEndoscopic ultrasound with needle aspirationTransbronchial needle aspirationComputed tomography–guided transthoracic needle aspirationSurgicalVideo-assisted mediastinoscopyTranscervical extended mediastinal lymphadenectomy (TEMLA)Video-assisted mediastinal lymphadenectomy (VAMLA)Thoracoscopic transthoracic |
Surgery_Schwartz_4633 | Surgery_Schwartz | needle aspirationSurgicalVideo-assisted mediastinoscopyTranscervical extended mediastinal lymphadenectomy (TEMLA)Video-assisted mediastinal lymphadenectomy (VAMLA)Thoracoscopic transthoracic lymphadenectomyIndications for invasive mediastinal staging in lung cancer1. Radiographically enlarged mediastinal lymph nodes2. Centrally located tumors3. N1 nodal enlargement4. Tumor size >3 cm5. Peripheral clinical stage I tumor with nonenlarged but FDG-avid mediastinal lymph nodesIndications for prethoracotomy/thoracoscopy biopsy of stations 5 and 6 lymph nodes1. Criteria for invasive staging met and other mediastinal lymph node stations are negative (assuming patient would have induction therapy if any nodal station positive)2. Enrollment criteria for induction therapy protocol require pathologic confirmation of N2 disease3. Computed tomography scan shows evidence of bulky nodal metastasis or extracapsular spread that could prevent complete resection4. Tissue diagnosis of a hilar mass or of | Surgery_Schwartz. needle aspirationSurgicalVideo-assisted mediastinoscopyTranscervical extended mediastinal lymphadenectomy (TEMLA)Video-assisted mediastinal lymphadenectomy (VAMLA)Thoracoscopic transthoracic lymphadenectomyIndications for invasive mediastinal staging in lung cancer1. Radiographically enlarged mediastinal lymph nodes2. Centrally located tumors3. N1 nodal enlargement4. Tumor size >3 cm5. Peripheral clinical stage I tumor with nonenlarged but FDG-avid mediastinal lymph nodesIndications for prethoracotomy/thoracoscopy biopsy of stations 5 and 6 lymph nodes1. Criteria for invasive staging met and other mediastinal lymph node stations are negative (assuming patient would have induction therapy if any nodal station positive)2. Enrollment criteria for induction therapy protocol require pathologic confirmation of N2 disease3. Computed tomography scan shows evidence of bulky nodal metastasis or extracapsular spread that could prevent complete resection4. Tissue diagnosis of a hilar mass or of |
Surgery_Schwartz_4634 | Surgery_Schwartz | confirmation of N2 disease3. Computed tomography scan shows evidence of bulky nodal metastasis or extracapsular spread that could prevent complete resection4. Tissue diagnosis of a hilar mass or of lymph nodes causing recurrent laryngeal nerve paralysis is neededN3 disease, the patient would be incorrectly staged as having IIIB disease and would not be considered a candidate for potentially curative surgical resection.It is important for surgeons who are managing patients with lung cancer to have a clear algorithm for invasive medias-tinal staging. In general, invasive staging is underutilized, plac-ing many patients at risk for overor understaging and, thus, inappropriate treatment. An absolute indication for obtaining a tissue diagnosis is mediastinal lymph node enlargement greater than 1.0 cm by CT scan. There are several options for invasive mediastinal staging (Table 19-10):1. Endobronchial Ultrasound (EBUS)-guided transbron-chial needle aspiration. Less invasive than | Surgery_Schwartz. confirmation of N2 disease3. Computed tomography scan shows evidence of bulky nodal metastasis or extracapsular spread that could prevent complete resection4. Tissue diagnosis of a hilar mass or of lymph nodes causing recurrent laryngeal nerve paralysis is neededN3 disease, the patient would be incorrectly staged as having IIIB disease and would not be considered a candidate for potentially curative surgical resection.It is important for surgeons who are managing patients with lung cancer to have a clear algorithm for invasive medias-tinal staging. In general, invasive staging is underutilized, plac-ing many patients at risk for overor understaging and, thus, inappropriate treatment. An absolute indication for obtaining a tissue diagnosis is mediastinal lymph node enlargement greater than 1.0 cm by CT scan. There are several options for invasive mediastinal staging (Table 19-10):1. Endobronchial Ultrasound (EBUS)-guided transbron-chial needle aspiration. Less invasive than |
Surgery_Schwartz_4635 | Surgery_Schwartz | than 1.0 cm by CT scan. There are several options for invasive mediastinal staging (Table 19-10):1. Endobronchial Ultrasound (EBUS)-guided transbron-chial needle aspiration. Less invasive than mediasti-noscopy, EBUS enables image-guided transtracheal and transbronchial FNA cytologic samples from hilar masses and lymph nodes from level 4R and 4L, level 7, level 10, and level 11. Rapid onsite pathologic evaluation with expert cytopathology evaluation greatly increases the diagnostic accuracy of the procedure; importantly, the intraoperative evaluation will confirm whether the target lesion is being sampled and greatly facilitates acquisition of satisfactory samples for determining the morphologic diagnosis as well as sufficient material for cell block for immunohistochemistry Brunicardi_Ch19_p0661-p0750.indd 68701/03/19 7:01 PM 688SPECIFIC CONSIDERATIONSPART IIFigure 19-20. Cervical mediastinoscopy. Paratracheal and sub-carinal lymph node tissues (within the pretracheal space) can | Surgery_Schwartz. than 1.0 cm by CT scan. There are several options for invasive mediastinal staging (Table 19-10):1. Endobronchial Ultrasound (EBUS)-guided transbron-chial needle aspiration. Less invasive than mediasti-noscopy, EBUS enables image-guided transtracheal and transbronchial FNA cytologic samples from hilar masses and lymph nodes from level 4R and 4L, level 7, level 10, and level 11. Rapid onsite pathologic evaluation with expert cytopathology evaluation greatly increases the diagnostic accuracy of the procedure; importantly, the intraoperative evaluation will confirm whether the target lesion is being sampled and greatly facilitates acquisition of satisfactory samples for determining the morphologic diagnosis as well as sufficient material for cell block for immunohistochemistry Brunicardi_Ch19_p0661-p0750.indd 68701/03/19 7:01 PM 688SPECIFIC CONSIDERATIONSPART IIFigure 19-20. Cervical mediastinoscopy. Paratracheal and sub-carinal lymph node tissues (within the pretracheal space) can |
Surgery_Schwartz_4636 | Surgery_Schwartz | 68701/03/19 7:01 PM 688SPECIFIC CONSIDERATIONSPART IIFigure 19-20. Cervical mediastinoscopy. Paratracheal and sub-carinal lymph node tissues (within the pretracheal space) can be sampled using a mediastinoscope introduced through a suprasternal skin incision.and molecular testing. EBUS does not allow assessment of level 3, 5, or 6 nodal stations.2. Endoscopic ultrasound (EUS). EUS can accurately visual-ize mediastinal paratracheal lymph nodes (stations 4R, 7, and 4L), paraesophageal (station 8) and inferior pulmonary ligament (station 9) lymph nodes and visualize primary lung lesions contiguous with or near the esophagus (see Fig. 19-8). Using FNA or core-needle biopsy, samples of lymph nodes or primary lesions can be obtained. Diagnos-tic yield is improved with intraoperative cytologic evalua-tion, which can be performed with the cytopathologist in the operating room. Limitations of EUS include the inability to visualize the anterior (pretracheal) mediastinum; thus, EUS does not | Surgery_Schwartz. 68701/03/19 7:01 PM 688SPECIFIC CONSIDERATIONSPART IIFigure 19-20. Cervical mediastinoscopy. Paratracheal and sub-carinal lymph node tissues (within the pretracheal space) can be sampled using a mediastinoscope introduced through a suprasternal skin incision.and molecular testing. EBUS does not allow assessment of level 3, 5, or 6 nodal stations.2. Endoscopic ultrasound (EUS). EUS can accurately visual-ize mediastinal paratracheal lymph nodes (stations 4R, 7, and 4L), paraesophageal (station 8) and inferior pulmonary ligament (station 9) lymph nodes and visualize primary lung lesions contiguous with or near the esophagus (see Fig. 19-8). Using FNA or core-needle biopsy, samples of lymph nodes or primary lesions can be obtained. Diagnos-tic yield is improved with intraoperative cytologic evalua-tion, which can be performed with the cytopathologist in the operating room. Limitations of EUS include the inability to visualize the anterior (pretracheal) mediastinum; thus, EUS does not |
Surgery_Schwartz_4637 | Surgery_Schwartz | evalua-tion, which can be performed with the cytopathologist in the operating room. Limitations of EUS include the inability to visualize the anterior (pretracheal) mediastinum; thus, EUS does not replace mediastinoscopy/EBUS for complete medi-astinal nodal staging. However, it may not be necessary to perform mediastinoscopy if findings on EUS are positive for N2 nodal disease, particularly if more than one station is found to harbor metastases.3. Cervical video-assisted mediastinoscopy. Mediastinos-copy provides tissue sampling of all paratracheal and sub-carinal lymph nodes and permits visual determination of the presence of extracapsular extension of nodal metastasis (Fig. 19-20). With complex hilar or right paratracheal primary tumors, it allows direct biopsies and assessment of invasion into the mediastinum. Mediastinoscopy is recommended for centrally located tumors, T2 and T3 primary tumors, and occasionally for T1 adenocarcinomas or large cell carcinomas (due to their higher | Surgery_Schwartz. evalua-tion, which can be performed with the cytopathologist in the operating room. Limitations of EUS include the inability to visualize the anterior (pretracheal) mediastinum; thus, EUS does not replace mediastinoscopy/EBUS for complete medi-astinal nodal staging. However, it may not be necessary to perform mediastinoscopy if findings on EUS are positive for N2 nodal disease, particularly if more than one station is found to harbor metastases.3. Cervical video-assisted mediastinoscopy. Mediastinos-copy provides tissue sampling of all paratracheal and sub-carinal lymph nodes and permits visual determination of the presence of extracapsular extension of nodal metastasis (Fig. 19-20). With complex hilar or right paratracheal primary tumors, it allows direct biopsies and assessment of invasion into the mediastinum. Mediastinoscopy is recommended for centrally located tumors, T2 and T3 primary tumors, and occasionally for T1 adenocarcinomas or large cell carcinomas (due to their higher |
Surgery_Schwartz_4638 | Surgery_Schwartz | into the mediastinum. Mediastinoscopy is recommended for centrally located tumors, T2 and T3 primary tumors, and occasionally for T1 adenocarcinomas or large cell carcinomas (due to their higher rate of metastatic spread). Some surgeons perform mediastinoscopy in all lung cancer patients because of the poor survival associated with surgi-cal resection of N2 disease.4. It is important to note that EBUS or EUS can be used for initial diagnosis in enlarged lymph nodes, but the predictive value of a negative EBUS in a patient with radiographically suspicious mediastinal disease is not sufficient to accurately guide treatment. At the authors’ institutions, it is standard to begin mediastinal lymph node staging with EBUS-guided FNA of clinically suspicious mediastinal lymphadenopathy. If intraoperative rapid onsite cytologic evaluation is nega-tive, mediastinoscopy is performed in the same operative setting to ensure accurate mediastinal staging. However, if the FNA is positive, | Surgery_Schwartz. into the mediastinum. Mediastinoscopy is recommended for centrally located tumors, T2 and T3 primary tumors, and occasionally for T1 adenocarcinomas or large cell carcinomas (due to their higher rate of metastatic spread). Some surgeons perform mediastinoscopy in all lung cancer patients because of the poor survival associated with surgi-cal resection of N2 disease.4. It is important to note that EBUS or EUS can be used for initial diagnosis in enlarged lymph nodes, but the predictive value of a negative EBUS in a patient with radiographically suspicious mediastinal disease is not sufficient to accurately guide treatment. At the authors’ institutions, it is standard to begin mediastinal lymph node staging with EBUS-guided FNA of clinically suspicious mediastinal lymphadenopathy. If intraoperative rapid onsite cytologic evaluation is nega-tive, mediastinoscopy is performed in the same operative setting to ensure accurate mediastinal staging. However, if the FNA is positive, |
Surgery_Schwartz_4639 | Surgery_Schwartz | If intraoperative rapid onsite cytologic evaluation is nega-tive, mediastinoscopy is performed in the same operative setting to ensure accurate mediastinal staging. However, if the FNA is positive, mediastinoscopy is not performed, and the patient is referred to medical oncology for induc-tion therapy; avoiding a pretreatment mediastinoscopy in this manner facilitates the safe performance of a postinduc-tion mediastinoscopy for restaging of the mediastinum in patients who respond favorably to induction therapy.5. Left video-assisted thoracoscopic lymph node sampling may be needed for patients with left upper lobe tumors who have localized regional spread to stations 5 and 6 lymph nodes, without mediastinal paratracheal involvement (see Fig. 19-8). If there is a low index of suspicion for nodal metastasis, the patient can be schedule for VATS biopsy and lobectomy under the same anesthesia; the procedure begins by sampling the level 5 and 6 nodes for frozen section, and if the nodes are | Surgery_Schwartz. If intraoperative rapid onsite cytologic evaluation is nega-tive, mediastinoscopy is performed in the same operative setting to ensure accurate mediastinal staging. However, if the FNA is positive, mediastinoscopy is not performed, and the patient is referred to medical oncology for induc-tion therapy; avoiding a pretreatment mediastinoscopy in this manner facilitates the safe performance of a postinduc-tion mediastinoscopy for restaging of the mediastinum in patients who respond favorably to induction therapy.5. Left video-assisted thoracoscopic lymph node sampling may be needed for patients with left upper lobe tumors who have localized regional spread to stations 5 and 6 lymph nodes, without mediastinal paratracheal involvement (see Fig. 19-8). If there is a low index of suspicion for nodal metastasis, the patient can be schedule for VATS biopsy and lobectomy under the same anesthesia; the procedure begins by sampling the level 5 and 6 nodes for frozen section, and if the nodes are |
Surgery_Schwartz_4640 | Surgery_Schwartz | metastasis, the patient can be schedule for VATS biopsy and lobectomy under the same anesthesia; the procedure begins by sampling the level 5 and 6 nodes for frozen section, and if the nodes are negative, the anatomic lung resection is performed. If the index of suspicion is high, the VATS biopsy is performed as a separate procedure. Cervical mediastinoscopy should precede VATS biopsy, even if patients have normal para-tracheal lymph nodes. Additional diagnostic evaluation of the lymph nodes in stations 5 and 6 may be unnecessary if the mediastinal lymph nodes are proven to be benign with biopsy during cervical mediastinoscopy and the preoperative CT scan suggests complete respectability of the tumor. There are, however, several indications for prethoracotomy biopsy of stations 5 and 6 lymph nodes, which are listed in Table 19-10. It is particularly important to prove that mediastinal lymph nodes are pathologically involved and not just radio-graphically suspicious for nodal | Surgery_Schwartz. metastasis, the patient can be schedule for VATS biopsy and lobectomy under the same anesthesia; the procedure begins by sampling the level 5 and 6 nodes for frozen section, and if the nodes are negative, the anatomic lung resection is performed. If the index of suspicion is high, the VATS biopsy is performed as a separate procedure. Cervical mediastinoscopy should precede VATS biopsy, even if patients have normal para-tracheal lymph nodes. Additional diagnostic evaluation of the lymph nodes in stations 5 and 6 may be unnecessary if the mediastinal lymph nodes are proven to be benign with biopsy during cervical mediastinoscopy and the preoperative CT scan suggests complete respectability of the tumor. There are, however, several indications for prethoracotomy biopsy of stations 5 and 6 lymph nodes, which are listed in Table 19-10. It is particularly important to prove that mediastinal lymph nodes are pathologically involved and not just radio-graphically suspicious for nodal |
