European Multidisciplinary Conference in Thoracic Oncology (EMCTO 2011) 24—26th February 2011, Lugano

Optimal care for patients with stage I-III non-small cell lung cancer

Dr Paul van Shil (Antwerp University Hospital, Belgium)

Professor Paul van Shil, you are a surgeon here at the Multidisciplinary Conference on Thoracic Oncology here in Lugano. You are looking particularly at optimal care for the patients with stage I-III non-small cell lung cancer. What are the big issues that need to be considered from a surgical point of view?

Thank you. From a surgical point view, we really want to stress that when we operate on a patient with a non-small cell lung cancer, or even a small cell lung cancer now as this is also considered in the new TNM classification, that you obtain a complete resection. So this can seem to be rather straightforward but it is a rather difficult issue to define really what is a complete resection. So usually what we mean by that, because there has been a sub-committee of the International Association for the Study of Lung Cancer, headed by Rami-Porter from Barcelona, specifically looking at detailed analysis of what is a complete resection. So some criteria are now put forward, meaning that, this is very logical of course, that the primary tumour is completely removed, that as a surgeon we also perform a lymph node dissection so meaning that at least six lymph node stations are removed during the procedure, of which three should be in the mediastinum; that after pathological examination all the resection margins should be free of tumour and that the highest mediastinal lymph node is negative. So we have very precise criteria now to define what is a complete resection, and we have seen in very many trials that those patients who had a complete resection have the best survival on the long term.

In TNM staging what are the stages that are OK for just a purely surgical approach, and when do you introduce chemotherapy?

We make a distinction between definite indications for surgery and still investigation or exceptional stages that can be operated, and definite indications are those patients with stage 1 and 2 disease, which we call early stage disease so not very locally advanced tumours, and use discussion going on on those patients with locally advanced disease; so meaning that the mediastinal lymph nodes are involved or larger bulky tumours that invade different organs besides the lung.

So N1 makes you think of chemotherapy in addition to surgery?

Yes. Then we give, in addition to surgery, for N1 disease when we find it during the operation and we exclude N2 disease, then those patients would usually be treated by adjuvant chemotherapy when they have a good performance status.

And then in more advanced disease you could still decide to use surgery but it’s more investigational?

It’s more difficult to define the role of surgery in locally advanced disease. The reason is that it is difficult to obtain a complete resection by surgery only, so we look at what is called combined modality treatment, so a combination of sometimes chemotherapy or chemotherapy with radiation followed by surgery; or in some cases even giving induction chemotherapy, so before the operation, and then do the operation and then give adjuvant therapy afterwards. In some cases we would consider that. But we aim with our induction treatment, be it chemotherapy alone or chemo-radiation, to have a down staging of the tumour. So shrink the volume of the tumour or, for example in those cases where the mediastinal lymph nodes are involved on the same side, which we call N2 disease, that the tumour would disappear from those nodes. But it is difficult to evaluate that after the induction therapy, so sometimes we need invasive staging techniques to look at the lymph nodes after induction therapy.

Now you have just been giving your talk here in Lugano and I know you were asked about the best strategy in locally advanced disease, which of course is a difficult area. What do you have to say about that?

Yes, for locally advanced disease we will look very precisely and determine the stage before the operation. Sometimes we need invasive techniques, even thoracoscopy or mediastinoscopy, to look at the lymph nodes of the primary tumour which give a very precise idea of the involvement of the primary tumour, and then we will decide at the Multidisciplinary Conference which treatment should be given, so in fact it is a very individualised treatment. As we have no precise idea of the randomised trials that have been performed, what is the best strategy for every patient? We know even stage 3 disease is a very heterogeneous population of patients. Even with the new TNM classifications there are different levels of involvement with locally advanced disease. It can be the primary tumour that involves another organ, for example the aorta, the oesophagus or the chest wall, or it can be involvement locally inside the hilum or the mediastinum. So those are very different patient populations.

And how much does the contribution of other member of the Multidisciplinary Team help you with your decision making?

Very much because we have also a medical oncologist, a radiation oncologist and the pulmonary physicians are always on board to discuss every patient, and then we decide what is the best treatment strategy. And what has not been discussed now at this conference is not only the operability or the resectability of the patient but also the functional stages and the comoribidity is equally important. For example, when you have a patient who is a smoker who does not only have a lung cancer but severe emphysema with COPD, so chronic obstructive pulmonary disease, he can have a very poor pulmonary function. And we know beforehand that you have to do a pneumonectomy, so a complete removal of the lung, so it can sometimes be impossible for that patient to perform that kind of operation because of his general condition and his poor pulmonary function. So that is the reason we like to discuss every patient with every specialty involved.

Now you say, “We come to a decision”, how easy is it to come to a decision? Do you often find that there are disagreements?

Not disagreements but the question is often which risks you have to take with a patient, for example when you know beforehand that the mortality will be around 10% will you do the operation or will you not do the operation? And sometimes you have to call in for the family physician or even discuss with the patients and relatives. When you have a rather young patient you are willing to take higher risks than when your patient is 80 years old and he says, “OK I have had my life and I just want some smoother treatment with chemotherapy or radiation therapy at a lower level”, and sometimes we will go for that. You always respect the patients and try to involve, for difficult cases also, the patient in the decision making.

So what are the clinical implications of really understanding this staging and using the information to make your planning? What are the basic take home messages?

The main take home messages for the surgeon is we all start to obtain a complete resection with the definition I have given, and we try to very precisely stage the patients before the operation so that you know beforehand which clinical stage your patient is in, to decide on the further treatment. And then we have kind of general algorithms but for locally advanced disease it remains controversial. So we should aim for that more individualised therapy.

Well Paul, thank you very much for joining us on ecancer.tv.

Thank you very much.