THORACIK RICK Outline and objectives Lungs Management of a solitary lung nodule Mediastinum Management of a mediastinal mass Pleura Management of a pleural fluid & pneumothorax Esophagus & Stomach Management of dyspepsia & dysphagia Lungs Richard A. Malthaner MD MSc FRCSC FACS Thoracic Surgery 1
Story A 58 -year old singer, smoker, comes to your office with a 6-month history of cough and a CXR. He asks for a CT scan. What do you do? CXR and CT thorax 1.5 cm nodule in the right upper lobe Spiculated Non-calcified Is it cancer? What do you think? Solitary lung nodule Bronchoscopy Benign Granuloma, hamartoma, fibroma, lipoma, chondroma, hemangioma, leiomyoma, xanthoma, lymphoma, Wegener s, AVM, amyloidosis, mucous impaction, rheumatoid arthritis, carcinoma, infection, sarcoidosis. Malignant Primary Secondary What do you do? 2
CT guided lung biopsy Repeat chest x-ray Repeat CT scan PET scan Diagnostic options Repeat imaging CT scan with 3D voxels CT needle biopsy Non diagnostic biopsies Pneumothorax PET Not for < 1 cm lesions Resect 3
Stage I Stage II Stage III Stage IV Mediastinoscopy 4
Mediastinoscopy EBUS Stage 1 Needle biopsy shows an adenocarcinoma PET shows no metastases Mediastinal lymph nodes clear CT head normal Pulmonary function tests are good FEV1 > 30% DLCO > 30% What do you do? 5
Surgery Wedge resection How much to remove? Lobectomy Pneumonectomy Best Evidence in Surgical Treatment Randomized Control Trial Journal Club 6
To wedge or not to wedge? Reference Survival- are they equivalent? Brother Ed s tweet home message Lobectomy remains the standard for operable stage I NSCLC. p < 0.1, reject the H 0 They are not equivalent Thoracotomy vs VATS Post-op 7
VATS risks Bleeding Equipment malfunction Stapler malfunction Port seeding Need for rib spreading / resection for specimen removal Post op risks Air leak SVT Infections Pneumonia Respiratory failure MI or stroke VTE Death 2% lobectomy 5% pneumonectomy December 9, 2008 WHO: Cancer to surpass heart disease as world's leading killer Public Enemy #1 Who gets Lung Cancer? Lung cancer What are the causes? 8
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Patient too ill for resection One block / one flight = lobectomy Two blocks / two flights = pneumonectomy Options SABR Stereotatic ABlative Radiotheray? Chemotherapy? Skillful neglect? What do you do? Intervention SABR 1. STARS only used the CyberKnife (Accuray) 2. ROSEL used various linear accelerators 10
Skeptik BEST commentary The good Best evidence to date Only included randomized trials Central randomization Used individual patient data Used intention to treat analysis Probably were clinically homogeneous All had stage I NSCLC (<4 cm) Good performance status All had staging PET The bad Small numbers More authors than patients in the ROSEL trial! Discrepancy in Figure 2 survival p=0.037 yet the 95% CI (0.017 1.19)! Why did they not include the ACOSOG Z4099? Survival was calculated from date of treatment and not from date of randomization No quality assessment of the trials Not publication bias assessment No sensitivity analysis Not all patients had biopsy confirmed cancer The bad No assessment of heterogeneity Most surgical cases were done with a thoracotomy Locoregional recurrence higher in SABR SABR 16% vs 4% in lobectomy SABR cases are often be salvaged by lobectomy The ugly They lumped all the data together as if it was one large trial!!! This not how to do an IPD meta analysis The trial, authors, and biostaticians were funded by the SABR machines Accuray and Varian Medical Systems CyberKnife system 11
Brother Ed s tweet home message SABR appears to be a reasonable option for stage I lung cancer. 2 years later Worsening shortness of breath Now needs oxygen Back pain Options? Stent Radiation Brachytherapy Photodynamic therapy Laser Nothing 12
Lung cancer A new nodule in a smoker is a cancer until proven otherwise. Lobectomy is the standard of care for early stage. What you must know. 13
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