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448
How is NSCLC
treated?
Stage I: Surgery
Stage II: Surgery and adjuvant chemotherapy
Stage III: Surgery and adjuvant chemotherapy
+/− radiation
Stage IV: Chemotherapy +/− radiation
What are the
types of surgical
treatments for
NSCLC?
Standard treatment: lobectomy with mediastinal
nodal sampling.
Segmentectomy and wedge resection:
Appropriate in patients with a nodule
≤2cm and purely adenocarcinoma in situ on
histology, ≥50% ground glass appearance, or
long doubling time (>400days)
Poor pulmonary reserve or major comorbidity
that contraindicates lobectomy
Must be able to achieve surgical margins
greater than or equal to 2cm or the size of
the nodule
Pneumonectomy: when lobectomy is insufficient
for tumor removal (i.e., tumor crosses the
fissure, involves hilar structures, such as
pulmonary arteries/veins or mainstem bronchi).
T3 or T4 tumors require en bloc resection of the
involved structure with negative margins.
What makes
lung cancer
“inoperable”?
What are the
treatment
options for
these patients?
A tumor is inoperable if appropriate surgical
resection (lobectomy, segmentectomy/wedge
resection, or pneumonectomy) cannot be
performed due to a patient’s poor functional
status or medical comorbidities, such as poor
pulmonary reserve and cardiac disease. In
these patients, definitive radiation therapy
(stereotactic ablative radiotherapy, SABR)
or image-guided thermal ablation may be
appropriate definitive treatment methods.
Further, in patients with invasive disease, if
en bloc resection of involved structures with
appropriate margins cannot be achieved, surgical
management is not indicated.
J. Smirniotopoulos and M. Mitry
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What are the
challenges
in treating
superior sulcus
(Pancoast)
tumors?
Superior sulcus tumors are located in the apex
of the lung and involve the apical chest wall
and/or thoracic inlet structures. They are most
commonly adenocarcinomas. By definition,
all superior sulcus tumors are at least T3 and
invade the chest wall and/or sympathetic chain.
If there is no nodal involvement (T3 N0),
superior sulcus tumors can be treated with
chemoradiation followed by surgical resection.
However, if there is invasion of vertebral bodies,
brachial plexus, or vascular structures, the tumor
is classified as T4. Because en bloc resection of
invaded structures (i.e., vertebral bodies and/
or subclavian vessels) is required, T4 superior
sulcus tumors may be rendered inoperable even
without nodal disease (stage IIIB).
What is the
staging of
small-cell lung
(SCLC) cancer?
Limited stage: disease is confined to ipsilateral
hemithorax, including regional lymph nodes,
which can fit into a radiotherapy plan.
Extensive stage: all other disease exceeding
above boundaries, including contralateral
disease involvement and distant metastases.
How is SCLC
treated?
Chemoradiation therapy (not surgery)
What is the
role of targeted
therapy?
Development of lung cancers has been shown
to be related to several genetic mutations,
including those involving the VEGF, EGFR,
ALK, ROS1, BRAF, RET, MET, and NTRK
genes. Drugs that target cells with these types of
mutations have been shown to be efficacious in
the treatment of metastatic lung cancer, in some
instances even improving overall survival when
compared to traditional chemotherapy regimens.
Immunohistochemical analysis of lung tumors
can thereby elucidate additional therapies for
patients.
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Indications/Contraindications
When to biopsy? Lung nodules > 8mm, not amenable to
endobronchial approach. Please note that
this is highly variable from institution to
institution.
What is the
purpose of a lung
biopsy?
To determine whether a pulmonary lesion is
benign or malignant (i.e., new or enlarging
mass)
Is there any
benefit to biopsy
of a nodule if it’s
not cancer?
A biopsy may be beneficial in determining
infectious or inflammatory etiology of a lung
nodule, as this will direct patient care and
therapies, such as steroids for noninfectious or
cryptogenic organizing pneumonia.
When to ablate
primary lung
cancer?
Early (stage I/II) primary non-small-cell lung
cancer without lymph node involvement in
nonsurgical candidates
When to ablate
a metastatic lung
nodule?
For palliation in nonsurgical candidates
What are
the absolute
contraindications
to lung biopsy?
Pulmonary AVM or venous aneurysm/
abnormality, as these increase the risk of
bleeding.
Inaccessible and/or a safer alternative is
preferred.
Lung biopsy should not be considered in
patients within 6weeks of a myocardial
infarction.
What are
the relative
contraindications
to lung biopsy?
Fibrotic and emphysematous lung disease
with multiple blebs and bullae
History of pneumonectomy of the non-
affected lung
Uncorrected coagulopathy, unstable
cardiopulmonary status, and pregnancy
J. Smirniotopoulos and M. Mitry
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What are the
contraindications
for ablation?
