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Surgery_Schwartz. metastasis, the patient can be schedule for VATS biopsy and lobectomy under the same anesthesia; the procedure begins by sampling the level 5 and 6 nodes for frozen section, and if the nodes are negative, the anatomic lung resection is performed. If the index of suspicion is high, the VATS biopsy is performed as a separate procedure. Cervical mediastinoscopy should precede VATS biopsy, even if patients have normal para-tracheal lymph nodes. Additional diagnostic evaluation of the lymph nodes in stations 5 and 6 may be unnecessary if the mediastinal lymph nodes are proven to be benign with biopsy during cervical mediastinoscopy and the preoperative CT scan suggests complete respectability of the tumor. There are, however, several indications for prethoracotomy biopsy of stations 5 and 6 lymph nodes, which are listed in Table 19-10. It is particularly important to prove that mediastinal lymph nodes are pathologically involved and not just radio-graphically suspicious for nodal


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Surgery_Schwartz. and 6 lymph nodes, which are listed in Table 19-10. It is particularly important to prove that mediastinal lymph nodes are pathologically involved and not just radio-graphically suspicious for nodal metastasis prior to deciding that the patient is not a candidate for resection.Pleural Effusion. The presence of pleural effusion on radio-graphic imaging should not be assumed to be malignant. Pleural effusion may be secondary to atelectasis or consolidation (seen with central tumors), cardiac dysfunction, or may be a reac-tive effusion. When associated with a peripherally based tumor abutting the visceral or parietal pleural surface, probability of being malignant is higher. If this is the only site concerning for metastatic disease, pathologic confirmation is mandatory. It is reasonable to start with thoracentesis, but cytology reveals malignant cells in only 50% of malignant effusions on initial thoracentesis; negative cytology 5 times is needed to have 95% certainty of a benign


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Surgery_Schwartz. to start with thoracentesis, but cytology reveals malignant cells in only 50% of malignant effusions on initial thoracentesis; negative cytology 5 times is needed to have 95% certainty of a benign process. Thoracoscopy may be needed to rule out pleural metastases in select patients and is usually per-formed as a separate staging procedure, often with subsequent mediastinoscopy if thoracoscopy is negative for metastasis.Distant Metastases. Currently, chest CT and PET are rou-tine in the evaluation of patients with lung cancer. Integrated PET-CT scanners have become standard and have substan-tially improved accuracy of detection and localization of lymph node and distant metastases, as compared with independently performed PET and CT scans (Fig. 19-21). This technology overcomes the imprecise information on the exact location of focal abnormalities seen on PET and has become the standard imaging modality for lung cancer. Compared to routine chest or abdominal CT and bone scans, PET


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Surgery_Schwartz. information on the exact location of focal abnormalities seen on PET and has become the standard imaging modality for lung cancer. Compared to routine chest or abdominal CT and bone scans, PET scanning detects 10% to 15% more distant metastases, but should be confirmed with MRI and/or biopsies if the patient otherwise has early-stage dis-ease. Brain MRI should be performed when the suspicion or risk of brain metastases is increased, such as in patients with Brunicardi_Ch19_p0661-p0750.indd 68801/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19689CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAABCFigure 19-21. Imaging of non–small cell lung cancer by integrated positron emission tomography (PET)-computed tomography (CT) scan. A. CT of the chest showing a tumor in the left upper lobe. B. PET scan of the chest at the identical cross-sectional level. C. Coregistered PET-CT scan clearly showing tumor invasion (con-firmed intraoperatively). (Adapted with permission from Lardinois D, Weder W, Hany TF, et al. Staging of non-small-cell lung can-cer with integrated positron-emission tomography and computed tomography, N Engl J Med. 2003 Jun 19;348(25):2500-2507.)clinical stage III disease. In the absence of neurologic symp-toms or signs, the probability of a negative head CT scan is 95%. Liver abnormalities that are not clearly simple cysts or hemangiomas and adrenal enlargement, nodules, or masses are further evaluated by MRI scanning and, occasionally, by needle biopsy. Adrenal adenomas have a high lipid content (secondary to


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Surgery_Schwartz. cysts or hemangiomas and adrenal enlargement, nodules, or masses are further evaluated by MRI scanning and, occasionally, by needle biopsy. Adrenal adenomas have a high lipid content (secondary to steroid production), but metastases and most primary adrenal malignancies contain little if any lipid; thus, MRI is usually able to distinguish the two.Tumor, Node, and Metastasis: Lung Cancer Staging The staging of any tumor is an attempt to estimate the extent of dis-ease and determine the patient’s prognosis; in a given patient, tumors are typically classified into a clinical stage and a patho-logic stage. Clinical staging includes history and physical examination, radiographic test results, and diagnostic biopsy information. Therapeutic plans are generated based on clinical stage. After surgical resection of tumor and lymph nodes, post-operative pathologic stage (pTNM) is determined, providing further prognostic information.The staging of solid epithelial tumors is based on the TNM


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Surgery_Schwartz. surgical resection of tumor and lymph nodes, post-operative pathologic stage (pTNM) is determined, providing further prognostic information.The staging of solid epithelial tumors is based on the TNM staging system. The primary tumor “T” status provides infor-mation about tumor size and relationship to surrounding struc-tures; the “N” status provides information about regional lymph nodes; and the “M” status provides information about the pres-ence or absence of metastatic disease. The designation of lymph nodes as N1, N2, or N3 requires familiarity with the lymph node mapping system41 (see Fig. 19-8). Based on clearly delineated anatomic boundaries, accurate and reproducible localization of thoracic lymph nodes is possible, facilitating detailed nodal staging for individual patients and standardization of nodal assessment between surgeons.Pathologic staging criteria are based on the predicted sur-vival relative to each combination of tumor, node, and metas-tasis status. In 2018, the


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Surgery_Schwartz. standardization of nodal assessment between surgeons.Pathologic staging criteria are based on the predicted sur-vival relative to each combination of tumor, node, and metas-tasis status. In 2018, the AJCC eighth edition incorporated multiple changes into the staging system for NSCLC based on analysis of survival predictors from 77,156 lung cancer patients worldwide. Table 19-11a shows the clinical and pathologic cri-teria changes implemented and each of the TNM descriptors currently used in staging NSCLC (Table 19-11b) and the over-all stage classifications (Table 19-11c). T-staging is markedly changed, including T category designation for each centimeter in size up to 5 cm, as well as size of the invasive component in lepidic growth tumors. Visceral pleural invasion increases T-stage to T2 for patients with tumors ≤3 cm in size, and syn-chronous primary tumors have an added T suffix (m) in tumor staging. Metastatic disease has also been subdivided into intra-thoracic, single-site


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Surgery_Schwartz. to T2 for patients with tumors ≤3 cm in size, and syn-chronous primary tumors have an added T suffix (m) in tumor staging. Metastatic disease has also been subdivided into intra-thoracic, single-site extrathoracic, and multiple extrathoracic metastasis. In addition to the TNM stage, it is recommended that histologic grade, lymphovascular invasion, adequacy of resec-tion margins and mediastinal dissection, tumor mutation status, treatment, and residual tumor after treatment also be recorded into cancer registries to facilitate evaluation of these potential predictors in future analysis of staging criteria.Staging for small cell lung cancer (SCLC) is typically based on the extent of disease. SCLC presenting with bulky locoregional disease confined to the ipsilateral hemithorax, with no evidence for distant metastatic disease, is termed “limited” SCLC. Limited disease must be treatable within a tolerable field of radiation. Using AJCC descriptors, this includes any T stage, any N stage,


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Surgery_Schwartz. for distant metastatic disease, is termed “limited” SCLC. Limited disease must be treatable within a tolerable field of radiation. Using AJCC descriptors, this includes any T stage, any N stage, without metastatic disease (M0). The only excep-tion is when multiple lung nodules are widely spread throughout the ipsilateral lung in the same hemithorax; in these patients, the size of the involved area would preclude a “safe” radiation field. In contrast, in “disseminated” disease, tumor is beyond the ipsi-lateral hemithorax or widely spread within the ipsilateral lung and to distant sites. Metastases to the pleura and pericardium, with resultant effusions, are considered disseminated disease. Brunicardi_Ch19_p0661-p0750.indd 68901/03/19 7:01 PM 690SPECIFIC CONSIDERATIONSPART IITable 19-11aChanges in Descriptors for non-small cell lung cancer comparing the 7th and 8th editions of the American Joint Committee on Cancer Staging ManualDESCRIPTORSEVENTH EDITIONEIGHTH EDITIONT component0 cm


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Surgery_Schwartz. in Descriptors for non-small cell lung cancer comparing the 7th and 8th editions of the American Joint Committee on Cancer Staging ManualDESCRIPTORSEVENTH EDITIONEIGHTH EDITIONT component0 cm (pure lepidic adenocarcinoma ≤3 cm total size)T1a if ≤2 cm; T1b if >2–3 cmTis (AIS)≤0.5 cm invasive size (lepidic predominant adenocarcinoma ≤3 cm total size)T1a if ≤2 cm; T1b if >2–3 cmT1mi≤1 cmT1aT1a>1–2 cmT1aT1b>2–3 cmT1bT1c>3–4 cmT2aT2a>4–5 cmT2aT2b>5–7 cmT2bT3>7 cmT3T4Bronchus <2 cm from carinaT3T2Total atelectasis/pneumonitisT3T2Invasion of diaphragmT3T4Invasion of mediastinal pleuraT3-N componentNo assessment, no involvement, or involvement of regional lymph nodesNX, N0, N1, N2, N3No changeM componentMetastases within the thoracic cavityM1aM1aSingle extrathoracic metastasisM1bM1bMultiple extrathoracic metastasesM1bM1cAbbreviations: AIS, adenocarcinoma in situ; mi, minimally invasive adenocarcinoma; Tis, tumor in situ.Modified with permission from Rami-Porta R, Asamura H, Travis WD, et al:


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Surgery_Schwartz. metastasesM1bM1cAbbreviations: AIS, adenocarcinoma in situ; mi, minimally invasive adenocarcinoma; Tis, tumor in situ.Modified with permission from Rami-Porta R, Asamura H, Travis WD, et al: Lung cancer — major changes in the American Joint Committee on Cancer eighth edition cancer staging manual, A Cancer J Clin. 2017 Mar;67(2):138-155.(Continued)Table 19-11bAmerican Joint Committee on Cancer Lung Cancer Staging Eight EditionTPRIMARY TUMORTXPrimary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopyT0No evidence of primary tumorTisCarcinoma in situSquamous cell carcinoma in situ (SCIS)Adenocarcinoma in situ (AIS); adenocarcinoma with pure lepidic pattern, ≤3 cm in greatest dimensionT1Tumor ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) T1miMinimally


