Lung Cancer: Determining Resectability

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1 Lung Cancer: Determining Resectability Leslie E. Quint No disclosures

2 Lung Cancer: Determining Resectability AIM: Review imaging features that suggest resectability / unresectability Primary tumor invasion Multiple lung nodules Regional lymph nodes

3 Primary Tumor Invasion affects resectability: Mediastinal fat Vital mediastinal structure Vertebral body Chest wall Brachial plexus

4 Mediastinal Fat Invasion Extensive invasion unresectable

5 Mediastinal Fat Invasion Minimal invasion resectable

6 Mediastinal Fat Invasion Minimal invasion resectable

7 Mediastinal Fat Invasion Extensive invasion unresectable Sometimes difficult to determine unresectable

8 Vital Mediastinal Structure Extensive invasion unresectable Heart, pulmonary artery Invasion

9 Vital Mediastinal Structure Extensive invasion unresectable Esophagus Invasion

10 Vital Mediastinal Structure Extensive invasion unresectable SVC Invasion

11 Vital Mediastinal Structure Minimal invasion resectable SVC invasion Hole sutured closed Invasion

12 Vital Mediastinal Structure Contiguity invasion Invasion

13 Vital Mediastinal Structure Contiguity invasion When in doubt, err on side of undercalling invasion Invasion resectable unresectable

14 Left Atrial Invasion May be resectable Extension from PV Suture close atrial defect Ratto GB. Ann Thorac Surg 2004;78:234

15 Vertebral Invasion En bloc resectable possible, esp. if minimal Can resect up to entire vert body Martin LW. Thoracic Surgery Clinics. 2004;14:241

16 Chest Wall Invasion Generally resectable Loss of extrapleural fat plane >3 cm contact between mass and chest wall Pleural thickening Obtuse angle

17 Chest Wall Invasion Generally resectable Loss of extrapleural fat plane >3 cm contact between mass and chest wall Pleural thickening Obtuse angle Soft tissue in extrapleural fat

18 Chest Wall Invasion Generally resectable Loss of extrapleural fat plane >3 cm contact between mass and chest wall Pleural thickening Obtuse angle Soft tissue in extrapleural fat

19 Chest Wall Invasion Only reliable CT features Bone destruction Soft tissue mass in chest wall Riquet M. Thoracic Surgery Clinics. 2010;20:519

20 Chest Wall Invasion MR features: Disruption of extrapleural fat?better than CT Cine MR to look for sliding b/n tumor and chest wall Lee CH. Korean Journal of Radiology 2010; 11:37

21 Chest Wall Invasion Chest wall reconstruction for stabilization after extensive resection

22 Superior Sulcus Invasion Minimal invasion may be resectable after chemo/rt Except if brachial plexus is involved

23 Superior Sulcus Invasion Courtesy of Dr. Jeremy Erasmus

24 Ipsilateral often resectable Lobectomy and wedge Pneumonectomy if necessary Multiple Lung Nodules

25 Regional Lymph Nodes N1 resectable Hilar, peribronchial

26 Regional Lymph Nodes N2 resectable Ipsilateral mediastinal, subcarinal lymph nodes Neoadjuvant chemo/rt If not numerous or bulky Several other exceptions

27 Regional Lymph Nodes N2 unresectable Bulky lymph nodes

28 Regional Lymph Nodes N2 unresectable Bulky lymph nodes

29 Regional Lymph Nodes N2 unresectable Chest wall invasion Poor prognosis (7% 5 yr survival)

30 Regional Lymph Nodes N2 unresectable If pneumonectomy needed Poor prognosis

31 Regional Lymph Nodes N2 unresectable Mediastinal invasion? for adenocarcinomas Poor prognosis Lucchi M. Journal of Cardiovascular Surgery. 2007;48:369

32 Regional Lymph Nodes N3 unresectable Contralateral mediastinal or hilar Any scalene or supraclavicular nodes Courtesy of Dr. Jeremy Erasmus

33 Mediastinal Lymph Nodes Sensitivity % Specificity % CT PET Meta-analysis PET better than CT Imperfect specificity need proof of positive findings Toloza EM. Chest 2003;123:137S

34 Conclusions Resectability is influenced by: Primary tumor invasion Multiple lung nodules Regional lymph nodes Combinations Need tissue proof of abnormal lymph nodes at CT and PET

35 Thank you for your attention!