Proximity to the hilum, large blood vessels,
and bronchi
Bleeding diathesis, most relevant for
cryoablation
Prior pneumonectomy
Unilateral functioning lung
Life expectancy of < 12months
Acute pneumonia
Severe pulmonary arterial hypertension
(> 40mmHg)
Poor lung function (FEV1<1.0L)
Relevant Anatomy
What are
the relevant
pleural layers
in the lungs?
Parietal pleura: outer pleural layer, lines the inner
chest wall.
Visceral pleura: inner pleural layer, lines the
surface of the lungs. Decreasing the number of
passes through the pleura during lung biopsy
or ablation decreases the risk of periprocedural
complications such as pneumothorax.
(continued)
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What are the
borders of
the superior/
anterior/
middle/
posterior
mediastinum,
and what do
they contain?
Superior mediastinum:
Superior border, thoracic outlet; inferior
border, sternal angle; lateral borders, medial
pleural sacs; anterior border, dorsal surface
of manubrium; and posterior border, ventral
surface of T1–T4 vertebral bodies
Contains: thymus, trachea, aortic arch,
brachiocephalic trunk, left common carotid and
brachiocephalic arteries, SVC, brachiocephalic
veins, arch of the azygous vein, thoracic duct,
left and right vagus and phrenic nerves, and
recurrent laryngeal nerve
Anterior mediastinum:
Superior border, sternal angle; inferior border,
diaphragm; lateral borders, medial reflections
of the pleural sacs; anterior border, sternum;
and posterior border, pericardium
Contains: thymus, internal thoracic arteries and
veins, and parasternal lymph nodes
Anterior junction line: below the level of the
carina
Middle mediastinum:
Superior border: sternal angle; inferior border:
diaphragm; lateral borders: medial reflections
of the pleural sacs; anterior and posterior
borders: pericardium
Contains: heart, ascending aorta and great
vessels, SVC/IVC, pulmonary trunk, trachea
and main bronchi, phrenic nerve, vagus nerve,
and sympathetic nerves
Posterior mediastinum:
Superior border, sternal angle; inferior border,
diaphragm; lateral borders, pleural reflections;
anterior border, pericardium; and posterior
border, T5–T12 vertebral bodies
Contains: esophagus, descending thoracic aorta,
azygous and hemiazygos veins, thoracic duct,
vagus nerve, splanchnic nerve, and sympathetic
nerves
Posterior junction line: above the level of the
aortic arch
J. Smirniotopoulos and M. Mitry
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Where do
the primary
and accessory
neurovascular
bundles lie?
How does
this affect
percutaneous
approach?
Intercostal veins, arteries, and nerves run along
the inferior margin of the ribs, with the nerves
coursing most inferiorly. Therefore, percutaneous
approach should be along the superior margin of
the inferior rib in the region of interest.
What are
the pertinent
vascular
structures
to pay close
attention to?
Chest wall vasculature, such as the internal
mammary and intercostal vessels and the
subclavian and intrapulmonary vessels
What is the
branching
pattern of
the right and
left mainstem
bronchi?
Right: the right main bronchus branches in the
mediastinum; the right upper lobe bronchus
is behind and below the right pulmonary
artery (eparterial– arises above where the
right pulmonary artery crosses the right main
bronchus).
Left: the left main bronchus courses below the
left pulmonary artery before branching into the
left upper lobe bronchus (hyparterial– arises
below where the left PA crosses the left main
bronchus).
How can
pulmonary
arteries and
veins be
distinguished?
At the hilum, the superior pulmonary veins
are anterior and inferior to the pulmonary
arteries. In the lungs, the pulmonary veins course
through the intersegmental septa (not adjacent
to bronchi), whereas the segmental pulmonary
arteries course adjacent to the corresponding
bronchi.
(continued)
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What are
the major
intrathoracic
lymphatic
structures and
their location?
The thoracic duct is located in the posterior
mediastinum and provides lymphatic drainage
from the abdomen, bilateral lower extremities,
left hemithorax, left upper extremity, and
left face/neck. Can be idiopathic, malignant,
or traumatic (damaged during intrathoracic
surgery), and can result in chyle leaks, including
chylothorax. May be managed with nonfat diet,
surgery, or thoracic duct embolization.
What is the
anatomy of
the azygos/
hemiazygos
system?
Azygos vein: originates at the junction of the
right ascending lumbar and subcostal veins,
enters the chest at the aortic hiatus, courses
through the posterior mediastinum, and empties
anteriorly into the SVC at the level of T5–T6
(anterior to right main bronchus)
Hemiazygos vein: originates at the junction of the
left ascending lumbar and subcostal veins, enters
the chest at the aortic hiatus, and crosses midline
to join the azygos vein at the level of T8–T9,
posterior to the aorta
What would
a persistent
left-sided
SVC (PLSVC)
and total
anomalous
pulmonary
venous return
(TAPVR)
look like?