Surgery_Schwartz_4641 | Surgery_Schwartz | and 6 lymph nodes, which are listed in Table 19-10. It is particularly important to prove that mediastinal lymph nodes are pathologically involved and not just radio-graphically suspicious for nodal metastasis prior to deciding that the patient is not a candidate for resection.Pleural Effusion. The presence of pleural effusion on radio-graphic imaging should not be assumed to be malignant. Pleural effusion may be secondary to atelectasis or consolidation (seen with central tumors), cardiac dysfunction, or may be a reac-tive effusion. When associated with a peripherally based tumor abutting the visceral or parietal pleural surface, probability of being malignant is higher. If this is the only site concerning for metastatic disease, pathologic confirmation is mandatory. It is reasonable to start with thoracentesis, but cytology reveals malignant cells in only 50% of malignant effusions on initial thoracentesis; negative cytology 5 times is needed to have 95% certainty of a benign | Surgery_Schwartz. and 6 lymph nodes, which are listed in Table 19-10. It is particularly important to prove that mediastinal lymph nodes are pathologically involved and not just radio-graphically suspicious for nodal metastasis prior to deciding that the patient is not a candidate for resection.Pleural Effusion. The presence of pleural effusion on radio-graphic imaging should not be assumed to be malignant. Pleural effusion may be secondary to atelectasis or consolidation (seen with central tumors), cardiac dysfunction, or may be a reac-tive effusion. When associated with a peripherally based tumor abutting the visceral or parietal pleural surface, probability of being malignant is higher. If this is the only site concerning for metastatic disease, pathologic confirmation is mandatory. It is reasonable to start with thoracentesis, but cytology reveals malignant cells in only 50% of malignant effusions on initial thoracentesis; negative cytology 5 times is needed to have 95% certainty of a benign |
Surgery_Schwartz_4642 | Surgery_Schwartz | to start with thoracentesis, but cytology reveals malignant cells in only 50% of malignant effusions on initial thoracentesis; negative cytology 5 times is needed to have 95% certainty of a benign process. Thoracoscopy may be needed to rule out pleural metastases in select patients and is usually per-formed as a separate staging procedure, often with subsequent mediastinoscopy if thoracoscopy is negative for metastasis.Distant Metastases. Currently, chest CT and PET are rou-tine in the evaluation of patients with lung cancer. Integrated PET-CT scanners have become standard and have substan-tially improved accuracy of detection and localization of lymph node and distant metastases, as compared with independently performed PET and CT scans (Fig. 19-21). This technology overcomes the imprecise information on the exact location of focal abnormalities seen on PET and has become the standard imaging modality for lung cancer. Compared to routine chest or abdominal CT and bone scans, PET | Surgery_Schwartz. to start with thoracentesis, but cytology reveals malignant cells in only 50% of malignant effusions on initial thoracentesis; negative cytology 5 times is needed to have 95% certainty of a benign process. Thoracoscopy may be needed to rule out pleural metastases in select patients and is usually per-formed as a separate staging procedure, often with subsequent mediastinoscopy if thoracoscopy is negative for metastasis.Distant Metastases. Currently, chest CT and PET are rou-tine in the evaluation of patients with lung cancer. Integrated PET-CT scanners have become standard and have substan-tially improved accuracy of detection and localization of lymph node and distant metastases, as compared with independently performed PET and CT scans (Fig. 19-21). This technology overcomes the imprecise information on the exact location of focal abnormalities seen on PET and has become the standard imaging modality for lung cancer. Compared to routine chest or abdominal CT and bone scans, PET |
Surgery_Schwartz_4643 | Surgery_Schwartz | information on the exact location of focal abnormalities seen on PET and has become the standard imaging modality for lung cancer. Compared to routine chest or abdominal CT and bone scans, PET scanning detects 10% to 15% more distant metastases, but should be confirmed with MRI and/or biopsies if the patient otherwise has early-stage dis-ease. Brain MRI should be performed when the suspicion or risk of brain metastases is increased, such as in patients with Brunicardi_Ch19_p0661-p0750.indd 68801/03/19 7:01 PM | Surgery_Schwartz. information on the exact location of focal abnormalities seen on PET and has become the standard imaging modality for lung cancer. Compared to routine chest or abdominal CT and bone scans, PET scanning detects 10% to 15% more distant metastases, but should be confirmed with MRI and/or biopsies if the patient otherwise has early-stage dis-ease. Brain MRI should be performed when the suspicion or risk of brain metastases is increased, such as in patients with Brunicardi_Ch19_p0661-p0750.indd 68801/03/19 7:01 PM |
Surgery_Schwartz_4644 | Surgery_Schwartz | CHAPTER 19689CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAABCFigure 19-21. Imaging of non–small cell lung cancer by integrated positron emission tomography (PET)-computed tomography (CT) scan. A. CT of the chest showing a tumor in the left upper lobe. B. PET scan of the chest at the identical cross-sectional level. C. Coregistered PET-CT scan clearly showing tumor invasion (con-firmed intraoperatively). (Adapted with permission from Lardinois D, Weder W, Hany TF, et al. Staging of non-small-cell lung can-cer with integrated positron-emission tomography and computed tomography, N Engl J Med. 2003 Jun 19;348(25):2500-2507.)clinical stage III disease. In the absence of neurologic symp-toms or signs, the probability of a negative head CT scan is 95%. Liver abnormalities that are not clearly simple cysts or hemangiomas and adrenal enlargement, nodules, or masses are further evaluated by MRI scanning and, occasionally, by needle biopsy. Adrenal adenomas have a high lipid content (secondary to | Surgery_Schwartz. CHAPTER 19689CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAABCFigure 19-21. Imaging of non–small cell lung cancer by integrated positron emission tomography (PET)-computed tomography (CT) scan. A. CT of the chest showing a tumor in the left upper lobe. B. PET scan of the chest at the identical cross-sectional level. C. Coregistered PET-CT scan clearly showing tumor invasion (con-firmed intraoperatively). (Adapted with permission from Lardinois D, Weder W, Hany TF, et al. Staging of non-small-cell lung can-cer with integrated positron-emission tomography and computed tomography, N Engl J Med. 2003 Jun 19;348(25):2500-2507.)clinical stage III disease. In the absence of neurologic symp-toms or signs, the probability of a negative head CT scan is 95%. Liver abnormalities that are not clearly simple cysts or hemangiomas and adrenal enlargement, nodules, or masses are further evaluated by MRI scanning and, occasionally, by needle biopsy. Adrenal adenomas have a high lipid content (secondary to |
Surgery_Schwartz_4645 | Surgery_Schwartz | cysts or hemangiomas and adrenal enlargement, nodules, or masses are further evaluated by MRI scanning and, occasionally, by needle biopsy. Adrenal adenomas have a high lipid content (secondary to steroid production), but metastases and most primary adrenal malignancies contain little if any lipid; thus, MRI is usually able to distinguish the two.Tumor, Node, and Metastasis: Lung Cancer Staging The staging of any tumor is an attempt to estimate the extent of dis-ease and determine the patient’s prognosis; in a given patient, tumors are typically classified into a clinical stage and a patho-logic stage. Clinical staging includes history and physical examination, radiographic test results, and diagnostic biopsy information. Therapeutic plans are generated based on clinical stage. After surgical resection of tumor and lymph nodes, post-operative pathologic stage (pTNM) is determined, providing further prognostic information.The staging of solid epithelial tumors is based on the TNM | Surgery_Schwartz. cysts or hemangiomas and adrenal enlargement, nodules, or masses are further evaluated by MRI scanning and, occasionally, by needle biopsy. Adrenal adenomas have a high lipid content (secondary to steroid production), but metastases and most primary adrenal malignancies contain little if any lipid; thus, MRI is usually able to distinguish the two.Tumor, Node, and Metastasis: Lung Cancer Staging The staging of any tumor is an attempt to estimate the extent of dis-ease and determine the patient’s prognosis; in a given patient, tumors are typically classified into a clinical stage and a patho-logic stage. Clinical staging includes history and physical examination, radiographic test results, and diagnostic biopsy information. Therapeutic plans are generated based on clinical stage. After surgical resection of tumor and lymph nodes, post-operative pathologic stage (pTNM) is determined, providing further prognostic information.The staging of solid epithelial tumors is based on the TNM |
Surgery_Schwartz_4646 | Surgery_Schwartz | surgical resection of tumor and lymph nodes, post-operative pathologic stage (pTNM) is determined, providing further prognostic information.The staging of solid epithelial tumors is based on the TNM staging system. The primary tumor “T” status provides infor-mation about tumor size and relationship to surrounding struc-tures; the “N” status provides information about regional lymph nodes; and the “M” status provides information about the pres-ence or absence of metastatic disease. The designation of lymph nodes as N1, N2, or N3 requires familiarity with the lymph node mapping system41 (see Fig. 19-8). Based on clearly delineated anatomic boundaries, accurate and reproducible localization of thoracic lymph nodes is possible, facilitating detailed nodal staging for individual patients and standardization of nodal assessment between surgeons.Pathologic staging criteria are based on the predicted sur-vival relative to each combination of tumor, node, and metas-tasis status. In 2018, the | Surgery_Schwartz. surgical resection of tumor and lymph nodes, post-operative pathologic stage (pTNM) is determined, providing further prognostic information.The staging of solid epithelial tumors is based on the TNM staging system. The primary tumor “T” status provides infor-mation about tumor size and relationship to surrounding struc-tures; the “N” status provides information about regional lymph nodes; and the “M” status provides information about the pres-ence or absence of metastatic disease. The designation of lymph nodes as N1, N2, or N3 requires familiarity with the lymph node mapping system41 (see Fig. 19-8). Based on clearly delineated anatomic boundaries, accurate and reproducible localization of thoracic lymph nodes is possible, facilitating detailed nodal staging for individual patients and standardization of nodal assessment between surgeons.Pathologic staging criteria are based on the predicted sur-vival relative to each combination of tumor, node, and metas-tasis status. In 2018, the |
Surgery_Schwartz_4647 | Surgery_Schwartz | standardization of nodal assessment between surgeons.Pathologic staging criteria are based on the predicted sur-vival relative to each combination of tumor, node, and metas-tasis status. In 2018, the AJCC eighth edition incorporated multiple changes into the staging system for NSCLC based on analysis of survival predictors from 77,156 lung cancer patients worldwide. Table 19-11a shows the clinical and pathologic cri-teria changes implemented and each of the TNM descriptors currently used in staging NSCLC (Table 19-11b) and the over-all stage classifications (Table 19-11c). T-staging is markedly changed, including T category designation for each centimeter in size up to 5 cm, as well as size of the invasive component in lepidic growth tumors. Visceral pleural invasion increases T-stage to T2 for patients with tumors ≤3 cm in size, and syn-chronous primary tumors have an added T suffix (m) in tumor staging. Metastatic disease has also been subdivided into intra-thoracic, single-site | Surgery_Schwartz. standardization of nodal assessment between surgeons.Pathologic staging criteria are based on the predicted sur-vival relative to each combination of tumor, node, and metas-tasis status. In 2018, the AJCC eighth edition incorporated multiple changes into the staging system for NSCLC based on analysis of survival predictors from 77,156 lung cancer patients worldwide. Table 19-11a shows the clinical and pathologic cri-teria changes implemented and each of the TNM descriptors currently used in staging NSCLC (Table 19-11b) and the over-all stage classifications (Table 19-11c). T-staging is markedly changed, including T category designation for each centimeter in size up to 5 cm, as well as size of the invasive component in lepidic growth tumors. Visceral pleural invasion increases T-stage to T2 for patients with tumors ≤3 cm in size, and syn-chronous primary tumors have an added T suffix (m) in tumor staging. Metastatic disease has also been subdivided into intra-thoracic, single-site |
Surgery_Schwartz_4648 | Surgery_Schwartz | to T2 for patients with tumors ≤3 cm in size, and syn-chronous primary tumors have an added T suffix (m) in tumor staging. Metastatic disease has also been subdivided into intra-thoracic, single-site extrathoracic, and multiple extrathoracic metastasis. In addition to the TNM stage, it is recommended that histologic grade, lymphovascular invasion, adequacy of resec-tion margins and mediastinal dissection, tumor mutation status, treatment, and residual tumor after treatment also be recorded into cancer registries to facilitate evaluation of these potential predictors in future analysis of staging criteria.Staging for small cell lung cancer (SCLC) is typically based on the extent of disease. SCLC presenting with bulky locoregional disease confined to the ipsilateral hemithorax, with no evidence for distant metastatic disease, is termed “limited” SCLC. Limited disease must be treatable within a tolerable field of radiation. Using AJCC descriptors, this includes any T stage, any N stage, | Surgery_Schwartz. to T2 for patients with tumors ≤3 cm in size, and syn-chronous primary tumors have an added T suffix (m) in tumor staging. Metastatic disease has also been subdivided into intra-thoracic, single-site extrathoracic, and multiple extrathoracic metastasis. In addition to the TNM stage, it is recommended that histologic grade, lymphovascular invasion, adequacy of resec-tion margins and mediastinal dissection, tumor mutation status, treatment, and residual tumor after treatment also be recorded into cancer registries to facilitate evaluation of these potential predictors in future analysis of staging criteria.Staging for small cell lung cancer (SCLC) is typically based on the extent of disease. SCLC presenting with bulky locoregional disease confined to the ipsilateral hemithorax, with no evidence for distant metastatic disease, is termed “limited” SCLC. Limited disease must be treatable within a tolerable field of radiation. Using AJCC descriptors, this includes any T stage, any N stage, |
Surgery_Schwartz_4649 | Surgery_Schwartz | for distant metastatic disease, is termed “limited” SCLC. Limited disease must be treatable within a tolerable field of radiation. Using AJCC descriptors, this includes any T stage, any N stage, without metastatic disease (M0). The only excep-tion is when multiple lung nodules are widely spread throughout the ipsilateral lung in the same hemithorax; in these patients, the size of the involved area would preclude a “safe” radiation field. In contrast, in “disseminated” disease, tumor is beyond the ipsi-lateral hemithorax or widely spread within the ipsilateral lung and to distant sites. Metastases to the pleura and pericardium, with resultant effusions, are considered disseminated disease. Brunicardi_Ch19_p0661-p0750.indd 68901/03/19 7:01 PM 690SPECIFIC CONSIDERATIONSPART IITable 19-11aChanges in Descriptors for non-small cell lung cancer comparing the 7th and 8th editions of the American Joint Committee on Cancer Staging ManualDESCRIPTORSEVENTH EDITIONEIGHTH EDITIONT component0 cm | Surgery_Schwartz. for distant metastatic disease, is termed “limited” SCLC. Limited disease must be treatable within a tolerable field of radiation. Using AJCC descriptors, this includes any T stage, any N stage, without metastatic disease (M0). The only excep-tion is when multiple lung nodules are widely spread throughout the ipsilateral lung in the same hemithorax; in these patients, the size of the involved area would preclude a “safe” radiation field. In contrast, in “disseminated” disease, tumor is beyond the ipsi-lateral hemithorax or widely spread within the ipsilateral lung and to distant sites. Metastases to the pleura and pericardium, with resultant effusions, are considered disseminated disease. Brunicardi_Ch19_p0661-p0750.indd 68901/03/19 7:01 PM 690SPECIFIC CONSIDERATIONSPART IITable 19-11aChanges in Descriptors for non-small cell lung cancer comparing the 7th and 8th editions of the American Joint Committee on Cancer Staging ManualDESCRIPTORSEVENTH EDITIONEIGHTH EDITIONT component0 cm |
