Treatment of Non-Small Cell Lung Cancer (NSCLC)

Surgery for NSCLC can be performed for curative, debulking or palliative reasons. Curative surgery is done in an attempt to remove the cancerous tumor completely. This is performed when the tumor appears to be confined to a certain area and may include a wedge resection, lobectomy or pneumonectomy. Debulking surgery is done when the entire tumor cannot be removed. The goal of this surgery is to reduce the tumor size and maximize the potential effectiveness of chemotherapy and radiation therapy. Palliative surgery is not an attempt to cure lung cancer. It is done in the hope of alleviating some of the discomfort from the symptoms associated with advanced disease. Types of surgical resections for the treatment of NSCLC include wedge or segmental resection, lobectomy and pneumonectomy.

• Wedge resection or segmental resection - a type of surgical resection in which only a small portion of the affected lung is removed.
• Lobectomy - the surgical removal of a lobe of the lung.
• Pneumonectomy - the surgical removal of an entire lung.

Surgical techniques for the treatment of lung cancer include:

Thoracotomy: a surgical procedure involving an incision between two ribs opening the chest wall to allow the surgeon to access the lungs, esophagus, trachea, aorta, heart and diaphragm. The incision is placed on the right or left side of the chest depending on the location of the disease. The access to the structures within the chest wall allows for the removal of tissue, lymph nodes and/or tumors. This approach can be used to perform wedge or segmental resections, lobectomies or pneumonectomies as determined to be necessary for the treatment of lung cancer.

Video-Assisted Thoracoscopic Surgery (VATS) - is a minimally invasive alternative for a variety of thoracic conditions. VATS can be used for either diagnostic or therapeutic purposes and has been applied to many organ systems within the chest area and sometimes allows for easier surgical access. In addition, it may reduce pain after surgery and may lead to more rapid recovery. In some cases, VATS has enhanced complex open surgical techniques. At Cardiovascular and Thoracic Surgeons of Ventura County we are committed to offering minimally invasive procedures whenever possible and VATS is done frequently for our patients.

Indications for VATS:

• Diagnosis of indeterminate masses and pleural effusions
• Drainage of pleural effusions empyema and hemothorax
• Biopsy of lymph nodes and mediastinal masses
• Pericardial window
• Lung resections
• Esophageal procedures
• Spinal injuries

Surgery is the most potentially curative option for the treatment of NSCLC. Radiation therapy has provided a small number of patients with a cure and palliation in most patients. Chemotherapy has offered patients an improvement in outcome survival and has shown an overall improvement in disease related symptoms.

Standard treatment options vary according to the staging and TNM subset of NSCLC (see section on staging for more detail)

Stage 0:
Tis, N0, M0
Carcinoma in situ is cancer in its earliest form. The tumors are noninvasive and nonmetasisized. Surgical resection with the least extensive method possible such as a wedge or segemental resection.

Stage I:
T1, N0, M0
T2, N0, M0
Surgery is the treatment of choice for Stage I NSCLC. Careful pre-operative assessment of the patient s overall medical condition and pulmonary function testing to determine pulmonary reserves allow the surgeon to determine the best surgical option for the patient. Surgical options include lobectomy, segmental or wedge resection. Radiation therapy may be an option for patients with contraindications to surgery. Chemotherapy may be used as adjuvant therapy after resection.

Stage II:
T1, N1, M0
T2, N1, M0
T3, N0, M0
Surgery for Stage II NSCLC remains the standard treatment of choice. overall medical condition and pulmonary function testing for pulmonary option for the patient. Surgical options include: lobectomy, pneumonectomy, appropriate. Radiation therapy may be used in patients who have contraindications without radiation therapy may be used as an adjuvant to surgery.

Stage IIIA:
T1, N2, M0
T2, N2, M0
T3, N1, M0
T3, N2, M0
After careful consideration to the patient s overall medical condition, the principal treatments for Stage IIIA NSCLC are chemotherapy, radiation therapy, and surgical resection. Combination therapy for patients with respectable Stage IIIA NCSLC has reportedly improved survival rates as compared to surgery without adjuvant therapy. Patients who have undergone a thoracotomy that has been identified as an unresectable tumor are treated with chemotherapy and radiation therapy. Although responses to treatment vary, objective and subjective palliative results have been significant.

Stage IIIB:
Any T, N3, M0 T4, any N, M0 And Stage IV: Any T, Any N, M1 Patients with Stage IIIB NSCLC benefit from chemotherapy, chemotherapy with radiation therapy or radiation therapy alone, depending on their overall medical condition and the sites of tumor involvement. Patients with malignant pleural effusions are generally not considered candidates for radiation therapy and are usually treated similarly to Stage IV patients. Patients with concurrent radiation and chemotherapy have shown improved survival outcomes. Patients who have medical conditions that prohibit the use of chemotherapy are candidates for palliative treatment with radiation therapy to relieve pulmonary symptoms such as cough, shortness of breath and pain. Stage IV NSCLC patients are given palliative chemotherapy regimens with some benefit to short term survival.