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Surgery_Schwartz. ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) T1miMinimally invasive adenocarcinoma: adenocarcinoma (≤3 cm in greatest dimension) with a predominantly lepidic pattern and ≤5 mm invasion in greatest dimension T1aTumor ≤1 cm in greatest dimension. A superficial, spreading tumor of any size whose invasive component is limited to the bronchial wall and may extend proximal to the main bronchus also is classified as T1a, but these tumors are uncommon. T1bTumor >1 cm but ≤2 cm in greatest dimension T1cTumor >2 cm but ≤3 cm in greatest dimensionT2Tumor >3 cm but ≤5 cm or having any of the following features:• Involves the main bronchus regardless of distance to the carina, but without involvement of the carina• Invades visceral pleura (PL1 or PL2)• Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all


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Surgery_Schwartz. the carina, but without involvement of the carina• Invades visceral pleura (PL1 or PL2)• Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lungT2 tumors with these features are classified as T2a if ≤4 cm or if the size cannot be determined and T2b if >4 cm but ≤5 cm.Brunicardi_Ch19_p0661-p0750.indd 69001/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19691CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATable 19-11cStage Group in the 8th AJCC Tumor, Node, Metastasis staging systemN0N1N2N3T1/M0T1aIA1IIBIIIAIIIBT1bIA2IIBIIIAIIIBT1cIA3IIBIIIAIIIBT2/M0T2aIBIIBIIIAIIIBT2bIIAIIBIIIAIIIBT3/M0IIBIIIAIIIBIIICT4/M0IIIAIIIAIIIBIIICTX/M1M1aIVAIVAIVAIVAM1bIVAIVAIVAIVAM1cIVBIVBIVBIVBUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 19-11bAmerican Joint Committee on Cancer Lung Cancer Staging Eight Edition T2aTumor >3 cm but ≤4 cm in greatest dimension T2bTumor >4 cm but ≤5 cm in greatest dimensionT3Tumor >5 cm but ≤7 cm in greatest dimension or directly invading any of the following: parietal pleura (PL3), chest wall (including superior sulcus tumors), phrenic nerve, parietal pericardium; or separate tumor nodule(s) in the same lobe as the primaryT4Tumor >7 cm or tumor of any size invading one or more of the following:


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Surgery_Schwartz. superior sulcus tumors), phrenic nerve, parietal pericardium; or separate tumor nodule(s) in the same lobe as the primaryT4Tumor >7 cm or tumor of any size invading one or more of the following: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; separate tumor nodule(s) in an ipsilateral lobe different from that of the primaryNREGIONAL LYMPH NODENXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extensionN2Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)N3Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)MDISTANT METASTASISM0No distant metastasisM1Distant metastasis M1aSeparate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial


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Surgery_Schwartz. scalene, or supraclavicular lymph node(s)MDISTANT METASTASISM0No distant metastasisM1Distant metastasis M1aSeparate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodules or malignant pleural or pericardial effusion. Most pleural (pericardial) effusions with lung cancer are a result of the tumor. In a few patients, however, multiple microscopic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is nonbloody and not an exudate. If these elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging descriptor. M1bSingle extrathoracic metastasis in a single organ (including involvement of a single nonregional node) M1cMultiple extrathoracic metastases in a single organ or in multiple organsUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Metastases


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Surgery_Schwartz. or in multiple organsUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Metastases to brain, bone, bone marrow, and the pleural and pericardial spaces are common.Assessment of Functional Status Patients with potentially resectable tumors require careful assessment of their functional status and ability to tolerate either lobectomy or pneumonectomy. The surgeon should first estimate the likelihood of pneumonec-tomy, lobectomy, or possibly sleeve resection, based on the CT images. A sequential process of evaluation then unfolds.5A patient’s history is the most important tool for gauging risk. Specific questions regarding performance status should be routinely asked. If the patient can walk on a flat surface indefi-nitely, without oxygen and without having to stop and rest sec-ondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two


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Surgery_Schwartz. can walk on a flat surface indefi-nitely, without oxygen and without having to stop and rest sec-ondary to dyspnea, he will be very likely to tolerate lobectomy. If the patient can walk up two flights of stairs (up two stan-dard levels), without having to stop and rest secondary to dys-pnea, she will likely tolerate pneumonectomy. Finally, nearly (Continued)Brunicardi_Ch19_p0661-p0750.indd 69101/03/19 7:01 PM 692SPECIFIC CONSIDERATIONSPART IIPercent mortalityppoDLCO%504030201002030405060708090100Figure 19-22. Operative mortality after major pulmonary resec-tion for non–small cell lung cancer (334 patients) as a function of percent predicted postoperative carbon monoxide diffusion capacity (ppoDlco%). Solid line indicates logistic regression model; dashed lines indicate 95% confidence limits. (Reproduced with permission from Wang J, Olak J, Ferguson MK: Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer, J Thorac Cardiovasc


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Surgery_Schwartz. limits. (Reproduced with permission from Wang J, Olak J, Ferguson MK: Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer, J Thorac Cardiovasc Surg. 1999 Mar;117(3):581-586.)all patients, except those with carbon dioxide (CO2) retention on arterial blood gas analysis, will be able to tolerate periods of single-lung ventilation and wedge resection. Formal assess-ment of cardiac fitness is mandatory; use of risk scores such as the Thoracic Revised Cardiac Risk Index developed by Dr. Brunelli and colleagues provides useful prognostic infor-mation for postresection survival from early-stage lung cancer.Current smoking status and sputum production are also pertinent. Current smokers and patients with a greater than 60 pack-year history of smoking have a significantly increased risk of postoperative pulmonary complications; heavy smokers are 2.5 times more likely to develop pulmonary complications and three times more likely to


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Surgery_Schwartz. of smoking have a significantly increased risk of postoperative pulmonary complications; heavy smokers are 2.5 times more likely to develop pulmonary complications and three times more likely to develop pneumonia compared to patients with a ≤60 pack-year history (odds ratio [OR] 2.54; 95% CI 1.28–5.04; P = .0008). Impaired exchange of CO2 is also pre-dictive of increased risk, independent of the smoking history. For every 10% decline in percent carbon monoxide diffusion capac-ity (%Dlco), the risk of any pulmonary complication increased by 42% (OR 1.42; 95% CI 1.16–1.75; P = .008).42 Risk reduc-tion requires smoking cessation at least 8 weeks preoperatively, a requirement that is often not feasible in a cancer patient. Nev-ertheless, abstinence for at least 2 weeks before surgery should be encouraged. Smoking cessation on the day of surgery leads to increased sputum production and potential secretion reten-tion postoperatively, and some authors have reported increased rates of


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Surgery_Schwartz. be encouraged. Smoking cessation on the day of surgery leads to increased sputum production and potential secretion reten-tion postoperatively, and some authors have reported increased rates of pulmonary complications in this group.43 Patients with chronic daily sputum production will have more problems post-operatively with retention and atelectasis; they are also at higher risk for pneumonia. Sputum culture, antibiotic administration, and bronchodilators may be warranted preoperatively.Pulmonary function studies are routinely performed when any resection greater than a wedge resection will be performed. Of all the measurements available, the two most valuable are forced expiratory volume in 1 second (FEV1) and carbon mon-oxide diffusion capacity (Dlco). General guidelines for the use of FEV1 in assessing the patient’s ability to tolerate pulmonary resection are as follows: greater than 2.0 L can tolerate pneumo-nectomy, and greater than 1.5 L can tolerate lobectomy. It must be


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Surgery_Schwartz. of FEV1 in assessing the patient’s ability to tolerate pulmonary resection are as follows: greater than 2.0 L can tolerate pneumo-nectomy, and greater than 1.5 L can tolerate lobectomy. It must be emphasized that these are guidelines only. It is also important to note that the raw value is often imprecise because normal values are reported as “percent predicted” based on corrections made for age, height, and gender. For example, a raw FEV1 value of 1.3 L in a 62-year-old, 75-inch (190-cm) male has a percent predicted value of 30% (because the normal expected value is 4.31 L); in a 62-year-old, 62-inch female, the predicted value is 59% (normal expected value 2.21 L). The male patient is at high risk for lobectomy, while the female could potentially tolerate pneumonectomy.To calculate the predicted postoperative value for FEV1 or Dlco, the percent predicted value of FEV1 or Dlco is mul-tiplied by the fraction of remaining lung after the proposed sur-gery. For example, with a planned


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Surgery_Schwartz. predicted postoperative value for FEV1 or Dlco, the percent predicted value of FEV1 or Dlco is mul-tiplied by the fraction of remaining lung after the proposed sur-gery. For example, with a planned right upper lobectomy, a total of three segments will be removed. Therefore, three of a total 20 segments will leave the patient with (20 – 3/20) × 100 = 85% of their original lung capacity. In the two patients mentioned ear-lier, the man will have a predicted postoperative FEV1 of 30% × 0.85 = 25%, whereas the woman will have a predicted postop-erative FEV1 of 50%. Percent predicted value of less than 50% for either FEV1 or Dlco correlates with risk for postoperative complications, particularly pulmonary complications; the risk of complications increases in a stepwise fashion for each 10% decline. Figure 19-22 shows the relationship between predicted postoperative Dlco and estimated operative mortality.Quantitative perfusion scanning is used in select circum-stances to help estimate the


Surgery_Schwartz

Surgery_Schwartz. Figure 19-22 shows the relationship between predicted postoperative Dlco and estimated operative mortality.Quantitative perfusion scanning is used in select circum-stances to help estimate the functional contribution of a lobe or whole lung. Such perfusion scanning is most useful when the impact of a tumor on pulmonary physiology is difficult to discern. With complete collapse of a lobe or whole lung, the impact is apparent, and perfusion scanning is usually unneces-sary. Figure 19-23 shows a tumor with significant right main stem airway obstruction with associated atelectasis and volume loss of the right lung. At presentation, the patient was dyspneic with ambulation, and the FEV1 was 1.38 L. Six months prior, this patient could walk up two flights of stairs without dyspnea. The surgeon can anticipate that the patient will tolerate pneumo-nectomy because the lung is already not functioning due to main stem airway obstruction, and may, in fact, be contributing to a shunt. However,


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Surgery_Schwartz. can anticipate that the patient will tolerate pneumo-nectomy because the lung is already not functioning due to main stem airway obstruction, and may, in fact, be contributing to a shunt. However, with centrally located tumors associated with partial obstruction of a lobar or main bronchus or of the pulmo-nary artery, perfusion scanning may be valuable in predicting the postoperative result of resection. For example, if the quan-titative perfusion to the right lung is measured to be 21% (nor-mal is 55%) and the patient’s percent predicted FEV1 is 60%, the predicted postoperative FEV1 after a right pneumonectomy would be 60% × 0.79 = 47%, indicating the ability to tolerate pneumonectomy. If the perfusion value is 55%, the predicted postoperative value would be 27%, and pneumonectomy would pose a significantly higher risk.It is not uncommon to encounter patients with significant reductions in their percent predicted FEV1 and Dlco whose his-tory shows a functional status that is


