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Is The Surgical Treatment for Patients with Advanced Lung Cancer beneficial? Pro and Con

Is The Surgical Treatment for Patients with Advanced Lung Cancer beneficial? Pro and Con. Ufuk Yilmaz M.D. Suat Seren Chest Disease and Surgery Training and research Hospital, Izmir. In patients with suspected NSCLC;

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Is The Surgical Treatment for Patients with Advanced Lung Cancer beneficial? Pro and Con

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  1. Is The Surgical Treatment for Patients with Advanced Lung Cancer beneficial?Proand Con Ufuk Yilmaz M.D. Suat Seren Chest Disease and Surgery Training and research Hospital, Izmir April 27, 2007, Antalya

  2. In patients with suspected NSCLC; The initial evaluation includes both the diagnosis of the primary tumor and the determination of the extent of tumor spread to regional and distant lymph nodes as well as to other structures April 27, 2007, Antalya

  3. The accurate staging of NSCLC is central to determining the appropriate stage dependent therapeutic choices. April 27, 2007, Antalya

  4. Almost all patients with stage IV non-small cell lung cancer (NSCLC) have diffusely metastatic disease, and therefore, the standard of care for NSCLC is chemotherapy or palliative care. These patients are usually considered unsuitable for surgery with curative intent. April 27, 2007, Antalya

  5. Big Question • Does these patients be sutiable for curative surgery? April 27, 2007, Antalya

  6. Answers, which one? • No ? • Yes ? April 27, 2007, Antalya

  7. My answer • No • These patients does not be sutiable for curative surgery. April 27, 2007, Antalya

  8. Why no? April 27, 2007, Antalya

  9. Quality of the evidence • Good = evidence based on good randomized controlled trials or meta-analyses • Fair = evidence based on other controlled trials or randomized controlled trials with minor flaws • Low = evidence based on nonrandomized, case-control, or other observational studies • Expert opinion = evidence based on the consensus of the carefully selected panel of experts in the topic field. There are no studies that meet the criteria for inclusion in the literature review. April 27, 2007, Antalya

  10. Pitfalls in the interpretation of data regarding to the treatment The number of patients studied Retrospective trial Bias Heterogeneous patient populations No randomization April 27, 2007, Antalya

  11. From an oncological point of view • The potential benefit from metastasectomy and Detailed tumor evaluation Distant spread of the primary tumor The resectability of the metastases The resectability of the primary tumor The nodal involvement status April 27, 2007, Antalya

  12. Isolated metastasis • Solitary metastasis • Soliter metastasis • Oligometastasis • Single hematogenous distant metastasis April 27, 2007, Antalya

  13. To detect of the solitary metastasis(1) • The FN rate of the clinical evaluation in cI-II NSCLC pts is <5% • The FN rate of clinical evaluation for pts that include cIII NSLC is ~15-30% April 27, 2007, Antalya

  14. To detect of the solitary metastasis(2) • The FN rate of a contrast-enhanced brain CT for metastases in NSCLC pts is <10% • The FN rate of a bone scaning for metastases in NSCLC pts is ~ 4-6% • The FN rate of a contrast-enhanced liver CT for metastases in NSCLC pts is <10% April 27, 2007, Antalya

  15. To detect of the solitary metastasis(3) • The FN rate of the PET scaning for metastases in NSCLC pts is <8% April 27, 2007, Antalya

  16. To detect of the solitary metastasis(4) • Monoclonal antibodies to epithelial markers expressed in cancer cells have shown that occult tumor cells are often present in distant sites, even though they cannot be seen using conventional microscopy. • Occult metastasis has correlated with worse disease-free survival and a higher rate of recurrens. April 27, 2007, Antalya

  17. Most common sites of exthrathoracic metastases in NSCLC • Brain, bone, liver, adrenal glands • Lung, plevra, subcutaneous tissue April 27, 2007, Antalya

  18. Liver metastases from lung cancer:is surgical resection justified ?I. Di Carlo . Ann Thorac Surg 2003; 76: 291-3. • Resection of the liver for metastatic lesions has largely been done for secondary colorectal or neuroendocrine tumors, • Should it be considered whenever there is an isolated lesion. • A successful resection of an isolated secondary hepatic lesion from a lung primary tumor, which wasresected approximately 4 years beforehand April 27, 2007, Antalya

  19. Isolated solitary splenic metastasis of a pulmonary tumor: a successful surgicapproach in one stageA. Şanlı ve ark. Türk Göğüs Kalp Damar Cerrahisi Dergisi 2006; 14: 73-5. • T3N0M1 Lung adenocarcinoma, 64 years-old • Left posterolateral thoracotomy + Phrenotomy ,chest wall resection , left pneumonectomy ve splenectomy . • Adjuvant chemotherapy • Surgical approach in one stage April 27, 2007, Antalya

  20. The prognosis of the pts with brain metastasis is poor. • The results of surgical treatment of synchronous brain metastases along with the primary tumor is controversial April 27, 2007, Antalya

