Is Surgery Still the Best Option for Early Stage NSCLC?
Is Surgery Still the Best Option for Early Stage NSCLC?
Adequate patient selection is crucial to obtain long-term results when any local modality of lung cancer treatment is used. In this context, correct clinical and pathological staging represents a tenet of modern thoracic surgery. Guidelines have proposed to effect standardized protocols for both preoperative and intraoperative staging. The quest for the identification of subsets of mediastinal nodal involvement amenable to primary surgery has provided important practical consequences. As an example, in Europe, occult as well as single station N2 NSCLC are now increasingly considered a surgical disease given the encouraging survival rates reported in surgical series. Minimally invasive techniques, especially VATS, enable surgeons to solve clinical dilemmas with staging procedures which can be performed under locoregional anesthesia. Operations effected via single port (uniportal) VATS are used to distinguish between T2 and T3 or N2 and N3 when EBUS and mediastinoscopy are not helpful or cannot be technically carried out. In the setting of prethoracotomy exploration of the mediastinum, video assisted mediastinal lymphadenectomy (VAMLA) and trascervical extended mediastinal lymphadenectomy (TEMLA) represent another example of single port surgery which can be used to better select surgical candidates for lung resection. The whole staging-based prognostic infrastructure of oncologic treatment modalities is the guiding principle for the selection of surgery for early stage lung cancer. Without histological confirmation, only clinical stages can be compared between treatment yielding an apparent outcome equipoise; this is particularly relevant if one thinks that regional failures after SBRT may account to 15% and mediastinal failures can be found in 7.5% of the patients originally treated with ablative radiation. To further complicate this issue, it has been reported that histological confirmation of lung cancer patients treated with SBRT is needed in only 35% of the patient population. To justify this paradigm shift not yet supported by conventional collected evidence (i.e., prospective, randomized trials-see above), a theoretical pathway leading to SBRT-led treatment of early stage lung cancer has been put forward which includes ad hoc interpretation of current guidelines, PET driven decision analysis, extremely conservative estimate of patients' preoperative cardio-respiratory reserve or the adoption of somewhat vague and unconventional terminology (i.e., pulmonary insufficiency) when defining operability, and the accidental inattention to thoracic surgical input into tumor boards. However, the quality issues in SBRT administration are partially counterbalanced by similar pitfalls of surgical treatment. Indeed, advocates of SBRT emphasize the non homogeneous quality of surgery outside clinical trials, especially in terms of intraoperative nodal sampling or dissection. The thoracic surgical community is taking action and a more rigorous attitude towards mediastinal lymphadenectomy is currently advised.
Correct Staging
Adequate patient selection is crucial to obtain long-term results when any local modality of lung cancer treatment is used. In this context, correct clinical and pathological staging represents a tenet of modern thoracic surgery. Guidelines have proposed to effect standardized protocols for both preoperative and intraoperative staging. The quest for the identification of subsets of mediastinal nodal involvement amenable to primary surgery has provided important practical consequences. As an example, in Europe, occult as well as single station N2 NSCLC are now increasingly considered a surgical disease given the encouraging survival rates reported in surgical series. Minimally invasive techniques, especially VATS, enable surgeons to solve clinical dilemmas with staging procedures which can be performed under locoregional anesthesia. Operations effected via single port (uniportal) VATS are used to distinguish between T2 and T3 or N2 and N3 when EBUS and mediastinoscopy are not helpful or cannot be technically carried out. In the setting of prethoracotomy exploration of the mediastinum, video assisted mediastinal lymphadenectomy (VAMLA) and trascervical extended mediastinal lymphadenectomy (TEMLA) represent another example of single port surgery which can be used to better select surgical candidates for lung resection. The whole staging-based prognostic infrastructure of oncologic treatment modalities is the guiding principle for the selection of surgery for early stage lung cancer. Without histological confirmation, only clinical stages can be compared between treatment yielding an apparent outcome equipoise; this is particularly relevant if one thinks that regional failures after SBRT may account to 15% and mediastinal failures can be found in 7.5% of the patients originally treated with ablative radiation. To further complicate this issue, it has been reported that histological confirmation of lung cancer patients treated with SBRT is needed in only 35% of the patient population. To justify this paradigm shift not yet supported by conventional collected evidence (i.e., prospective, randomized trials-see above), a theoretical pathway leading to SBRT-led treatment of early stage lung cancer has been put forward which includes ad hoc interpretation of current guidelines, PET driven decision analysis, extremely conservative estimate of patients' preoperative cardio-respiratory reserve or the adoption of somewhat vague and unconventional terminology (i.e., pulmonary insufficiency) when defining operability, and the accidental inattention to thoracic surgical input into tumor boards. However, the quality issues in SBRT administration are partially counterbalanced by similar pitfalls of surgical treatment. Indeed, advocates of SBRT emphasize the non homogeneous quality of surgery outside clinical trials, especially in terms of intraoperative nodal sampling or dissection. The thoracic surgical community is taking action and a more rigorous attitude towards mediastinal lymphadenectomy is currently advised.
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