Cardiothoracic Surgery: Lung Cancer Treatment

Management

• Small Cell Lung Carcinoma (SCLC)
  • Primary Treatment: Chemotherapy & Radiation Therapy
  • Only Consider Surgical Resection for Early-Stage Disease (Rare)
• Non-Small Cell Lung Carcinoma (NSCLC)
  • Stage I/II: Surgical Resection
    • Adjuvant Chemotherapy Indications:
      • Stage IB with High-Risk Features
      • Stage II-III
      • Positive Margins
    • Consider Definitive Radiation Therapy if Not a Surgical Candidate
  • Stage III-IV: Chemotherapy & Radiation Therapy

Terms

• Resectable – Able to Resect Based on Tumor Characteristics
• Operable – Able to Undergo Surgery Based on Patient Characteristics

“Operable” – Patient Selection for Surgery

• Initial Test: Pulmonary Function Tests (PFT’s)
  • Tests:
    • Forced Expiratory Value in One Second (FEV1) – Best Test
    • Diffusing Capacity for Carbon Monoxide (DLCO)
  • Interpretation:
    • FEV1 & DLCO ≥ 80% Predicted: Low-Risk, No Further Testing Necessary
    • FEV1 or DLCO < 80% Predicted: Further Testing Required (PPO PFT’s)
• Second Step: Predicted Postoperative (PPO) PFT’s
  • Tests:
    • Perfusion Scintigraphy (VQ Scan) – Preferred for Pneumonectomy
    • Volumetric CT – Preferred for Lobectomy
  • Interpretation:
    • PPO FEV1 & DLCO ≥ 60% Predicted: Low-Risk, No Further Testing Necessary
    • PPO FEV1 or DLCO < 60% Predicted: Further Testing Required (Exercise Testing)
• Third Step: Exercise Testing
  • Tests:
    • Low Technology Exercise Testing – Preferred if PPO FEV1 & DLCO ≥ 30% Predicted
    • Cardiopulmonary Exercise Testing (CPET) – Preferred if PPO FEV1 or DLCO < 30% Predicted
  • Interpretation:
    • Exercise Testing (Stair Climb):
      • ≥ 22 m: Low-Risk, No Further Testing Necessary
      • < 22 m: Further Testing Required (CPET)
    • Exercise Testing (Incremental Shuttle Walk Test):
      • ≥ 400 m: Low-Risk, No Further Testing Necessary
      • < 400 m: Further Testing Required (CPET)
    • Cardiopulmonary Exercise Testing (CPET)
      • VO2 Max > 15 ml/kg/min: Acceptable for Surgery
      • VO2 Max < 10 ml/kg/min: Surgery Contraindicated
• *Historical Standards Used Absolute Cutoff Values – No Longer Used (Ignores Size, Age & Gender)
  • FEV1 > 2.0 L Required for Pneumonectomy
  • FEV1 > 1.5 L Required for Lobectomy
  • Predicted Postoperative FEV1 > 800 cc by VQ Scan Required if Initial PFT’s Insufficient

Surgery Contraindications

• N2/N3 Lymph Node Involvement
• Metastases (M1)
• Malignant Pleural Effusion
• Tumor Invasion of the Diaphragm, Mediastinum, Heart, Great Vessels, Trachea, Recurrent Laryngeal Nerve, Esophagus, Carina or Vertebral Body
• Brachial Plexus Involvement
• Superior Vena Cava (SVC) Syndrome

Superior Vena Cava (SVC) Syndrome

• Severe/Life-Threatening Symptoms: Endovascular Stenting
  • *Immediate Radiation Therapy was Previously Used for Rapid Control Prior to Stenting
• Other Treatments:
  • Chemotherapy for Chemotherapy-Sensitive Tumors (SCLC or Lymphoma)
  • Radiation Therapy for Radiosensitive Tumors
  • Systemic Anticoagulation if Thrombus is Present