Surgery_Schwartz_4650 | Surgery_Schwartz | in Descriptors for non-small cell lung cancer comparing the 7th and 8th editions of the American Joint Committee on Cancer Staging ManualDESCRIPTORSEVENTH EDITIONEIGHTH EDITIONT component0 cm (pure lepidic adenocarcinoma ≤3 cm total size)T1a if ≤2 cm; T1b if >2–3 cmTis (AIS)≤0.5 cm invasive size (lepidic predominant adenocarcinoma ≤3 cm total size)T1a if ≤2 cm; T1b if >2–3 cmT1mi≤1 cmT1aT1a>1–2 cmT1aT1b>2–3 cmT1bT1c>3–4 cmT2aT2a>4–5 cmT2aT2b>5–7 cmT2bT3>7 cmT3T4Bronchus <2 cm from carinaT3T2Total atelectasis/pneumonitisT3T2Invasion of diaphragmT3T4Invasion of mediastinal pleuraT3-N componentNo assessment, no involvement, or involvement of regional lymph nodesNX, N0, N1, N2, N3No changeM componentMetastases within the thoracic cavityM1aM1aSingle extrathoracic metastasisM1bM1bMultiple extrathoracic metastasesM1bM1cAbbreviations: AIS, adenocarcinoma in situ; mi, minimally invasive adenocarcinoma; Tis, tumor in situ.Modified with permission from Rami-Porta R, Asamura H, Travis WD, et al: | Surgery_Schwartz. in Descriptors for non-small cell lung cancer comparing the 7th and 8th editions of the American Joint Committee on Cancer Staging ManualDESCRIPTORSEVENTH EDITIONEIGHTH EDITIONT component0 cm (pure lepidic adenocarcinoma ≤3 cm total size)T1a if ≤2 cm; T1b if >2–3 cmTis (AIS)≤0.5 cm invasive size (lepidic predominant adenocarcinoma ≤3 cm total size)T1a if ≤2 cm; T1b if >2–3 cmT1mi≤1 cmT1aT1a>1–2 cmT1aT1b>2–3 cmT1bT1c>3–4 cmT2aT2a>4–5 cmT2aT2b>5–7 cmT2bT3>7 cmT3T4Bronchus <2 cm from carinaT3T2Total atelectasis/pneumonitisT3T2Invasion of diaphragmT3T4Invasion of mediastinal pleuraT3-N componentNo assessment, no involvement, or involvement of regional lymph nodesNX, N0, N1, N2, N3No changeM componentMetastases within the thoracic cavityM1aM1aSingle extrathoracic metastasisM1bM1bMultiple extrathoracic metastasesM1bM1cAbbreviations: AIS, adenocarcinoma in situ; mi, minimally invasive adenocarcinoma; Tis, tumor in situ.Modified with permission from Rami-Porta R, Asamura H, Travis WD, et al: |
Surgery_Schwartz_4651 | Surgery_Schwartz | metastasesM1bM1cAbbreviations: AIS, adenocarcinoma in situ; mi, minimally invasive adenocarcinoma; Tis, tumor in situ.Modified with permission from Rami-Porta R, Asamura H, Travis WD, et al: Lung cancer — major changes in the American Joint Committee on Cancer eighth edition cancer staging manual, A Cancer J Clin. 2017 Mar;67(2):138-155.(Continued)Table 19-11bAmerican Joint Committee on Cancer Lung Cancer Staging Eight EditionTPRIMARY TUMORTXPrimary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopyT0No evidence of primary tumorTisCarcinoma in situSquamous cell carcinoma in situ (SCIS)Adenocarcinoma in situ (AIS); adenocarcinoma with pure lepidic pattern, ≤3 cm in greatest dimensionT1Tumor ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) T1miMinimally | Surgery_Schwartz. metastasesM1bM1cAbbreviations: AIS, adenocarcinoma in situ; mi, minimally invasive adenocarcinoma; Tis, tumor in situ.Modified with permission from Rami-Porta R, Asamura H, Travis WD, et al: Lung cancer — major changes in the American Joint Committee on Cancer eighth edition cancer staging manual, A Cancer J Clin. 2017 Mar;67(2):138-155.(Continued)Table 19-11bAmerican Joint Committee on Cancer Lung Cancer Staging Eight EditionTPRIMARY TUMORTXPrimary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopyT0No evidence of primary tumorTisCarcinoma in situSquamous cell carcinoma in situ (SCIS)Adenocarcinoma in situ (AIS); adenocarcinoma with pure lepidic pattern, ≤3 cm in greatest dimensionT1Tumor ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) T1miMinimally |
Surgery_Schwartz_4652 | Surgery_Schwartz | ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) T1miMinimally invasive adenocarcinoma: adenocarcinoma (≤3 cm in greatest dimension) with a predominantly lepidic pattern and ≤5 mm invasion in greatest dimension T1aTumor ≤1 cm in greatest dimension. A superficial, spreading tumor of any size whose invasive component is limited to the bronchial wall and may extend proximal to the main bronchus also is classified as T1a, but these tumors are uncommon. T1bTumor >1 cm but ≤2 cm in greatest dimension T1cTumor >2 cm but ≤3 cm in greatest dimensionT2Tumor >3 cm but ≤5 cm or having any of the following features:• Involves the main bronchus regardless of distance to the carina, but without involvement of the carina• Invades visceral pleura (PL1 or PL2)• Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all | Surgery_Schwartz. ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) T1miMinimally invasive adenocarcinoma: adenocarcinoma (≤3 cm in greatest dimension) with a predominantly lepidic pattern and ≤5 mm invasion in greatest dimension T1aTumor ≤1 cm in greatest dimension. A superficial, spreading tumor of any size whose invasive component is limited to the bronchial wall and may extend proximal to the main bronchus also is classified as T1a, but these tumors are uncommon. T1bTumor >1 cm but ≤2 cm in greatest dimension T1cTumor >2 cm but ≤3 cm in greatest dimensionT2Tumor >3 cm but ≤5 cm or having any of the following features:• Involves the main bronchus regardless of distance to the carina, but without involvement of the carina• Invades visceral pleura (PL1 or PL2)• Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all |
Surgery_Schwartz_4653 | Surgery_Schwartz | the carina, but without involvement of the carina• Invades visceral pleura (PL1 or PL2)• Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lungT2 tumors with these features are classified as T2a if ≤4 cm or if the size cannot be determined and T2b if >4 cm but ≤5 cm.Brunicardi_Ch19_p0661-p0750.indd 69001/03/19 7:01 PM | Surgery_Schwartz. the carina, but without involvement of the carina• Invades visceral pleura (PL1 or PL2)• Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lungT2 tumors with these features are classified as T2a if ≤4 cm or if the size cannot be determined and T2b if >4 cm but ≤5 cm.Brunicardi_Ch19_p0661-p0750.indd 69001/03/19 7:01 PM |
Surgery_Schwartz_4654 | Surgery_Schwartz | CHAPTER 19691CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATable 19-11cStage Group in the 8th AJCC Tumor, Node, Metastasis staging systemN0N1N2N3T1/M0T1aIA1IIBIIIAIIIBT1bIA2IIBIIIAIIIBT1cIA3IIBIIIAIIIBT2/M0T2aIBIIBIIIAIIIBT2bIIAIIBIIIAIIIBT3/M0IIBIIIAIIIBIIICT4/M0IIIAIIIAIIIBIIICTX/M1M1aIVAIVAIVAIVAM1bIVAIVAIVAIVAM1cIVBIVBIVBIVBUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 19-11bAmerican Joint Committee on Cancer Lung Cancer Staging Eight Edition T2aTumor >3 cm but ≤4 cm in greatest dimension T2bTumor >4 cm but ≤5 cm in greatest dimensionT3Tumor >5 cm but ≤7 cm in greatest dimension or directly invading any of the following: parietal pleura (PL3), chest wall (including superior sulcus tumors), phrenic nerve, parietal pericardium; or separate tumor nodule(s) in the same lobe as the primaryT4Tumor >7 cm or tumor of any size invading one or more of the following: | Surgery_Schwartz. CHAPTER 19691CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATable 19-11cStage Group in the 8th AJCC Tumor, Node, Metastasis staging systemN0N1N2N3T1/M0T1aIA1IIBIIIAIIIBT1bIA2IIBIIIAIIIBT1cIA3IIBIIIAIIIBT2/M0T2aIBIIBIIIAIIIBT2bIIAIIBIIIAIIIBT3/M0IIBIIIAIIIBIIICT4/M0IIIAIIIAIIIBIIICTX/M1M1aIVAIVAIVAIVAM1bIVAIVAIVAIVAM1cIVBIVBIVBIVBUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 19-11bAmerican Joint Committee on Cancer Lung Cancer Staging Eight Edition T2aTumor >3 cm but ≤4 cm in greatest dimension T2bTumor >4 cm but ≤5 cm in greatest dimensionT3Tumor >5 cm but ≤7 cm in greatest dimension or directly invading any of the following: parietal pleura (PL3), chest wall (including superior sulcus tumors), phrenic nerve, parietal pericardium; or separate tumor nodule(s) in the same lobe as the primaryT4Tumor >7 cm or tumor of any size invading one or more of the following: |
Surgery_Schwartz_4655 | Surgery_Schwartz | superior sulcus tumors), phrenic nerve, parietal pericardium; or separate tumor nodule(s) in the same lobe as the primaryT4Tumor >7 cm or tumor of any size invading one or more of the following: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; separate tumor nodule(s) in an ipsilateral lobe different from that of the primaryNREGIONAL LYMPH NODENXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extensionN2Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)N3Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)MDISTANT METASTASISM0No distant metastasisM1Distant metastasis M1aSeparate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial | Surgery_Schwartz. superior sulcus tumors), phrenic nerve, parietal pericardium; or separate tumor nodule(s) in the same lobe as the primaryT4Tumor >7 cm or tumor of any size invading one or more of the following: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; separate tumor nodule(s) in an ipsilateral lobe different from that of the primaryNREGIONAL LYMPH NODENXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extensionN2Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)N3Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)MDISTANT METASTASISM0No distant metastasisM1Distant metastasis M1aSeparate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial |
Surgery_Schwartz_4656 | Surgery_Schwartz | scalene, or supraclavicular lymph node(s)MDISTANT METASTASISM0No distant metastasisM1Distant metastasis M1aSeparate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodules or malignant pleural or pericardial effusion. Most pleural (pericardial) effusions with lung cancer are a result of the tumor. In a few patients, however, multiple microscopic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is nonbloody and not an exudate. If these elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging descriptor. M1bSingle extrathoracic metastasis in a single organ (including involvement of a single nonregional node) M1cMultiple extrathoracic metastases in a single organ or in multiple organsUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Metastases | Surgery_Schwartz. scalene, or supraclavicular lymph node(s)MDISTANT METASTASISM0No distant metastasisM1Distant metastasis M1aSeparate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodules or malignant pleural or pericardial effusion. Most pleural (pericardial) effusions with lung cancer are a result of the tumor. In a few patients, however, multiple microscopic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is nonbloody and not an exudate. If these elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging descriptor. M1bSingle extrathoracic metastasis in a single organ (including involvement of a single nonregional node) M1cMultiple extrathoracic metastases in a single organ or in multiple organsUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Metastases |
Surgery_Schwartz_4657 | Surgery_Schwartz | or in multiple organsUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Metastases to brain, bone, bone marrow, and the pleural and pericardial spaces are common.Assessment of Functional Status Patients with potentially resectable tumors require careful assessment of their functional status and ability to tolerate either lobectomy or pneumonectomy. The surgeon should first estimate the likelihood of pneumonec-tomy, lobectomy, or possibly sleeve resection, based on the CT images. A sequential process of evaluation then unfolds.5A patient’s history is the most important tool for gauging risk. Specific questions regarding performance status should be routinely asked. If the patient can walk on a flat surface indefi-nitely, without oxygen and without having to stop and rest sec-ondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two | Surgery_Schwartz. or in multiple organsUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Metastases to brain, bone, bone marrow, and the pleural and pericardial spaces are common.Assessment of Functional Status Patients with potentially resectable tumors require careful assessment of their functional status and ability to tolerate either lobectomy or pneumonectomy. The surgeon should first estimate the likelihood of pneumonec-tomy, lobectomy, or possibly sleeve resection, based on the CT images. A sequential process of evaluation then unfolds.5A patient’s history is the most important tool for gauging risk. Specific questions regarding performance status should be routinely asked. If the patient can walk on a flat surface indefi-nitely, without oxygen and without having to stop and rest sec-ondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two |
Surgery_Schwartz_4658 | Surgery_Schwartz | can walk on a flat surface indefi-nitely, without oxygen and without having to stop and rest sec-ondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two flights of stairs (up two stan-dard levels), without having to stop and rest secondary to dys-pnea, she will likely tolerate pneumonectomy. Finally, nearly (Continued)Brunicardi_Ch19_p0661-p0750.indd 69101/03/19 7:01 PM 692SPECIFIC CONSIDERATIONSPART IIPercent mortalityppoDLCO%504030201002030405060708090100Figure 19-22. Operative mortality after major pulmonary resec-tion for non–small cell lung cancer (334 patients) as a function of percent predicted postoperative carbon monoxide diffusion capacity (ppoDlco%). Solid line indicates logistic regression model; dashed lines indicate 95% confidence limits. (Reproduced with permission from Wang J, Olak J, Ferguson MK: Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer, J Thorac Cardiovasc | Surgery_Schwartz. can walk on a flat surface indefi-nitely, without oxygen and without having to stop and rest sec-ondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two flights of stairs (up two stan-dard levels), without having to stop and rest secondary to dys-pnea, she will likely tolerate pneumonectomy. Finally, nearly (Continued)Brunicardi_Ch19_p0661-p0750.indd 69101/03/19 7:01 PM 692SPECIFIC CONSIDERATIONSPART IIPercent mortalityppoDLCO%504030201002030405060708090100Figure 19-22. Operative mortality after major pulmonary resec-tion for non–small cell lung cancer (334 patients) as a function of percent predicted postoperative carbon monoxide diffusion capacity (ppoDlco%). Solid line indicates logistic regression model; dashed lines indicate 95% confidence limits. (Reproduced with permission from Wang J, Olak J, Ferguson MK: Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer, J Thorac Cardiovasc |
Surgery_Schwartz_4659 | Surgery_Schwartz | limits. (Reproduced with permission from Wang J, Olak J, Ferguson MK: Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer, J Thorac Cardiovasc Surg. 1999 Mar;117(3):581-586.)all patients, except those with carbon dioxide (CO2) retention on arterial blood gas analysis, will be able to tolerate periods of single-lung ventilation and wedge resection. Formal assess-ment of cardiac fitness is mandatory; use of risk scores such as the Thoracic Revised Cardiac Risk Index developed by Dr. Brunelli and colleagues provides useful prognostic infor-mation for postresection survival from early-stage lung cancer.Current smoking status and sputum production are also pertinent. Current smokers and patients with a greater than 60 pack-year history of smoking have a significantly increased risk of postoperative pulmonary complications; heavy smokers are 2.5 times more likely to develop pulmonary complications and three times more likely to | Surgery_Schwartz. limits. (Reproduced with permission from Wang J, Olak J, Ferguson MK: Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer, J Thorac Cardiovasc Surg. 1999 Mar;117(3):581-586.)all patients, except those with carbon dioxide (CO2) retention on arterial blood gas analysis, will be able to tolerate periods of single-lung ventilation and wedge resection. Formal assess-ment of cardiac fitness is mandatory; use of risk scores such as the Thoracic Revised Cardiac Risk Index developed by Dr. Brunelli and colleagues provides useful prognostic infor-mation for postresection survival from early-stage lung cancer.Current smoking status and sputum production are also pertinent. Current smokers and patients with a greater than 60 pack-year history of smoking have a significantly increased risk of postoperative pulmonary complications; heavy smokers are 2.5 times more likely to develop pulmonary complications and three times more likely to |
