Lung Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative evaluation for extent of disease, and role of the surgeon in diagnosis and treatment. Separate sections on adjuvant therapy, follow-up programs, or management of recurrent cancer have been intentionally omitted. Where appropriate, perioperative adjuvant combined-modality therapy is discussed under surgical management. Each guideline is presented in minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aim of the Society, the extensive development cycle necessary to produce evidence-based practice guidelines did not apply. We used the broad clinical experience residing in the membership of the Society, under the direction of Alfred M. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer Center, to produce guidelines that were not likely to result in significant controversy.

Following each guideline is a brief narrative highlighting and expanding on selected sections of the guideline document, with a few relevant references. The current staging system for the site and approximate 5-year survival data are also included.

The Society does not suggest that these guidelines replace good medical judgment. That always comes first. We do believe that the family physician, as well as the health maintenance organization director, will appreciate the provision of these guidelines as a reference for better patient care.

Society of Surgical Oncology Practice Guidelines: Lung Cancer

Symptoms and Signs

Early-stage disease

• Asymptomatic--abnormal chest x-ray
• Intrabronchial symptoms--cough, hemoptysis, wheeze, stridor, recurrent pneumonia, shortness of breath
• Paraneoplastic syndromes (eg, clubbing)

Advanced-stage disease

• Locally advanced--hoarseness, hiccups, chest pain, Pancoast syndrome, superior vena cava syndrome
• Distant metastases--neurologic symptoms/signs, bone pain, weight loss, generalized debility

Evaluation of the Symptomatic Patient

Diagnosis

• Chest x-ray
• CT scan

Cytologic or histologic confirmation

• Sputum cytology
• Bronchoscopy--cytologic washings, brushings, biopsy, needle aspiration
• Transthoracic needle aspiration biopsy
• Mediastinoscopy or mediastinotomy
• Thoracoscopy or thoracotomy
• Timeliness--evaluation of all patients with persistent (few weeks) symptoms suggestive of distant metastases

Preoperative Evaluation for Extent of Disease

Complete history and physical examination

• Rule out local invasive manifestations and distant metastases (systemic or nodal).
• Evaluate all symptoms suggestive of metastatic disease.

Chest x-ray

CT scan

• Chest and upper abdomen to include adrenal glands

Further studies

• Depend on determination from above of locally advanced disease or suspected distant metastases
• Mediastinoscopy and/or mediastinotomy
• Bone scan
• CT scan of head (MRI if indicated)
• Percutaneous needle biopsy--for suspected metastases discovered on imaging (eg, pleura, lung, liver, adrenal gland, bone)
• Thoracoscopy

Role of Surgeon in Management

Preoperative

• The surgeon may be responsible for all preoperative assessment, including diagnostic and extent of disease work-ups and cardiopulmonary assessments.

Diagnostic procedures

• The surgeon must be totally adept at performing bronchoscopy (rigid and flexible), mediastinoscopy, mediastinotomy, and thoracoscopy, and is responsible for clinically staging the tumor.

Surgical considerations

• Curative resection, ie, complete excision of tumor. Intentional palliative (incomplete) resections are not commonly indicated. Patients shown to have mediastinal lymph node disease, if consid- ered for ultimate surgical therapy, are usually placed on preoperative induction chemotherapy or chemoradiotherapy protocols.
• Surgeon must be adept at all techniques of pulmonary resection and extended resections, including wedge resection, segmental resection, lobectomy, pneumonectomy, sleeve resections, en bloc chest wall resection, etc. The surgeon should be able to perform mediastinal lymph node dissections and more complex resections, eg, resections for superior sulcus tumors, sleeve pneumonectomies, and vascular sleeve resections.

These guidelines are copyrighted by the Society of Surgical Oncology (SSO). All rights reserved. These guidelines may not be reproduced in any form without the express written permission of SSO. Requests for reprints should be sent to: James R. Slawny, Executive Director, Society of Surgical Oncology, 85 W Algonquin Road, Arlington Heights, IL 60005.

Lung cancer is the most common cause of cancer death for both men and women in North America. The age-adjusted incidence is 60 cases per 100,000 people, but by age 70 in males incidence exceeds 500 cases per 100,000.

Cigarette smoking has been firmly implicated as the primary cause of this cancer. Other environmental pollutants that have been implicated include passive smoking, radon exposure, and occupational exposure to polycyclic aromatic hydrocarbons, nickel, uranium, and asbestos. Most of these occupational factors act as cocarcinogens with smoking. There is a proven familial incidence of this disease.

Despite the well-known etiologic factors, attempts at mass screening of high-risk individuals using annual sputum cytology and chest x-ray have failed to improve ultimate survival from lung cancer, although early cases can be detected by such screening.