DISCUSSIONS IN CARDIOTHORACIC TREATMENT AND CARE

Solitary Pulmonary Nodules M. Blair Marshall, MD (Moderator), Scott J. Swanson, MD, Raja M. Flores, MD, and Thomas L. Bauer, MD THE CHANGING PRACTICE OF NODULE MANAGEMENT DR. MARSHALL: How has lung cancer screening changed your practice? DR. SWANSON: I think what has changed is we’re seeing smaller, more peripheral nodules, and we’re also seeing multiple nodules. Twenty years ago, you might see a 3-cm lesion solitary and now you’ll see a 1.2-cm lesion in the right lower lobe and then a 3- or 4-mm lesion in the left upper lobe or something in the right upper lobe in addition. How do you triage different multiple lesion scenarios in addition to just ground glass vs solid. DR. BAUER: I think the number has definitely increased for 2 reasons. One, there’s lung cancer screening that’s being done in the high-risk patients, but then it seems as though the vast majority of people who come into the emergency room end up with a CT of something. DR. MARSHALL: I have found that just the thickness of the slices in CT, as they have become so fine, these scans are picking up 3-mm nodules, 4mm nodules, which at times are just intraparenchymal lymph nodes. These are usually in patients who are being followed with a previous malignancy. I don’t recall seeing these a decade ago. DR. SWANSON: Agree. The high-resolution CTs have shown us a lot of pathology. But I think if they’re small and new, it’s easy to say “let’s see what happens to this in 3 months or 4 months.” If you see a spiculated mass or a concerning mass and then maybe 1 or 2 others, do you just focus on the one you’re worried about and does it affect what kind of operation you’re going to do, how you’re going to work it up? I’m more aggressive with mediastinal evaluation if there are multiple nodules. DR. FLORES: I think the most important thing is to figure out what is real and what is not real. Are you sitting on something that’s going to develop into January 27, 2014 Marriott Orlando, World Center, Orlando, FL. Address reprint requests to M. Blair Marshall, MD, Chief, Thoracic Surgery, MedStar Georgetown University Hospital, 4PHC, 3800 Reservoir Rd. NW, Washington, DC 20007. E-mail: [email protected]

1043-0679/$-see front matter ª 2014 Published by Elsevier Inc. http://dx.doi.org/10.1053/j.semtcvs.2014.06.001

something bad down the line? Or are you intervening too soon for something that really doesn’t need anything, and as a result, are you going to put that patient through an unnecessary procedure? It’s definitely a balance, I think all of us know when we see it. It’s very difficult, however, to come up with a specific algorithm that can be applied to the general population. DR. BAUER: In addition, the other benefit is with a thinner-slice CT scan, not only is it finding more nodules but we can get more information on those nodules. Our ability to detect accurate growth is markedly enhanced. We find more small nodules but we’re better able to follow them and more accurately determine if there is actual and real growth in a short interval. DR. MARSHALL: Do you use volumetric analysis in all of the nodules that you’re following? DR. BAUER: As much as I can. We have a Siemens system, so we use the lung CARE protocol. It’s a semiautomatic system, so the technician can easily pick the nodule and then do a volume rendering on that, and then I will follow that for subsequent CT scans.

I think the most important thing is to figure out what is real and what is not real. Are you sitting on something that's going to develop into something bad down the line? Or are you intervening too soon for something that really doesn't need anything, and as a result, are you going to put that patient through an unnecessary procedure? DR. FLORES, MD

THE ISSUE OF THE CENTRAL NODULE INCLUDING GROUND-GLASS ONES DR. MARSHALL: How does the shape of the nodule and the location of the nodule, peripheral vs central, impact how you’re going to follow it or what you might do to make the diagnosis? 157