How are they
differentiated/
what are they
associated
with?
PLSVC: most commonly drains into the coronary
sinus (associated with unroofed coronary sinus),
usually not seen on chest X-ray unless catheter
is present, may see widened shadow of the aorta,
“half-moon” opacity from left of aortic arch to
middle of left clavicle. Often it co-occurs with a
right SVC.It is associated with other anomalies
such as anomalous pulmonary veins, coarctation
of the aorta, tetralogy of Fallot, transposition of
the great vessels, and dextroversion.
TAPVR: all pulmonary veins drain directly to
the right atrium. “Snowman sign” on chest X-ray
reflects dilated vertical vein on the left with a
dilated right atrium. It is associated with other
cardiac anomalies and heterotaxy.
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What
are some
important
radiographic
signs for
masses?
Hilar overlay: if hilar opacity obscures hilar
structures, abnormality is within the hilum. If
hilar structures are visible, abnormality is either
anterior or posterior to the hilum.
Cervicothoracic sign: distinguish if a mediastinal
mass is anterior (ill-defined superior border, in
contact with soft tissue of the neck at or below
the clavicle) or posterior (well-defined superior
border since the posterior lung extends above
the clavicle). The upper border of an anterior
mediastinal mass cannot extend above the level
of the clavicles.
Incomplete border: distinguish if mass is
pleural/extrapleural versus intrapulmonary.
Intrapulmonary masses are surrounded by the
lung, so complete borders can be visualized,
whereas extrapulmonary mass borders are not
well delineated where they extend to the pleura/
chest wall.
Relevant Materials
What do I need for a
lung biopsy?
A coaxial system is often used, even for
fine needle aspiration (FNA). Typically,
a 17 or 19 gauge coaxial needle is
appropriate with biopsy needle
included in the kit, and 20–22 gauge
hollow needles with 10cc syringes for
aspiration.
What are the types of
ablation modalities?
1. Microwave ablation
2. Radiofrequency ablation (RFA)
3. Cryoablation
Is one ablative tool
superior over another?
If the nodule is < 3cm, differing
modalities are equally efficacious
(RFA=microwave=cryo).
If the nodule is > 3cm, then microwave
> cryo > RFA.
(continued)
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Does location play
a role in the type of
ablation probe?
If the nodule is within 1.5cm of the
pleura, all modalities are equally
efficacious.
What may contribute to
suboptimal ablation?
Heat sinks such as bronchi and adjacent
vasculature
If there is concern
for a heat sink, is
one ablation probe
superior?
Similar to nodules > 3cm, if there is
concern for heat sink, microwave > cryo
> RFA.
The patient has a
pacemaker/ICD/
LVAD.Does that
matter?
For pacemakers and other implantable
cardiac devices, cryo > microwave >
RFA
General Step by Step
Lung biopsy 1. Position the patient, preferably prone
for a posterior approach. Lateral decubitus
positioning (biopsy side down) may help
prevent pneumothorax.
2. Apply guiding template or laser grid (if
possible); use CT to mark the point of entry.
3. Sterilize and anesthetize site, including
parietal pleura.
4. Use CT guidance to advance and confirm
position of coaxial/core biopsy needle.
5. Obtain FNA/core biopsy samples.
6. If there is concern for a pneumothorax,
administer 1–3cc of patient blood for blood
patch, or other device such as BioSentry,
through the outer coaxial needle.
7. Remove the coaxial needle.
8. CT of the entire chest to rule out
pneumothorax.
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Lung ablation: 1. Position the patient, preferably prone for a
posterior approach.
2. Securely apply grounding pads to the
opposite chest wall if RFA.
3. Apply guiding template or laser grid (if
possible); use CT to mark the point of entry.
4. Sterilize and anesthetize site, including
parietal pleura
5. Use CT to advance applicator(s).
6. Confirm position of applicator(s).
7. Apply energy to achieve tumor necrosis with
a 1cm margin of normal lung parenchyma.
8. Remove applicator(s).
9. CT of the entire chest to rule out
pneumothorax and estimate area of ablation.
Sometimes
the pleura is
transversed
twice through
a longer
trajectory. Why?
Occasionally, due to complexity of a nodule
location, inability to position the patient
appropriately, or a combination of the two,
a fissure must be crossed for a biopsy to be
performed successfully. Therefore, the pleura
of more than one lobe is crossed, leading to a
technical passage of four layers of pleura.
Do I need
additional
post-procedure
imaging?
One or two chest radiographs should be
obtained post-procedure depending on your
institution.
Typically, a chest radiograph is obtained
immediately after the procedure and then
2hours following the procedure.
The patient is
having increased
shortness of
breath post-
biopsy. What do
I do?
If there is increasing pain or shortness of
breath, repeat a chest radiograph to assess for
pneumothorax.
(continued)
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