A major clinical challenge encountered by thoracic surgeons lies in the decision to pursue surgery, which must be weighed between surgical risk and the reliability of CT findings.
Gaetano Rocco, MD
How removed is a thoracic surgeon from the beginning of a lung cancer screening (LCS) process?
Most commonly, clinicians follow a step-by-step practice of computed tomography (CT), multidisciplinary discussion, and tissue sample collection before a surgical referral is actually made.
In light of the new implementation guide published by the American Lung Association and the American Thoracic Society for LCS programs1, Gaetano Rocco, MD, a specialist in the treatment of lung nodules at Memorial Sloan Kettering (MSK) Cancer Center in New York City, New York, and MSK Monmouth in New Jersey, offered insight into the challenges, decision-making processes, and future directions of LCS from a thoracic surgeon’s perspective.When designing and implementing an LCS program, Dr. Rocco said, what is true on paper must also be true in practice. “The absence of a true multidisciplinary approach could be a challenge for the participating thoracic surgeon,” he said. “In fact, a successful LCS program must include a coordinating referral center based on [an] effective communication strategy with patients and referring physicians. Moreover, the coordinating effort must facilitate communication with the other units—ie, chest imaging, interventional radiology, pulmonary medicine, pathology, smoking cessation—included in the LCS-specific tumor board, whose effectiveness should be measured with performance quality metrics.”A major clinical challenge encountered by thoracic surgeons lies in the decision to pursue surgery, which must be weighed between surgical risk and the reliability of CT findings, the latter of which may not inspire confidence. “A major challenge results from the interpretation of the nodule features…which is crucial to plan for a surgical option,” Dr. Rocco said. “In this setting, the incidence of false positives at CT scan remains an issue; in the National Lung Screening Trial [NLST], 20% of CT scans at each screening round showed suspicious lesions, but 90% of them turn out to be benign. Pulmonary nodules [of] less than 1 cm may be difficult to characterize preoperatively…in relation to the PET [positron emission tomography] detection threshold, usually 0.8 cm. Thoracic surgeons must also bear in mind and evaluate the surgical risk of overdiagnosing indolent—ie, clinically insignificant—cancers.”
In the operating room, a surgeon’s path may remain unclear, particularly when the surgeon searching for a small nodule. “Small nodules may pose challenges to their identification in the lung parenchyma,” Dr. Rocco said, “thereby jeopardizing the possibility of a minimally invasive approach, which must be one of the requirements for thoracic surgical participation in the LCS program.”Dr. Rocco highlighted the relatively low complication rates of LCS programs, despite those challenges, and noted that complication statistics require perspective. “It has to be remembered that LCS programs include high-risk patients for lung cancer who in turn may present a significant number of comorbidities,” he said. “And yet, mortality is rare—0.8%—and the major complication rate ranges between 3% and 8% in NLST and other LCS trials.”
The most common complications are residual incisional pain, pneumonia, bleeding, and air leak. Fortunately, the frequency of these and other complications can be reduced with newer surgical techniques and imaging. “A widespread resort to minimally invasive surgery—video-assisted thoracoscopic or robotic—and the use of hybrid operating rooms that accommodate CT scanners to better identify lung lesions represent a suitable strategy to reduce the morbidity of a surgical biopsy,” Dr. Rocco said.
“It needs to be emphasized that surgery, as a rule, leads to the complete removal of the lesion, which is then available to pathologists and biomolecular experts for genomic profile definition and potential therapeutic implications,” Dr. Rocco said. Despite the potential for false positives, suspicious nodules in patients at high risk of lung cancer must be evaluated. At present, this requires actual tissue samples; however, this paradigm may shift in the future, he said.Emerging techniques and technologies may allow some patients to avoid the operating room. Dr. Rocco said that the need for biopsies may be reduced by other ways of characterizing lung nodules, such as using specific CT scanning techniques (ie, volumetric definition of a nodule), assessing biomarkers in the blood of patients with suspicious nodules (ie, microRNA), and, more recently analyzing breath using electronic nose technology.
For patients who still require surgery, the future likely holds fewer complications and quicker recovery times. “The anticipated technological advancements in thoracic surgery will include the use of [just] 1 single small incision for a robotic arm to remove the nodule,” Dr. Rocco said. “[Following surgery,] “peri- and postoperative management protocols [such as] nonintubated, no drain, and Enhanced Recovery After Surgery…may limit hospitalization and facilitate a prompt return to daily activities.”