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Solitary pulmonary nodule moderator and discussants (left to right): M. Blair Marshall, Scott Swanson, Raja Flores, and Thomas Bauer. DR. FLORES: Independent of location, spiculation makes you a little more concerned for malignancy as opposed to something round and smooth. Size factors in as well. I think that’s another piece of information that people need to know in dealing with these types of nodules. What do you have at your disposal? Do you have someone that can do needle biopsies? Are all your biopsies done surgically? That may influence how you treat a nodule that has a specific size or a specific shape characteristic. If performing a wedge resection is not possible, and a lobectomy would be the procedure to diagnose it, then I think you would be less likely to go in there unless you confirmed characteristics that suggest malignancy. DR. BAUER: If it’s central and it’s amenable to electromagnetic navigational bronchoscopy, then I may use that to get tissue. If it’s peripheral, then it depends on the size, and if it’s PET scan positive or indeterminate, that’s also going to drive our conversation. So if it’s more central, I’m more apt to follow it until I’m more certain that it’s going to be cancer if I can’t get tissue confirmation, and if it’s peripheral, I still want to know that it’s likely to be cancer, but that threshold is a little bit lower. DR. SWANSON: I think if it’s central and I’m worried about it, then I’m going to act on it. I’m going to ideally want histologic confirmation before going in on it. A central one, with the caveat if there is no way to do it and I’m still worried, I’ll do a core needle in the OR VATS. DR. FLORES: If you have a negative needle at surgery for a central lesion that would need a lobectomy, and you don’t get a diagnosis of malignancy, do you leave it there? Or, do you do a lobectomy? What do you do in that situation?

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DR. SWANSON: So those are the cases where you have a really careful conversation with someone and you say, “We might be taking your lobe out and it’s benign. How do you feel about it?” And if they’re like, “I get it, take it out, I want it out,” and that’s witnessed and everybody understands the issues, I’m all right with it. If they’re saying, “wow, that really seems much,” then I’m going to be a little more careful about potentially doing a lobectomy on an inflammatory condition. DR. BAUER: And that’s what I ask the patients. We have 2 opportunities to be wrong. We’re either going to follow this and it’s definitely going to grow and we’re

If it's central and it's amenable to electromagnetic navigational bronchoscopy, then I may use that to get tissue. If it's peripheral, then it depends on the size, and if it's PET scan positive or indeterminate, that's also going to drive our conversation. DR. BAUER, MD going to take it, and then we may look back on that first conversation, I wish I had gone to the OR right away, or we may end up having resected, maybe done a lobe, and then we’re looking back, going, oh, that wasn’t the right thing to do; we should have followed it. I also explain that if it grows in the interval, there is likely to be no stage migration. In other words, there is no proven benefit of resecting a 8-mm lung cancer over an 11-mm lung cancer. That allows us to perform less nontherapeutic lung surgeries.

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SOLITARY PULMONARY NODULES If you invest time in the conversation up front and explain why you’re thinking what you want to do, I think it avoids those difficult situations later on. DR. MARSHALL: For central ground-glass opacities, do you think that the size, a 4-cm lesion vs a 1.5-cm lesion, impacts what you’re going to do with that patient? DR. FLORES: Without a solid component? DR. MARSHALL: Without a solid component, just pure ground glass. DR. SWANSON: Yes, I think that’s probably the hardest case of all, it’s a central ground-glass lesion. If it’s pure ground glass, you can wedge that with close to a 100% cure. So I think those are the ones where the timing of it matters and the conversation again matters, because doing a big central wedge is one of the harder operations, I think. It’s harder than a lobe. DR. BAUER: And the thing I find difficult with that is knowing where to stop my wedge for a GGO. DR. SWANSON: Right. DR. BAUER: I’m more inclined to follow that, looking for either increase in density, forming a solid component within it, or definite expansion that has me more concerned that it’s more than a noninvasive adenocarcinoma. And if I know where it’s going to be anatomically and that I can get it with a wedge, then we will obtain a frozen, but at 4 cm, it’s really challenging, because there’s nothing to know whether you have it. And so if I can do the wedge and it’s not going to affect my ability to do a lobe if I have a positive margin, then I will, and if it’s going to really distort the anatomy to go back in and complete the lobe, then I may just do the lobe. But I want to have growth or increase in density or a solid component forming in it to get me to be in the OR. DR. FLORES: I think that’s a difficult thing. You have this 4-cm ground-glass opacity and you take this patient to surgery, you have got to be ready to do the lobectomy there. You don’t take them in with the idea of, “Okay, we can probably manage to get out a wedge.” So to do that, to say, “Yes, I will commit and do a lobectomy on this patient,” you need to look at a bunch of other factors: how old is the patient, are there any other nodules in any other place, are you looking for a lung-sparing procedure; what are the PFTs, etc. There are so many factors that I think come into our mind as we’re evaluating that patient. The fact that they have a 4-cm central ground-glass opacity is just as important and on the equivalent level as age, PFTs, and comorbidities. There are so many things that you have to take into account. You may get a similar patient and for some reason decide to do something else. You may decide to observe or decide to just go in there and do a lobectomy.

