Lung-Sparing Nodule Resection Gains Traction in Lung Cancer, But Needs Multidisciplinary Considerations

Henning Gaissert, MD

Although lung-sparing lung nodule resection is available to some patients with lung cancer, it is critical to tailor surgical interventions based on pathologic assessment results, said Henning Gaissert, MD, who added that utilizing a multimodal approach in treatment can help alleviate some of the burden of treatment selection.

“It is very challenging to [determine] the right surgical approach for each individual patient,” said Gaissert. “[Lung cancer] has changed over time, and our sensitivity for what kind of lesions we wish to pursue has changed. We are now more interested in smaller lesions because we see fewer larger lesions. That has changed the outcome for lung cancer resection.”

However, some patients who undergo lesser resections may need to then undergo total lobectomy in order to decrease their risk of recurrence in the future.

“Surgeons need to revisit [patients after lesser resection] to determine whether they selected the best option,” said Gaissert. “Sometimes we may need to go back [to do a lobectomy] after completing an operation that we thought was already done.”

In an interview with OncLive^® during a 2020 Institutional Perspectives in Cancer webinar on lung cancer, Gaissert, chief of thoracic surgery at Newton-Wellesley Hospital and a member of the Department of Surgery at Massachusetts General Hospital, discussed the importance of tailoring surgical resection strategies to individual patients with lung cancer, eliciting insight from a multimodality team, and implementing total lobectomy in certain patients to avoid future recurrences.

OncLive^®: How have improvements in radiographic imaging affected the surgical management of lung nodules?

Gaissert: These strategies have evolved over time because we are better at diagnosing radiographically what is present pathologically. Our radiologists know how to better characterize lesions. These days we are not only characterizing solid lesions, but we also are most often characterizing mixed-attenuation lesions or lesions that are composed of solid and ground-glass opacity. Those are mainly lung adenocarcinomas.

Our sensitivity has changed. With that, we are seeing that lesions that are on different parts of the malignancy have different degrees of malignancy. That means that we can consider lesser resections sometimes. That is not always straightforward, because having a smaller lesion doesn’t always mean having an earlier[-stage] lesion. One can underestimate and overestimate disease. The decisions have not necessarily become easier, but the spectrum of lesions has changed. Thus, the spectrum of resection types has changed. Therefore, we are using a greater number of lesser resections, which has also provided us with different challenges.

How has the shift toward lesser resection created new challenges for surgeons and pathologists?

The main challenge is that for every individual patient we have to find the right resection. [We have had to determine when] not to apply lesser resections to lesions that have a greater potential to [spread] to the lymph nodes and [how to] not overuse a lobectomy for lesions that could be served with lesser resection. Because many of these decisions need to be made in the operating room, we are presenting pathologists with different challenges, since we want to have all of the information that we saw on permanent pathology. In the past, we almost always selected lobectomy for resection. Then, the extent of the resection didn’t matter so much because we couldn’t vary it.

Now, we start off with a lesser resection and ask our pathologists: Was that good enough? They sometimes feel overwhelmed in giving us that answer. We have [to] individually [select] patients in whom we may stop at a lesser resection, but then [we might have to] tell these patients that they require a greater resection with a lobectomy. That is a different challenge compared with 20 or 30 years ago.

In what ways should surgeons collaborate with pathologists and medical oncologists?

There is the collaboration between surgeons and pathologists. However, another collaboration needed is between medical oncologists and surgeons. For surgeons, the task is quite clear as it relates to their collaboration with oncologists. We cannot underestimate diseases. We have to recognize mediastinal lymph node involvement early. Then, if possible, we should refrain from resection and consult medical oncologists and radiation therapists. The challenge there is identifying all patients who may be candidates for multimodality therapy.

The other collaboration refers to patients who are rightfully undergoing surgical resection first and who are then found to have [extensive disease] into their lymph nodes. Those patients [are eligible] for adjuvant chemotherapy. Although these types of patients are not particularly challenging [to treat], surgeons [need] to identify what malignant potential the small lung nodule has. If we underestimate that, we will falsely select a lesser resection when a lobectomy would be [indicated]. We don’t always get that information from pathologists.

I’m referring to the class of patients who concern me as a surgeon. These patients have cancers in which cancer cells are present outside of the main tumor mass in airways. [This refers to tumor STAS (spread through air spaces)], and STAS is difficult to recognize on frozen sections. Yet, it matters because when we select a lesser resection, the outcome is not as good as with lobectomy. We will face some patients who had a lesser resection [but] who will then be taken for a complete lobectomy. We’d like to avoid these situations, but they are not always avoidable [when] we try to select the most appropriate surgical resection.

What could provide reassurance that a lesser resection is the optimal approach?

I cannot foresee what the pathologists are going to come up with to identify all relevant factors. It could be that we are placing a lot of pressure on our pathologists to submit the specimen and a complete opinion. That is difficult because we are in the operating room waiting for the outcome of the pathologic examination. We give them perhaps a half hour or 45 minutes, but we do not give them an hour to make up their minds.

These challenges and tensions will persist. That means that we, [as surgeons], have strategies to deal with that. We have to prepare our patients that, during the operation, we may want to avoid lobectomy. However, the operation might consist of 2 stages where we have [to perform] a complete lobectomy if we do not have all the information during the [lesser resection]. That is a difficult discussion to have with an individual, but all of my patients to whom I recommended a second operation forgive me. A less forgivable situation is if I don’t do the important second operation and the patient then has a higher risk of local recurrence and a higher risk of death.

I encourage surgeons and oncologists to consider a second operation if appropriate.

If there’s not complete confidence that a lesser resection will be sufficient, do you proceed with a lesser resection first or do you move forward with a lobectomy?

That is an excellent question that requires consideration of many individual points. Whenever I answer that question, I try to come up with individual examples.

I recently saw a woman in whom I did a wedge resection for a very small adenocarcinoma 7 or 8 years ago; I still follow her. I identified a very small ground-glass opacity [nodule] that was slowly enlarging and was deep in a contralateral lobe. I did a wedge resection on this patient, aided by placement of fiducial [markers] so that I could identify where that lesion was. Then I agonized with a pathologist over the appropriateness of leaving the wedge resection.

[Ultimately], I decided to proceed with a lobectomy because the patient could tolerate it. Then I got the pathology report back and saw other features of very small cancer with poor differentiation and micropapillary disease that I didn’t even consider at the time of [reviewing] the frozen section. That makes [moving beyond wedge resection] not only defensible, but it also makes lobectomy the best possible procedure for this patient.

Those are just individual factors. I might have done a wedge resection. Then I would have had to agonize with this patient over whether to do a lobectomy.

What benefits do a multidisciplinary approach bring to the surgical management of patients?

When we bring excellent radiologists and multidisciplinary colleagues to the table to review these radiographs carefully, we can deliver astonishing results. One result I find [impressive] from our Lung Nodule Clinic is that 40% of patients with lung cancer had lesions that were 10 mm or smaller in diameter. Also, the proportion of patients who underwent resection for benign lesions is quite small.

That happens when you bring people together to review treatment options. [It is important to elicit the help of] well-trained radiologists who can afford to specialize in chest disease alone. As we know, that is not the situation in the United States. I may be speaking to general radiologists who cannot afford to do that.

The purpose of the Lung Nodule Clinic is also very important because it means we have more than 1 set of eyes looking at seemingly small problems. [Establishing lung nodule clinics] is important to improve [care] and provide individual patients with the best possible advice.