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Surgery for N3 disease Garrett L. Walsh, MD

Surgery for N3 disease Garrett L. Walsh, MD AATS, Focus on Thoracic Surgery: Lung Cancer Boston 20 12. Financial Disclosures. None. ACCP guidelines.

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Surgery for N3 disease Garrett L. Walsh, MD

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  1. Surgery for N3 disease Garrett L. Walsh, MD AATS, Focus on Thoracic Surgery: Lung Cancer Boston 2012

  2. Financial Disclosures None

  3. ACCP guidelines For patients with stage IIIB NSCLC as a result of N3 disease, treatment with neoadjuvant (induction) chemotherapy or chemoradiotherapy followed by surgery is not recommended. Grade of recommendation 1C

  4. Thank you Questions?

  5. Since when do surgeons follow guidelines?

  6. Watanabe Thor and CardiovasSurg 1988 and 1991 • Described 17 year experience with resection IIIA disease patients • Described use of median sternotomy after left thoracotomy for left sided tumors • Can do extended resection all from the right for right sided tumors

  7. Surgical approaches • Toker et al. EJCTS 2011 from left thoracotomy • After dissection (5,6,7,8,9,10) then blunt dissection superior and contralateral mediastinum by an opening post to left main pulmonary artery and anterior and superior to left main stem bronchus • Peanuts retract aorta and push down LMSB. Small bronchials and veins need to be clipped. Ductus is not divided • For 2L finger dissection under the aortic arch and above the trachea is performed. • An index finger behind the subclavian artery and the longitudinal incision posterior to subclavian is performed • 14/51 complications including 5 recurrent nerve, 2 chylothorax • LardinoisEurJCTS 2006 by division of the ductus and mobilization of the aortic arch

  8. 40 pts. Phase II, all IIIB based on thoracotomy or mediastinoscopy • Cis, 5-FU and vinblastine with 42 Gy • 30 T4 18 N3 ; 73% response 29 thoracotomy and R0 in 23 (58%) • Two deaths (7 %) 4 CR (10%) • 5- yr overall 19%; Node negative 42%

  9. Retrospective 167 pts, 84 T4 patients without nodal confirmed were excluded • 83 potentially resectable N2/N3 • Accepted single and multilevel N2, bulky N2, formal N3 but not bulky N3 and N2 or supraclavicular or contralateral hilum • 44 pneumonectomies and 76% extended resections. • Everything had to be reached with one incision. If it could not be reached it was “assumed” to be sterilized. Occasional separate incision for supraclavicular

  10. 35 patients had persistent mediastinal nodal disease • Hospital mortality 2.4%; Median survival 21 months • 15 patients had formal N3 on presentation with the median survival of 31 months and 5 still alive. “In our opinion a limited extension of N2 to a formal N3 or a limited formal N3 do not justify refusing surgery” • The median progression free survival of the 35 patients is 17 months and 13 have had no progression or recurrence since. “The latter point cannot happen without surgery and is an exclusive advantage of surgery in cases with persistent nodal disease although this theoretic advantage is difficult to prove.” • Pneumonectomieswere not a risk to survival and are justified even in persistent N2/N3 disease

  11. In summary, patients with persistent N2/N3 disease after chemoradiotherapy in stage III NSCLC are the most unfavorable subgroup in the neoadjuvant approaches. • At the present time, if surgery can be undertaken with curative intent with similar mortality to that of primary radiochemotherapy-- surgery should be used to complete the treatment with acceptable outcome

  12. Observations • Many studies combine stage IIIA with stage IIIB • T4 and N3 are different biologically • Very few N3 patients in the IIIB group • Often radiographic criteria used for clinical staging rather than histologic confirmation • N3 supraclavicular nodes often excluded • Multistation N2 have a high likelihood of occult N3 • No studies include contralateral hilar nodes

  13. Inconsistent restaging after induction treatment • Some use remediastinoscopy • Is there a role for VATS, TEMLA, VAMLA, EBUS/EUS • Lymphatic drainage of Right sided and left sided lesions • Newer series with CT/PET

  14. Thoughts • Is there really much difference in limited N2 or limited N3 • In right sided tumors during paratracheal dissections, are we not dissecting past midline and taking N3 nodes in the nodal packet? • In subcarinal node dissections from the right, are we not nearly to the hilum of the left lung? • Is it a matter of access to the contralateral nodes in left sided lesions? • Will TEMLA procedures help select N3 patients better for surgery? • Should supraclavicular nodes in pancoast tumor resections be considered loco-regional disease rather than N4?

  15. IIIB (only) Trials Without Surgery

  16. IIIB (only) Trimodality Trials With Surgery

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