I wish there was a way for us to come to a consensus, but you can’t, because every patient is different. That’s the hard part, which is, what is best for that particular patient? One patient may not want to take that risk; one patient may want to just wait. And you have to take all that information and come up with what is the best treatment plan for that particular patient. DR. SWANSON: The strategy I use for those central ones where it’s a deep wedge or possibly a lobe, and it could go either way in the OR is to look at it and say, if this grew a bit in any direction, would it change my operation, and if the answer is no, then I’d say, why don’t we watch this 3-6 months and just make sure you don’t see another ground glass somewhere else or if the patient gets comfortable with the idea they’re going to probably lose a lobe. The chance of curing a pure ground glass, whether it’s 4 or 5 cm, as far as I know doesn’t change. If you get a margin and it’s all ground glass, according to the Japanese data, those should be curable. And it gives the patient and everyone else a chance to make sure there isn’t a curve ball. It isn’t an inflammatory mass that’s going to recede, you’re not going to get something else somewhere else in the lung that changes how you’d manage it, because, again, the operation really isn’t going to change now or in 3 months.

The strategy I use for those central ones where it’s a deep wedge or possibly a lobe, and it could go either way in the OR is to look at it and say, if this grew a bit in any direction, would it change my operation, and if the answer is no, then I’d say, why don’t we watch this 3-6 months and just make sure you don’t see another ground glass somewhere else or if the patient gets comfortable with the idea they’re going to probably lose a lobe. DR. SWANSON, MD On the other hand, if it’s in an area where a centimeter of growth turns it into a bilobe or a PA sleeve or something like that, then you’re thinking maybe you have to consider doing something sooner rather than later or at least having a closer follow-up.

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SOLITARY PULMONARY NODULES Now, ground-glass opacities aren’t the classic ones that will wrap around things. So it’s a solid that would more likely apply to that situation. But sometimes, I use that as a way to help determine my pace. FOLLOW-UP INTERVALS FOR NODULES DR. MARSHALL: Do you alter your interval of follow-up based on the shape or the size or the characteristics of the lesion? Previously, the standard length of follow-up was 2 years, without change. However, this does not appear to be adequate for ground-glass opacities. DR. BAUER: For GGO’s, as you mentioned, we will do an early follow-up just to make sure, because when we are in a trial, if you have an algorithm you’re following, it’s easy to defend to the patient why we waited 6 months, but in the absence of that, I apply it 3, 6, 12 months and then I follow annually for the GGO’s, and for solitary nodules, the same thing, unless it’s less than 5 mm, in which case a 3-month interval is not likely to be able to detect a measurable difference. You’re just as likely to be wrong in saying there was growth than you are if there isn’t. So it will be 6 months if it’s less than 5 mm, but then follow it after that. And the reason, unless they’re a nonsmoker, is that you’re then sort of falling into the screening guidelines. And if they’re within the NLST range, it’s easy to defend following them until the age of 75 or 79 years. If they’re outside of those criteria, then I tell them the criteria, I tell them what we did with IELCAP and how we followed patients that way and educate them, and most of them want to be followed annually. DR. FLORES: For me, it depends on why I’m following them. Am I following because I want to see a change in growth? Or am I following because I have a high index suspicion that this is inflammatory and I want to get another CT scan in a month or two to see if it went away. There are some lesions that I’ll evaluate and I’ll say that there is a good chance given the history, etc, that this could be inflammatory, let’s give it some time. Then if a month or two later, it still hasn’t gone away and it looks the same, then maybe that’s a patient I’ll want to take it out. As opposed to someone who I want to see some growth, where I’ll say, “Okay, let’s wait 3-6 months to see if it grows; okay, no growth, wait under 6 months, wait a year.” It depends. Am I watching to see if it’s going away or am I watching because I don’t think it’s going to go away but I want to see if there is any growth. DR. BAUER: If I think it’s PET positive but it could be inflammatory, then I’ll do my interval at 1 month. I’m looking for resolution and lack of it increases the