Surgery_Schwartz_4660 | Surgery_Schwartz | of smoking have a significantly increased risk of postoperative pulmonary complications; heavy smokers are 2.5 times more likely to develop pulmonary complications and three times more likely to develop pneumonia compared to patients with a ≤60 pack-year history (odds ratio [OR] 2.54; 95% CI 1.28–5.04; P = .0008). Impaired exchange of CO2 is also pre-dictive of increased risk, independent of the smoking history. For every 10% decline in percent carbon monoxide diffusion capac-ity (%Dlco), the risk of any pulmonary complication increased by 42% (OR 1.42; 95% CI 1.16–1.75; P = .008).42 Risk reduc-tion requires smoking cessation at least 8 weeks preoperatively, a requirement that is often not feasible in a cancer patient. Nev-ertheless, abstinence for at least 2 weeks before surgery should be encouraged. Smoking cessation on the day of surgery leads to increased sputum production and potential secretion reten-tion postoperatively, and some authors have reported increased rates of | Surgery_Schwartz. of smoking have a significantly increased risk of postoperative pulmonary complications; heavy smokers are 2.5 times more likely to develop pulmonary complications and three times more likely to develop pneumonia compared to patients with a ≤60 pack-year history (odds ratio [OR] 2.54; 95% CI 1.28–5.04; P = .0008). Impaired exchange of CO2 is also pre-dictive of increased risk, independent of the smoking history. For every 10% decline in percent carbon monoxide diffusion capac-ity (%Dlco), the risk of any pulmonary complication increased by 42% (OR 1.42; 95% CI 1.16–1.75; P = .008).42 Risk reduc-tion requires smoking cessation at least 8 weeks preoperatively, a requirement that is often not feasible in a cancer patient. Nev-ertheless, abstinence for at least 2 weeks before surgery should be encouraged. Smoking cessation on the day of surgery leads to increased sputum production and potential secretion reten-tion postoperatively, and some authors have reported increased rates of |
Surgery_Schwartz_4661 | Surgery_Schwartz | be encouraged. Smoking cessation on the day of surgery leads to increased sputum production and potential secretion reten-tion postoperatively, and some authors have reported increased rates of pulmonary complications in this group.43 Patients with chronic daily sputum production will have more problems post-operatively with retention and atelectasis; they are also at higher risk for pneumonia. Sputum culture, antibiotic administration, and bronchodilators may be warranted preoperatively.Pulmonary function studies are routinely performed when any resection greater than a wedge resection will be performed. Of all the measurements available, the two most valuable are forced expiratory volume in 1 second (FEV1) and carbon mon-oxide diffusion capacity (Dlco). General guidelines for the use of FEV1 in assessing the patient’s ability to tolerate pulmonary resection are as follows: greater than 2.0 L can tolerate pneumo-nectomy, and greater than 1.5 L can tolerate lobectomy. It must be | Surgery_Schwartz. be encouraged. Smoking cessation on the day of surgery leads to increased sputum production and potential secretion reten-tion postoperatively, and some authors have reported increased rates of pulmonary complications in this group.43 Patients with chronic daily sputum production will have more problems post-operatively with retention and atelectasis; they are also at higher risk for pneumonia. Sputum culture, antibiotic administration, and bronchodilators may be warranted preoperatively.Pulmonary function studies are routinely performed when any resection greater than a wedge resection will be performed. Of all the measurements available, the two most valuable are forced expiratory volume in 1 second (FEV1) and carbon mon-oxide diffusion capacity (Dlco). General guidelines for the use of FEV1 in assessing the patient’s ability to tolerate pulmonary resection are as follows: greater than 2.0 L can tolerate pneumo-nectomy, and greater than 1.5 L can tolerate lobectomy. It must be |
Surgery_Schwartz_4662 | Surgery_Schwartz | of FEV1 in assessing the patient’s ability to tolerate pulmonary resection are as follows: greater than 2.0 L can tolerate pneumo-nectomy, and greater than 1.5 L can tolerate lobectomy. It must be emphasized that these are guidelines only. It is also important to note that the raw value is often imprecise because normal values are reported as “percent predicted” based on corrections made for age, height, and gender. For example, a raw FEV1 value of 1.3 L in a 62-year-old, 75-inch (190-cm) male has a percent predicted value of 30% (because the normal expected value is 4.31 L); in a 62-year-old, 62-inch female, the predicted value is 59% (normal expected value 2.21 L). The male patient is at high risk for lobectomy, while the female could potentially tolerate pneumonectomy.To calculate the predicted postoperative value for FEV1 or Dlco, the percent predicted value of FEV1 or Dlco is mul-tiplied by the fraction of remaining lung after the proposed sur-gery. For example, with a planned | Surgery_Schwartz. of FEV1 in assessing the patient’s ability to tolerate pulmonary resection are as follows: greater than 2.0 L can tolerate pneumo-nectomy, and greater than 1.5 L can tolerate lobectomy. It must be emphasized that these are guidelines only. It is also important to note that the raw value is often imprecise because normal values are reported as “percent predicted” based on corrections made for age, height, and gender. For example, a raw FEV1 value of 1.3 L in a 62-year-old, 75-inch (190-cm) male has a percent predicted value of 30% (because the normal expected value is 4.31 L); in a 62-year-old, 62-inch female, the predicted value is 59% (normal expected value 2.21 L). The male patient is at high risk for lobectomy, while the female could potentially tolerate pneumonectomy.To calculate the predicted postoperative value for FEV1 or Dlco, the percent predicted value of FEV1 or Dlco is mul-tiplied by the fraction of remaining lung after the proposed sur-gery. For example, with a planned |
Surgery_Schwartz_4663 | Surgery_Schwartz | predicted postoperative value for FEV1 or Dlco, the percent predicted value of FEV1 or Dlco is mul-tiplied by the fraction of remaining lung after the proposed sur-gery. For example, with a planned right upper lobectomy, a total of three segments will be removed. Therefore, three of a total 20 segments will leave the patient with (20 – 3/20) × 100 = 85% of their original lung capacity. In the two patients mentioned ear-lier, the man will have a predicted postoperative FEV1 of 30% × 0.85 = 25%, whereas the woman will have a predicted postop-erative FEV1 of 50%. Percent predicted value of less than 50% for either FEV1 or Dlco correlates with risk for postoperative complications, particularly pulmonary complications; the risk of complications increases in a stepwise fashion for each 10% decline. Figure 19-22 shows the relationship between predicted postoperative Dlco and estimated operative mortality.Quantitative perfusion scanning is used in select circum-stances to help estimate the | Surgery_Schwartz. predicted postoperative value for FEV1 or Dlco, the percent predicted value of FEV1 or Dlco is mul-tiplied by the fraction of remaining lung after the proposed sur-gery. For example, with a planned right upper lobectomy, a total of three segments will be removed. Therefore, three of a total 20 segments will leave the patient with (20 – 3/20) × 100 = 85% of their original lung capacity. In the two patients mentioned ear-lier, the man will have a predicted postoperative FEV1 of 30% × 0.85 = 25%, whereas the woman will have a predicted postop-erative FEV1 of 50%. Percent predicted value of less than 50% for either FEV1 or Dlco correlates with risk for postoperative complications, particularly pulmonary complications; the risk of complications increases in a stepwise fashion for each 10% decline. Figure 19-22 shows the relationship between predicted postoperative Dlco and estimated operative mortality.Quantitative perfusion scanning is used in select circum-stances to help estimate the |
Surgery_Schwartz_4664 | Surgery_Schwartz | Figure 19-22 shows the relationship between predicted postoperative Dlco and estimated operative mortality.Quantitative perfusion scanning is used in select circum-stances to help estimate the functional contribution of a lobe or whole lung. Such perfusion scanning is most useful when the impact of a tumor on pulmonary physiology is difficult to discern. With complete collapse of a lobe or whole lung, the impact is apparent, and perfusion scanning is usually unneces-sary. Figure 19-23 shows a tumor with significant right main stem airway obstruction with associated atelectasis and volume loss of the right lung. At presentation, the patient was dyspneic with ambulation, and the FEV1 was 1.38 L. Six months prior, this patient could walk up two flights of stairs without dyspnea. The surgeon can anticipate that the patient will tolerate pneumo-nectomy because the lung is already not functioning due to main stem airway obstruction, and may, in fact, be contributing to a shunt. However, | Surgery_Schwartz. Figure 19-22 shows the relationship between predicted postoperative Dlco and estimated operative mortality.Quantitative perfusion scanning is used in select circum-stances to help estimate the functional contribution of a lobe or whole lung. Such perfusion scanning is most useful when the impact of a tumor on pulmonary physiology is difficult to discern. With complete collapse of a lobe or whole lung, the impact is apparent, and perfusion scanning is usually unneces-sary. Figure 19-23 shows a tumor with significant right main stem airway obstruction with associated atelectasis and volume loss of the right lung. At presentation, the patient was dyspneic with ambulation, and the FEV1 was 1.38 L. Six months prior, this patient could walk up two flights of stairs without dyspnea. The surgeon can anticipate that the patient will tolerate pneumo-nectomy because the lung is already not functioning due to main stem airway obstruction, and may, in fact, be contributing to a shunt. However, |
Surgery_Schwartz_4665 | Surgery_Schwartz | can anticipate that the patient will tolerate pneumo-nectomy because the lung is already not functioning due to main stem airway obstruction, and may, in fact, be contributing to a shunt. However, with centrally located tumors associated with partial obstruction of a lobar or main bronchus or of the pulmo-nary artery, perfusion scanning may be valuable in predicting the postoperative result of resection. For example, if the quan-titative perfusion to the right lung is measured to be 21% (nor-mal is 55%) and the patient’s percent predicted FEV1 is 60%, the predicted postoperative FEV1 after a right pneumonectomy would be 60% × 0.79 = 47%, indicating the ability to tolerate pneumonectomy. If the perfusion value is 55%, the predicted postoperative value would be 27%, and pneumonectomy would pose a significantly higher risk.It is not uncommon to encounter patients with significant reductions in their percent predicted FEV1 and Dlco whose his-tory shows a functional status that is | Surgery_Schwartz. can anticipate that the patient will tolerate pneumo-nectomy because the lung is already not functioning due to main stem airway obstruction, and may, in fact, be contributing to a shunt. However, with centrally located tumors associated with partial obstruction of a lobar or main bronchus or of the pulmo-nary artery, perfusion scanning may be valuable in predicting the postoperative result of resection. For example, if the quan-titative perfusion to the right lung is measured to be 21% (nor-mal is 55%) and the patient’s percent predicted FEV1 is 60%, the predicted postoperative FEV1 after a right pneumonectomy would be 60% × 0.79 = 47%, indicating the ability to tolerate pneumonectomy. If the perfusion value is 55%, the predicted postoperative value would be 27%, and pneumonectomy would pose a significantly higher risk.It is not uncommon to encounter patients with significant reductions in their percent predicted FEV1 and Dlco whose his-tory shows a functional status that is |
Surgery_Schwartz_4666 | Surgery_Schwartz | would pose a significantly higher risk.It is not uncommon to encounter patients with significant reductions in their percent predicted FEV1 and Dlco whose his-tory shows a functional status that is inconsistent with the pul-monary function tests. In these circumstances, exercise testing that yields maximal oxygen consumption (v. o2max ) has emerged as a valuable decision-making technique to help patients with abnormal FEV1 and Dlco (Table 19-12). Values <10 mL/kg/min are associated with a 26% mortality after major pulmonary Brunicardi_Ch19_p0661-p0750.indd 69201/03/19 7:01 PM | Surgery_Schwartz. would pose a significantly higher risk.It is not uncommon to encounter patients with significant reductions in their percent predicted FEV1 and Dlco whose his-tory shows a functional status that is inconsistent with the pul-monary function tests. In these circumstances, exercise testing that yields maximal oxygen consumption (v. o2max ) has emerged as a valuable decision-making technique to help patients with abnormal FEV1 and Dlco (Table 19-12). Values <10 mL/kg/min are associated with a 26% mortality after major pulmonary Brunicardi_Ch19_p0661-p0750.indd 69201/03/19 7:01 PM |
Surgery_Schwartz_4667 | Surgery_Schwartz | CHAPTER 19693CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-23. Chest computed tomography scan of an obstructing right main stem lung tumor. Arrow indicates location of right main bron-chus. The right lung volume is much less than the left lung volume.Table 19-12Relation between maximum oxygen consumption (v. o2max) as determined by preoperative exercise testing and perioperative mortalitySTUDYDEATHS/TOTALv. o2max 10–15 mL/kg per minute Smith et al1961/6 (33%) Bechard and Wetstein1970/15 (0%) Olsen et al1981/14 (7.1%) Walsh et al1991/5 (20%) Bolliger et al2002/17 (11.7%) Markos et al2011/11 (9.1%) Wang et al2020/12 (0%) Win et al2032/16 (12.5%) Total8/96 (8.3%)v. o2max <10 mL/kg per minute Bechard and Wetstein1972/7 (29%) Olsen et al1983/11 (27%) Holden et al2042/4 (50%) Markos et al2010/5 (0%) Total7/27 (26%)Reproduced with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP | Surgery_Schwartz. CHAPTER 19693CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-23. Chest computed tomography scan of an obstructing right main stem lung tumor. Arrow indicates location of right main bron-chus. The right lung volume is much less than the left lung volume.Table 19-12Relation between maximum oxygen consumption (v. o2max) as determined by preoperative exercise testing and perioperative mortalitySTUDYDEATHS/TOTALv. o2max 10–15 mL/kg per minute Smith et al1961/6 (33%) Bechard and Wetstein1970/15 (0%) Olsen et al1981/14 (7.1%) Walsh et al1991/5 (20%) Bolliger et al2002/17 (11.7%) Markos et al2011/11 (9.1%) Wang et al2020/12 (0%) Win et al2032/16 (12.5%) Total8/96 (8.3%)v. o2max <10 mL/kg per minute Bechard and Wetstein1972/7 (29%) Olsen et al1983/11 (27%) Holden et al2042/4 (50%) Markos et al2010/5 (0%) Total7/27 (26%)Reproduced with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP |
