Trattamento chirurgico: il ruolo

delle resezioni polmonari limitate Dott. Nicolò Fabbri

Dott. Nicola Tamburini

Istituto di Chirurgia Generale e Toracica AOU S. Anna Ferrara

22 febbraio 2017

Aula 3 Polo Didattico Cona

Il “nodulo” Ground Glass

• Adenocarcinoma non invasivo (ex BAC);

• Iperplasia adenomatosa atipica (AAH) (lesione precancerosa);

• Maltoma, Baltoma;

• Metastasi (pancreas, colon)

Si suddividono in:

Puri

Misti

Solidi

Lesioni preneoplastiche e neoplastiche:

Società di Radiologia Medica Italiana (SIRM)

1. polmonite organizzativa,

2. fibrosi focale,

3. vasculiti,

4. lesioni micotiche,

5. bronchiolite respiratoria (noduli ground-

glass multipli di diametro minore di 5 mm),

6. altro

Il “nodulo” Ground Glass

cause di nodulazioni ground-glass benigne:

Società di Radiologia Medica Italiana (SIRM)

?

FATTORI DI RISCHIO:

• Età (>\< 40 aa.)

• Abitudine tabagica

• Esposizione all’asbesto, Radon, Uranio

• Fibrosi polmonare

• Familiarità positiva per neoplasia (primo grado)

Società di Radiologia Medica Italiana (SIRM)

Percentuale di malignità per noduli polmonari:

• - 63% per noduli parzialmente solidi (sub-.solido),

• - 18% per noduli non solidi,

• - 7% per noduli solidi,

FATTORI DISCRIMINANTI NELLA VALUTAZIONE

DELLA LESIONE POLMONARE

Società di Radiologia Medica Italiana (SIRM)

Diagnosi cito\istologica

preoperatoria?

Quando la chirurgia per ground glass?

Aumento dimensionale al follow up + biopsia positiva

Comparsa di noduli solidi nel contesto di ground glass (biopsiachirurgia)

Nodulo solitario misto con componente solida >5 mm (probabilità significativamente maggiore di lesione maligna)

Società di Radiologia Medica Italiana (SIRM)

La chirurgia è il trattamento di scelta nel

tumore del polmone non a piccole cellule in

stadio iniziale sopravvivenza a 5 aa del 90%

Resezione anatomica Segmentectomy provides a survival rate similar to that with lobectomy

for tumours <\= 2 cm in size, but not for larger tumours

•

Resezione non anatomica

• intento diagnostico

• Lung sparing surgery

• Resezione di noduli benigni

NSCLC e Chirurgia

• Lobectomy has generally been accepted as the standard extent

of resection required for NSCLC surgery,

• 1995: Lung Cancer Study Group (LCSG) randomized study

comparing open lobectomy with more limited pulmonary resection in

stage I non–small-cell lung cancer (NSCLC;T1N0)

• 30% increase in mortality in the sublobar group and a statistically

higher locoregional recurrence (P = .08) in the limited resection

group

CHIRURGIA PER NODULI MULTIPLI

Noduli ground-glass puri e parzialmente solidi,

MULTIPLI con\senza lesione dominante, con

aumento dimensionale al follow up

The standard-of-care surgical treatment of early lung cancer is still minimally invasive lobectomy

with systematic lymph node dissection.

Recent research has shown that some GGO lesions may be treated with sublobar resections;

these findings may expand the surgical treatment options available in the future.

Ground-Glass Opacity Lung Nodules in the Era of Lung Cancer CT Screening: Radiology, Pathology, and Clinical Management

Chirurgia per noduli multipli

Conclusion:

Video-assisted thoracic surgery management of multifocal

bronchioloalveolar carcinoma yielded satisfactory results.

However, the appearance of new lesions remains a

problem.

Mingyon Mun, MD, and Tadasu Kohno, MD Department of Thoracic Surgery, Toranomon Hospital, Tokyo, Japan.

June 15, 2007. The Journal of Thoracic and Cardiovascular Surgery ● Volume 134, Number 4 877

Quale approccio chirurgico?

Open Toracoscopico

Eur J Cardiothorac Surg (2016) 49 (2): 602-609 Aprile 2015

28771 pazienti totali:

-26050 toracotomia,

-2721 toracoscopia.