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likelihood that it’s cancerous. If I don’t think it’s cancerous, then this is where I’m going for 3-, 6-, and 12-month follow-up CT scans. DR. MARSHALL: Do you wait for ground-glass opacities to change before removal or do you think we should be taking them out when they’re pure ground-glass opacities? DR. BAUER: If we took all of them out, I think we would be doing a lot of unnecessary surgery, and a lot of these patients will have more than one spot. I really don’t think all GGOs should be resected, because you’re going to be taking out a lot of lung in patients who don’t need it, and they need that reserve when you actually go to do a needed operation. I think it has to be some change. Otherwise you don’t know that you need to be taking it out. DR. SWANSON: I think it has changed over the years that patients come in with a preconceived notion. And so I see the world in sort of 2 groups. One, the patient who comes in with a ground-glass lesion or some other lesion and is just so anxious and worried that I will do maybe a short interval followup, a couple of months, and then we have to do something, and then there are others who are much more comfortable with all the nuances and complexities and they’re comfortable watching. You have to explain the pluses and minuses. And that’s sort of the other group. I think in those cases, you can give them a diagnosis, you can establish pathology, you can measure mutation, look for EGFR, etc, and that’s important. But going back for multiple wedges in the same patient for benign disease, I think that’s a little extreme.

I think an important point to make is that these GGOs without a solid component are highly unlikely to kill people. And I do whatever I can not to operate on those patients. DR. FLORES, MD

DR. BAUER: I think where you are and what your population mix is really ends up pushing us one way or the other as to how much we can educate and they’ll follow our opinion as opposed to it’s already been formulated and we’re not going to change it. DR. FLORES: I think an important point to make is that these GGOs without a solid component are

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SOLITARY PULMONARY NODULES highly unlikely to kill people. And I do whatever I can not to operate on those patients. They say, “Well, you know, 8, 9 years from now let’s say he develops a solid component.” All right, at that point you take it out. You have had an extra decade of having all that lung function. And you never know. What if something on the other side is a really aggressive moving cancer? At least you have a little more reserve. So I do have an issue sometimes when a patient comes to me with a small GGO and they want it out when I don’t think it should come out. Sometimes I don’t let them talk me into it. I will tell them, “Listen, if this were me, I would not take this out.” I would continue to follow it. I think there are 2 different things. In your head as a surgeon, you’ve seen this stuff; you know how this can evolve. What would you do if this were you? And then you have to take into account the patient who is influencing you or pushing you to do what they want as well. And that’s the hardest thing. That’s why you can’t say you have this, we need to do that. There’s just a lot more decision making involved. DR. BAUER: I think the hardest question is, “so can you guarantee me this isn’t cancer,” I may respond, “do you want to operate next Thursday or Monday? No, I can’t guarantee you.” DR. SWANSON: The 2 pieces of information that make it hard or that you need, one is pathology, and if you don’t have it, it’s hard to be too dogmatic. You can be very persuasive and as strong as you can, but if you don’t know what it is, it’s really hard to say, you’re fine; I know for sure 100%, you don’t. And you also have to know your own data about what happens when you do the operation you have in mind. And then you tell them there’s a 1% risk of this, 2% of that, and tell their family and whoever is with them and let them integrate all that. And if they say after all that, we want it out, I don’t see how you can—again, without pathology, it’s really hard to be 100% dogmatic. DR. BAUER: I’ll give them my data and tell them that 91%-94% of the time I’m right, that if I’m taking you to surgery, it’s going to be cancer, and 6%-9% of the time I’m going to take out something that I couldn’t prove wasn’t cancer. And so I’m telling you that I don’t think this is, so that’s putting your odds lower than if you’re willing to flip a coin and be just as accurate as to whether you need to have surgery and you want it. We can educate the patient. I’m not going to do a needle biopsy because a negative needle biopsy doesn’t rule it out. DR. FLORES: The problem is that some of these GGOs that you look at, you know it is cancer. Or at

least you take it out, and you know you’re going to get a diagnosis of cancer. The question is, is that GGO something that’s going to grow to a point where it’s going to kill that particular patient during a short period of time? We’ve watched these GGOs, and with the Japanese data, etc, we know 10 years you can watch these things. So it’s not saying 10 years ago you didn’t have a cancer. Yes, you did have a cancer, but it’s not a cancer that’s growing in a way that is going to kill you. I think that’s the difficult area, because once people hear that word cancer, they want it out. If you did a needle biopsy on those GGOs, you’re going to get cancer most of the time. The real question is, Is that a cancer that should come out at this time? For example, let’s say you do a left upper lobectomy for this central 2-cm GGO and then down the line, he develops a solid tumor on the right side and he needs a lobectomy, yet you only