Surgery_Schwartz_4668 | Surgery_Schwartz | al2010/5 (0%) Total7/27 (26%)Reproduced with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):161S-177S.resection compared to only 8.3% with v. o2max ≥10 mL/kg/min. Values >15 mL/kg/min generally indicate the patient’s ability to tolerate pneumonectomy.The risk assessment of a patient is an amalgam of clinical judgment and data that must be integrated with the experienced clinician’s sense of the patient and with the patient’s attitude 6toward the disease and toward life. Figure 19-24 provides a useful algorithm for determining suitability for lung resection.44Lung Cancer TreatmentGrade IV NEC (Small Cell) Lung Carcinoma. In rare cir-cumstances where SCLC presents as an isolated lung lesion, lobectomy followed by chemotherapy is warranted after sur-gical mediastinal staging has confirmed the | Surgery_Schwartz. al2010/5 (0%) Total7/27 (26%)Reproduced with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):161S-177S.resection compared to only 8.3% with v. o2max ≥10 mL/kg/min. Values >15 mL/kg/min generally indicate the patient’s ability to tolerate pneumonectomy.The risk assessment of a patient is an amalgam of clinical judgment and data that must be integrated with the experienced clinician’s sense of the patient and with the patient’s attitude 6toward the disease and toward life. Figure 19-24 provides a useful algorithm for determining suitability for lung resection.44Lung Cancer TreatmentGrade IV NEC (Small Cell) Lung Carcinoma. In rare cir-cumstances where SCLC presents as an isolated lung lesion, lobectomy followed by chemotherapy is warranted after sur-gical mediastinal staging has confirmed the |
Surgery_Schwartz_4669 | Surgery_Schwartz | Cell) Lung Carcinoma. In rare cir-cumstances where SCLC presents as an isolated lung lesion, lobectomy followed by chemotherapy is warranted after sur-gical mediastinal staging has confirmed the absence of N2 disease. Often, ultrasound-guided FNA provides a definitive positive diagnosis and more invasive approaches are not needed. However, less than 5% are stage I, and there is no benefit from surgical resection for more advanced-stage disease; treatment is chemotherapy with or without radiation therapy depending on the extent of disease and the patient performance status.Early-Stage Non–Small Cell Lung Cancer. Early-stage disease includes T1 and T2 tumors (with or without N1 nodal involvement) and T3 tumors (without N1 nodal involvement). This group represents a small but increasing proportion of the total number of patients diagnosed with lung cancer each year (approximately 16% of an estimated 222,500 patients in 2017).18 Surgical resection is the current standard, ideally | Surgery_Schwartz. Cell) Lung Carcinoma. In rare cir-cumstances where SCLC presents as an isolated lung lesion, lobectomy followed by chemotherapy is warranted after sur-gical mediastinal staging has confirmed the absence of N2 disease. Often, ultrasound-guided FNA provides a definitive positive diagnosis and more invasive approaches are not needed. However, less than 5% are stage I, and there is no benefit from surgical resection for more advanced-stage disease; treatment is chemotherapy with or without radiation therapy depending on the extent of disease and the patient performance status.Early-Stage Non–Small Cell Lung Cancer. Early-stage disease includes T1 and T2 tumors (with or without N1 nodal involvement) and T3 tumors (without N1 nodal involvement). This group represents a small but increasing proportion of the total number of patients diagnosed with lung cancer each year (approximately 16% of an estimated 222,500 patients in 2017).18 Surgical resection is the current standard, ideally |
Surgery_Schwartz_4670 | Surgery_Schwartz | proportion of the total number of patients diagnosed with lung cancer each year (approximately 16% of an estimated 222,500 patients in 2017).18 Surgical resection is the current standard, ideally accomplished by video-assisted lobectomy or pneumonectomy, depending on the tumor location.Despite the term “early-stage,” the overall 5-year sur-vival rate for all localized lung cancer is 55% and only 26% when regional metastasis was present between 2004 and 2009.45 Median survival for untreated patients with stage IA NSCLC is 14 months, and 5-year survival rate is 22%.46 After surgical resection of postoperative pathologic stage IA disease, 5-year survival is better than with no treatment, but still only 67%.41 Survival declines with higher stages. Advanced age at diagno-sis, male sex, low socioeconomic status, nonsurgical treatment, and poor histologic grade are associated with increased mortal-ity risk on multivariate analysis.45Depending on tumor size and location, lobectomy, sleeve | Surgery_Schwartz. proportion of the total number of patients diagnosed with lung cancer each year (approximately 16% of an estimated 222,500 patients in 2017).18 Surgical resection is the current standard, ideally accomplished by video-assisted lobectomy or pneumonectomy, depending on the tumor location.Despite the term “early-stage,” the overall 5-year sur-vival rate for all localized lung cancer is 55% and only 26% when regional metastasis was present between 2004 and 2009.45 Median survival for untreated patients with stage IA NSCLC is 14 months, and 5-year survival rate is 22%.46 After surgical resection of postoperative pathologic stage IA disease, 5-year survival is better than with no treatment, but still only 67%.41 Survival declines with higher stages. Advanced age at diagno-sis, male sex, low socioeconomic status, nonsurgical treatment, and poor histologic grade are associated with increased mortal-ity risk on multivariate analysis.45Depending on tumor size and location, lobectomy, sleeve |
Surgery_Schwartz_4671 | Surgery_Schwartz | socioeconomic status, nonsurgical treatment, and poor histologic grade are associated with increased mortal-ity risk on multivariate analysis.45Depending on tumor size and location, lobectomy, sleeve lobectomy, and occasionally pneumonectomy, with mediastinal lymph node dissection or sampling, are appropriate for patients with clinical early-stage disease. Sleeve resection is performed for tumors located at airway bifurcations when an adequate bronchial Brunicardi_Ch19_p0661-p0750.indd 69301/03/19 7:01 PM 694SPECIFIC CONSIDERATIONSPART IIVO2max > 15 ml/kg/minPerform spirometryUnexplained dyspneaor diffuse parenchymaldisease on CXR/CT?Perform CPETEstimate %ppoFEV1 and %ppoDLCOIncreased riskVO2max>15 mL/kg/minVO2max10 to 15 mL/kg/minVO2max<10 mL/kg/minFEV1 >1.5 L lobectomyFEV1 >2 L pneumonectomyFEV1 >80% predictedFEV1 <1.5 L lobectomyFEV1 <2 L pneumonectomyFEV1 <80% predictedYesNoDLCO >80%predictedDLCO <80%predicted%ppo FEV1 and%ppo DLCO >40%ppo FEV1 or%ppo DLCO <40%ppo FEV1 <30 | Surgery_Schwartz. socioeconomic status, nonsurgical treatment, and poor histologic grade are associated with increased mortal-ity risk on multivariate analysis.45Depending on tumor size and location, lobectomy, sleeve lobectomy, and occasionally pneumonectomy, with mediastinal lymph node dissection or sampling, are appropriate for patients with clinical early-stage disease. Sleeve resection is performed for tumors located at airway bifurcations when an adequate bronchial Brunicardi_Ch19_p0661-p0750.indd 69301/03/19 7:01 PM 694SPECIFIC CONSIDERATIONSPART IIVO2max > 15 ml/kg/minPerform spirometryUnexplained dyspneaor diffuse parenchymaldisease on CXR/CT?Perform CPETEstimate %ppoFEV1 and %ppoDLCOIncreased riskVO2max>15 mL/kg/minVO2max10 to 15 mL/kg/minVO2max<10 mL/kg/minFEV1 >1.5 L lobectomyFEV1 >2 L pneumonectomyFEV1 >80% predictedFEV1 <1.5 L lobectomyFEV1 <2 L pneumonectomyFEV1 <80% predictedYesNoDLCO >80%predictedDLCO <80%predicted%ppo FEV1 and%ppo DLCO >40%ppo FEV1 or%ppo DLCO <40%ppo FEV1 <30 |
Surgery_Schwartz_4672 | Surgery_Schwartz | >80% predictedFEV1 <1.5 L lobectomyFEV1 <2 L pneumonectomyFEV1 <80% predictedYesNoDLCO >80%predictedDLCO <80%predicted%ppo FEV1 and%ppo DLCO >40%ppo FEV1 or%ppo DLCO <40%ppo FEV1 <30 or%ppo FEV1 x%ppo DLCO <1650Measure DLCOAverage riskIncreased riskFigure 19-24. Algorithm for preoperative evaluation of pulmonary function and reserve prior to resectional lung surgery. CPET = cardiopulmonary exercise test; CT = computed tomographic scan; CXR = chest radiograph; Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second; %ppo = percent predicted postoperative lung function; V.o2max = maximum oxygen consumption. (Modified with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):161S-177S.44)Brunicardi_Ch19_p0661-p0750.indd 69401/03/19 7:01 PM | Surgery_Schwartz. >80% predictedFEV1 <1.5 L lobectomyFEV1 <2 L pneumonectomyFEV1 <80% predictedYesNoDLCO >80%predictedDLCO <80%predicted%ppo FEV1 and%ppo DLCO >40%ppo FEV1 or%ppo DLCO <40%ppo FEV1 <30 or%ppo FEV1 x%ppo DLCO <1650Measure DLCOAverage riskIncreased riskFigure 19-24. Algorithm for preoperative evaluation of pulmonary function and reserve prior to resectional lung surgery. CPET = cardiopulmonary exercise test; CT = computed tomographic scan; CXR = chest radiograph; Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second; %ppo = percent predicted postoperative lung function; V.o2max = maximum oxygen consumption. (Modified with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):161S-177S.44)Brunicardi_Ch19_p0661-p0750.indd 69401/03/19 7:01 PM |
Surgery_Schwartz_4673 | Surgery_Schwartz | CHAPTER 19695CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAmargin cannot be obtained by standard lobectomy. Pneumonec-tomy is rarely performed; primary indications for pneumonec-tomy in early-stage disease include large central tumors involving the distal main stem bronchus and inability to completely resect involved N1 lymph nodes. The latter circumstance occurs with bulky adenopathy or with extracapsular nodal spread.Management of Early-Stage Lung Cancer in the High-Risk Patient Lobectomy may not be an option for some patients with early-stage disease, due to poor cardiopulmonary function or other comorbid illnesses. The ultimate decision that a patient is inoperable, both with regard to the patient’s ability to tolerate surgery and the likelihood of successful resection, should be accepted only after evaluation by an expert surgeon. Surgeons with limited expertise, when faced with a complicated patient, should refer the patient to a high-volume center for further eval-uation if they are | Surgery_Schwartz. CHAPTER 19695CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAmargin cannot be obtained by standard lobectomy. Pneumonec-tomy is rarely performed; primary indications for pneumonec-tomy in early-stage disease include large central tumors involving the distal main stem bronchus and inability to completely resect involved N1 lymph nodes. The latter circumstance occurs with bulky adenopathy or with extracapsular nodal spread.Management of Early-Stage Lung Cancer in the High-Risk Patient Lobectomy may not be an option for some patients with early-stage disease, due to poor cardiopulmonary function or other comorbid illnesses. The ultimate decision that a patient is inoperable, both with regard to the patient’s ability to tolerate surgery and the likelihood of successful resection, should be accepted only after evaluation by an expert surgeon. Surgeons with limited expertise, when faced with a complicated patient, should refer the patient to a high-volume center for further eval-uation if they are |
Surgery_Schwartz_4674 | Surgery_Schwartz | after evaluation by an expert surgeon. Surgeons with limited expertise, when faced with a complicated patient, should refer the patient to a high-volume center for further eval-uation if they are unable to offer the patient surgical resection in their own center.Rationale for Limited Resection in Early-Stage Lung Cancer. Limited resection, defined as segmentectomy or wedge resec-tion, is a viable option for achieving local control in high-risk patients. Historically, limited resection with wedge or segmen-tectomy has been considered a compromise operation due to unacceptably high rates of local recurrence and concerns for worse survival.47,48 Subsequent meta-analysis of the literature shows that the difference in death rate is likely negligible49 (Table 19-13). The high rates of local recurrence demonstrated by Ginsberg and others, however, remain a significant concern and continue to restrict the use of limited resection for early-stage lung cancer to the high-risk patient.With the | Surgery_Schwartz. after evaluation by an expert surgeon. Surgeons with limited expertise, when faced with a complicated patient, should refer the patient to a high-volume center for further eval-uation if they are unable to offer the patient surgical resection in their own center.Rationale for Limited Resection in Early-Stage Lung Cancer. Limited resection, defined as segmentectomy or wedge resec-tion, is a viable option for achieving local control in high-risk patients. Historically, limited resection with wedge or segmen-tectomy has been considered a compromise operation due to unacceptably high rates of local recurrence and concerns for worse survival.47,48 Subsequent meta-analysis of the literature shows that the difference in death rate is likely negligible49 (Table 19-13). The high rates of local recurrence demonstrated by Ginsberg and others, however, remain a significant concern and continue to restrict the use of limited resection for early-stage lung cancer to the high-risk patient.With the |
Surgery_Schwartz_4675 | Surgery_Schwartz | demonstrated by Ginsberg and others, however, remain a significant concern and continue to restrict the use of limited resection for early-stage lung cancer to the high-risk patient.With the recent publication of a 20% reduction in lung cancer mortality with screening CT scans in high-risk popula-tions, the topic of limited resection is again the subject of inten-sive review. Studies investigating anatomic segmentectomy (or extended wedge resection) with hilar and mediastinal lymph node dissection suggest that close attention to the ratio of surgi-cal margin to tumor diameter and a careful assessment of the lymph nodes substantially reduce local recurrence.50-52 Recur-rence rates were 6.2%, comparable to rates associated with lobectomy, when the margin-to-tumor diameter ratio exceeded 1, compared to 25% if the margin-to-tumor diameter ratio was less than 1.50 In most centers, this requires use of a thora-cotomy, although increasing experience with VATS in highvolume centers shows that | Surgery_Schwartz. demonstrated by Ginsberg and others, however, remain a significant concern and continue to restrict the use of limited resection for early-stage lung cancer to the high-risk patient.With the recent publication of a 20% reduction in lung cancer mortality with screening CT scans in high-risk popula-tions, the topic of limited resection is again the subject of inten-sive review. Studies investigating anatomic segmentectomy (or extended wedge resection) with hilar and mediastinal lymph node dissection suggest that close attention to the ratio of surgi-cal margin to tumor diameter and a careful assessment of the lymph nodes substantially reduce local recurrence.50-52 Recur-rence rates were 6.2%, comparable to rates associated with lobectomy, when the margin-to-tumor diameter ratio exceeded 1, compared to 25% if the margin-to-tumor diameter ratio was less than 1.50 In most centers, this requires use of a thora-cotomy, although increasing experience with VATS in highvolume centers shows that |
Surgery_Schwartz_4676 | Surgery_Schwartz | to 25% if the margin-to-tumor diameter ratio was less than 1.50 In most centers, this requires use of a thora-cotomy, although increasing experience with VATS in highvolume centers shows that limited resection is safe and feasi-ble, with perioperative adverse outcomes that are comparable to lobectomy.52-55Rationale for Tumor Ablation in the Management of Primary Lung Cancer. Limited resection, by definition, requires that the patient has sufficient cardiopulmonary reserve to undergo a general anesthesia and loss of at least one pulmonary seg-ment. For the high-risk or nonoperable patient, as determined by experience pulmonary surgeons, tumor ablation techniques have been developed for treatment of early-stage lung cancers.Current limitations of this approach include the absence of nodal staging, lack of tissue for molecular profiling, chemo-resistance, or sensitivity testing, concerns about definitions of locoregional recurrence, and a lack of uniformity across cen-ters. Surgeons | Surgery_Schwartz. to 25% if the margin-to-tumor diameter ratio was less than 1.50 In most centers, this requires use of a thora-cotomy, although increasing experience with VATS in highvolume centers shows that limited resection is safe and feasi-ble, with perioperative adverse outcomes that are comparable to lobectomy.52-55Rationale for Tumor Ablation in the Management of Primary Lung Cancer. Limited resection, by definition, requires that the patient has sufficient cardiopulmonary reserve to undergo a general anesthesia and loss of at least one pulmonary seg-ment. For the high-risk or nonoperable patient, as determined by experience pulmonary surgeons, tumor ablation techniques have been developed for treatment of early-stage lung cancers.Current limitations of this approach include the absence of nodal staging, lack of tissue for molecular profiling, chemo-resistance, or sensitivity testing, concerns about definitions of locoregional recurrence, and a lack of uniformity across cen-ters. Surgeons |