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Surgery_Schwartz. would pose a significantly higher risk.It is not uncommon to encounter patients with significant reductions in their percent predicted FEV1 and Dlco whose his-tory shows a functional status that is inconsistent with the pul-monary function tests. In these circumstances, exercise testing that yields maximal oxygen consumption (v. o2max ) has emerged as a valuable decision-making technique to help patients with abnormal FEV1 and Dlco (Table 19-12). Values <10 mL/kg/min are associated with a 26% mortality after major pulmonary Brunicardi_Ch19_p0661-p0750.indd 69201/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19693CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-23. Chest computed tomography scan of an obstructing right main stem lung tumor. Arrow indicates location of right main bron-chus. The right lung volume is much less than the left lung volume.Table 19-12Relation between maximum oxygen consumption (v. o2max) as determined by preoperative exercise testing and perioperative mortalitySTUDYDEATHS/TOTALv. o2max 10–15 mL/kg per minute Smith et al1961/6 (33%) Bechard and Wetstein1970/15 (0%) Olsen et al1981/14 (7.1%) Walsh et al1991/5 (20%) Bolliger et al2002/17 (11.7%) Markos et al2011/11 (9.1%) Wang et al2020/12 (0%) Win et al2032/16 (12.5%) Total8/96 (8.3%)v. o2max <10 mL/kg per minute Bechard and Wetstein1972/7 (29%) Olsen et al1983/11 (27%) Holden et al2042/4 (50%) Markos et al2010/5 (0%) Total7/27 (26%)Reproduced with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP


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Surgery_Schwartz. al2010/5 (0%) Total7/27 (26%)Reproduced with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):161S-177S.resection compared to only 8.3% with v. o2max ≥10 mL/kg/min. Values >15 mL/kg/min generally indicate the patient’s ability to tolerate pneumonectomy.The risk assessment of a patient is an amalgam of clinical judgment and data that must be integrated with the experienced clinician’s sense of the patient and with the patient’s attitude 6toward the disease and toward life. Figure 19-24 provides a useful algorithm for determining suitability for lung resection.44Lung Cancer TreatmentGrade IV NEC (Small Cell) Lung Carcinoma. In rare cir-cumstances where SCLC presents as an isolated lung lesion, lobectomy followed by chemotherapy is warranted after sur-gical mediastinal staging has confirmed the


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Surgery_Schwartz. Cell) Lung Carcinoma. In rare cir-cumstances where SCLC presents as an isolated lung lesion, lobectomy followed by chemotherapy is warranted after sur-gical mediastinal staging has confirmed the absence of N2 disease. Often, ultrasound-guided FNA provides a definitive positive diagnosis and more invasive approaches are not needed. However, less than 5% are stage I, and there is no benefit from surgical resection for more advanced-stage disease; treatment is chemotherapy with or without radiation therapy depending on the extent of disease and the patient performance status.Early-Stage Non–Small Cell Lung Cancer. Early-stage disease includes T1 and T2 tumors (with or without N1 nodal involvement) and T3 tumors (without N1 nodal involvement). This group represents a small but increasing proportion of the total number of patients diagnosed with lung cancer each year (approximately 16% of an estimated 222,500 patients in 2017).18 Surgical resection is the current standard, ideally


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Surgery_Schwartz. proportion of the total number of patients diagnosed with lung cancer each year (approximately 16% of an estimated 222,500 patients in 2017).18 Surgical resection is the current standard, ideally accomplished by video-assisted lobectomy or pneumonectomy, depending on the tumor location.Despite the term “early-stage,” the overall 5-year sur-vival rate for all localized lung cancer is 55% and only 26% when regional metastasis was present between 2004 and 2009.45 Median survival for untreated patients with stage IA NSCLC is 14 months, and 5-year survival rate is 22%.46 After surgical resection of postoperative pathologic stage IA disease, 5-year survival is better than with no treatment, but still only 67%.41 Survival declines with higher stages. Advanced age at diagno-sis, male sex, low socioeconomic status, nonsurgical treatment, and poor histologic grade are associated with increased mortal-ity risk on multivariate analysis.45Depending on tumor size and location, lobectomy, sleeve


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Surgery_Schwartz. socioeconomic status, nonsurgical treatment, and poor histologic grade are associated with increased mortal-ity risk on multivariate analysis.45Depending on tumor size and location, lobectomy, sleeve lobectomy, and occasionally pneumonectomy, with mediastinal lymph node dissection or sampling, are appropriate for patients with clinical early-stage disease. Sleeve resection is performed for tumors located at airway bifurcations when an adequate bronchial Brunicardi_Ch19_p0661-p0750.indd 69301/03/19 7:01 PM 694SPECIFIC CONSIDERATIONSPART IIVO2max > 15 ml/kg/minPerform spirometryUnexplained dyspneaor diffuse parenchymaldisease on CXR/CT?Perform CPETEstimate %ppoFEV1 and %ppoDLCOIncreased riskVO2max>15 mL/kg/minVO2max10 to 15 mL/kg/minVO2max<10 mL/kg/minFEV1 >1.5 L lobectomyFEV1 >2 L pneumonectomyFEV1 >80% predictedFEV1 <1.5 L lobectomyFEV1 <2 L pneumonectomyFEV1 <80% predictedYesNoDLCO >80%predictedDLCO <80%predicted%ppo FEV1 and%ppo DLCO >40%ppo FEV1 or%ppo DLCO <40%ppo FEV1 <30


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Surgery_Schwartz. >80% predictedFEV1 <1.5 L lobectomyFEV1 <2 L pneumonectomyFEV1 <80% predictedYesNoDLCO >80%predictedDLCO <80%predicted%ppo FEV1 and%ppo DLCO >40%ppo FEV1 or%ppo DLCO <40%ppo FEV1 <30 or%ppo FEV1 x%ppo DLCO <1650Measure DLCOAverage riskIncreased riskFigure 19-24. Algorithm for preoperative evaluation of pulmonary function and reserve prior to resectional lung surgery. CPET = cardiopulmonary exercise test; CT = computed tomographic scan; CXR = chest radiograph; Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second; %ppo = percent predicted postoperative lung function; V.o2max = maximum oxygen consumption. (Modified with permission from Colice GL, Shafazand S, Griffin JP: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition), Chest. 2007 Sep;132(3 Suppl):161S-177S.44)Brunicardi_Ch19_p0661-p0750.indd 69401/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19695CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAmargin cannot be obtained by standard lobectomy. Pneumonec-tomy is rarely performed; primary indications for pneumonec-tomy in early-stage disease include large central tumors involving the distal main stem bronchus and inability to completely resect involved N1 lymph nodes. The latter circumstance occurs with bulky adenopathy or with extracapsular nodal spread.Management of Early-Stage Lung Cancer in the High-Risk Patient Lobectomy may not be an option for some patients with early-stage disease, due to poor cardiopulmonary function or other comorbid illnesses. The ultimate decision that a patient is inoperable, both with regard to the patient’s ability to tolerate surgery and the likelihood of successful resection, should be accepted only after evaluation by an expert surgeon. Surgeons with limited expertise, when faced with a complicated patient, should refer the patient to a high-volume center for further eval-uation if they are


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Surgery_Schwartz. after evaluation by an expert surgeon. Surgeons with limited expertise, when faced with a complicated patient, should refer the patient to a high-volume center for further eval-uation if they are unable to offer the patient surgical resection in their own center.Rationale for Limited Resection in Early-Stage Lung Cancer. Limited resection, defined as segmentectomy or wedge resec-tion, is a viable option for achieving local control in high-risk patients. Historically, limited resection with wedge or segmen-tectomy has been considered a compromise operation due to unacceptably high rates of local recurrence and concerns for worse survival.47,48 Subsequent meta-analysis of the literature shows that the difference in death rate is likely negligible49 (Table 19-13). The high rates of local recurrence demonstrated by Ginsberg and others, however, remain a significant concern and continue to restrict the use of limited resection for early-stage lung cancer to the high-risk patient.With the


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Surgery_Schwartz. demonstrated by Ginsberg and others, however, remain a significant concern and continue to restrict the use of limited resection for early-stage lung cancer to the high-risk patient.With the recent publication of a 20% reduction in lung cancer mortality with screening CT scans in high-risk popula-tions, the topic of limited resection is again the subject of inten-sive review. Studies investigating anatomic segmentectomy (or extended wedge resection) with hilar and mediastinal lymph node dissection suggest that close attention to the ratio of surgi-cal margin to tumor diameter and a careful assessment of the lymph nodes substantially reduce local recurrence.50-52 Recur-rence rates were 6.2%, comparable to rates associated with lobectomy, when the margin-to-tumor diameter ratio exceeded 1, compared to 25% if the margin-to-tumor diameter ratio was less than 1.50 In most centers, this requires use of a thora-cotomy, although increasing experience with VATS in highvolume centers shows that


Surgery_Schwartz

Surgery_Schwartz. to 25% if the margin-to-tumor diameter ratio was less than 1.50 In most centers, this requires use of a thora-cotomy, although increasing experience with VATS in highvolume centers shows that limited resection is safe and feasi-ble, with perioperative adverse outcomes that are comparable to lobectomy.52-55Rationale for Tumor Ablation in the Management of Primary Lung Cancer. Limited resection, by definition, requires that the patient has sufficient cardiopulmonary reserve to undergo a general anesthesia and loss of at least one pulmonary seg-ment. For the high-risk or nonoperable patient, as determined by experience pulmonary surgeons, tumor ablation techniques have been developed for treatment of early-stage lung cancers.Current limitations of this approach include the absence of nodal staging, lack of tissue for molecular profiling, chemo-resistance, or sensitivity testing, concerns about definitions of locoregional recurrence, and a lack of uniformity across cen-ters. Surgeons


Surgery_Schwartz

Surgery_Schwartz. staging, lack of tissue for molecular profiling, chemo-resistance, or sensitivity testing, concerns about definitions of locoregional recurrence, and a lack of uniformity across cen-ters. Surgeons typically define locoregional recurrence as tumor growth within the operative field, including resectable lymph nodes, whereas local recurrence after ablation is most com-monly defined as tumor growth within the field of treatment. Despite the fact that in-transit or lymph node metastases are present in up to 27% of clinically stage I NSCLCs at resection, any tumor growth outside the field of ablative treatment is not be considered treatment failure.56Despite these limitations, tumor ablative strategies are increasingly proposed as viable alternatives to surgical resec-tion, even in potentially operable patients.57-62 While prema-ture, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the primary treatment of very small peripheral early-stage lung


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Surgery_Schwartz. operable patients.57-62 While prema-ture, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the primary treatment of very small peripheral early-stage lung cancers. Multidisci-plinary collaboration between thoracic surgery, interventional radiology/pulmonology, and radiation oncology is required to ensure that development of these ablative techniques occurs through properly designed and well-controlled prospective studies and will ensure that patients receive the best available therapy, regardless of whether it is surgical resection or ablative therapy.The two most commonly applied ablation techniques are radiofrequency ablation and stereotactic body radiotherapy.1. Radiofrequency ablation. Radiofrequency ablation is per-formed using either monopolar or bipolar delivery of elec-trical current to electrodes placed within the tumor tissue. In lung tumors, the electrodes are typically inserted into the tumor mass under CT guidance. An electrical