The 2 pieces of information that make it hard or that you need, one is pathology, and if you don’t have it, it’s hard to be too dogmatic. You can be very persuasive and as strong as you can, but if you don’t know what it is, it’s really hard to say, you’re fine; I know for sure 100%, you don’t. DR. SWANSON, MD

want to do a wedge because he has already had a lobectomy on the other side. So another important question is, how are you going to prolong this patient’s life and maintain their quality of life with a good amount of lung function that’s present while preventing them from developing a cancer that’s going to kill them? So the key question is not necessarily, Is that a cancer? But should it come out? Is it a cancer that’s going to kill you? It’s impossible to say. But when you have the GGOs, these are more likely to be adenocarcinoma in situ or minimally invasive carcinomas that are not going to be so aggressive and quick to get you. DR. BAUER: That’s why I think growth or some change is important. I think it is important to educate people that not every GGO should come out. Otherwise you’re putting a lot of patients through unnecessary surgery.

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SOLITARY PULMONARY NODULES DR. FLORES: I take the opposite stance. I tell them yes, I think this is a cancer. I think if you get this out, it will show cancer. However, the bigger question is, Is this a cancer that’s going to grow and kill you? And that’s the more difficult question. Because when you see that GGO, I do think most of the time you can say, “Yes, that’s cancer.” The pathologist will look at that and call that cancer. DR. MARSHALL: Is there ever a point that you stop following GGOs? DR. FLORES: Forever. DR. BAUER: I leave it up to the patient, but my recommendation is annually. DR. MARSHALL: Forever? DR. BAUER: So then you get to a certain point, and I use age or their other comorbidities. If the people are continuing to smoke, they’re not managing their diabetes, then we have a conversation of, I don’t understand why you’re coming back. If you’re not going to do the things that are going to help you live longer, then why are we getting CT scans on a GGO? This usually helps them address risk modification, because that’s going to be more impactful than getting another CT scan. But once they get to the point where it’s not really likely to alter their lifespan, then we’ll stop following. And so somewhere between 75 and 80 years on most of those patients, I really question how many more CT scans you need to get, because it’s a race between is it going to turn into an invasive cancer or are they going to pass away from other comorbidities? DR. SWANSON: I think the Japanese have—I think you’re referring to very small GGOs—very clear algorithms. Once you get over 10-15 mm, they recommend surgery on all of them. That’s just their way of dealing with it. So I don’t know that they accept the fact that the large GGOs aren’t a problem. I think it’s the small ones, the sort of 5-10-mm ones, where you can watch and wait. But once they get over a certain size, at least the Japanese recommendations are to remove them, solitary GGOs.

FINDING THE NODULES INTRAOPERATIVELY DR. MARSHALL: Have the new techniques available for localization of these solitary pulmonary nodules impacted how you manage these patients at all? DR. SWANSON: Are we talking about solid now, the solid ones? DR. MARSHALL: Solid, yes, but still the difficult ones where you don’t think you’re going to be able to feel it, too small to really localize with the ring

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forceps. Do you use tattooing, do you use wire needle localization techniques, or anything else? DR. SWANSON: We have used a few instances of each of those. I don’t think we have bought into one way of doing it. I think we’re looking at ENB now as a methodology that we can control and try to use more readily. Again, our radiologists are excellent, but they’re a little nervous around small lesions and putting things in them or biopsying them. So that hasn’t been the best way for us. We just heard about this afternoon using fiducials, CT-guided fiducial placement, methylene blue and things. We don’t have a big experience with that. DR. BAUER: That’s my inclination, because I’ve used the wires, but they can become dislodged. The tattooing can spread, and then you’re trying to figure out.