  21. Survival results of surgical resection of brain metastases and primary tumor (retrospective studies) April 27, 2007, Antalya

  22. Prognostic factors pts with NSCLC with syncronous, isolated brain metastases undergoing combined surgical treatment April 27, 2007, Antalya

  23. Surgical treatment of solitary adrenal metastasis from NSCLCO. Mercier.J Thorac Cardiovasc Surg 2005;130:136-140 • 1989 - 2003, 23 patients ( synchronous in 6 pts , metachronous in 17 pts. • The overall 5-year survival was 23.3% • All patients with a disease-free interval of less than 6 months died within 2 years of the operation. • Surgical resection of metachronous isolated adrenal metastasis with a DFI of greater than 6 months can provide long-term survival in patients previously undergoing complete resection of the primary NSCLC. April 27, 2007, Antalya

  24. Surgical treatment of solitary adrenal metastasis from NSCLC H. PorteAnn Thorac Surg 2001;71:981-985 • 43 pts ; 32 synchronously • Median survival was 11 months, and 3 patients survived more than 5 years • Survival was not affected by the histology of the NSCLC, TNM stage, any adjuvant and neoadjuvant treatment • No clinical or pathologic criteria were detected to identify patients amenable to potential cure. April 27, 2007, Antalya

  25. Adrenalectomy for solitary adrenal metastases from NSCLC.Pfannschmidt J. Lung Cancer 2005;49(2):203 • Between 1997 and 2000, • 11 pts (methacronous -6 pts-, Synchronous-5 pts-) • Pts with synchronous adrenal metastases MST; 10.3 m. April 27, 2007, Antalya

  26. Resected solitary adrenal metastasis from non-small cell lung cancer.Aranguren D. Lung Cancer 2005;49(2) S2:234 • 1984 to 2004 • 31 pts (14 synchronously) • R0; a median TTP of 7m, and a MST of 15 m. • Non-R0; TTP of 3m, and a MST of 12 m. • 7 (37%) resected pts alive at 3 years (4 synch, 3 meta) April 27, 2007, Antalya

  27. Pulmonary Metastases • The 1997 staging system classifies a satellite nodule of cancer that is within the same lobe as the primary tumor as T4(stage IIIb), and additional foci of cancer in different lobes as M1 (stage IV) April 27, 2007, Antalya

  28. Pulmonary Metastases • The classification of pulmonary metastases is difficult because of the existence of several factors that appear to influence patient outcome. -Pts with bronchioalveolar cancers -Pts with same-lobe satellite nodules April 27, 2007, Antalya

  29. Survival following resection of a primary lung cancer and a pulmonary metastasis Detterbeck FC.Lung Cancer. An evidence-based guide for the practicing clinician April 27, 2007, Antalya

  30. Survival following resection of a primary lung cancer and a pulmonary metastasis Detterbeck FC.Lung Cancer. An evidence-based guide for the practicing clinician • Yano et al ; 8 pts , 5-year survival 0% • Shimizu et al ; 5 pts, 5-year survival 20% • Fukuse et al ; 21 pts, 3-year survival 21% • Naruke et al ; 57 pts , 5-year survival 5% April 27, 2007, Antalya

  31. Prolonged survival after extracranial metastasectomy from synchronous resectable lung cancerV. Ambrogi Ann of Surg Oncology 2001:8;663 • 9 pts with NSCLC with synchronous, solitarymetastasis: adrenal (5), cutaneous (2), axillary lymph node (1),kidney (1). • 5-year survival rate was 55.6%. Five patients who had adrenal (3), or skin (1), or axillary (1) metastases, survived more than 5 years. All N2 patients (n = 2) died. • Unexpected, prolonged survival was demonstrated in our limited series April 27, 2007, Antalya

  32. Oligometastatic NSCLC: A Multidisciplinary Approach in the PET ScanEraT. M. De Pas, Ann Thorac Surg 2007;83:231-234 • Analyzed the data from 1509 pts who underwent surgical procedures for a primary NSCLC from 2000 to 2005 , after a work-up that included a PET scan. • Ten pts (0.7%) exhibited a solitary hematogenous metastasis. April 27, 2007, Antalya

  33. Oligometastatic NSCLC: A Multidisciplinary Approach in the PET ScanEraT. M. De Pas, Ann Thorac Surg 2007;83:231-234 • The data from 1,509 pts who underwent surgical procedıres for a primary NSCLC, after a workup that included a PET scan • 10 pts (0.7%) . The median overall survival was 26 months, and the median time to progression was 20 months; 6 patients were alive at the time of analysis, with a median follow-up of 30 months. April 27, 2007, Antalya

  34. Oligometastatic NSCLC: A Multidisciplinary Approach in the PET ScanEra T. M. De Pas, Ann Thorac Surg 2007;83:231-234 April 27, 2007, Antalya

  35. Clear data regarding this issue is lacking April 27, 2007, Antalya

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