Surgery_Schwartz

Surgery_Schwartz. or bipolar delivery of elec-trical current to electrodes placed within the tumor tissue. In lung tumors, the electrodes are typically inserted into the tumor mass under CT guidance. An electrical current is delivered; the current is converted by means of friction into heat, which quickly leads to immediate and irreparable tissue destruction in the tissue surrounding the electrode. The efficacy of radiofrequency ablation for controlling the primary tumor and improving survival in poor operative candidates (either due to significant comorbid diseases precluding general anesthesia or poor pulmonary function excluding lung resection) is safe and feasible for peripheral lung nodules. In tumors <3.5 cm, the rate of radiographic resolution of tumor is up to 80%, and cancer-specific sur-vival at 2 years was approximately 90%, indicating excel-lent local control of the primary site.57-59,63 It has become the preferred modality for small peripheral tumors over standard external-beam radiation


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Surgery_Schwartz. 2 years was approximately 90%, indicating excel-lent local control of the primary site.57-59,63 It has become the preferred modality for small peripheral tumors over standard external-beam radiation in centers where the tech-nique is available. Radiofrequency ablation is an excellent modality for the patient at risk for adverse outcomes with pulmonary resec-tion or for patients who refuse surgery, and surgeons should have an algorithm for determining which patients are optimal for this modality64-69 (see Fig. 19-24). Target lesions larger than 5 cm, tumor abutting the hilum, associated malignant pleural or pericardial effusion, greater than three lesions in one lung, and the presence of pulmonary hypertension are all contraindications to radiofrequency ablation.64 Proximity to a large vessel is a contraindication not only due to the risk of massive bleeding, but also because large blood vessels act as a heat sink and lethal cellular temperatures are less likely to be achieved. For


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Surgery_Schwartz. vessel is a contraindication not only due to the risk of massive bleeding, but also because large blood vessels act as a heat sink and lethal cellular temperatures are less likely to be achieved. For these patients, stereotactic body radiotherapy may provide local tumor control with less risk of major complications. Combination therapy with either external-beam radiation or stereotactic body radiotherapy is also under investigation.2. Stereotactic body radiotherapy. Stereotactic body radiotherapy applies highly focused, high-intensity, three-dimensional conformal radiation to the target lesion over a few sessions. Tumor motion quantification and image guidance technologies have significantly improved the delivery of radiation with high levels of precision 7Brunicardi_Ch19_p0661-p0750.indd 69501/03/19 7:01 PM 696SPECIFIC CONSIDERATIONSPART IITable 19-13New classification system for lung adenocarcinomaSTUDY OR SUBGROUPlog [HAZARD RATIO]SESEGMENTECTOMY TOTALLOBECTOMY


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Surgery_Schwartz. 69501/03/19 7:01 PM 696SPECIFIC CONSIDERATIONSPART IITable 19-13New classification system for lung adenocarcinomaSTUDY OR SUBGROUPlog [HAZARD RATIO]SESEGMENTECTOMY TOTALLOBECTOMY TOTALWEIGHTHAZARD RATIO IV, RANDOM, 95% CIHAZARD RATIO IV, RANDOM, 95% CIBando 2002–0,3150,3495741323,3%0,73 [0,37,1,45]Favours Segmentectomy0.005200100.11Favours LobectomyCheng 2012–0,210,2908132324,8%0,81 [0,46, 1,43]Dai 20160,3320,21044240115209,2%1,39 [0,92, 2,11]Ginsberg 19950,3680,21571221258,7%1,44 [0,95, 2,21]Hamatake 20120,19890,280632775,1%1,22 [0,70, 2,11]Iwasaki 2007–0,083380,5076531551,6%0,92 [0,34, 2,49]Keenan 20040,1310,4158541472,3%1,14 [0,50, 2,58]Kilic 2009–0,23570,21683106788,6%0,79 [0,52, 1,21]Kodama 19970,10110,573246771,2%1,11 [0,36, 3,40]Koike 20030,07730,4385741592,1%1,08 [0,46, 2,55]Landreneau 20140,460,24821021176,6%1,58 [0,97, 2,58]Martin–Ucar 2005–1,04350,707117170,8%0,35 [0,09, 1,41]Nakamura 20110,2391382890,4%1,27 [0,18, 9,02]Okada 2001–0,11650,7168681040,8%0,89 [0,22,


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Surgery_Schwartz. 2,55]Landreneau 20140,460,24821021176,6%1,58 [0,97, 2,58]Martin–Ucar 2005–1,04350,707117170,8%0,35 [0,09, 1,41]Nakamura 20110,2391382890,4%1,27 [0,18, 9,02]Okada 2001–0,11650,7168681040,8%0,89 [0,22, 3,63]Okumura 2007–0,16320,3595672733,1%0,85 [0,42, 1,72]Razi 2016–0,020,256911910516,1%0,98 [0,59, 1,62]Read 19900,31480,41841131312,3%1,37 [0,60, 3,11]Sienel 20071,04020,91581491500,5%2,83 [0,47,17,03]Soukiasian 20120,28521,6735561780,1%1,33 [0,05, 35,35]Sugi 2010–0,02020,2543956,5%0,98 [0,60, 1,60]Tsutani 2014–0,71330,3087983834,3%0,49 [0,27, 0,90]Warren 19940,54810,5661031,6%1,73 [0,65, 4,61]Watanabe 2005–0,61620,8979620570,5%0,54 [0,09, 3,14]Yamashita 20120,198860,73469901240,8%1,22 [0,29, 5,15]Yamato 20080,30010,40561532772,5%1,35 [0,61 , 2,99]Yendamuri 20110,2390,2756216225995,3%1,27 [0,74, 2,18]Zhong 2012–0,16250,19388398110,8%0,85 [0,58, 1,24]Total (95% CI)611118431100,0%1,04 [0,92, 1,18]Heterogeneity: Tau2 = 0,00; Chi2 = 25,04, df = 26 (P = 0,52); I2 = 0%Test for overall effect:


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Surgery_Schwartz. 2,18]Zhong 2012–0,16250,19388398110,8%0,85 [0,58, 1,24]Total (95% CI)611118431100,0%1,04 [0,92, 1,18]Heterogeneity: Tau2 = 0,00; Chi2 = 25,04, df = 26 (P = 0,52); I2 = 0%Test for overall effect: Z = 0,68 (P = 0,50)Forest plot of HR for overall survival impact of operative approach (segmentectomy versus lobectomy) of stage I NSCLC patients. The pooled HR displayed in this figure when compared with segmentectomy suggested that there was not a significant benefit of lobectomy on HR of stage I patients (7-21) (HR 1.04; 95% CI, 0.92–1.18, P = 0.50) (22–33).Abbreviations: HR = hazard ratio; NSCLC = non–small cell lung cancer; CI = confidence interval; df = degree of freedom; SE = standard error.Reproduced with permission from Bedetti B, Bertolaccini L, Rocco R, et al: Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis, J Thorac Dis. 2017 Jun; 9(6):1615-1623.Brunicardi_Ch19_p0661-p0750.indd 69601/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19697CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAto the target lesion. This accuracy is important because the lung is extremely sensitive to radiation injury and the majority of patients with early-stage lung cancer who are currently considered candidates for ablative therapy have marginal lung function; excessive injury to normal surrounding lung tissue is not desirable. Importantly, these techniques allow the safe delivery of up to 66 Gy of radiation to the target tumors without exceeding the maximum-tolerated dose.62-70 A phase II North American multicenter study recently demonstrated the safety and efficacy of this approach in 59 nonoperable patients.62 Patients with biopsy-proven, node-negative peripheral NSCLCs less than 5 cm in diameter (T1 or T2) were treated with stereotactic body radiotherapy after they were deemed inoperable, based on coexisting medical conditions, by a thoracic surgeon and/or pulmonolo-gist. Primary tumor control was excellent; at 3 years, 97.6% were


Surgery_Schwartz

Surgery_Schwartz. body radiotherapy after they were deemed inoperable, based on coexisting medical conditions, by a thoracic surgeon and/or pulmonolo-gist. Primary tumor control was excellent; at 3 years, 97.6% were deemed to have primary tumor control by the authors, and 90.6% had local control. However, it is important to note that primary tumor failure was defined specifically as at least a 20% increase in the longest diam-eter of the gross tumor volume by CT scan and evidence of tumor viability either by biopsy confirming carcinoma or by demonstration of FDG avidity on PET scan. For viability to be confirmed with PET scan, the uptake was required to be of similar intensity to the pretreatment staging PET scan. Failure beyond a 1.5to 2-cm margin around the primary tumor volume was considered local failure. Failure in regional node basins was seen in two patients. When compared to locoregional control rates of approximately 6.5% with limited resection, the 3-year locoregional recurrence was higher at


Surgery_Schwartz

Surgery_Schwartz. Failure in regional node basins was seen in two patients. When compared to locoregional control rates of approximately 6.5% with limited resection, the 3-year locoregional recurrence was higher at 12.8%.3. Patient selection for stereotactic body radiotherapy, as with limited resection and radiofrequency ablation, is impor-tant. Because the radiation field is so precise, patients with severe emphysema and chronic obstructive pulmonary dis-ease can be safely treated without significant concern for worsening lung function. However, patients with central tumors near the mediastinum and hilum have increased incidence of significant hypoxia, hemoptysis, atelecta-sis, pneumonitis, and reduced pulmonary function.70 In the multicenter trial detailed earlier, treated tumors were required to be greater than 2 cm from the proximal bron-chial tree in all directions (which they defined as the distal 2 cm of the trachea, carina, and named major lobar bronchi up to their first


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Surgery_Schwartz. required to be greater than 2 cm from the proximal bron-chial tree in all directions (which they defined as the distal 2 cm of the trachea, carina, and named major lobar bronchi up to their first bifurcation).62Rationale for Chemotherapy in the Management of Early-Stage NSCLC. The role of chemotherapy in early-stage (stages I and II) NSCLC is evolving, with several pro-spective phase 2 studies having shown a potential benefit.71,72 Initial concerns that induction chemotherapy may result in increased perioperative morbidity or mortality appear to be unwarranted, as the incidence of perioperative morbidity and mortality is not different between the two groups, except in patients undergoing right-sided pneumonectomy after induc-tion chemotherapy.73 As shown in Table 19-14, an absolute survival benefit of 4% to 7% can be realized using induction for all stages of lung cancer, and in situations where use of adjuvant chemotherapy is anticipated, induction chemother-apy is an acceptable