And so my preferred approach is if I don’t think I’m going to be able to accurately either palpate it, rub an instrument across it and be able to appreciate or know what aspect of what segment it’s in, then either a CT-guided or electromagnetic navigational fiducial placement done previously or at the time of surgery and then use fluoro, because I don’t have to put it in it. DR. BAUER, MD And so my preferred approach is if I don’t think I’m going to be able to accurately either palpate it, rub an instrument across it and be able to appreciate or know what aspect of what segment it’s in, then either a CT-guided or electromagnetic navigational fiducial placement done previously or at the time of surgery and then use fluoro, because I don’t have to put it in it. I just have to know the association between the fiducial and the lesion. I can then use flouroscopy, and if I know that I have got a margin around my fiducial, then I know that my nodule in question is going to be in my wedge. DR. FLORES: I use needle biopsy frequently. If the radiologist sticks a needle in and gets a diagnosis of cancer, usually you can find that in surgery. If I think I’m going to have a difficult time finding a nodule at surgery, that usually happens with a ground-glass opacity. With a smaller lesion, it usually correlates

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SOLITARY PULMONARY NODULES more with someone that you are on the fence with regard to whether you need to watch or whether you should operate. If I’m battling whether or not I should take this out or whether I should watch it, if I think I’m going to have a difficult time finding it at the time of surgery, if it’s too small, etc, that may be a patient I may be more apt to follow instead of taking them to the OR and wait until it gets to a point where I’m confident that I’m going to be able to palpate it or visualize it. DR. SWANSON: Did you say that if they do a needle biopsy, do they put something in? DR. FLORES: The fact that if they do a needle biopsy and they get a diagnosis of malignancy, then I’m more comfortable going in on those patients, because if they found it with the needle, usually you can find it with surgery. If you can’t find it with surgery and your fallback is a lobectomy to get it out, so at least you’re not caught with going in there and not being able to identify anything. Sometimes I’ve done thoracotomies so I can get a bimanual palpation. I’m not crazy about doing that. DR. MARSHALL: But you mean if you have a needle biopsy-proven diagnosis of cancer? DR. FLORES: Yes. DR. SWANSON: Deep? DR. BAUER: Yes. It’s so small and you have got so much lung between you and feeling that even if you can put your finger on it and grab and pull the lung up to your finger, you’re going through a lot of lung to try to appreciate. Now, I have had at least one case where I found something, I resected, they said it’s a lymph node, I felt confident that I had resected the area in question, only to follow and find a lesion growing, and then I’m going back and doing a completion lobectomy. You hate to have one case change how you do everything, but that really made me try to be that much more careful. Now the incidence of that is exceedingly low. So it’s very uncommon, fortunately, but nonetheless, it makes me want to be more certain that I’m not confused. DR. FLORES: If it’s so deep that you can’t feel it, yet a needle goes in there to get it, that patient probably needs a lobectomy, because you’re not going to be able to get a good enough margin around it. So that’s why in those situations, I’m more comfortable with going straight to the lobe. DR. BAUER: Sure. If it has been needled, you know it’s cancer. Then, yes, I don’t need to feel it. I’m doing the lobe or segmentectomy because I know what lobe or segment it’s in. And that’s why I like to be working the lesions up. If I think I want to do a wedge, because of pulmonary reserve, and I think it’s going to be hard to find, then

I’ll have them put a fiducial in at the time they do the biopsy. DR. SWANSON: But I think you can use the anatomy of the CT scan and your knowledge of how to divide up the chest and essentially create 9 segments of the chest. On the right you can use the azygous vein, the inferior vein, to divide up the superior, middle, and inferior aspect, and then you know where anterior, middle, and posterior thirds are, and then you can anatomically resect that segment. And using that strategy, I don’t think I’ve ever missed a lesion that I couldn’t feel. You can do a segment or a wedge of that area and reliably get it because the CT tells you right where it is. All you have to do is figure out how to localize that part of the body during surgery.

