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What role surgery plays in the multi-

modality therapy for lung cancer

Yong Li M.D. Ph.D


Department of Thoracic Surgery of Fourth Hospital,
Hebei Medical University & Hebei Cancer Hosptital,
China
E-mail: liyongdoctor@126.com
Ø Lung cancer is leading cause of 1 in 5 cancer
deaths worldwide (of an estimated 1.8 million
new cases of lung cancer in 2012)
Ø Lung cancer is the #1 cause of cancer death
among both men and women
Ø In China, lung cancer has increased by 465%
over the past 30 years
Top 5 of malignant carcinoma in China
Lung Breast
stomach Lung
Liver Male female stomach
esophagus Colon
Colon Thyroid
Ø The estimated cases of lung cancer will be 1
million by 2025 in China which will be the top
1 in the world
Higher genetic mutations in Smokers (vs. Non-smokers)
detected by NGS

Smokers: Non-smokers:
How Tobacco get involved with Lung Cancer
OVERVIEW

Global prevalence of smoking (2012)


Source: Wikipedia
OVERVIEW

Incidences of cancers worldwide


Source : GLOBOCAN 2012(IARC)
How to treat lung cancer?
Ø Surgery is the best treatment for early stage
lung cancer

Ø Chemotherapy is the best for advanced lung


cancer(targeted therapy, immunotherapy, etc.)

Ø Radiotherapy is effective local treatment


Surgery
Ø Best treatment for and stage NSCLC.
Ø VATS(video-assisted thoracoscopic surgery
lobectomy) developed quickly in the past 20
years from 1990.
Ø America, Europe, Japan and China leaded the
research direction.
1910
Hans Christian Jacobaeus
(1879 –1937) provided the
first description of a
thoracoscopy

The Journal of Arthroscopic and Related Surgery, Vol 19, No 7 (September),


2003: pp 771-776
1992

• The first published


report on VATS
operation by Ralph J.
Lewis

Ann Thorac Surg 1992;54:421-6)


1993

• The first published


report on VATS
Lobectomy by
Thomas J. Kirby

A vascul ar en dostap ler (30-V3 En do GIA; Un ited States


Surgi cal Coy, Norwalk, CT) with the knife blade removed has
been placed across a large pulmona y arterial branch farrow) to Ann Thorac Surg 1993;56:784-6)
the right upper lobe
1994

• Lobectomy with
mediastinal node
sampling on VATS by
Robert McKenna

J Thorac Cardiovasc Surg 1994;107 (3): 879-81;


Video-Assisted Thoracic Surgery Lobectomy:
Report of CALGB 39802—A Prospective, Multi-Institution Feasibility Study

J Clin Oncol 25:4993-4997. © 2007


2009——NCCN guideline
Goal of clinical research
VATS—right paratracheal lymph node
dissection

Semin Thoracic Surg 24:131-141 © 2012


Systematic node dissection by VATS is
not inferior to that through an open thoracotomy

Surgery 2005;138: 510–7.


Perioperative Perspective
• Open

• VATs
Perioperative Outcomes
Surgery Time (hours), Blood Loss (ml),
Chest Drain (days), Hospital Stay (days)

J Clin Oncol 27:2553-2562. © 2009


Quality of Life Considerations
Pain control
home health services

Ann Thorac Surg 2001;72:362–5


Ann Thorac Surg 2008;85:S719–28
Local recurrence and systemic metastasis

J Clin Oncol 27:2553-2562. © 2009


Typical Port placement

left side VATS lobectomy. Thoracoscope


Port placement for right side VATS
is introduced through working window and
lobectomy. Thoracoscope is a peanut holder for lung retraction is
introduced through working window. inserted through 10 mm back port.

Korean J Thorac Cardiovasc Surg. 2011;44(1):1-8.


Open surgery lobectomy Minimally invasive surgeries
Adjustment of T Staging: Tumor Size
Ever y centimeter counts!
7th Edition 8th Edition
New cutpoints
T1a: 1cm
1 cm
T1a: 2cm
T1b: >1cm, but 2cm
Upstage
T1b: >2cm, but 3cm T1c: >2cm, but 3cm

New cutpoints T2a: >3cm, but 4cm


4 cm
T2a: >3cm, but 5cm
T2b: >4cm, but 5cm

Upstage
T2b: >5cm, but 7cm T3: >5cm, but 7cm

Upstage
T3: >7cm T4: >7cm
Population based study on SEER show that 1 to 2cm or <1cm
determine the selection for lobectomy, wedge resection and
segmentectomy.

NSCLC 肿瘤 1-2cm,
OS 和 LCSS:肺叶切除>肺段切除
>楔形切除

J Clin Oncol. 2016 Jul 5. pii: JCO646729


Role of Sur ger y in Differ ent Stages
Follow up Indolent

Ⅰ SBRT Intolerable Age, PFT

Size, Location, Multiple


Surgery
GGO component lesions

Ⅱ Surgery
NSCLC
Ⅲ MDT Surgery LN Staging

Oligometastasis Local Tx+Combination

Ⅳ Indolent M1a Local Tx? Follow up?

Systemic metastasesMolecular Diagnosis


Sur gical Inter vention in GGO:
Probability of malignancies
(CT featur es and dynamic changes)
T1c 2-3cm Lobectomy

GGO>50%
Segmentectomy or Lobectomy
T1b 1-2cm
Solid>50% Lobectomy

SPN
Outer Field Wedge
Pure GGO
Inner/Middle Field Follow up Anxiety ?