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Surgery_Schwartz. benefit of 4% to 7% can be realized using induction for all stages of lung cancer, and in situations where use of adjuvant chemotherapy is anticipated, induction chemother-apy is an acceptable alternative.Table 19-14Five-year stage-specific survival after induction chemotherapy followed by surgerySTAGE5-YEAR SURVIVAL (%)ABSOLUTE BENEFIT (%)NEW 5-YEAR SURVIVAL (%)IA75479IB55661IIA50757IIB40747IIIA15–356–721–42IIIB5–103–58–15Reproduced with permission from Burdett SS, Stewart LA, Rydzewska L: Chemotherapy and surgery versus surgery alone in non-small cell lung cancer, Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006157.National Comprehensive Cancer Network guidelines cur-rently recommend observation for T1a (≤1 cm), T1b (>1–2 cm), and T1c (>2–3 cm), node-negative, completely resected NSCLCs (T1abcN0M0). For patients with larger tumors (T2a tumor >3–4 cm; T2b tumor >4–5 cm) that are node-negative, it is recommended that chemotherapy be considered in high-risk patients, ideally in


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Surgery_Schwartz. NSCLCs (T1abcN0M0). For patients with larger tumors (T2a tumor >3–4 cm; T2b tumor >4–5 cm) that are node-negative, it is recommended that chemotherapy be considered in high-risk patients, ideally in the setting of a clinical trial. High-risk tumor characteristics include poorly differentiated tumors, moderately to poorly differentiated lung neuroendocrine tumors, vascular invasion, resection limited to wedge resection only, tumors >4 cm in size, visceral pleural involvement, and when lymph node sampling at the time of resection was incomplete (Nx).Evaluation and Management of Locally Advanced NSCLC. Five-year relative survival in patients with locore-gional disease is 28%, but there is significant heterogeneity within the group. Stage III disease includes patients with small tumors that have metastasized to the mediastinal lymph nodes as well as large tumors (>7 cm), and tumor invading unresectable structures or the major carina with no nodal metastasis at all. Patients with


Surgery_Schwartz

Surgery_Schwartz. that have metastasized to the mediastinal lymph nodes as well as large tumors (>7 cm), and tumor invading unresectable structures or the major carina with no nodal metastasis at all. Patients with clinically evident N2 disease (i.e., bulky adenopa-thy present on CT scan or mediastinoscopy, with lymph nodes often replaced by tumor) have a 5-year survival rate of 5% to 10% with surgery alone. In contrast, patients with microscopic N2 disease discovered incidentally in one lymph node station after surgical resection have a 5-year survival rate that may be as high as 30%. As a result, many surgeons and oncologists dif-ferentiate between microscopic and bulky N2 lymphadenopathy and the number of involved N2 nodal stations in determining whether to proceed with resection following induction therapy. It is generally accepted that surgical resection is appropriate for patients with a single-station metastasis with a single lymph node smaller than 3 cm, although randomized trials specifically


Surgery_Schwartz

Surgery_Schwartz. It is generally accepted that surgical resection is appropriate for patients with a single-station metastasis with a single lymph node smaller than 3 cm, although randomized trials specifically investigating resection following induction therapy for patients with single-station microscopic disease have not yet been performed.Histologic confirmation of N2 nodal metastases is impera-tive; false-positive findings on PET scan are unacceptably high, and reliance on this modality will lead to significant undertreat-ment of patients with earlier stage cancers. This is particularly true in regions with high incidence of granulomatous diseases. Brunicardi_Ch19_p0661-p0750.indd 69701/03/19 7:01 PM 698SPECIFIC CONSIDERATIONSPART IIWhen N2 nodes are found, incidentally, to harbor metastasis at the time of planned anatomic lung resection, the decision to proceed with resection varies depending on surgeon preference; it is acceptable to either proceed with anatomic resection and mediastinal


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Surgery_Schwartz. the time of planned anatomic lung resection, the decision to proceed with resection varies depending on surgeon preference; it is acceptable to either proceed with anatomic resection and mediastinal lymph node sampling/dissection or to stop the pro-cedure, refer the patient for induction therapy, and reevaluate for resection after induction therapy is completed.When histologically confirmed metastases are found dur-ing preoperative staging evaluation, patients should be referred for induction chemotherapy; patients in whom the mediastinal nodes are sterilized by induction therapy have a better prognosis, and surgical resection is generally warranted as part of a mul-timodal approach. As with preinduction evaluation, histologic confirmation of persistent N2 disease after induction therapy is imperative; patients should not be denied surgical resection fol-lowing induction chemotherapy based on radiographic evidence for N2 disease because the survival for resected NSCLC is


Surgery_Schwartz

Surgery_Schwartz. therapy is imperative; patients should not be denied surgical resection fol-lowing induction chemotherapy based on radiographic evidence for N2 disease because the survival for resected NSCLC is sig-nificantly better than with definitive chemotherapy.Surgery in T4 and Stage IV Disease Surgery is occasion-ally appropriate for highly selected patients with tumors invad-ing the SVC, carinal or vertebral body involvement, or satellite nodules in the same lobe (T3, N0-1, M0) or in T4, N0-1 tumors with limited invasion into the mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, diaphragm or carina through direct extension. Surgery gener-ally does not have a role in the care of patients with any tumor with N3 disease or T4 tumors with N2 disease. Survival rates remain extremely low for these patients. Similarly, the treat-ment of patients with stage IV disease is chemotherapy. How-ever, on occasion, patients with a single site of metastasis are


Surgery_Schwartz

Surgery_Schwartz. rates remain extremely low for these patients. Similarly, the treat-ment of patients with stage IV disease is chemotherapy. How-ever, on occasion, patients with a single site of metastasis are encountered, particularly with adenocarcinomas presenting with a solitary brain metastasis. In this highly select group, 5-year survival rates of 10% to 15% can be achieved with surgical exci-sion of the brain metastasis and the primary tumor, assuming it is early stage.Surgery for Management of Pancoast’s Tumor Carcinoma arising in the extreme apex of the chest with associated arm and shoulder pain, atrophy of the muscles of the hand, and Horner’s syndrome presents a unique challenge to the surgeon. Any tumor of the superior sulcus, including tumors without evi-dence for involvement of the neurovascular bundle, is now com-monly known as Pancoast’s tumors, after Henry Pancoast who described the syndrome in 1932. The designation is reserved for tumors involving the parietal pleura or deeper


Surgery_Schwartz

Surgery_Schwartz. bundle, is now com-monly known as Pancoast’s tumors, after Henry Pancoast who described the syndrome in 1932. The designation is reserved for tumors involving the parietal pleura or deeper structures overly-ing the first rib. Chest wall involvement at or below the second rib is not a Pancoast’s tumor.74 Treatment is multidisciplinary; due to the location of the tumor and involvement of the neu-rovascular bundle that supplies the ipsilateral extremity, pre-serving postoperative function of the extremity is critical. For this reason, resection should only be performed in patients who are proven negative for mediastinal lymph node involvement. Survival with N2 positive nodes is poor, and the morbidity and mortality associated with surgical resection are high. If bulky lymphadenopathy is present, EBUSor EUS-guided FNA may prove nodal involvement. However, a negative FNA is not suf-ficient for proving the absence of mediastinal involvement and should be followed by mediastinoscopy to


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Surgery_Schwartz. present, EBUSor EUS-guided FNA may prove nodal involvement. However, a negative FNA is not suf-ficient for proving the absence of mediastinal involvement and should be followed by mediastinoscopy to ensure accurate and complete evaluation of the mediastinum.Because Pancoast’s tumors have high rates of local recur-rence and incomplete resection, induction chemoradiotherapy fol-lowed by surgery is recommended. This treatment regimen was well tolerated in a study performed by the Southwest Oncology Group, with 95% of patients completing induction treatment. Com-plete resection was achieved in 76%. Five-year survival was 44% overall and 54% when complete resection was achieved. Disease progression with this regimen was predominantly at distant sites, with the brain being the most common.75 The current treatment algorithm for Pancoast’s tumors is presented in Fig. 19-25.Surgical excision is performed via thoracotomy with en bloc resection of the chest wall and vascular structures and


Surgery_Schwartz

Surgery_Schwartz. The current treatment algorithm for Pancoast’s tumors is presented in Fig. 19-25.Surgical excision is performed via thoracotomy with en bloc resection of the chest wall and vascular structures and ana-tomic lobectomy. A portion of the lower trunk of the brachial plexus and the stellate ganglion are also typically resected. With chest wall involvement, en bloc chest wall resection, along with lobectomy, is performed, with or without chest wall reconstruction.For small rib resections or those posterior to the scapula, chest wall reconstruction is usually unnecessary. Larger defects (two rib segments or more) are usually reconstructed with Gore-Tex to provide chest wall contour and stability. En bloc resection is also used for other locally advanced tumors (T3) with direct invasion of the adjacent chest wall, diaphragm, or pericardium. If a large portion of the pericardium is removed, reconstruction with thin Gore-Tex membrane will be required to prevent cardiac herniation and venous


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Surgery_Schwartz. adjacent chest wall, diaphragm, or pericardium. If a large portion of the pericardium is removed, reconstruction with thin Gore-Tex membrane will be required to prevent cardiac herniation and venous obstruction.Preoperative (Induction) Chemotherapy for NSCLC The use of chemotherapy before anatomic surgical resection has a number of potential advantages:1. The tumor’s blood supply is still intact, allowing better chemotherapy delivery and avoiding tumor cell hypoxia (in any residual microscopic tumor remaining postoperatively), which would increase radioresistance.2. The primary tumor may be downstaged, enhancing resectability.3. Patients are better able to tolerate chemotherapy before sur-gery and are more likely to complete the prescribed regimen than after surgery.4. It functions as an in vivo test of the primary tumor’s sensi-tivity to chemotherapy.5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy.6. Systemic micrometastases are


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Surgery_Schwartz. an in vivo test of the primary tumor’s sensi-tivity to chemotherapy.5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy.6. Systemic micrometastases are treated.7. It identifies patients with progressive disease/nonresponders and spares them a pulmonary resection.Potential disadvantages include:1. There is a possible increase in the perioperative complica-tion rate in patients requiring right pneumonectomy after induction chemotherapy.2. While the patient is receiving chemotherapy, potentially curative resection is delayed; if the patient does not respond, this delay could result in tumor spread.In stage IIIA N2 disease, the response rates to induction chemotherapy are high, in the range of 70%. The treatment is generally safe, as it does not cause a significant increase in peri-operative morbidity. Two randomized trials have now compared surgery alone for patients with N2 disease to preoperative che-motherapy followed by surgery. Both