But I think you can use the anatomy of the CT scan and your knowledge of how to divide up the chest and essentially create 9 segments of the chest. On the right you can use the azygous vein, the inferior vein, to divide up the superior, middle, and inferior aspect, and then you know where anterior, middle, and posterior thirds are, and then you can anatomically resect that segment. DR. SWANSON, MD DR. BAUER: I do electromagnetic navigational bronchoscopy myself, so I don’t have to get someone else to do it if I don’t, for whatever reason, think that that’s going to be reliable for me. DR. SWANSON: Yes, put in a fiducial. DR. BAUER: But the frequency of placing fiducials is incredibly low for the points you’ve just made. DR. SWANSON: Let’s say you do a wedge and on the frozen you don’t get cancer, has that ever come up? DR. MARSHALL: Where you don’t have a nodule? That’s what I find the real problem is. You couldn’t feel it well before you fired a stapler into the pulmonary parenchyma. Now that is likely to be close to the staple line, it will be impossible to palpate. In particular, with nodules in the lower lobe, the bronchus can fool you. Sometimes it can be quite challenging to identify some nodules. DR. BAUER: That’s where the preoperative conversation is critical, because in those patients, I don’t

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SOLITARY PULMONARY NODULES want to miss it and I don’t want it to come back. It depends on how confident I am that it’s probably cancer. And if I really feel that it probably is and I don’t feel I got it, then I’m just doing a lobe, because I won’t accept missing cancer. I may have stapled across it and it’s never really going to be found. And I’ll tell people that afterwards that they couldn’t find it. The problem is the staple line is obliterating a lot of lung, and then they cut that away to actually do their sectioning. So I may very well have cut out the cancer. It just happened to be right in the staple line. DR. SWANSON: The conversation is important, because I have had 3 cases where they didn’t find cancer, it was ground glass, and I was sure I got it, and I waited and on final they found it. So, you’re right. It’s sort of your own confidence level of did you wedge out the segment you wanted and what does the patient know about what you are planning.

TYPES OF RESECTIONS DR. MARSHALL: So are you performing superselective segmentectomies with VATS, for all of these nodules? DR. SWANSON: I prefer a segment. So what I do if it’s a deep lesion is I get out all the vessels and then I decide at that point if I wedge it, is it going to compromise my ability to get those vessels to complete a lobe or an anatomical segment, and if the answer is yes, then I will do a segment straight away. DR. BAUER: Which segments? Will you do all of them? DR. SWANSON: So the superior segments, upper division, lingula, posterior segment, right upper lobe, basal, or segment. I’ll dissect out the vessels in the fissure. If it’s going to be a deep wedge, if it’s going to compromise your ability to then complete the vascular division, I just do that as the operation, both diagnostic and therapeutic. If it won’t, then I’ll do the wedge with a fallback if it’s cancer and I want to do an anatomic resection, I’ll do that after. If it’s peripheral, it’s not an issue. DR. FLORES: I tend to go more for a segmentectomy when it’s a larger solid nodule. If it’s just a ground glass with just a little tiny solid component to it, I’m more apt to do a wedge resection. But if it’s in an anatomical segmentable area, then I’m more prone to do a superior segmentectomy, right upper lobe posterior segmentectomy, or lingulectomy. So, there are 2 components: one, how aggressive do I think the nodule is and is it in a location where a segmentectomy is feasible? Do I agree with doing a lower lobectomy and sparing the superior segment? I’m not crazy about doing that. I know Scott likes to

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do that. I think it depends on where you’re coming from. DR. MARSHALL: Why not? There’s a lot of pulmonary parenchyma left when you see it on the follow-up scan. DR. SWANSON: I have started doing individual lower lobe segments. Some are easier than others, but the more you try to do it the easier it gets, I think. Whether it’s worth it or not, I have no idea. But the Japanese, I’ve been reading their literature, they use CT angiographies and follow these vessels. Our CT scans now are good enough that you can really look at the vascular anatomy and have a sense going in what you’re going to come across and where the lesion is relative to the segmental artery. So I think it’s getting more doable. DR. MARSHALL: I think you’re right, it is possible. I find significant anatomical variability. The Japanese use 3D reconstruction to identify the aberrant vascular branches to facilitate segmental dissection. They seem to have all the technology with them in the operating room. THE IMPACT OF SCREENING PROGRAMS DR. MARSHALL: Do you all have lung cancer screening programs at your institutions and how were they implemented? DR. SWANSON: We have one that has been very sporadic so far. I don’t know that we bring 200 people maybe. But with CMS coming on line, we have got all the pieces in place that Nasser talked about this afternoon, including having radiology on board and reporting the forms correctly and sending them to the PCP and all those checks and balances. But so far, cash on the barrel in Boston, not a lot of people paying at the moment. DR. FLORES: Fortunately, we have the I-ELCAP group, Claudia Henschke, who started the whole CT screening back in the early 1990s at our institution. They have over 60,000 patients already in an ongoing screening program. We are very fortunate in that I have learned a lot since we’ve started working together about early-stage lung cancer. They have a well-oiled machine where 70 institutions throughout the world are involved in their screening program. Tom and Harvey are both involved. Now I think with the NLST trial, you’re going to start hearing of a lot of studies that they need to look at. Oh, wait, have we looked at if we decrease our size requirements, what will happen? With I-ELCAP, when you look at Henschke’s work, all these questions that are arising now, they have already answered them and have written the articles about them. So going forward from NLST, I think it’s important not to keep reinventing the wheel. Go