Outer Field Wedge


T1a 1cm
GGO>50%
Inner/Middle Field Segmentectomy

Malignancy:
Solid>50% Sublobectomy
Lobectomy
SPN: Imaging—Pathology—Pr ognosis
AIS Lepidic IAD Solid IAD

Pur e GGO Mixed GGO Pur e Solid


5-y OS 100% 5-y OS 75% 5-y OS 52%
Sublobectomy
Nakamura, et al. Lung cancer, 2004
Asamura, et al. Ann Thorac Surg, 2003
Nakada, et al. Ann Thorac Surg,2003
Watanabe, et al. Ann Thorac Surg, 2003
Lobectomy vs. Sublobectomy ?
Adjuvant chemo in Stage IB Lung Cancer s
DFS
Papillary/Acinar Micr opapillar y/Solid

Different Subtypes
Lepidic Acinar

Papillar y Micr opapillar y

Solid

JCO. 2015 Apr 27;


JCO.2014.58.8335.
Per sonalized Sur ger y in Lung Cancer s
Pr ecise
Classification

Tumor Evolution TNM Staging

Pr ecise Sur ger y


Molecular Pathology &
Classification Pr ognosis

Pr ecision
medicine
Now let us think about it again

VATS Sur ger y is the best tr eatment for


ear ly stage lung cancer ?
stereotactic body radiation therapy( SBRT),(stereotactic
ablative radiotherapy, SABR)

Chang JY, Senan S, Paul MA, et al. Stereotactic ablative


radiotherapy versus lobectomy for operable stage I non-
small-cell lung cancer: a pooled analysis of two
randomised trials. Lancet Oncol 2015;16:630-7.
Comparsion SABR with surgery for lung cancer

(Chang and Senan et al., 2015)


What’
s the next landscape for thoracic surgeon?
When

More and more patients with early stage lung cancer influx into OR
for surgery. It seems like surgeon WIN the business in early stage
lung cancer.
But

Radiation therepy(SABR), plus chemotherapy, SUPERIOR to surgery?


And
Other treatments like radiofrequency ablation(RFA), cryoablation
(extreme cold), proton therapy etc.
Finally
DECREASING role of surgery compared to alternative lung cancer
treatment!
How about the role of surgery in
advanced lung cancer?

Locally Advanced Even resectable,


(Stage IIIA, IIIB, and surgery remains a
IIIC) matter of debate

Metastatic (Stage No surgery


IVA and IVB)
Another powerful weapon against
lung cancer--drug
Personalized Therapy in Advanced-Stage
NSCLC: Current Therapeutic Landscape

Chemotherapy*† Targeted TKI Therapy Checkpoint Inhibitors

EGFR
Histologic Anti–PD-1
ALK
subtype Anti–PD-L1
ROS1

1970s - today 2000s - today 2015 - today

*± EGFR/VEGF mAbs from 2000s - today.



± PD-1 mAb from May 2017.
EGFR TKI
1st generation 2nd generation 3rd generation
Drugs Gefitinib Afatinib Osimertinib
Erlotinib
Characteristic Irreversible ErbB For secondary
family blocker mutation
PFS 9 –13 mo. 11 mo. 10.1 mo.
OS 20 –30 mo. 23 –31 mo. NR
RR 62 –84 % 56 –67 % 71%
Adverse Event Rash Diarrhea Rash
Mucositis Rash Diarrhea
Diarrhea Mucositis Paronychia
Paronychia Dry skin
Hepatitis

J Clin Oncol 2011;29:2866-74.


N Engl J Med 2009;361:947-57. J Clin Oncol. 2013 Sep 20;31(27):3327-34.
Lancet Oncol 2012;13:239-46. Lancet Oncol. 2014 Feb;15(2):213-22.
Lancet Oncol 2011;12:735-42. N Engl J Med. 2017 Feb 16;376(7):629-640.
Lancet Oncol. 2015 Feb;16(2):141-51
J Clin Oncol 2012;30:abstr 7520.
Immunotherapy is an exploding area in NSCLC with
many combination trials underway or planned
PD-1 INHIBITION

From Sacher A and Gandhi L. JAMA Oncology, June 2016


overview
Early stage lung surgery
cancer SBRT, proton,
RFA, etc.

Advanced stage Sugery is controversial


lung cancer radiation, chemo,
targeted , immuntherapy
etc.
As a surgeon, Keep updating what
changes. Not only surgical skills, but also
the chemotherapy, radiation and what
changes out of the surgery.

Good surgeon not only means good skills!


Take Home Message
Cancer never die , treatment never stop
multidisciplinary treatment is an exploding
area in NSCLC
It will be important to take a long view of
change paradigm of treatment of lung cancer
Radiation, targeted and immunotherapy are
also exploding—sorting out the best clinical
path forward.
Collaborating with each other in the world
is important for long-term outcome of
patients!
Welcome to Hebei Medical University and
Hebei tumor Hospital!
Hebei Medical University: http://www.hebmu.edu.cn/

Hebei tumor Hospital: http://www.hbydsy.com/

My E-mail: liyongdoctor@126.com
THANK YOU!

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