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S. Swanson

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    SC02 - Multifocal Lung Cancer (ID 326)

    • Event: WCLC 2016
    • Type: Science Session
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      SC02.02 - Surgical Choices for Patients with Multifocal Lung Cancer (ID 6605)

      11:00 - 12:30  |  Author(s): S. Swanson

      • Abstract
      • Presentation
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      The Surgical Choices for Patients with Multifocal Lung Cancers Surgery for patients with multiple lung lesions is a growing domain. CT scans are obtained frequently and have high resolution such that any lesion in the lung that is 2 millimeters or larger can be identified. Also, it appears that multifocal lung lesions are more common now. At the same time, surgical technique and technology (minimally invasive) have evolved so identifying and resecting small lesions is straightforward and associated with very little morbidity and pain. In most cases there is one lesion (primary lesion) that is more concerning and others that are smaller, less solid or relatively unchanged over time. Often a diagnosis of all of the lesions is not known at the time of surgical intervention and in many cases no diagnosis is known ahead of time. Thus, the surgeon must integrate many factors when operating on multifocal lung findings. What are risk factors that the patient will have lung cancer, what are the patient’s co-morbidities and underlying lung function? When is it important to establish a pre-operative diagnosis? How important is it to resect all of the pulmonary lesions seen on CT scan? Will other therapy be needed? In general, our approach is to obtain a pre-operative diagnosis when possible if the surgery will be particularly challenging based on the location and number of the lesions and/or if the patient has very compromised lung function. The most important point is to anatomically resect the primary lesion; that nodule which is largest, most solid and/or growing the fastest. If the lesion is 2 centimeters or smaller and located within a segment that is straightforward to resect (superior segment lower lobe, lingula or upper division of the left upper lobe, posterior segment of the right upper lobe, medial basilar segment of the lower lobe or composite basilar segments of lower lobe) then a segmentectomy is the procedure of choice. This will provide an excellent oncologic outcome and more readily permit other pulmonary resection than if a lobectomy or greater had been carried out. In all cases a lymph node dissection should be performed and in the case of a sublobar resection it is important to assess, by frozen section, the intersegmental node or nodes between the area being removed and the part of the lobe being left (sump), to be sure no disease remains related to this primary lesion. If the sump node is positive then a lobectomy should be strongly considered. If the lesion is greater than 2 centimeters and for those deep seated more central lesions, a lobectomy is the best operation. If the lesion is about one centimeter and subpleural then a wide wedge resection can be considered though this is an unusual situation for the primary lesion. For the other lesions (non-primary), if they are ipsilateral and easy to identify and resect then they should be removed at the time of the surgery for the primary lesion. If it is possible to resect these lesions with a segment (preferable) or wide wedge this is best. If the non-primary lesions are pure ground glass, relatively small (i.e. less than 2-3 centimeters) and stable then it is reasonable to leave them in place for close follow-up. Once the permanent pathology including molecular analysis is done and the patient has recovered then surgery for the contralateral lesions is considered. Factors that are important in this are residual pulmonary function (repeat pft’s after the first operation), size (both baseline and recent growth) and density of the contralateral lesions. Also, pathology of the resected tumors and whether they represented separate primary tumors or possibly were metastatic tumors, although even with molecular analysis this can be difficult to ascertain, is important in planning. Surgery on the contralateral lesions should be as lung-sparing as possible with segmentectomy being the procedure of choice when possible followed by wide-wedge resections or lobectomy if dictated by size and location. The outcome of patients who had surgery for multiple lung cancers is generally quite good and not statistically different than the outcome for a solitary lung cancer. The patients in these series were highly selected. In most cases the pathology of these lesions is a mix between invasive adenocarcinoma (various subtypes), minimally invasive adenocarcinoma and adenocarcinoma in-situ. Whether mutations are identified is variable and does not seem to influence prognosis. Use of adjuvant therapy depends on the completeness of resection, the nodal status and the molecular analysis of the resected tumors. In general, assuming no nodal involvement and complete resection of the lesions removed, no adjuvant therapy is recommended. In all cases close follow-up is mandatory with visits and frequent ct scans (2-3/yr for 2 years then 1-2/year for 3 years then 1/yr for life). Graph of Survival for patients treated by surgical resection for synchronous primary lung cancers. Figure taken from: Finley et al. Journal of Thoracic Oncology. 2010. (ref 2) Figure 1 References: Shimada et al. Survival of a surgical series of lung cancer patients with synchronousmultiple ground-glass opacities, and the management of the residual lesions. Lung Cancer 2015 Finley et al. Predictors of outcomes after surgical treatment of synchronous primary lung cancers. Journal of Thoracic Oncology. 2010. Bonanno et al. Morphological and genetic heterogeneity in multifocal lung adenocarcinoma: The case of a never-smoker woman. Lung Cancer 2016. Fonseca A and Detterbeck FC. How many names for a rose: Inconsistent classification of multiple foci of lung cancer due to ambiguous rules. Lung Cancer 2014. Yasuda M et al. How should synchronous multiple primary adenocarcinomas of the lung be resected? Annals of Thoracic Surgery 2014. Wolf AS et al. Lobectomy versus sublobar resection for small (2 cm or less) non-small cell lung cancers. Annals of Thoracic Surgery 2011. Mohiuddin K et al. Relationship between margin distance and local recurrence among patients undergoing wedge resection for small (<2 cm) non-small cell lung cancer. Journal of Thoracic and Cardiovascular Surgery. 2014. Nakata M et al. Surgical treatments for multiple primary adenocarcinoma of the lung. Annals of Thoracic Surgery. 2004. Battafarano RJ et al. Surgical resection of multifocal non-small cell lung cancer is associated with prolonged survival. Annals of Thoracic Surgery. 2002. Gu B et al. A dominant adenocarcinoma with multifocal ground glass lesions does not behave as advanced disease. Annals of Thoracic Surgery. 2013.

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