Surgery_Schwartz_4677 | Surgery_Schwartz | staging, lack of tissue for molecular profiling, chemo-resistance, or sensitivity testing, concerns about definitions of locoregional recurrence, and a lack of uniformity across cen-ters. Surgeons typically define locoregional recurrence as tumor growth within the operative field, including resectable lymph nodes, whereas local recurrence after ablation is most com-monly defined as tumor growth within the field of treatment. Despite the fact that in-transit or lymph node metastases are present in up to 27% of clinically stage I NSCLCs at resection, any tumor growth outside the field of ablative treatment is not be considered treatment failure.56Despite these limitations, tumor ablative strategies are increasingly proposed as viable alternatives to surgical resec-tion, even in potentially operable patients.57-62 While prema-ture, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the primary treatment of very small peripheral early-stage lung | Surgery_Schwartz. staging, lack of tissue for molecular profiling, chemo-resistance, or sensitivity testing, concerns about definitions of locoregional recurrence, and a lack of uniformity across cen-ters. Surgeons typically define locoregional recurrence as tumor growth within the operative field, including resectable lymph nodes, whereas local recurrence after ablation is most com-monly defined as tumor growth within the field of treatment. Despite the fact that in-transit or lymph node metastases are present in up to 27% of clinically stage I NSCLCs at resection, any tumor growth outside the field of ablative treatment is not be considered treatment failure.56Despite these limitations, tumor ablative strategies are increasingly proposed as viable alternatives to surgical resec-tion, even in potentially operable patients.57-62 While prema-ture, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the primary treatment of very small peripheral early-stage lung |
Surgery_Schwartz_4678 | Surgery_Schwartz | operable patients.57-62 While prema-ture, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the primary treatment of very small peripheral early-stage lung cancers. Multidisci-plinary collaboration between thoracic surgery, interventional radiology/pulmonology, and radiation oncology is required to ensure that development of these ablative techniques occurs through properly designed and well-controlled prospective studies and will ensure that patients receive the best available therapy, regardless of whether it is surgical resection or ablative therapy.The two most commonly applied ablation techniques are radiofrequency ablation and stereotactic body radiotherapy.1. Radiofrequency ablation. Radiofrequency ablation is per-formed using either monopolar or bipolar delivery of elec-trical current to electrodes placed within the tumor tissue. In lung tumors, the electrodes are typically inserted into the tumor mass under CT guidance. An electrical | Surgery_Schwartz. operable patients.57-62 While prema-ture, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the primary treatment of very small peripheral early-stage lung cancers. Multidisci-plinary collaboration between thoracic surgery, interventional radiology/pulmonology, and radiation oncology is required to ensure that development of these ablative techniques occurs through properly designed and well-controlled prospective studies and will ensure that patients receive the best available therapy, regardless of whether it is surgical resection or ablative therapy.The two most commonly applied ablation techniques are radiofrequency ablation and stereotactic body radiotherapy.1. Radiofrequency ablation. Radiofrequency ablation is per-formed using either monopolar or bipolar delivery of elec-trical current to electrodes placed within the tumor tissue. In lung tumors, the electrodes are typically inserted into the tumor mass under CT guidance. An electrical |
Surgery_Schwartz_4679 | Surgery_Schwartz | or bipolar delivery of elec-trical current to electrodes placed within the tumor tissue. In lung tumors, the electrodes are typically inserted into the tumor mass under CT guidance. An electrical current is delivered; the current is converted by means of friction into heat, which quickly leads to immediate and irreparable tissue destruction in the tissue surrounding the electrode. The efficacy of radiofrequency ablation for controlling the primary tumor and improving survival in poor operative candidates (either due to significant comorbid diseases precluding general anesthesia or poor pulmonary function excluding lung resection) is safe and feasible for peripheral lung nodules. In tumors <3.5 cm, the rate of radiographic resolution of tumor is up to 80%, and cancer-specific sur-vival at 2 years was approximately 90%, indicating excel-lent local control of the primary site.57-59,63 It has become the preferred modality for small peripheral tumors over standard external-beam radiation | Surgery_Schwartz. or bipolar delivery of elec-trical current to electrodes placed within the tumor tissue. In lung tumors, the electrodes are typically inserted into the tumor mass under CT guidance. An electrical current is delivered; the current is converted by means of friction into heat, which quickly leads to immediate and irreparable tissue destruction in the tissue surrounding the electrode. The efficacy of radiofrequency ablation for controlling the primary tumor and improving survival in poor operative candidates (either due to significant comorbid diseases precluding general anesthesia or poor pulmonary function excluding lung resection) is safe and feasible for peripheral lung nodules. In tumors <3.5 cm, the rate of radiographic resolution of tumor is up to 80%, and cancer-specific sur-vival at 2 years was approximately 90%, indicating excel-lent local control of the primary site.57-59,63 It has become the preferred modality for small peripheral tumors over standard external-beam radiation |
Surgery_Schwartz_4680 | Surgery_Schwartz | 2 years was approximately 90%, indicating excel-lent local control of the primary site.57-59,63 It has become the preferred modality for small peripheral tumors over standard external-beam radiation in centers where the tech-nique is available. Radiofrequency ablation is an excellent modality for the patient at risk for adverse outcomes with pulmonary resec-tion or for patients who refuse surgery, and surgeons should have an algorithm for determining which patients are optimal for this modality64-69 (see Fig. 19-24). Target lesions larger than 5 cm, tumor abutting the hilum, associated malignant pleural or pericardial effusion, greater than three lesions in one lung, and the presence of pulmonary hypertension are all contraindications to radiofrequency ablation.64 Proximity to a large vessel is a contraindication not only due to the risk of massive bleeding, but also because large blood vessels act as a heat sink and lethal cellular temperatures are less likely to be achieved. For | Surgery_Schwartz. 2 years was approximately 90%, indicating excel-lent local control of the primary site.57-59,63 It has become the preferred modality for small peripheral tumors over standard external-beam radiation in centers where the tech-nique is available. Radiofrequency ablation is an excellent modality for the patient at risk for adverse outcomes with pulmonary resec-tion or for patients who refuse surgery, and surgeons should have an algorithm for determining which patients are optimal for this modality64-69 (see Fig. 19-24). Target lesions larger than 5 cm, tumor abutting the hilum, associated malignant pleural or pericardial effusion, greater than three lesions in one lung, and the presence of pulmonary hypertension are all contraindications to radiofrequency ablation.64 Proximity to a large vessel is a contraindication not only due to the risk of massive bleeding, but also because large blood vessels act as a heat sink and lethal cellular temperatures are less likely to be achieved. For |
Surgery_Schwartz_4681 | Surgery_Schwartz | vessel is a contraindication not only due to the risk of massive bleeding, but also because large blood vessels act as a heat sink and lethal cellular temperatures are less likely to be achieved. For these patients, stereotactic body radiotherapy may provide local tumor control with less risk of major complications. Combination therapy with either external-beam radiation or stereotactic body radiotherapy is also under investigation.2. Stereotactic body radiotherapy. Stereotactic body radiotherapy applies highly focused, high-intensity, three-dimensional conformal radiation to the target lesion over a few sessions. Tumor motion quantification and image guidance technologies have significantly improved the delivery of radiation with high levels of precision 7Brunicardi_Ch19_p0661-p0750.indd 69501/03/19 7:01 PM 696SPECIFIC CONSIDERATIONSPART IITable 19-13New classification system for lung adenocarcinomaSTUDY OR SUBGROUPlog [HAZARD RATIO]SESEGMENTECTOMY TOTALLOBECTOMY | Surgery_Schwartz. vessel is a contraindication not only due to the risk of massive bleeding, but also because large blood vessels act as a heat sink and lethal cellular temperatures are less likely to be achieved. For these patients, stereotactic body radiotherapy may provide local tumor control with less risk of major complications. Combination therapy with either external-beam radiation or stereotactic body radiotherapy is also under investigation.2. Stereotactic body radiotherapy. Stereotactic body radiotherapy applies highly focused, high-intensity, three-dimensional conformal radiation to the target lesion over a few sessions. Tumor motion quantification and image guidance technologies have significantly improved the delivery of radiation with high levels of precision 7Brunicardi_Ch19_p0661-p0750.indd 69501/03/19 7:01 PM 696SPECIFIC CONSIDERATIONSPART IITable 19-13New classification system for lung adenocarcinomaSTUDY OR SUBGROUPlog [HAZARD RATIO]SESEGMENTECTOMY TOTALLOBECTOMY |
Surgery_Schwartz_4682 | Surgery_Schwartz | 69501/03/19 7:01 PM 696SPECIFIC CONSIDERATIONSPART IITable 19-13New classification system for lung adenocarcinomaSTUDY OR SUBGROUPlog [HAZARD RATIO]SESEGMENTECTOMY TOTALLOBECTOMY TOTALWEIGHTHAZARD RATIO IV, RANDOM, 95% CIHAZARD RATIO IV, RANDOM, 95% CIBando 2002–0,3150,3495741323,3%0,73 [0,37,1,45]Favours Segmentectomy0.005200100.11Favours LobectomyCheng 2012–0,210,2908132324,8%0,81 [0,46, 1,43]Dai 20160,3320,21044240115209,2%1,39 [0,92, 2,11]Ginsberg 19950,3680,21571221258,7%1,44 [0,95, 2,21]Hamatake 20120,19890,280632775,1%1,22 [0,70, 2,11]Iwasaki 2007–0,083380,5076531551,6%0,92 [0,34, 2,49]Keenan 20040,1310,4158541472,3%1,14 [0,50, 2,58]Kilic 2009–0,23570,21683106788,6%0,79 [0,52, 1,21]Kodama 19970,10110,573246771,2%1,11 [0,36, 3,40]Koike 20030,07730,4385741592,1%1,08 [0,46, 2,55]Landreneau 20140,460,24821021176,6%1,58 [0,97, 2,58]Martin–Ucar 2005–1,04350,707117170,8%0,35 [0,09, 1,41]Nakamura 20110,2391382890,4%1,27 [0,18, 9,02]Okada 2001–0,11650,7168681040,8%0,89 [0,22, | Surgery_Schwartz. 69501/03/19 7:01 PM 696SPECIFIC CONSIDERATIONSPART IITable 19-13New classification system for lung adenocarcinomaSTUDY OR SUBGROUPlog [HAZARD RATIO]SESEGMENTECTOMY TOTALLOBECTOMY TOTALWEIGHTHAZARD RATIO IV, RANDOM, 95% CIHAZARD RATIO IV, RANDOM, 95% CIBando 2002–0,3150,3495741323,3%0,73 [0,37,1,45]Favours Segmentectomy0.005200100.11Favours LobectomyCheng 2012–0,210,2908132324,8%0,81 [0,46, 1,43]Dai 20160,3320,21044240115209,2%1,39 [0,92, 2,11]Ginsberg 19950,3680,21571221258,7%1,44 [0,95, 2,21]Hamatake 20120,19890,280632775,1%1,22 [0,70, 2,11]Iwasaki 2007–0,083380,5076531551,6%0,92 [0,34, 2,49]Keenan 20040,1310,4158541472,3%1,14 [0,50, 2,58]Kilic 2009–0,23570,21683106788,6%0,79 [0,52, 1,21]Kodama 19970,10110,573246771,2%1,11 [0,36, 3,40]Koike 20030,07730,4385741592,1%1,08 [0,46, 2,55]Landreneau 20140,460,24821021176,6%1,58 [0,97, 2,58]Martin–Ucar 2005–1,04350,707117170,8%0,35 [0,09, 1,41]Nakamura 20110,2391382890,4%1,27 [0,18, 9,02]Okada 2001–0,11650,7168681040,8%0,89 [0,22, |
Surgery_Schwartz_4683 | Surgery_Schwartz | 2,55]Landreneau 20140,460,24821021176,6%1,58 [0,97, 2,58]Martin–Ucar 2005–1,04350,707117170,8%0,35 [0,09, 1,41]Nakamura 20110,2391382890,4%1,27 [0,18, 9,02]Okada 2001–0,11650,7168681040,8%0,89 [0,22, 3,63]Okumura 2007–0,16320,3595672733,1%0,85 [0,42, 1,72]Razi 2016–0,020,256911910516,1%0,98 [0,59, 1,62]Read 19900,31480,41841131312,3%1,37 [0,60, 3,11]Sienel 20071,04020,91581491500,5%2,83 [0,47,17,03]Soukiasian 20120,28521,6735561780,1%1,33 [0,05, 35,35]Sugi 2010–0,02020,2543956,5%0,98 [0,60, 1,60]Tsutani 2014–0,71330,3087983834,3%0,49 [0,27, 0,90]Warren 19940,54810,5661031,6%1,73 [0,65, 4,61]Watanabe 2005–0,61620,8979620570,5%0,54 [0,09, 3,14]Yamashita 20120,198860,73469901240,8%1,22 [0,29, 5,15]Yamato 20080,30010,40561532772,5%1,35 [0,61 , 2,99]Yendamuri 20110,2390,2756216225995,3%1,27 [0,74, 2,18]Zhong 2012–0,16250,19388398110,8%0,85 [0,58, 1,24]Total (95% CI)611118431100,0%1,04 [0,92, 1,18]Heterogeneity: Tau2 = 0,00; Chi2 = 25,04, df = 26 (P = 0,52); I2 = 0%Test for overall effect: | Surgery_Schwartz. 2,55]Landreneau 20140,460,24821021176,6%1,58 [0,97, 2,58]Martin–Ucar 2005–1,04350,707117170,8%0,35 [0,09, 1,41]Nakamura 20110,2391382890,4%1,27 [0,18, 9,02]Okada 2001–0,11650,7168681040,8%0,89 [0,22, 3,63]Okumura 2007–0,16320,3595672733,1%0,85 [0,42, 1,72]Razi 2016–0,020,256911910516,1%0,98 [0,59, 1,62]Read 19900,31480,41841131312,3%1,37 [0,60, 3,11]Sienel 20071,04020,91581491500,5%2,83 [0,47,17,03]Soukiasian 20120,28521,6735561780,1%1,33 [0,05, 35,35]Sugi 2010–0,02020,2543956,5%0,98 [0,60, 1,60]Tsutani 2014–0,71330,3087983834,3%0,49 [0,27, 0,90]Warren 19940,54810,5661031,6%1,73 [0,65, 4,61]Watanabe 2005–0,61620,8979620570,5%0,54 [0,09, 3,14]Yamashita 20120,198860,73469901240,8%1,22 [0,29, 5,15]Yamato 20080,30010,40561532772,5%1,35 [0,61 , 2,99]Yendamuri 20110,2390,2756216225995,3%1,27 [0,74, 2,18]Zhong 2012–0,16250,19388398110,8%0,85 [0,58, 1,24]Total (95% CI)611118431100,0%1,04 [0,92, 1,18]Heterogeneity: Tau2 = 0,00; Chi2 = 25,04, df = 26 (P = 0,52); I2 = 0%Test for overall effect: |
Surgery_Schwartz_4684 | Surgery_Schwartz | 2,18]Zhong 2012–0,16250,19388398110,8%0,85 [0,58, 1,24]Total (95% CI)611118431100,0%1,04 [0,92, 1,18]Heterogeneity: Tau2 = 0,00; Chi2 = 25,04, df = 26 (P = 0,52); I2 = 0%Test for overall effect: Z = 0,68 (P = 0,50)Forest plot of HR for overall survival impact of operative approach (segmentectomy versus lobectomy) of stage I NSCLC patients. The pooled HR displayed in this figure when compared with segmentectomy suggested that there was not a significant benefit of lobectomy on HR of stage I patients (7-21) (HR 1.04; 95% CI, 0.92–1.18, P = 0.50) (22–33).Abbreviations: HR = hazard ratio; NSCLC = non–small cell lung cancer; CI = confidence interval; df = degree of freedom; SE = standard error.Reproduced with permission from Bedetti B, Bertolaccini L, Rocco R, et al: Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis, J Thorac Dis. 2017 Jun; 9(6):1615-1623.Brunicardi_Ch19_p0661-p0750.indd 69601/03/19 7:01 PM | Surgery_Schwartz. 2,18]Zhong 2012–0,16250,19388398110,8%0,85 [0,58, 1,24]Total (95% CI)611118431100,0%1,04 [0,92, 1,18]Heterogeneity: Tau2 = 0,00; Chi2 = 25,04, df = 26 (P = 0,52); I2 = 0%Test for overall effect: Z = 0,68 (P = 0,50)Forest plot of HR for overall survival impact of operative approach (segmentectomy versus lobectomy) of stage I NSCLC patients. The pooled HR displayed in this figure when compared with segmentectomy suggested that there was not a significant benefit of lobectomy on HR of stage I patients (7-21) (HR 1.04; 95% CI, 0.92–1.18, P = 0.50) (22–33).Abbreviations: HR = hazard ratio; NSCLC = non–small cell lung cancer; CI = confidence interval; df = degree of freedom; SE = standard error.Reproduced with permission from Bedetti B, Bertolaccini L, Rocco R, et al: Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis, J Thorac Dis. 2017 Jun; 9(6):1615-1623.Brunicardi_Ch19_p0661-p0750.indd 69601/03/19 7:01 PM |
