Lung cancer is one of the most commonly diagnosed type of cancer and so it is fitting that we start the first of our disease-specific oncology series with this diagnosis. This week, we sit down with Thoracic Surgeon, Dr. Jane Yanagawa to discuss surgical considerations in treatment of NSCLC.

* How do you choose what type of surgical resection to do?

- Considerations:

--Lung anatomy

--Location of the nodule within lung

--Lymph node involvement

-Options:

--Pneumonectomy: removal of whole lung

--Lobectomy: remove a whole lobe

--Segmentectomy/sublobar resection: part of a lobe

* What does “adequate margins” mean? And how do you know if it’s enough?

- If you’re removing the whole lobe, it does not matter as much

- If you’re doing a segmentectomy, you want to have samples evaluated while in the OR because if there is signs of more disease that initially thought, you would take this one step further and do a lobectomy.

- Need to consider the patient’s situation - how good is their status

* Why does preoperative workup matter?

- Pulmonary function tests: Surgeons are looking at the %FEV1 and %DLCO to then predict what their function would be AFTER surgery. After surgery, they want to ensure patient has %FEV1 or %DLCO >40%.

- Lung anatomy: In patients with COPD and endobronchial lesions, sometimes they also get V/Q scans to evaluate ratio

- Cardiac echo: Important in pneumonectomy where removal of lung tissue will also remove a significant amount of blood vessels. Want to rule out pulmonary hypertension pre-operatively.

- Pulmonary hypertension can also affect someone’s survival while they’re ventilating with only one lung during the procedure (“single lung ventilation”).

- Smoking status: Smoking can increase complications by ~60%.

- Pre-habilitation: Encouraging patients to be fit prior to surgery with walking, nutrition, +/- pulmonary rehabilitation

* What is “VATS”?

- VATS stands for video-assisted thoracoscopic surgery; it is not, in itself, a procedure. But a VATS allows for minimally invasive surgery through the use of a camera.

- It involves three incisions (axilla, lowest part of mid-axillary line, one posterior)

* In what scenario is a mediastinoscopy warranted?

- Needed after EBUS if there is still high index of suspicion for cancer involvement in lymph nodes, even if lymph nodes are negative from EBUS

* What is “systematic lymph node sampling”?

- An organized way to sample lymph nodes, including all lymph nodes that are along the way, not just the ones that may be involved

* As a surgeon, how do you determine if a patient is okay for surgery if the mass is invading another structure?

- Need to take the anatomy into consideration - are there major blood vessels or nerves there, for instance, which can impact outcome and recovery.

* When should we consider induction chemotherapy from a surgeon’s perspective?

- Lots of changes in this sphere coming; lots of discrepancy between institutions when there is N2 disease

- In Dr. Yanagawa’s opinion, anyone with N2 disease should get neoadjuvant therapy

* If there is neoadjuvant chemoradiation given, how does that effect your surgery?

- Radiation increases scar tissue in the lung tissue. But what is worse is that radiation neoadjuvantly may make wound healing more difficult. She does not prefer radiation pre-operatively

- Chemotherapy also adds scar tissue

*How does neoadjuvant IO therapy affect scar tissue formation?

- The hilum and lymph nodes are more swollen, but does not translate to more complications

- She has even seen patients who had gotten IO for another cancer and then get lung cancer, she can still appreciate swollen nodes!

* How long after surgery is it safe to start adjuvant therapy?

- If patient has a complication from surgery, would not start right away. It is important to discuss with the surgeon about when it is okay to proceed with adjuvant therapy.

- If patient has good recovery/without complications, okay to start about 4 weeks after

- There is no good guidance yet about when it is safe to start IO after surgery

About our guest: Jane Yanagawa, MD is an Assistant Professor of Thoracic Surgery at the UCLA David Geffen School of Medicine and the UCLA Jonsson Comprehensive Cancer Center. She completed medical school at Baylor College of Medicine, after which she went to UCLA for her surgical residency. She went onto Memorial Sloan-Kettering for her Thoracic Surgery Fellowship. In addition to her practice as a thoracic surgeon at UCLA, Dr. Yanagawa also sits on the NCCN NSCLC guidelines committee! We are so grateful she was able to join us despite her very busy schedule!

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Episode 031: Lung Cancer Series, Pt. 8: Surgical considerations in early stage NSCLC

The Fellow on Call: The Heme/Onc Podcast