肺癌外科治疗适应症_杨宁肿瘤介入医学网

Gold Standard: Surgical Resection

Standard of care for early stage NSCLC (80 % of primary lung cancers)

Surgery depends on:

Stage Criteria
Clinical conditions

Abbas G, et al.Radiofrequency and microwave ablation of lung tumors. J Surg Oncol 2009; 100:645-50.

Gold Standard: Surgical Resection

Since the first pulmonary resections in the early 20th century, pneumonectomy and lobectomy were considered the standard operations for lung cancer. 自20世纪初第一次肺切除术以来，肺切除术和肺叶切除术被认为是肺癌的标准手术
Sublobar resection emerged as attractive option – three-fold local recurrence (Lung Cancer Study Group) 亚叶切除成了有吸引力的选择——三重局部复发（肺癌研究组）
Sublobar resections (wedge resection or segmentectomy): for patients at increased risk for morbidity and mortality after lobectomy that can still tolerate a smaller pulmonary resection 亚叶切除术（楔形切除术或段切除术）：对于肺叶切除术后发生并发症率和死亡率增加的情况、仍能耐受较小肺切除术的患者
Best chance of cure in early stage disease 早期疾病治愈几率最大
Benefitial in limited pulmonary metastases 局限性肺转移的有益处

Churchill ED et al. J Thoracic Cardiovasc Surgery 1950;20:349-65.
Ginsberg RJ, et al. Ann Thorac Surg 1995;60(3):613-22.
Warren WH. J Thorarc Cardiovsc Surg 1994;107(4):1087-1093.
Landreneau RJ. J Thorac Cardiovasc Surg 1997; 113(4):691-8.
Abbas G, et al. J Surg Oncol 2009; 100:645-50.

Stage I and II

Surgical Indications for NSCLC: Stages I and II

Golstraw P, et al. J Thorac Oncol 2007;2:706-14.
Crinò L, et al. Annals of Oncology 2010; 21(S5):103-15.

Great benefit from surgical resection: around 70% of survival in 5 years, BUT:

> 15% of patients: tumors deemed surgically unresectable（尽管肿瘤分期低，但位置不适合手术？）

> 30% of patients: >75 years of age or medical inoperability（医学原因不能手术-非解剖因素？）

Goldstraw P, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours.J Thorac Oncol 2007;2:706-14.

Casal RF, et al. Clin Chest Med 2010;31:150-63.

Wolf FJ, et al. Medicine&Health 2009;92(12):407-11.

Most frequent comorbidities reported in Literature responsable of Inoperability

- Poor lung function

- Advanced age

- Comorbilities including：

Liver cirrhosis
CRF (Chronic Renal Failure)
Hemodynamic disorders
Multiple Sclerosis
Aortic Aneurysm
CCF (Cardiac Congestive Failure)
Low “perfomance status”: Zubrod, ECOG, Charlson
Stable Angina
Valvular disease
Cardiac risk

Impact of comorbidities on surgery

Birim Ö et al., Charlson comorbidity index as a predictor of long-term outcome after surgery for nonsmall cell lung cancer 2005, Eur J Cardiothoracic Surg

5-year overall survival: 60-80 % for stage I and 40- 50 % for stage II NSCLC

Surgical Indications for Primary Lung Tumors

Preoperative evaluation of lung resection candidate

Should not be denied surgery in the basis of age alone;
FEV1 >2L or > 80% predicted normal are suitable for pneumonectomy and FEV1 > 1.5L are suitable for lobectomy without further evaluation unless there is evidence of interstitial lung disesase or under dyspnea on exertion;
Individuals with very poor lung function may be considered for combined lung volume reduction surgery and lung cancer resection if the emphysema is heterogeneous and envolves primarily the lobe to be resected.

Poonyagariyagorn H, et al. Lung cancer: preoperative pulmonary evaluation of the lung resection candidate.Semin Resp Crit Care Med 2008; 29(3):271-84.

Surgical Indications for Pulmonary Metastases

The patient must be capable of tolerating the surgical procedure.
The patient’s pulmonary function tests are supportive of the patient’s ability to tolerate the loss of lung capacity resulting from the procedure;
The primary tumor has been controlled or is controllable, possibily by surgical means;
Any extrapulmonary disease is controlled or controllable, possibily by surgical means.

In the vast majority of cases not indicated for SCLC (since tumor spread at the time of diagnosis)

Patients with significant comorbidities (COPD, ...), are poor surgical candidates (cave: perioperative morbidity and mortality)

Scott WJ et al., Treatment of Non-Small Cell Lung Cancer Stage I and Stage II: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) 2007, Chest

Pereira PL et al.,Standards of Practice: Guidelines for Thermal Ablation of Primary and Secondary Lung Tumors 2012, Cardiovasc Intervent Radiol （free）

Conventional Treatment for NSCLC

Stage III

Golstraw P, et al. J Thorac Oncol 2007;2:706-14.

Crinò L, et al. Annals of Oncology 2010; 21(S5):103-15.

Conventional Treatment for NSCLC

Stage IV (palliation):

And what to do when surgery is not possible?

Goldstraw P, et al. The IASLC Lung Cancer Staging Project: Proposals for the Revision of the TNM Stage Groupings in the Forthcoming (Seventh) Edition of the TNM Classification of Malignant Tumours J Thorac Oncol 2007;2:706-14.

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肺癌外科治疗适应症