Lung Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focuson the signs and symptoms of primary cancer, timely evaluation of the symptomaticpatient, appropriate preoperative evaluation for extent of disease, androle of the surgeon in diagnosis and treatment. Separate sections on adjuvanttherapy, follow-up programs, or management of recurrent cancer have beenintentionally omitted. Where appropriate, perioperative adjuvant combined-modalitytherapy is discussed under surgical management. Each guideline is presentedin minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aimof the Society, the extensive development cycle necessary to produce evidence-basedpractice guidelines did not apply. We used the broad clinical experienceresiding in the membership of the Society, under the direction of AlfredM. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering CancerCenter, to produce guidelines that were not likely to result in significantcontroversy.

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

The Society does not suggest that these guidelines replace good medicaljudgment. That always comes first. We do believe that the family physician,as well as the health maintenance organization director, will appreciatethe 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, recurrentpneumonia, 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 (fewweeks) symptoms suggestive of distant metastases

Preoperative Evaluation for Extent of Disease Complete history and physical examination

• Rule out local invasive manifestations and distant metastases (systemicor 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 suspecteddistant metastases
• Mediastinoscopy and/or mediastinotomy
• Bone scan
• CT scan of head (MRI if indicated)
• Percutaneous needle biopsy--for suspected metastases discovered onimaging (eg, pleura, lung, liver, adrenal gland, bone)
• Thoracoscopy

Role of Surgeon in Management Preoperative

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

Diagnostic procedures

• The surgeon must be totally adept at performing bronchoscopy (rigidand flexible), mediastinoscopy, mediastinotomy, and thoracoscopy, and isresponsible 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 havemediastinal lymph node disease, if consid- ered for ultimate surgical therapy,are usually placed on preoperative induction chemotherapy or chemoradiotherapyprotocols.
• Surgeon must be adept at all techniques of pulmonary resection andextended resections, including wedge resection, segmental resection, lobectomy,pneumonectomy, sleeve resections, en bloc chest wall resection, etc. Thesurgeon should be able to perform mediastinal lymph node dissections andmore complex resections, eg, resections for superior sulcus tumors, sleevepneumonectomies, 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 anyform without the express written permission of SSO. Requests for reprintsshould be sent to: James R. Slawny, Executive Director, Society of SurgicalOncology, 85 W Algonquin Road, Arlington Heights, IL 60005.

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

Cigarette smoking has been firmly implicated as the primary cause ofthis cancer. Other environmental pollutants that have been implicated includepassive smoking, radon exposure, and occupational exposure to polycyclicaromatic hydrocarbons, nickel, uranium, and asbestos. Most of these occupationalfactors act as cocarcinogens with smoking. There is a proven familial incidenceof this disease.

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

Staging

Lung cancer is divided into two major pathologic types: non-small-celllung cancer and small-cell lung cancer. With non-small-cell lung cancer,the TNM staging system (Table 1) hasbeen used to determine treatment modalities and ultimate survival. Withsmall-cell lung cancer, the distinction between limited (disease limitedto the thorax) and extensive (metastatic) disease determines treatmentand prognosis. Subdividing small-cell lung cancer into more specific TNMcategories, as are used for non-small-cell lung cancer, can further defineprognosis but has little impact on treatment decisions.

The survival rates at each stage are outlined in Table1. The overall survival of patients who develop lung cancer is lessthan 15%. However, up to 80% of patients with very early-stage lung cancer(T1, N0) can be cured by surgical resection. In stage II disease, the rateof 5 year-survival drops to 40% and in stage IIIa, it is only 10% to 40%.Only the occasional patient with stage IIIb and IV (solitary metastases)disease can be cured by surgical resection.

Symptoms

Most stage I disease presents as an asymptomatic nodule or mass on routinechest x-ray. Once the tumor has spread locally within the lung or intothe mediastinum, symptoms develop due to intrabronchial irritation or obstructionor compression of intrathoracic structures.

Treatment

The goal of diagnosis and clinical staging is to determine the besttreatment approach for the patient.

Non-Small-Cell Lung Cancer

Early-stage lung cancer (stages I, II, and selected IIIA) is best treatedby surgical excision, whenever possible. Once mediastinal lymph nodes areinvolved, however, the role of surgical resection is more questionable.

Multimodality approaches including preoperative chemotherapy are beinginvestigated. In more advanced local disease (stages IIIA and IIIB), radiotherapy,now frequently combined with chemotherapy, is the treatment of choice.Once metastatic disease develops (stage IV), chemotherapy is the best option,except for the occasional patient with a solitary site of metastasis, whowould be treated surgically.

The aim of surgery is a complete resection together with complete mediastinallymph node staging performed by sampling or mediastinal lymphadenectomy.The role of palliative resections in the treatment of lung cancer, withoutcurative intent, is extremely questionable.

The role of postoperative adjuvant therapy has yet to be conclusivelydetermined. Randomized trials have demonstrated that postoperative radiotherapyfollowing surgical resection of N1 or N2 disease will improve local controlwithout any significant impact on ultimate survival. Most postoperativeadjuvant chemotherapy trials have failed to demonstrate an improvementin survival regardless of the pathologic stage. In locally advanced lungcancer (N2 disease), there has been an apparent improvement in survivalwith the use of chemotherapy or chemoradiotherapy prior to surgical resection.

Small-Cell Lung Cancer

Small-cell lung cancer is treated primarily with chemotherapy plus radiotherapy.Occasionally surgery is used for "very limited" (stage I andII) disease. The role of surgery in small-cell lung cancer is usually limitedto small peripheral tumors, which are often not diagnosed until the timeof surgery. Surgical resection following by adjuvant chemotherapy yieldsup to a 50% 5-year survival in patients with stage I small-cell lung cancer.

Palliative Therapy

Palliative maneuvers used in lung cancer are aimed at relieving airwayobstruction, controlling life-threatening complications, and relievingdyspnea. These may include: bronchoscopic removal of endobronchial tumor,endobronchial brachytherapy, and endoscopic insertion of stents; palliativere- sections to relieve otherwise uncontrollable situations (eg, massivehemoptysis or unrelenting lung abscesses); and relief of symptomatic pleuraleffusions by thoracentesis, thoracostomy drainage and sclerosis, shuntprocedures, or, rarely, decortication.

References:

American Joint Committee: Manual for Staging of Cancer, 4th ed. Chicago,American Joint Committee on Cancer, 1992.

Dillman RO, Seagren SL, Propert KJ, et al: A randomized trial of inductionchemo plus high- dose radiation versus radiation alone in stage III non-smallcell lung cancer. N Engl J Med 323(14):940-945, 1990.

Eddy DM: Screening for lung cancer. Ann Intern Med 111:232-237, 1989.

Flehinger BJ, Kimmel M, Melamed MR: The effect of surgical treatmentand survival from early lung cancer. Implications for screening. Chest101:1013-1018, 1992.

Pearson FG, Deslauriers J, Ginsberg RJ, et al (eds): Thoracic Surgery.New York,Churchill Livingstone, 1995.

Roth JA, Fossella F, Komaki R, et al: A randomized trial comparing perioperativechemotherapy and surgery with surgery alone in resectable stage IIIa non-smallcell lung cancer. J Nat Cancer Inst 86:673-680, 1994

Shepherd FA, Ginsberg RJ, Patterson GA, et al for The University ofToronto Lung Oncology Group: A prospective study of adjuvant surgical resectionafter chemotherapy for limited SCLC. J Thorac Cardiovasc Surg 97:177-186,1989.