Less Is More With Advanced Surgical Approaches in Early-Stage NSCLC

Alexis Chidi, MD, PhD, MSPH

Historically, lobectomies were the standard surgical technique for patients with early-stage non–small cell lung cancer (NSCLC); however, more recently the NSCLC treatment paradigm shifted, as doing less surgery has demonstrated comparable outcomes, according to Alexis Chidi, MD, PhD, MSPH.

“This is a pretty significant change in [how we approach] lung cancer,” Chidi explained in an interview with OncLive® following a State of the Science Summit™ on lung cancer, which she co-chaired. “We're learning that for a very well-selected group of people, we're able to accomplish a very different type of operation that preserves a lot of lung function for people who have early-stage lung cancer and hopefully helps them get back on their feet a little bit sooner.”

During the interview, Chidi discussed the implementation of wedge resections and segmentectomies in early-stage NSCLC, how these techniques compare with previous strategies, and the key benefits of a robotic surgery strategy.

Chidi is an assistant attending surgeon and co-director of the Lung Cancer Screening Program at Memorial Sloan Kettering Cancer Center in New York.

OncLive: What are the recent surgical advances in early-stage NSCLC?

Chidi: We're able to do less surgery for early-stage lung cancer with the same outcomes. A couple of studies have come out recently demonstrating that instead of having to take out an entire lobe of the lung for early-stage peripheral lung cancers, which are the ones that are small and at the edge of the lung, we're actually able to perform smaller lung resections and still get the same good outcomes.

The incorporation of robotics [has also entered] this protocol, and it sometimes helps us get more lymph nodes, as taking lymph nodes out during surgery is one of the benefits of doing surgery. Although we’re trying to do smaller surgeries for people who have early-stage lung cancer, it’s really important that we ensure we focus on lymph node dissection. One of the benefits of having [patients undergo] surgery at a place where they do a high volume of these surgeries [is] that [the staff] can make sure that patients still get the same good outcomes.

How do these recent surgical advances compare with previous strategies?

The classic way of doing surgery for lung cancer was an open incision and removing an entire lobe of the lung. If you take out an entire lobe of the lung, a person’s lung function can be significantly affected. Lobectomy is also sometimes a little bit more technically complicated, but some recent studies have demonstrated that we can do less complicated surgeries like wedge resections or segmentectomies. These are still complex procedures, but they preserve a lot of lung function. The key with both of those is making sure that we do enough sampling of the lymph nodes to identify whether there’s any lymph node disease. The reason that helps patients is that you know if they have an early-stage cancer, they can get a very limited removal of their lung. They can preserve as much lung function as possible, and we’re now able to do all this using robotics with a few small incisions. People are getting in and out of the hospital more quickly, they’re having fewer complications, and they’re breathing a little bit easier afterwards. There are a lot of benefits here.

Regarding robotic surgery, how does this technique make the process easier on you as the surgeon?

Robotics is an excellent approach. Just like with everything, it has a little bit of a learning curve, but as a surgeon, once you’ve gotten used to doing robotics, it’s a nice way to make sure that you’re getting a very meticulous dissection. I found that I’m able to be a little bit more meticulous about ensuring that there’s absolutely no bleeding, even with a complex lymph node dissection. You have excellent visualization, and some approaches allow you to take advantage of all the robotic technologies. Sometimes you can use robotic bronchoscopy to identify a lesion. You can inject a fluorescent agent like indocyanine green and then use the robotic surgical platform to visualize that area and take out small tumors that maybe might not even be visible without having to put your fingers in and feel the tumor.

There are a lot of advances that allow you to do less surgery for people who are well selected, and you’re able to do everything, sometimes faster, through smaller incisions. One of the biggest benefits, not really to me as the physician, but kind of to everybody, is that patients do very well with these operations. People are coming in for a lobectomy or a segmentectomy, which, in the past, might have required an epidural and a stay in the hospital for days, but now they’re coming in and out in maybe 2 days and doing pretty well.