VATS-L è associata a:

minor complicanze cardiopolmonari maggiori,

minor atelettasia polmonare,

minor rischio di infezione di ferite,

nessuna differenza nel rischio di insorgenza di F.A.

minor durata del ricovero ospedaliero.

Eur J Cardiothorac Surg (2016) 49 (2): 602-609 Aprile 2015

CONCLUSIONS:

lobectomy performed through VATS is associated

with a lower incidence of complications compared

with thoracotomy.

DA QUALI FATTORI DIPENDE LA CANDIDABILITA’

DI UN PAZIENTE ALL’INTERVENTO?

•Aspettativa di vita del paziente

•Compliance nell’intraprendere il

percorso chirurgico proposto

•Qualità di vita del paziente

•Valutare la possibilità di cure

alternative efficaci

“We are moving towards an era in which several

therapeutic possibilities are available, that are probably

equivalent from an oncological point of view”

Surgical and nonsurgical approaches to small-size nonsmall cell lung cancer Dirk De Ruysscher1,3, Kazuo Nakagawa2,3, Hisao Asamura2

Number 3 in the series ‘‘Challenges and Controversies in Thoracic Oncology’’ Edited by J-P. Sculier, B. Besse and P. Van Schil

…Come appare realmente!!! COME

LO IMMAGINIAMO…

IL PAZIENTE

February 2015: US insurers, the Center for Medicare and Medicaid

Services agreed to fund screening of asymptomatic insured individuals

aged 55–77 who meet the USPSTF smoking criteria.

Prospettive future

The National Lung Screening Trial (NLST) demonstrated a 20% reduction in

mortality with low-dose CT (LDCT) screening and guidelines now endorse

annual LDCT for those at high risk.

Early detection of lung cancer REVIEW Apr 2016

David E. Midthun Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA

Screening con LDCT

Fluoroscopically Guided Video-Assisted Thoracoscopic Resection

After Computed Tomography-Guided Localization Using Platinum

Microcoils Annals of Surgery • Volume 240, Number 3, September 2004

Prospettive future

Diffusione della

chirurgia mini-invasiva

Prospettive future

Lung Sparing Surgery?

Conclusioni

• Diagnosi precoce

• Approccio multidisciplinare (PDTA)

• chirurgia mininvasiva

GRAZIE PER L’ATTENZIONE

1915

2017

Bibliografia

Video-assisted thoracoscopic surgery versus open lobectomy for primary non-small-cell lung cancer: a propensity-

matched analysis of outcome

Eur J Cardiothorac Surg (2016) 49 (2): 602-609. Published: 26 April 2015

Minimally Invasive Resection of Early Lung Cancers

Review Article | March 15, 2015 | Oncology Journal , Lung Cancer , Screening

By Aaron M. Cheng, MD and Douglas E. Wood, MD

Efficacy of thoracoscopic resection for multifocal bronchioloalveolar carcinoma showing pure ground-glass opacities

of 20 mm or less in diameter The Journal of Thoracic and Cardiovascular Surgery ● Volume 134, Number 4 877

Surgical and nonsurgical approaches to small-size nonsmall cell lung cancer

Dirk De Ruysscher1,3, Kazuo Nakagawa2,3, Hisao Asamura2

Number 3 in the series ‘‘Challenges and Controversies in Thoracic Oncology’’

Edited by J-P. Sculier, B. Besse and P. Van Schil

Eur Respir J 2014; 44: 483–494 | DOI: 10.1183/09031936.00020214

Pulmonary nodules and CT screening: the past, present and future

Ruparel M, Quaife SL, Navani N, et al.Thorax 2016;71:367–375.

Ground-Glass Opacity Lung Nodules in the Era of Lung Cancer CT Screening: Radiology, Pathology, and

Clinical Management Review Article | March 15, 2016 | Oncology Journal, Lung CancerBy Jesper Holst Pedersen, MD,

DMsci, Zaigham Saghir, MD, PhD, Mathilde Marie Winkler Wille, PhD, Laura Hohwü Thomsen, MD, PhD, Birgit

Guldhammer Skov, MD, DMsci, and Haseem Ashraf, MD, PhD

Early detection of lung cancer REVIEW Apr 2016

David E. Midthun Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA

Peripheral Lung Nodules Fluoroscopically Guided Video-Assisted Thoracoscopic Resection After

Computed Tomography-Guided Localization Using Platinum Microcoils

Annals of Surgery • Volume 240, Number 3, September 2004