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Key Considerations in the Management of Stage 3 NSCLC

Panelists:Walter Curran, JR., MD, FACR, Winship Cancer Institute of Emory University; Mark G. Kris, MD, Memorial Sloan Kettering Cancer Center; Jyoti D. Patel, MD, University of Chicago
Published: Tuesday, Apr 03, 2018



Transcript: 

Mark Kris, MD: I’d also like to say a few words about this group of patients with stage 3 lung cancer. The focus, today, is going to be on people who are inoperable and unresectable. There’s no question that those folks are best managed with a chemotherapy and radiation approach. We have 2 medical oncologists and a radiation oncologist, here, today. We don’t have a thoracic surgeon. So, I’m going to play that role. There are some patients who clearly need to have surgery in their treatment plan. How do we decide that? We need to have a clear discussion, among all members of the treatment team—the thoracic surgeon, the medical oncologist, and the radiation oncologist. We usually have to come together, to get the treatment plan worked out.

The second thing, here, is the need to identify who is inoperable and who is resectable. The only person who can do both of those things is the thoracic surgeon. In my own practice, I never take on the responsibility of saying who’s resectable and who’s operable. And so, I urge you to make sure that a thoracic surgeon is a part of the care team, and that he or she makes those calls. Would either of you like to comment on that?

Jyoti D. Patel, MD: I would add that we need to do a better job in doing an appropriate mediastinal evaluation. I practice in the Midwest. There are multiple patients with things like histoplasmosis, who may have mediastinal nodes that are enlarged but aren’t pathologically proven—clear adjucation of N2 versus N3 nodes. By and large, that’s done by interventional pulmonologists who are now a part of the care team. There are things that are minimally invasive, such as EBUS (endobronchial ultrasound). But, clearly, understanding the mediastinal nodal status is paramount in adjucating for the appropriate therapy. Once we know which nodes are involved, most of us, very clearly, can say that patients with N3 nodes are unresectable. But beyond that, when considering multi-station versus single-station, or clinically enlarged versus microscopic disease, the thoracic surgeon must be involved in the decision-making process.

Walter J. Curran Jr., MD: In the past decade, what I’ve learned—that I did not appreciate, as well—is that there is the opportunity to improve a patient’s fitness to medically tolerate surgery. There are lots of comorbidities in lung cancer patients. If they are dealt with medically—sometimes, they can be dealt with by pulmonologists, cardiovascular professionals, or rehabilitation physicians—people who are in a marginal state for general anesthesia, with a difficult surgery, can actually be rendered as medically resectable. That can be of tremendous benefit to the patient.

Transcript Edited for Clarity 
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Transcript: 

Mark Kris, MD: I’d also like to say a few words about this group of patients with stage 3 lung cancer. The focus, today, is going to be on people who are inoperable and unresectable. There’s no question that those folks are best managed with a chemotherapy and radiation approach. We have 2 medical oncologists and a radiation oncologist, here, today. We don’t have a thoracic surgeon. So, I’m going to play that role. There are some patients who clearly need to have surgery in their treatment plan. How do we decide that? We need to have a clear discussion, among all members of the treatment team—the thoracic surgeon, the medical oncologist, and the radiation oncologist. We usually have to come together, to get the treatment plan worked out.

The second thing, here, is the need to identify who is inoperable and who is resectable. The only person who can do both of those things is the thoracic surgeon. In my own practice, I never take on the responsibility of saying who’s resectable and who’s operable. And so, I urge you to make sure that a thoracic surgeon is a part of the care team, and that he or she makes those calls. Would either of you like to comment on that?

Jyoti D. Patel, MD: I would add that we need to do a better job in doing an appropriate mediastinal evaluation. I practice in the Midwest. There are multiple patients with things like histoplasmosis, who may have mediastinal nodes that are enlarged but aren’t pathologically proven—clear adjucation of N2 versus N3 nodes. By and large, that’s done by interventional pulmonologists who are now a part of the care team. There are things that are minimally invasive, such as EBUS (endobronchial ultrasound). But, clearly, understanding the mediastinal nodal status is paramount in adjucating for the appropriate therapy. Once we know which nodes are involved, most of us, very clearly, can say that patients with N3 nodes are unresectable. But beyond that, when considering multi-station versus single-station, or clinically enlarged versus microscopic disease, the thoracic surgeon must be involved in the decision-making process.

Walter J. Curran Jr., MD: In the past decade, what I’ve learned—that I did not appreciate, as well—is that there is the opportunity to improve a patient’s fitness to medically tolerate surgery. There are lots of comorbidities in lung cancer patients. If they are dealt with medically—sometimes, they can be dealt with by pulmonologists, cardiovascular professionals, or rehabilitation physicians—people who are in a marginal state for general anesthesia, with a difficult surgery, can actually be rendered as medically resectable. That can be of tremendous benefit to the patient.

Transcript Edited for Clarity 
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