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Surgery_Schwartz. cause a significant increase in peri-operative morbidity. Two randomized trials have now compared surgery alone for patients with N2 disease to preoperative che-motherapy followed by surgery. Both trials were stopped before complete accrual because of a significant increase in survival for the chemotherapy arm.The initially observed survival differences have been maintained for up to 3 years and beyond (5-year data not shown). Given these results, induction chemotherapy with Brunicardi_Ch19_p0661-p0750.indd 69801/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19699CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAConfirm T3–4, N0-1 M0 NSCLCNo evidence for metastatic or N2 nodal diseaseTumor progression orpoor performance statusDefinitivechemoradiotherapyMetastatic disease or N2nodal diseaseConcurrent induction chemotherapy (Cisplatin/Etoposide)And radiotherapy: 45 Gy over 5 weeksCT chest/upper abdomenMRI/MRA of vessels/brachialplexusMediastinoscopyBrain CT or MRI andPET scanReassessment performance score, physiologic reserve,tumor responseRadiographic evaluation: CT scans of thechest, upper abdomen, and brain. PET scan for metastasesAdditional chemotherapyas toleratedAssess performance status:performance score, cardiopulmonary reserve,renal function and neurologic functionInitial evaluation, biopsy and stagingThoracotomy, en bloc chest wall resection, lobectomy, chest wall with reconstructionTumor stable/regression; good toexcellent performance statusPoor performance statusGood to excellent performance statusFigure 19-25. Treatment


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Surgery_Schwartz. wall resection, lobectomy, chest wall with reconstructionTumor stable/regression; good toexcellent performance statusPoor performance statusGood to excellent performance statusFigure 19-25. Treatment algo-rithm for Pancoast’s tumors. CT = computed tomography; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging; NSCLC = non–small cell lung cancer; PET = positron emission tomography.cisplatin-based regimen (two to three cycles) has become stan-dard for patients with N2 disease. Table 19-15 summarizes the findings of a systematic review and meta-analysis reporting response rates, progression-free survival, and overall survival after induction chemotherapy followed by surgical resection.Postoperative (Adjuvant) Chemotherapy for NSCLC Post-operative adjuvant chemotherapy was previously thought to confer no benefit based on multiple prospective randomized tri-als, in part because patients who had undergone thoracotomy and lung resection had difficulty tolerating the


Surgery_Schwartz

Surgery_Schwartz. was previously thought to confer no benefit based on multiple prospective randomized tri-als, in part because patients who had undergone thoracotomy and lung resection had difficulty tolerating the adjuvant regi-mens. More recently, however, newer, more effective agents have shown promise, and adjuvant therapy is better tolerated after minimally invasive lung resection (i.e., VATS or robotic anatomic resection). Targeted therapies, which have been shown to be beneficial in advanced-stage lung cancer, are of particular interest.Any patient with nodal metastasis (N1 or N2) or with T3 tumors (defined as tumors >5 to ≤7 cm or separate tumor in same lobe or direct invasion of chest wall [includes parietal pleura and superior sulcus]/parietal pericardium/phrenic nerve) should receive adjuvant chemotherapy if they are able to toler-ate the regimen. In the situation where the margins of resec-tion are positive, re-resection is recommended. If not possible, concurrent chemoradiation is


Surgery_Schwartz

Surgery_Schwartz. chemotherapy if they are able to toler-ate the regimen. In the situation where the margins of resec-tion are positive, re-resection is recommended. If not possible, concurrent chemoradiation is recommended for macroscopic residual tumor and sequential chemoradiation for microscopic residual tumor.Definitive Nonsurgical Treatment for NSCLC. Recent advances in targeted therapies have changed the management of advanced NSCLC from a generalized, platinum-based approach to one in which molecular analysis and targeted, personalized therapies are now standard of care. It is now mandatory that the pathologist clearly differentiate between squamous cell carcinoma and adenocarcinoma because the therapeutic options are different and use of bevacizumab, while beneficial in patients with adenocarcinoma, has been found to cause exces-sive pulmonary hemorrhage in patients with squamous histol-ogy. For the surgeon, this requirement translates into a much more aggressive approach to tissue diagnosis.


Surgery_Schwartz

Surgery_Schwartz. has been found to cause exces-sive pulmonary hemorrhage in patients with squamous histol-ogy. For the surgeon, this requirement translates into a much more aggressive approach to tissue diagnosis. At our institution, the cytopathologist provides onsite rapid assessment of the fine-needle aspirate to determine whether tumor cells are present and confirm that sufficient tumor cells are present to enable molecu-lar testing. This has increased the number of passes performed during an EBUS-guided FNA or during CT-guided aspiration of a pulmonary or intrathoracic lesion; typically, an additional two to three passes are made for cell block material after confirming the presence of tumor cells in the target area. When insufficient cells are obtained for molecular testing, despite having a diag-nosis, additional sampling is warranted; this is mandatory in patients with adenocarcinoma and likely to become necessary for other non–small cell histologic types as advances in targeted therapies


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Surgery_Schwartz. additional sampling is warranted; this is mandatory in patients with adenocarcinoma and likely to become necessary for other non–small cell histologic types as advances in targeted therapies become available for clinical use. Acquiring adequate tissue for diagnosis may require mediastinoscopy or VATS; close communication between the oncologist, surgeon, patholo-gist, and patient is needed to ensure that the benefits to the patient clearly outweigh the risks and that results obtained through more aggressive diagnostic measures are needed to direct subsequent care.8Brunicardi_Ch19_p0661-p0750.indd 69901/03/19 7:01 PM 700SPECIFIC CONSIDERATIONSPART IITable 19-15Selected randomized trials of neoadjuvant chemotherapy for stage III non–small cell lung cancerTRIAL (REFERENCE)NO. OF PATIENTS (STAGE III)CHEMOTHERAPYRESPONSE RATE (%)PCR (%)COMPLETE RESECTIONPFSOS5-YEAR SURVIVALRosell et al8560 (60)MitomycinIfosfamideCisplatin60485%12 vs. 5 mo (DFS; P = .006)22 vs. 10 mo (P = .005)16% vs.


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Surgery_Schwartz. (STAGE III)CHEMOTHERAPYRESPONSE RATE (%)PCR (%)COMPLETE RESECTIONPFSOS5-YEAR SURVIVALRosell et al8560 (60)MitomycinIfosfamideCisplatin60485%12 vs. 5 mo (DFS; P = .006)22 vs. 10 mo (P = .005)16% vs. 0%Roth et al9060 (60)Cyclophosphamide EtoposideCisplatin35NR39% vs. 31%Not reached vs. 9 mo (P = .006)64 vs. 11 mo (P = .008)56% vs. 15%aPass et al9127 (27)EtoposideCisplatin62885% vs. 86%12.7 vs. 5.8 mo (P = .083)28.7 vs. 15.6 mo (P = .095)NRNagai et al9262 (62)CisplatinVindesine28065% vs. 77%NR17 vs. 16 mo (P = .5274)10% vs. 22%Gilligan et al93519 (80)Platinum basedb49482% vs. 80%NR54 vs. 55 mo (P = .86)44% vs. 45%Depierre et al94355 (167)MitomycinIfosfamideCisplatin641192% vs. 86%26.7 vs. 12.9 mo (P = .033)37 vs. 26 mo (P = .15)43.9% vs. 35.3%cPisters et al95354 (113)dCarboplatinPaclitaxel41NR94% vs. 89%33 vs. 21 mo (P = .07)75 vs. 46 mo (P = .19)50% vs. 43%Sorensen et al9690 (NR)PaclitaxelCarboplatin46079% vs. 70%NR34.4 vs. 22.5 mo (NS)36% vs. 24% (NS)Mattson et al97274


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Surgery_Schwartz. vs. 89%33 vs. 21 mo (P = .07)75 vs. 46 mo (P = .19)50% vs. 43%Sorensen et al9690 (NR)PaclitaxelCarboplatin46079% vs. 70%NR34.4 vs. 22.5 mo (NS)36% vs. 24% (NS)Mattson et al97274 (274)Docetaxel28NR77% vs. 76%e9 vs. 7.6 mo (NS)14.8 vs. 12.6 mo (NS)NRa3-year survival.bOptions included MVP (mitomycin C, vindesine, and platinum), MIC (mitomycin, ifosfamide, and cisplatin), NP (cisplatin and vinorelbine), PacCarbo (paclitaxel and carboplatin), GemCis (gemcitabine and cisplatin), and DocCarbo (docetaxel and carboplatin).c4-year survival.d113 patients (32%) were reported to have stage IIB or IIIA disease.e22 patients in the chemotherapy arm and 29 patients in the control arm had resectable disease.Abbreviations: DFS = disease-free survival; NR = not recorded; NS = not significant; OS = overall survival; pCR = pathologic complete response; PFS = progression-free survival.Reproduced with permission from Allen J, Jahanzeb M: Neoadjuvant chemotherapy in stage III NSCLC, J Natl Compr Canc Netw.


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Surgery_Schwartz. survival; pCR = pathologic complete response; PFS = progression-free survival.Reproduced with permission from Allen J, Jahanzeb M: Neoadjuvant chemotherapy in stage III NSCLC, J Natl Compr Canc Netw. 2008 Mar;6(3):285-293.Brunicardi_Ch19_p0661-p0750.indd 70001/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19701CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAOnce a treatment plan has been devised, two strategies for delivery are available. “Sequential” chemoradiation involves full-dose systemic chemotherapy (i.e., cisplatin combined with a second agent) followed by standard radiotherapy (approxi-mately 60 Gy). The combination of chemotherapy followed by radiation has improved 5-year survival from 6% with radio-therapy alone to 17%.76 An alternative approach, referred to as “concurrent chemoradiation,” administers chemotherapy and radiation at the same time. Certain chemotherapeutic agents sen-sitize tumor cells to radiation and, thus, enhance the radiation effect. The advantages of this approach are improved primary tumor and locoregional lymph node control and elimination of the delay in administering radiotherapy that occurs with sequential treatment. A disadvantage, however, is the necessary reduction in chemotherapy dosage in order to diminish over-lapping toxicities; this can


Surgery_Schwartz

Surgery_Schwartz. in administering radiotherapy that occurs with sequential treatment. A disadvantage, however, is the necessary reduction in chemotherapy dosage in order to diminish over-lapping toxicities; this can potentially lead to undertreatment of systemic micrometastases. Randomized trials have shown a modest 5-year survival benefit as compared with chemotherapy. In a systematic review of 47 trials and six meta-analyses, an absolute survival benefit of 4% at 2 years was seen when con-current platinum-based chemoradiation was given compared to sequential radiation.77Definitive radiotherapy is predominantly used for pallia-tion of symptoms in patients with poor performance status; cure rates with radiation as a single modality in patients with N2 or N3 disease is less than 7%. Recent improvement has been seen with three-dimensional conformal radiotherapy and altered frac-tionation. Such poor results for patients with stage III lung cancer reflect the limitations of locoregional treatment in a


Surgery_Schwartz

Surgery_Schwartz. been seen with three-dimensional conformal radiotherapy and altered frac-tionation. Such poor results for patients with stage III lung cancer reflect the limitations of locoregional treatment in a disease where death results from systemic metastatic spread.Options for Thoracic Surgical ApproachesThoracic surgical approaches have changed over recent years with advancements in minimally invasive surgery. A surgeon trained in advanced minimally invasive techniques can now perform pleural-based, pulmonary and mediastinal procedures through multiple thoracoscopic ports without the need for a sub-stantial, rib-spreading incision. Subjective measures of quality of life after VATS, such as pain (Fig. 19-26) and perceived functional recovery, consistently and reproducibly favor VATS OpenVATSNoneMildModerateSeverep<0.001Figure 19-26. Pie chart comparison of pain control at 3 weeks after lobectomy by standard thoracotomy or video-assisted tho-racic surgery (VATS). The pie charts show that