Surgery_Schwartz_4685 | Surgery_Schwartz | CHAPTER 19697CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAto the target lesion. This accuracy is important because the lung is extremely sensitive to radiation injury and the majority of patients with early-stage lung cancer who are currently considered candidates for ablative therapy have marginal lung function; excessive injury to normal surrounding lung tissue is not desirable. Importantly, these techniques allow the safe delivery of up to 66 Gy of radiation to the target tumors without exceeding the maximum-tolerated dose.62-70 A phase II North American multicenter study recently demonstrated the safety and efficacy of this approach in 59 nonoperable patients.62 Patients with biopsy-proven, node-negative peripheral NSCLCs less than 5 cm in diameter (T1 or T2) were treated with stereotactic body radiotherapy after they were deemed inoperable, based on coexisting medical conditions, by a thoracic surgeon and/or pulmonolo-gist. Primary tumor control was excellent; at 3 years, 97.6% were | Surgery_Schwartz. CHAPTER 19697CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAto the target lesion. This accuracy is important because the lung is extremely sensitive to radiation injury and the majority of patients with early-stage lung cancer who are currently considered candidates for ablative therapy have marginal lung function; excessive injury to normal surrounding lung tissue is not desirable. Importantly, these techniques allow the safe delivery of up to 66 Gy of radiation to the target tumors without exceeding the maximum-tolerated dose.62-70 A phase II North American multicenter study recently demonstrated the safety and efficacy of this approach in 59 nonoperable patients.62 Patients with biopsy-proven, node-negative peripheral NSCLCs less than 5 cm in diameter (T1 or T2) were treated with stereotactic body radiotherapy after they were deemed inoperable, based on coexisting medical conditions, by a thoracic surgeon and/or pulmonolo-gist. Primary tumor control was excellent; at 3 years, 97.6% were |
Surgery_Schwartz_4686 | Surgery_Schwartz | body radiotherapy after they were deemed inoperable, based on coexisting medical conditions, by a thoracic surgeon and/or pulmonolo-gist. Primary tumor control was excellent; at 3 years, 97.6% were deemed to have primary tumor control by the authors, and 90.6% had local control. However, it is important to note that primary tumor failure was defined specifically as at least a 20% increase in the longest diam-eter of the gross tumor volume by CT scan and evidence of tumor viability either by biopsy confirming carcinoma or by demonstration of FDG avidity on PET scan. For viability to be confirmed with PET scan, the uptake was required to be of similar intensity to the pretreatment staging PET scan. Failure beyond a 1.5to 2-cm margin around the primary tumor volume was considered local failure. Failure in regional node basins was seen in two patients. When compared to locoregional control rates of approximately 6.5% with limited resection, the 3-year locoregional recurrence was higher at | Surgery_Schwartz. body radiotherapy after they were deemed inoperable, based on coexisting medical conditions, by a thoracic surgeon and/or pulmonolo-gist. Primary tumor control was excellent; at 3 years, 97.6% were deemed to have primary tumor control by the authors, and 90.6% had local control. However, it is important to note that primary tumor failure was defined specifically as at least a 20% increase in the longest diam-eter of the gross tumor volume by CT scan and evidence of tumor viability either by biopsy confirming carcinoma or by demonstration of FDG avidity on PET scan. For viability to be confirmed with PET scan, the uptake was required to be of similar intensity to the pretreatment staging PET scan. Failure beyond a 1.5to 2-cm margin around the primary tumor volume was considered local failure. Failure in regional node basins was seen in two patients. When compared to locoregional control rates of approximately 6.5% with limited resection, the 3-year locoregional recurrence was higher at |
Surgery_Schwartz_4687 | Surgery_Schwartz | Failure in regional node basins was seen in two patients. When compared to locoregional control rates of approximately 6.5% with limited resection, the 3-year locoregional recurrence was higher at 12.8%.3. Patient selection for stereotactic body radiotherapy, as with limited resection and radiofrequency ablation, is impor-tant. Because the radiation field is so precise, patients with severe emphysema and chronic obstructive pulmonary dis-ease can be safely treated without significant concern for worsening lung function. However, patients with central tumors near the mediastinum and hilum have increased incidence of significant hypoxia, hemoptysis, atelecta-sis, pneumonitis, and reduced pulmonary function.70 In the multicenter trial detailed earlier, treated tumors were required to be greater than 2 cm from the proximal bron-chial tree in all directions (which they defined as the distal 2 cm of the trachea, carina, and named major lobar bronchi up to their first | Surgery_Schwartz. Failure in regional node basins was seen in two patients. When compared to locoregional control rates of approximately 6.5% with limited resection, the 3-year locoregional recurrence was higher at 12.8%.3. Patient selection for stereotactic body radiotherapy, as with limited resection and radiofrequency ablation, is impor-tant. Because the radiation field is so precise, patients with severe emphysema and chronic obstructive pulmonary dis-ease can be safely treated without significant concern for worsening lung function. However, patients with central tumors near the mediastinum and hilum have increased incidence of significant hypoxia, hemoptysis, atelecta-sis, pneumonitis, and reduced pulmonary function.70 In the multicenter trial detailed earlier, treated tumors were required to be greater than 2 cm from the proximal bron-chial tree in all directions (which they defined as the distal 2 cm of the trachea, carina, and named major lobar bronchi up to their first |
Surgery_Schwartz_4688 | Surgery_Schwartz | required to be greater than 2 cm from the proximal bron-chial tree in all directions (which they defined as the distal 2 cm of the trachea, carina, and named major lobar bronchi up to their first bifurcation).62Rationale for Chemotherapy in the Management of Early-Stage NSCLC. The role of chemotherapy in early-stage (stages I and II) NSCLC is evolving, with several pro-spective phase 2 studies having shown a potential benefit.71,72 Initial concerns that induction chemotherapy may result in increased perioperative morbidity or mortality appear to be unwarranted, as the incidence of perioperative morbidity and mortality is not different between the two groups, except in patients undergoing right-sided pneumonectomy after induc-tion chemotherapy.73 As shown in Table 19-14, an absolute survival benefit of 4% to 7% can be realized using induction for all stages of lung cancer, and in situations where use of adjuvant chemotherapy is anticipated, induction chemother-apy is an acceptable | Surgery_Schwartz. required to be greater than 2 cm from the proximal bron-chial tree in all directions (which they defined as the distal 2 cm of the trachea, carina, and named major lobar bronchi up to their first bifurcation).62Rationale for Chemotherapy in the Management of Early-Stage NSCLC. The role of chemotherapy in early-stage (stages I and II) NSCLC is evolving, with several pro-spective phase 2 studies having shown a potential benefit.71,72 Initial concerns that induction chemotherapy may result in increased perioperative morbidity or mortality appear to be unwarranted, as the incidence of perioperative morbidity and mortality is not different between the two groups, except in patients undergoing right-sided pneumonectomy after induc-tion chemotherapy.73 As shown in Table 19-14, an absolute survival benefit of 4% to 7% can be realized using induction for all stages of lung cancer, and in situations where use of adjuvant chemotherapy is anticipated, induction chemother-apy is an acceptable |
Surgery_Schwartz_4689 | Surgery_Schwartz | benefit of 4% to 7% can be realized using induction for all stages of lung cancer, and in situations where use of adjuvant chemotherapy is anticipated, induction chemother-apy is an acceptable alternative.Table 19-14Five-year stage-specific survival after induction chemotherapy followed by surgerySTAGE5-YEAR SURVIVAL (%)ABSOLUTE BENEFIT (%)NEW 5-YEAR SURVIVAL (%)IA75479IB55661IIA50757IIB40747IIIA15–356–721–42IIIB5–103–58–15Reproduced with permission from Burdett SS, Stewart LA, Rydzewska L: Chemotherapy and surgery versus surgery alone in non-small cell lung cancer, Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006157.National Comprehensive Cancer Network guidelines cur-rently recommend observation for T1a (≤1 cm), T1b (>1–2 cm), and T1c (>2–3 cm), node-negative, completely resected NSCLCs (T1abcN0M0). For patients with larger tumors (T2a tumor >3–4 cm; T2b tumor >4–5 cm) that are node-negative, it is recommended that chemotherapy be considered in high-risk patients, ideally in | Surgery_Schwartz. benefit of 4% to 7% can be realized using induction for all stages of lung cancer, and in situations where use of adjuvant chemotherapy is anticipated, induction chemother-apy is an acceptable alternative.Table 19-14Five-year stage-specific survival after induction chemotherapy followed by surgerySTAGE5-YEAR SURVIVAL (%)ABSOLUTE BENEFIT (%)NEW 5-YEAR SURVIVAL (%)IA75479IB55661IIA50757IIB40747IIIA15–356–721–42IIIB5–103–58–15Reproduced with permission from Burdett SS, Stewart LA, Rydzewska L: Chemotherapy and surgery versus surgery alone in non-small cell lung cancer, Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006157.National Comprehensive Cancer Network guidelines cur-rently recommend observation for T1a (≤1 cm), T1b (>1–2 cm), and T1c (>2–3 cm), node-negative, completely resected NSCLCs (T1abcN0M0). For patients with larger tumors (T2a tumor >3–4 cm; T2b tumor >4–5 cm) that are node-negative, it is recommended that chemotherapy be considered in high-risk patients, ideally in |
Surgery_Schwartz_4690 | Surgery_Schwartz | NSCLCs (T1abcN0M0). For patients with larger tumors (T2a tumor >3–4 cm; T2b tumor >4–5 cm) that are node-negative, it is recommended that chemotherapy be considered in high-risk patients, ideally in the setting of a clinical trial. High-risk tumor characteristics include poorly differentiated tumors, moderately to poorly differentiated lung neuroendocrine tumors, vascular invasion, resection limited to wedge resection only, tumors >4 cm in size, visceral pleural involvement, and when lymph node sampling at the time of resection was incomplete (Nx).Evaluation and Management of Locally Advanced NSCLC. Five-year relative survival in patients with locore-gional disease is 28%, but there is significant heterogeneity within the group. Stage III disease includes patients with small tumors that have metastasized to the mediastinal lymph nodes as well as large tumors (>7 cm), and tumor invading unresectable structures or the major carina with no nodal metastasis at all. Patients with | Surgery_Schwartz. NSCLCs (T1abcN0M0). For patients with larger tumors (T2a tumor >3–4 cm; T2b tumor >4–5 cm) that are node-negative, it is recommended that chemotherapy be considered in high-risk patients, ideally in the setting of a clinical trial. High-risk tumor characteristics include poorly differentiated tumors, moderately to poorly differentiated lung neuroendocrine tumors, vascular invasion, resection limited to wedge resection only, tumors >4 cm in size, visceral pleural involvement, and when lymph node sampling at the time of resection was incomplete (Nx).Evaluation and Management of Locally Advanced NSCLC. Five-year relative survival in patients with locore-gional disease is 28%, but there is significant heterogeneity within the group. Stage III disease includes patients with small tumors that have metastasized to the mediastinal lymph nodes as well as large tumors (>7 cm), and tumor invading unresectable structures or the major carina with no nodal metastasis at all. Patients with |
Surgery_Schwartz_4691 | Surgery_Schwartz | that have metastasized to the mediastinal lymph nodes as well as large tumors (>7 cm), and tumor invading unresectable structures or the major carina with no nodal metastasis at all. Patients with clinically evident N2 disease (i.e., bulky adenopa-thy present on CT scan or mediastinoscopy, with lymph nodes often replaced by tumor) have a 5-year survival rate of 5% to 10% with surgery alone. In contrast, patients with microscopic N2 disease discovered incidentally in one lymph node station after surgical resection have a 5-year survival rate that may be as high as 30%. As a result, many surgeons and oncologists dif-ferentiate between microscopic and bulky N2 lymphadenopathy and the number of involved N2 nodal stations in determining whether to proceed with resection following induction therapy. It is generally accepted that surgical resection is appropriate for patients with a single-station metastasis with a single lymph node smaller than 3 cm, although randomized trials specifically | Surgery_Schwartz. that have metastasized to the mediastinal lymph nodes as well as large tumors (>7 cm), and tumor invading unresectable structures or the major carina with no nodal metastasis at all. Patients with clinically evident N2 disease (i.e., bulky adenopa-thy present on CT scan or mediastinoscopy, with lymph nodes often replaced by tumor) have a 5-year survival rate of 5% to 10% with surgery alone. In contrast, patients with microscopic N2 disease discovered incidentally in one lymph node station after surgical resection have a 5-year survival rate that may be as high as 30%. As a result, many surgeons and oncologists dif-ferentiate between microscopic and bulky N2 lymphadenopathy and the number of involved N2 nodal stations in determining whether to proceed with resection following induction therapy. It is generally accepted that surgical resection is appropriate for patients with a single-station metastasis with a single lymph node smaller than 3 cm, although randomized trials specifically |
Surgery_Schwartz_4692 | Surgery_Schwartz | It is generally accepted that surgical resection is appropriate for patients with a single-station metastasis with a single lymph node smaller than 3 cm, although randomized trials specifically investigating resection following induction therapy for patients with single-station microscopic disease have not yet been performed.Histologic confirmation of N2 nodal metastases is impera-tive; false-positive findings on PET scan are unacceptably high, and reliance on this modality will lead to significant undertreat-ment of patients with earlier stage cancers. This is particularly true in regions with high incidence of granulomatous diseases. Brunicardi_Ch19_p0661-p0750.indd 69701/03/19 7:01 PM 698SPECIFIC CONSIDERATIONSPART IIWhen N2 nodes are found, incidentally, to harbor metastasis at the time of planned anatomic lung resection, the decision to proceed with resection varies depending on surgeon preference; it is acceptable to either proceed with anatomic resection and mediastinal | Surgery_Schwartz. It is generally accepted that surgical resection is appropriate for patients with a single-station metastasis with a single lymph node smaller than 3 cm, although randomized trials specifically investigating resection following induction therapy for patients with single-station microscopic disease have not yet been performed.Histologic confirmation of N2 nodal metastases is impera-tive; false-positive findings on PET scan are unacceptably high, and reliance on this modality will lead to significant undertreat-ment of patients with earlier stage cancers. This is particularly true in regions with high incidence of granulomatous diseases. Brunicardi_Ch19_p0661-p0750.indd 69701/03/19 7:01 PM 698SPECIFIC CONSIDERATIONSPART IIWhen N2 nodes are found, incidentally, to harbor metastasis at the time of planned anatomic lung resection, the decision to proceed with resection varies depending on surgeon preference; it is acceptable to either proceed with anatomic resection and mediastinal |