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Surgery_Schwartz. 19-26. Pie chart comparison of pain control at 3 weeks after lobectomy by standard thoracotomy or video-assisted tho-racic surgery (VATS). The pie charts show that patients undergo-ing VATS have significantly less pain (P <.01) as measured by the most potent analgesic still required: severe—schedule II nar-cotic; moderate—schedule III or lower narcotic; mild–nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen. (Reproduced with permission from Demmy TL, Nwoque C. Is video-assisted thoracic surgery lobectomy better? Quality of life considerations, Ann Thorac Surg. 2008 Feb;85(2):S719-S728.)over thoracotomy. Objective measures such as functional sta-tus as measured by 6-minute walk, return to work, and ability to tolerate chemotherapy also favor VATS over thoracotomy. Finally, recovery of respiratory function occurs earlier in VATS patients. These findings are pronounced in patients with chronic obstructive pulmonary disease and in the elderly—populations whose quality of life


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Surgery_Schwartz. of respiratory function occurs earlier in VATS patients. These findings are pronounced in patients with chronic obstructive pulmonary disease and in the elderly—populations whose quality of life can be dramatically impacted by changes in their respiratory symptoms and function, thoracic pain, and physical performance. Table 19-16 provides a summary of pop-ulations that may benefit from VATS approaches.Video-Assisted (VATS)/Robotic-Assisted Thoraco-scopic Surgery (RATS). VATS/RATS has become the rec-ommended approach to diagnosis and treatment of pleural effusions, recurrent pneumothoraces, lung biopsies, lobec-tomy or segmental resection, resection of bronchogenic and mediastinal cysts, and intrathoracic esophageal mobilization for esophagectomy.78 These approaches are also utilized for pneumonectomy in some centers of excellence with very high Table 19-16Special circumstances under which lobectomy by video-assisted thoracic surgery may be preferableCONDITIONEXAMPLESPulmonary


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Surgery_Schwartz. for pneumonectomy in some centers of excellence with very high Table 19-16Special circumstances under which lobectomy by video-assisted thoracic surgery may be preferableCONDITIONEXAMPLESPulmonary compromisePoor FEV1/Dlco, heavy smoking, sleep apnea, recent pneumoniaCardiac dysfunctionCongestive heart failure, severe coronary artery disease, recent myocardial infarction, valvular diseaseExtrathoracic malignancySolitary brain metastasis from lung cancer, deep pulmonary metastases requiring lobectomyPoor physical performancePerformance status equivalent to a Zubrod score of 2 or 3, morbid obesityRheumatologic/orthopedic conditionSpinal disease, severe rheumatoid arthritis, severe kyphosis, lupus erythematosus, osteomyelitisAdvanced ageAge >70 yearsVascular problemsAneurysm, severe peripheral vascular diseaseRecent or impending major operationUrgent abdominal operation, joint replacement requiring use of crutches, need for contralateral thoracotomyPsychological/neurologic


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Surgery_Schwartz. peripheral vascular diseaseRecent or impending major operationUrgent abdominal operation, joint replacement requiring use of crutches, need for contralateral thoracotomyPsychological/neurologic conditionsSubstance abuse, poor command following, pain syndromesImmunosuppression/ impaired wound healingRecent transplantation, diabetesAbbreviations: Dlco = carbon monoxide diffusion capacity; FEV1 = forced expiratory volume in 1 second.Reproduced with permission from Demmy TL, Nwoque C. Is video-assisted thoracic surgery lobectomy better? Quality of life considerations, Ann Thorac Surg. 2008 Feb;85(2):S719-S728.Brunicardi_Ch19_p0661-p0750.indd 70101/03/19 7:01 PM 702SPECIFIC CONSIDERATIONSPART IIvolumes of VATS lung resection. VATS is performed via two to four incisions measuring 0.5 to 1.2 cm in length to allow insertion of the thoracoscope and instruments. An access incision, typically in the fourth or fifth intercostal space in the anterior axillary line, is used for dissection of


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Surgery_Schwartz. cm in length to allow insertion of the thoracoscope and instruments. An access incision, typically in the fourth or fifth intercostal space in the anterior axillary line, is used for dissection of the hilum during lung resection. The incision location varies accord-ing to the procedure. With respect to VATS lobectomy, port placement varies according to the lobe being resected and is highly variable among surgeons.79 The basic principle is to position the ports high enough on the thoracic cage to have access to the hilar structures. Endoscopic staplers are used to divide the major vascular structures and bronchus (Fig. 19-27). Robotic approaches are similarly tailored to the side and lobe under-going resection, with the entire operation performed using DissectBADCERetractRetractRetractRetractRetractViewViewViewViewHoldViewDissectFigure 19-27. Selected video-assisted thoracic surgery lobectomy maneuvers. All the maneuvers are shown with the patient positioned in the left lateral


Surgery_Schwartz

Surgery_Schwartz. 19-27. Selected video-assisted thoracic surgery lobectomy maneuvers. All the maneuvers are shown with the patient positioned in the left lateral decubitus position. The same maneuvers can be performed in mirror image for left-sided work. A. Medial viewing and inferior holding of lung to allow dissection through the access incision. Example shows dissection of the apical hilum. B. Medial viewing and access holding of lung to allow stapling of hilar structures from below. Example shows division of the apical pulmonary artery trunk to the right upper lobe (upper lobe branch of vein divided and reflected away). C. Standard viewing and use of working port to dissect and divide structures while lung is retracted through access incision. Example shows use of stapler to divide pulmonary artery to right lower lobe. D. Standard viewing and use of working port to retract lung and access incision to dissect structures. This method is commonly used to dis-sect the pulmonary artery in the major


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Surgery_Schwartz. to right lower lobe. D. Standard viewing and use of working port to retract lung and access incision to dissect structures. This method is commonly used to dis-sect the pulmonary artery in the major fissure. Example shows inferior pulmonary vein after the pulmonary ligament was divided using this maneuver. E. Standard viewing and use of access incision to deliver stapler to divide fissures. Example shows division of the posterior fissure between the right lower lobe and the upper lobe.Brunicardi_Ch19_p0661-p0750.indd 70201/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19703CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATrapeziusLatissimus dorsidividedLatissimus dorsiBADCSerratus anterior5th rib6th ribRhomboidmajorScapularetractedIncisionTrapeziusrobotic arms, except for one assistant port through which spec-imens can be removed and suctioning and stapling performed (in early models; the newest robotic models have robotic sta-plers, allowing the surgeon to have complete control of the entire operation).Open Approaches to Thoracic Surgery. When a thoraco-scopic approach is not possible, an open approach, most fre-quently the posterolateral thoracotomy, is used to gain access to the intrathoracic space.80,81 The posterolateral thoracotomy incision can be used for most pulmonary resections, esopha-geal operations, and operations in the posterior mediastinum and vertebral column (Fig. 19-28). The anterolateral thora-cotomy has traditionally been used in trauma victims. This approach allows quick entry into the chest with the patient supine. In the


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Surgery_Schwartz. and vertebral column (Fig. 19-28). The anterolateral thora-cotomy has traditionally been used in trauma victims. This approach allows quick entry into the chest with the patient supine. In the face of hemodynamic instability, the lateral decubitus position significantly compromises control over the patient’s cardiopulmonary system and resuscitation efforts, whereas the supine position allows the anesthesiologist full access to the patient. A bilateral anterior thoracotomy incision with a transverse sternotomy (“clamshell” thoracotomy) is a standard operative approach to the heart and mediastinum in certain elective circumstances. It is the preferred incision for double-lung transplantation in many centers. A partial median sternotomy can also be added to an anterior thoracotomy (“trap-door” or “hemiclamshell” thoracotomy) for access to mediastinal structures. A hypesthetic nipple is a frequent com-plication of this approach. The median sternotomy incision allows exposure of anterior


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Surgery_Schwartz. or “hemiclamshell” thoracotomy) for access to mediastinal structures. A hypesthetic nipple is a frequent com-plication of this approach. The median sternotomy incision allows exposure of anterior mediastinal structures and is prin-cipally used for cardiac operations. Although the surgeon has access to both pleural cavities, incision into the pleural cavity can be avoided if entry is unnecessary (Fig. 19-29).Postoperative CareChest Tube Management. At the conclusion of most thoracic operations, the pleural cavity is drained with a chest tube(s). If the visceral pleura has not been violated and there is no concern Figure 19-28. The posterolateral thoracotomy incision. A. Skin incision from the anterior axillary line to the lower extent of the scapula tip. B and C. Division of the latissimus dorsi and shoulder girdle musculature. D. The pleural cavity is entered after dividing the intercostal muscles along the lower margin of the interspace, taking care not to injure the neurovascular


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Surgery_Schwartz. dorsi and shoulder girdle musculature. D. The pleural cavity is entered after dividing the intercostal muscles along the lower margin of the interspace, taking care not to injure the neurovascular bundle lying below each rib.Brunicardi_Ch19_p0661-p0750.indd 70301/03/19 7:01 PM 704SPECIFIC CONSIDERATIONSPART IIABThymusR. atrialappendageR. ventriclePreperitonealfatDiaphragmL. atrialappendageAortic archInnominate v.Pulmonary a.Figure 19-29. The median sternotomy incision. A. Skin incision from the suprasternal notch to the xiphoid process. B. Exposure of the pleural space. a. = artery; v. = vein.for pneumoor hemothorax (e.g., after VATS sympathectomy), a chest tube is unnecessary. After chest tube placement, the lung is reexpanded with positive-pressure ventilation. There are two reasons for the use of pleural tubes in this setting: first, the tube allows evacuation of air if an air leak is present; sec-ond, blood and pleural fluid can be drained, thereby preventing accumulation


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Surgery_Schwartz. for the use of pleural tubes in this setting: first, the tube allows evacuation of air if an air leak is present; sec-ond, blood and pleural fluid can be drained, thereby preventing accumulation within the pleural space that would compromise the patient’s respiratory status. The tube is removed when the air leak is resolved and when the volume of drainage decreases below an acceptable level over 24 hours.Historically, many surgeons have somewhat arbitrarily required less than 150 mL of drainage volume over 24 hours prior to removing a chest tube to minimize risk of reaccu-mulation. The pleural lymphatics, however, can absorb up to 0.40 mL/kg per hour in a healthy individual, which may be as much as 500 mL over a 24-hour period. In fact, studies have shown that pleural tubes can be removed after VATS lobec-tomy or thoracotomy with 24-hour drainage volumes as high as 400 mL, without subsequent development of pleural effusions.82 It is our current practice to remove chest tubes with


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Surgery_Schwartz. after VATS lobec-tomy or thoracotomy with 24-hour drainage volumes as high as 400 mL, without subsequent development of pleural effusions.82 It is our current practice to remove chest tubes with 24-hour outputs of 400 mL or less after lobectomy or lesser pulmonary resections. In settings where normal pleural fluid dynamics have been altered, such as malignant pleural effusion, pleural space infections or inflammation, and pleurodesis, strict adherence to a volume requirement before tube removal is appropriate (typi-cally 100 to 150 mL over 24 hours).For operations involving lung resection or parenchymal injury, suction levels of –20 cm H2O are routinely used to eradi-cate residual air spaces and to control postoperative parenchy-mal air leaks for the first 12 to 24 hours. The following day, however, the decision to continue suction or place the patient to water seal (off suction) must be made. Applying suction to an air leak has been shown to prolong the duration of the air leak and


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Surgery_Schwartz. however, the decision to continue suction or place the patient to water seal (off suction) must be made. Applying suction to an air leak has been shown to prolong the duration of the air leak and extend the time frame during which tube thoracostomy is needed.83 The main guidelines for the continued use of suction if an air leak is present depend on the expansion of the remain-ing lung as determined by CXR. If the lung is well expanded, the chest tube can remain to water seal drainage. If an und-rained pneumothorax is present on CXR, the chest tube and its attached tubing should be examined to ensure that the chest tube is patent and the attached tubing is not kinked or mechanically obstructed, such as occurs when the patient is lying on the tube. If the tube is a small caliber tube (pigtail catheter), it should be flushed with sterile saline through a three-way stopcock that has been cleaned with alcohol because these tubes tend to become clogged with fibrin. These catheters are also


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Surgery_Schwartz. catheter), it should be flushed with sterile saline through a three-way stopcock that has been cleaned with alcohol because these tubes tend to become clogged with fibrin. These catheters are also prone to kinking at the insertion site into the skin. Once the surgeon has con-firmed that the chest tube is patent, the patient is asked to volun-tarily cough or perform the Valsalva maneuver. This maneuver increases the intrathoracic pressure and will push air that is contained within the hemithorax out of the chest tube. During the voluntary cough, the fluid level in the water seal chamber should move up and down with the cough and with deep respira-tion, reflecting the pleural pressure changes occurring with these maneuvers. A stationary fluid level implies either a mechanical blockage (e.g., due to external tube compression or to a clot/debris within the tube) or pleurodesis. If bubbles pass through the water seal chamber, an air leak is presumed. If the leak is significant enough to


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Surgery_Schwartz. due to external tube compression or to a clot/debris within the tube) or pleurodesis. If bubbles pass through the water seal chamber, an air leak is presumed. If the leak is significant enough to induce atelectasis or collapse of the lung during use of water seal, suction should be used to achieve lung reexpansion.Pain Control. Good pain control after intrathoracic proce-dures is critical; it permits the patient to actively clear and manage secretions and promotes ambulation and a feeling of well-being. The most common techniques of pain management are epidural, paravertebral, and intravenous. Epidural catheters are commonly used, although we prefer to use paravertebral catheters in our center. Epidural catheters should be inserted at about the T6 level, roughly at the level of the scapular tip. Lower placement risks inadequate pain control, and higher placement may provoke hand and arm numbness. Typically, combinations of fentanyl at 0.3 µg/mL with either bupivacaine (0.125%) or


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Surgery_Schwartz. tip. Lower placement risks inadequate pain control, and higher placement may provoke hand and arm numbness. Typically, combinations of fentanyl at 0.3 µg/mL with either bupivacaine (0.125%) or ropivacaine (0.1%) are used. Ropivacaine has less cardiotoxicity than bupivacaine; thus, in the case of inadver-tent intravenous injection, the potential for refractory complete heart block is significantly less with ropivacaine. Paravertebral blocks can be placed using the same epidural catheter kit 2.5 cm lateral to the spinous process at T4 to T6. Combinations of narcotic and topical analgesia are then infused as with the epi-dural catheter.When properly placed, a well-managed epidural can provide outstanding pain control without significant systemic sedation.84 Thoracic epidurals do not commonly cause urinary retention, although a low thoracic epidural may block the sen-sory fibers to the bladder. Motor function, however, remains intact. In some patients who are having difficulty voiding,


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Surgery_Schwartz. cause urinary retention, although a low thoracic epidural may block the sen-sory fibers to the bladder. Motor function, however, remains intact. In some patients who are having difficulty voiding, it Brunicardi_Ch19_p0661-p0750.indd 70401/03/19 7:01 PM


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Surgery_Schwartz. CHAPTER 19705CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAmay be possible to avoid Foley catheterization by simply reminding the patient to void on a regular basis. In male patients with voiding difficulty prior to surgery, urinary catheterization may be required. In addition, the use of local anesthetics may cause sympathetic outflow blockade, leading to vasodilation and hypotension often requiring intravenous vasoconstrictors (an α-agonist such as phenylephrine) and/or fluid administration. In such circumstances, fluid administration for hypotension may be undesirable in pulmonary surgery patients, particularly after pneumonectomy. Paravertebral catheters provide equivalent pain control with less effect on hemodynamics.85 Recently, lipo-somal bupivacaine was introduced and has become the standard approach to pain management after thoracic surgery in several centers. The formulation allows for slow-release of bupivacaine for up to 72 hours after injection. Injected directly into the


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Surgery_Schwartz. standard approach to pain management after thoracic surgery in several centers. The formulation allows for slow-release of bupivacaine for up to 72 hours after injection. Injected directly into the inter-costal spaces immediately prior to chest closure, the formulation has shown great promise in several retrospective reports, with randomized trials not yet completed. One limiting factor in use of the formulation is the cost; future trials are needed, with cost-analysis, to determine whether the benefits in pain, reduction in narcotic use, shorter hospital stay and possibly decreased pul-monary complications justify the cost.Alternatively, intravenous narcotics via patient-controlled analgesia can be used, often in conjunction with ketorolac, gabapentin, and intravenous Tylenol. Dosing must be titrated to balance the degree of pain relief with the degree of seda-tion. Oversedated patients are as ominous as patients without adequate pain control because of the significant risk of


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Surgery_Schwartz. must be titrated to balance the degree of pain relief with the degree of seda-tion. Oversedated patients are as ominous as patients without adequate pain control because of the significant risk of secre-tion retention, atelectasis/pneumonia, and pulmonary aspiration, especially in elderly patients who should be carefully assessed for aspiration risk when ordered for dietary advancement. Proper pain control with intravenous narcotics requires a care-fully regulated balance of pain relief and sedation to maximize the benefits of pain control while minimizing these very real and potentially life-threatening complications.Whether on epidural, paravertebral, or intravenous pain control, the patient is typically transitioned to oral pain medica-tion on the third or fourth postoperative day. During both the parenteral and oral phase of pain management, a standardized regimen of stool softeners and laxatives is advisable in order to prevent severe constipation.Respiratory Care. The best


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Surgery_Schwartz. During both the parenteral and oral phase of pain management, a standardized regimen of stool softeners and laxatives is advisable in order to prevent severe constipation.Respiratory Care. The best respiratory care is achieved when the patient is able to deliver an effective cough to clear secre-tions and results from the commitment and proper training of all involved healthcare providers. The process begins preopera-tively, with clear instructions on using pillows (or other support techniques) over the wound and then applying pressure.Postoperatively, proper pain control without oversedation (as outlined earlier) is essential. Daily morning rounds should include a careful assessment of the patient’s pulmonary status, reminders to the patient and family about the importance of coughing and deep breathing, including use of adjunctive respi-ratory equipment if ordered, and mobilization of the patient. Early transition to a chair and to ambulation is the best respira-tory therapy and


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Surgery_Schwartz. and deep breathing, including use of adjunctive respi-ratory equipment if ordered, and mobilization of the patient. Early transition to a chair and to ambulation is the best respira-tory therapy and should be strongly encouraged. When avail-able, physical and/or cardiopulmonary rehabilitation services are vital additional members of the care team.Postoperative ComplicationsPostoperative complications after pulmonary resection range from minor to life-threatening. Strict attention to volume sta-tus, early and aggressive pulmonary toilet, and good pain control can reduce the risk of most complications, but does not completely eliminate them, even in centers of excellence. The most devastating complication after pulmonary resection is postpneumonectomy pulmonary edema, which occurs in 1% to 5% of patients undergoing pneumonectomy and more often after right compared to left pneumonectomy. Clinically, symp-toms of respiratory distress manifest hours to days after sur-gery.


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Surgery_Schwartz. occurs in 1% to 5% of patients undergoing pneumonectomy and more often after right compared to left pneumonectomy. Clinically, symp-toms of respiratory distress manifest hours to days after sur-gery. Radiographically, diffuse interstitial infiltration or frank alveolar edema is seen. The pathophysiologic causes are related increased permeability and filtration pressure and decreased lymphatic drainage from the affected lung. Judicious use of intravenous fluids perioperatively, including use of vasopres-sors rather than fluid boluses for hypotension intraand post-operatively, is critical to minimizing the risk of this syndrome. Treatment consists of ventilatory support, fluid restriction, and diuretics. Extracorporeal membrane oxygenation may be life-saving in centers where this option is available. The syndrome reportedly has a nearly 100% mortality rate despite aggressive therapy.Other postoperative complications include air leak and bronchopleural fistula. Although these are two


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Surgery_Schwartz. is available. The syndrome reportedly has a nearly 100% mortality rate despite aggressive therapy.Other postoperative complications include air leak and bronchopleural fistula. Although these are two very differ-ent problems, distinguishing between them may be difficult. Postoperative air leaks are common after pulmonary resection, particularly in patients with emphysematous lung, because the fibrosis and destroyed blood supply impairs healing of surface injuries. Prolonged air leaks (i.e., those lasting >5 days) may be treated by diminishing or discontinuing suction (if used), by continuing chest drainage, or by instilling a pleurodesis agent, usually doxycycline or talcum powder, which will cause pleurodesis of the lung within the chest cavity and minimize the possible collapse of the lung due to persistent air leak. This is useful only in patients in whom full lung expansion is achieved, either with suction or on water seal, as patients with a persistent pneumothorax on CXR will


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Surgery_Schwartz. lung due to persistent air leak. This is useful only in patients in whom full lung expansion is achieved, either with suction or on water seal, as patients with a persistent pneumothorax on CXR will not have adequate lung-to-parietal pleural apposition to achieve adequate pleurodesis.If the leak is moderate to large, a high index of suspicion for bronchopleural fistula from the resected bronchial stump should be maintained, particularly if the patient is immunocom-promised or had induction chemoand/or radiation therapy. If suspected, flexible bronchoscopy is performed to evaluate the bronchial stump. Management options include continued pro-longed chest tube drainage, reoperation, and reclosure (with stump reinforcement with intercostal or pedicled serratus mus-cle flap). If the fistula is very small (<4 mm), bronchoscopic fibrin glue application has been used successfully to seal the hole in some patients. Patients often have concomitant empy-ema, and open drainage may be