Surgery_Schwartz_4693 | Surgery_Schwartz | the time of planned anatomic lung resection, the decision to proceed with resection varies depending on surgeon preference; it is acceptable to either proceed with anatomic resection and mediastinal lymph node sampling/dissection or to stop the pro-cedure, refer the patient for induction therapy, and reevaluate for resection after induction therapy is completed.When histologically confirmed metastases are found dur-ing preoperative staging evaluation, patients should be referred for induction chemotherapy; patients in whom the mediastinal nodes are sterilized by induction therapy have a better prognosis, and surgical resection is generally warranted as part of a mul-timodal approach. As with preinduction evaluation, histologic confirmation of persistent N2 disease after induction therapy is imperative; patients should not be denied surgical resection fol-lowing induction chemotherapy based on radiographic evidence for N2 disease because the survival for resected NSCLC is | Surgery_Schwartz. the time of planned anatomic lung resection, the decision to proceed with resection varies depending on surgeon preference; it is acceptable to either proceed with anatomic resection and mediastinal lymph node sampling/dissection or to stop the pro-cedure, refer the patient for induction therapy, and reevaluate for resection after induction therapy is completed.When histologically confirmed metastases are found dur-ing preoperative staging evaluation, patients should be referred for induction chemotherapy; patients in whom the mediastinal nodes are sterilized by induction therapy have a better prognosis, and surgical resection is generally warranted as part of a mul-timodal approach. As with preinduction evaluation, histologic confirmation of persistent N2 disease after induction therapy is imperative; patients should not be denied surgical resection fol-lowing induction chemotherapy based on radiographic evidence for N2 disease because the survival for resected NSCLC is |
Surgery_Schwartz_4694 | Surgery_Schwartz | therapy is imperative; patients should not be denied surgical resection fol-lowing induction chemotherapy based on radiographic evidence for N2 disease because the survival for resected NSCLC is sig-nificantly better than with definitive chemotherapy.Surgery in T4 and Stage IV Disease Surgery is occasion-ally appropriate for highly selected patients with tumors invad-ing the SVC, carinal or vertebral body involvement, or satellite nodules in the same lobe (T3, N0-1, M0) or in T4, N0-1 tumors with limited invasion into the mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, diaphragm or carina through direct extension. Surgery gener-ally does not have a role in the care of patients with any tumor with N3 disease or T4 tumors with N2 disease. Survival rates remain extremely low for these patients. Similarly, the treat-ment of patients with stage IV disease is chemotherapy. How-ever, on occasion, patients with a single site of metastasis are | Surgery_Schwartz. therapy is imperative; patients should not be denied surgical resection fol-lowing induction chemotherapy based on radiographic evidence for N2 disease because the survival for resected NSCLC is sig-nificantly better than with definitive chemotherapy.Surgery in T4 and Stage IV Disease Surgery is occasion-ally appropriate for highly selected patients with tumors invad-ing the SVC, carinal or vertebral body involvement, or satellite nodules in the same lobe (T3, N0-1, M0) or in T4, N0-1 tumors with limited invasion into the mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, diaphragm or carina through direct extension. Surgery gener-ally does not have a role in the care of patients with any tumor with N3 disease or T4 tumors with N2 disease. Survival rates remain extremely low for these patients. Similarly, the treat-ment of patients with stage IV disease is chemotherapy. How-ever, on occasion, patients with a single site of metastasis are |
Surgery_Schwartz_4695 | Surgery_Schwartz | rates remain extremely low for these patients. Similarly, the treat-ment of patients with stage IV disease is chemotherapy. How-ever, on occasion, patients with a single site of metastasis are encountered, particularly with adenocarcinomas presenting with a solitary brain metastasis. In this highly select group, 5-year survival rates of 10% to 15% can be achieved with surgical exci-sion of the brain metastasis and the primary tumor, assuming it is early stage.Surgery for Management of Pancoast’s Tumor Carcinoma arising in the extreme apex of the chest with associated arm and shoulder pain, atrophy of the muscles of the hand, and Horner’s syndrome presents a unique challenge to the surgeon. Any tumor of the superior sulcus, including tumors without evi-dence for involvement of the neurovascular bundle, is now com-monly known as Pancoast’s tumors, after Henry Pancoast who described the syndrome in 1932. The designation is reserved for tumors involving the parietal pleura or deeper | Surgery_Schwartz. rates remain extremely low for these patients. Similarly, the treat-ment of patients with stage IV disease is chemotherapy. How-ever, on occasion, patients with a single site of metastasis are encountered, particularly with adenocarcinomas presenting with a solitary brain metastasis. In this highly select group, 5-year survival rates of 10% to 15% can be achieved with surgical exci-sion of the brain metastasis and the primary tumor, assuming it is early stage.Surgery for Management of Pancoast’s Tumor Carcinoma arising in the extreme apex of the chest with associated arm and shoulder pain, atrophy of the muscles of the hand, and Horner’s syndrome presents a unique challenge to the surgeon. Any tumor of the superior sulcus, including tumors without evi-dence for involvement of the neurovascular bundle, is now com-monly known as Pancoast’s tumors, after Henry Pancoast who described the syndrome in 1932. The designation is reserved for tumors involving the parietal pleura or deeper |
Surgery_Schwartz_4696 | Surgery_Schwartz | bundle, is now com-monly known as Pancoast’s tumors, after Henry Pancoast who described the syndrome in 1932. The designation is reserved for tumors involving the parietal pleura or deeper structures overly-ing the first rib. Chest wall involvement at or below the second rib is not a Pancoast’s tumor.74 Treatment is multidisciplinary; due to the location of the tumor and involvement of the neu-rovascular bundle that supplies the ipsilateral extremity, pre-serving postoperative function of the extremity is critical. For this reason, resection should only be performed in patients who are proven negative for mediastinal lymph node involvement. Survival with N2 positive nodes is poor, and the morbidity and mortality associated with surgical resection are high. If bulky lymphadenopathy is present, EBUSor EUS-guided FNA may prove nodal involvement. However, a negative FNA is not suf-ficient for proving the absence of mediastinal involvement and should be followed by mediastinoscopy to | Surgery_Schwartz. bundle, is now com-monly known as Pancoast’s tumors, after Henry Pancoast who described the syndrome in 1932. The designation is reserved for tumors involving the parietal pleura or deeper structures overly-ing the first rib. Chest wall involvement at or below the second rib is not a Pancoast’s tumor.74 Treatment is multidisciplinary; due to the location of the tumor and involvement of the neu-rovascular bundle that supplies the ipsilateral extremity, pre-serving postoperative function of the extremity is critical. For this reason, resection should only be performed in patients who are proven negative for mediastinal lymph node involvement. Survival with N2 positive nodes is poor, and the morbidity and mortality associated with surgical resection are high. If bulky lymphadenopathy is present, EBUSor EUS-guided FNA may prove nodal involvement. However, a negative FNA is not suf-ficient for proving the absence of mediastinal involvement and should be followed by mediastinoscopy to |
Surgery_Schwartz_4697 | Surgery_Schwartz | present, EBUSor EUS-guided FNA may prove nodal involvement. However, a negative FNA is not suf-ficient for proving the absence of mediastinal involvement and should be followed by mediastinoscopy to ensure accurate and complete evaluation of the mediastinum.Because Pancoast’s tumors have high rates of local recur-rence and incomplete resection, induction chemoradiotherapy fol-lowed by surgery is recommended. This treatment regimen was well tolerated in a study performed by the Southwest Oncology Group, with 95% of patients completing induction treatment. Com-plete resection was achieved in 76%. Five-year survival was 44% overall and 54% when complete resection was achieved. Disease progression with this regimen was predominantly at distant sites, with the brain being the most common.75 The current treatment algorithm for Pancoast’s tumors is presented in Fig. 19-25.Surgical excision is performed via thoracotomy with en bloc resection of the chest wall and vascular structures and | Surgery_Schwartz. present, EBUSor EUS-guided FNA may prove nodal involvement. However, a negative FNA is not suf-ficient for proving the absence of mediastinal involvement and should be followed by mediastinoscopy to ensure accurate and complete evaluation of the mediastinum.Because Pancoast’s tumors have high rates of local recur-rence and incomplete resection, induction chemoradiotherapy fol-lowed by surgery is recommended. This treatment regimen was well tolerated in a study performed by the Southwest Oncology Group, with 95% of patients completing induction treatment. Com-plete resection was achieved in 76%. Five-year survival was 44% overall and 54% when complete resection was achieved. Disease progression with this regimen was predominantly at distant sites, with the brain being the most common.75 The current treatment algorithm for Pancoast’s tumors is presented in Fig. 19-25.Surgical excision is performed via thoracotomy with en bloc resection of the chest wall and vascular structures and |
Surgery_Schwartz_4698 | Surgery_Schwartz | The current treatment algorithm for Pancoast’s tumors is presented in Fig. 19-25.Surgical excision is performed via thoracotomy with en bloc resection of the chest wall and vascular structures and ana-tomic lobectomy. A portion of the lower trunk of the brachial plexus and the stellate ganglion are also typically resected. With chest wall involvement, en bloc chest wall resection, along with lobectomy, is performed, with or without chest wall reconstruction.For small rib resections or those posterior to the scapula, chest wall reconstruction is usually unnecessary. Larger defects (two rib segments or more) are usually reconstructed with Gore-Tex to provide chest wall contour and stability. En bloc resection is also used for other locally advanced tumors (T3) with direct invasion of the adjacent chest wall, diaphragm, or pericardium. If a large portion of the pericardium is removed, reconstruction with thin Gore-Tex membrane will be required to prevent cardiac herniation and venous | Surgery_Schwartz. The current treatment algorithm for Pancoast’s tumors is presented in Fig. 19-25.Surgical excision is performed via thoracotomy with en bloc resection of the chest wall and vascular structures and ana-tomic lobectomy. A portion of the lower trunk of the brachial plexus and the stellate ganglion are also typically resected. With chest wall involvement, en bloc chest wall resection, along with lobectomy, is performed, with or without chest wall reconstruction.For small rib resections or those posterior to the scapula, chest wall reconstruction is usually unnecessary. Larger defects (two rib segments or more) are usually reconstructed with Gore-Tex to provide chest wall contour and stability. En bloc resection is also used for other locally advanced tumors (T3) with direct invasion of the adjacent chest wall, diaphragm, or pericardium. If a large portion of the pericardium is removed, reconstruction with thin Gore-Tex membrane will be required to prevent cardiac herniation and venous |
Surgery_Schwartz_4699 | Surgery_Schwartz | adjacent chest wall, diaphragm, or pericardium. If a large portion of the pericardium is removed, reconstruction with thin Gore-Tex membrane will be required to prevent cardiac herniation and venous obstruction.Preoperative (Induction) Chemotherapy for NSCLC The use of chemotherapy before anatomic surgical resection has a number of potential advantages:1. The tumor’s blood supply is still intact, allowing better chemotherapy delivery and avoiding tumor cell hypoxia (in any residual microscopic tumor remaining postoperatively), which would increase radioresistance.2. The primary tumor may be downstaged, enhancing resectability.3. Patients are better able to tolerate chemotherapy before sur-gery and are more likely to complete the prescribed regimen than after surgery.4. It functions as an in vivo test of the primary tumor’s sensi-tivity to chemotherapy.5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy.6. Systemic micrometastases are | Surgery_Schwartz. adjacent chest wall, diaphragm, or pericardium. If a large portion of the pericardium is removed, reconstruction with thin Gore-Tex membrane will be required to prevent cardiac herniation and venous obstruction.Preoperative (Induction) Chemotherapy for NSCLC The use of chemotherapy before anatomic surgical resection has a number of potential advantages:1. The tumor’s blood supply is still intact, allowing better chemotherapy delivery and avoiding tumor cell hypoxia (in any residual microscopic tumor remaining postoperatively), which would increase radioresistance.2. The primary tumor may be downstaged, enhancing resectability.3. Patients are better able to tolerate chemotherapy before sur-gery and are more likely to complete the prescribed regimen than after surgery.4. It functions as an in vivo test of the primary tumor’s sensi-tivity to chemotherapy.5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy.6. Systemic micrometastases are |
Surgery_Schwartz_4700 | Surgery_Schwartz | an in vivo test of the primary tumor’s sensi-tivity to chemotherapy.5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy.6. Systemic micrometastases are treated.7. It identifies patients with progressive disease/nonresponders and spares them a pulmonary resection.Potential disadvantages include:1. There is a possible increase in the perioperative complica-tion rate in patients requiring right pneumonectomy after induction chemotherapy.2. While the patient is receiving chemotherapy, potentially curative resection is delayed; if the patient does not respond, this delay could result in tumor spread.In stage IIIA N2 disease, the response rates to induction chemotherapy are high, in the range of 70%. The treatment is generally safe, as it does not cause a significant increase in peri-operative morbidity. Two randomized trials have now compared surgery alone for patients with N2 disease to preoperative che-motherapy followed by surgery. Both | Surgery_Schwartz. an in vivo test of the primary tumor’s sensi-tivity to chemotherapy.5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy.6. Systemic micrometastases are treated.7. It identifies patients with progressive disease/nonresponders and spares them a pulmonary resection.Potential disadvantages include:1. There is a possible increase in the perioperative complica-tion rate in patients requiring right pneumonectomy after induction chemotherapy.2. While the patient is receiving chemotherapy, potentially curative resection is delayed; if the patient does not respond, this delay could result in tumor spread.In stage IIIA N2 disease, the response rates to induction chemotherapy are high, in the range of 70%. The treatment is generally safe, as it does not cause a significant increase in peri-operative morbidity. Two randomized trials have now compared surgery alone for patients with N2 disease to preoperative che-motherapy followed by surgery. Both |
Surgery_Schwartz_4701 | Surgery_Schwartz | cause a significant increase in peri-operative morbidity. Two randomized trials have now compared surgery alone for patients with N2 disease to preoperative che-motherapy followed by surgery. Both trials were stopped before complete accrual because of a significant increase in survival for the chemotherapy arm.The initially observed survival differences have been maintained for up to 3 years and beyond (5-year data not shown). Given these results, induction chemotherapy with Brunicardi_Ch19_p0661-p0750.indd 69801/03/19 7:01 PM | Surgery_Schwartz. cause a significant increase in peri-operative morbidity. Two randomized trials have now compared surgery alone for patients with N2 disease to preoperative che-motherapy followed by surgery. Both trials were stopped before complete accrual because of a significant increase in survival for the chemotherapy arm.The initially observed survival differences have been maintained for up to 3 years and beyond (5-year data not shown). Given these results, induction chemotherapy with Brunicardi_Ch19_p0661-p0750.indd 69801/03/19 7:01 PM |
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