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SOLITARY PULMONARY NODULES back and look at what I-ELCAP has done. You’ll find that there are a lot of good relevant studies that were done 10-12 years ago for questions that are being addressed right now.

So going forward from NLST, I think it’s important not to keep reinventing the wheel. Go back and look at what I-ELCAP has done. You’ll find that there are a lot of good relevant studies that were done 10-12 years ago for questions that are being addressed right now. DR. FLORES, MD DR. BAUER: We also participated in ELCAP from 2003-2010 as we waited on the NLST data and the impending reimbursement for it. We’re in the process at our institution of taking the I-ELCAP data registry and paring it down from a research tool to a very applicable registry that hopefully will be done at our institution. We are working with the state of Delaware to develop a screening program that we’ll roll out to our entire state. I think it’s important that screening programs start to be part of a registry. As we have been discussing, you’re going to start finding a lot of nodules, and the possibility of doing a lot of unnecessary surgery or other procedures is going to go way up. Part of the screening process is following protocols and being very cognizant of unnecessary procedures. Otherwise you erode any potential benefit. Just because NLST or I-ELCAP demonstrated a benefit, if you don’t follow those guidelines, the morbidity and mortality may outweigh any potential benefit. That’s how we’re going to approach it at our institution and within our state. PET SCANNING AND PULMONARY NODULES DR. MARSHALL: Do you follow an algorithm for the use of PET in the evaluation of solitary pulmonary nodules? DR. FLORES: I usually get a PET if it’s something that I would like to watch. But if I see a patient who has a single nodule that I would like to follow, I’ll get a PET on those patients. If the PET is low, that helps me say, “Okay, I have a lower index of suspicion; let’s continue to follow it.” Sometimes, the PET will come

back and show the mediastinum will light up, and then it’s one of those rare tumors that has spread to the mediastinum. So I think it helps for a couple of different things. One, to get assessment of the nodule, but also to make sure that there is no nodal involvement. Although that finding will be low; extremely low. DR. MARSHALL: Do you feel the same? DR. SWANSON: I think if it’s over 10 mm and solid, there’s a good chance they’ll come in with a PET. If they don’t, then generally if there’s anything suspicious in the mediastinum, I’d do a PET. If the mediastinum is negative on CT and it’s a 10- or 12mm range, I wouldn’t necessarily do a PET if I was planning to go to the OR. DR. BAUER: So then you won’t use PET as part of your staging? Like if you suspect it may be lung cancer when you go into surgery, they won’t necessarily get a PET then? DR. SWANSON: Not necessarily, not anymore. We have had probably 20% false-positive PETs, so you end up chasing them, whether it’s the adrenal or some hilar node on the left side or some low-grade activity somewhere. And it doesn’t prevent you from looking at the mediastinum either way. There has to be a specific reason. I think Raja’s point about if you’re going to sit on something, it’s reassuring that the PET is low activity if you’re on the fence. DR. FLORES: I also found it to be helpful for the smaller nodules, 1-1.2 cm. If it’s very active on PET, sometimes those have turned out to be small cell. Also, they’ve turned out to be granulomas. So you never know.

I think it’s important that screening programs start to be part of a registry. As we have been discussing, you’re going to start finding a lot of nodules, and the possibility of doing a lot of unnecessary surgery or other procedures is going to go way up. DR. BAUER, MD We have to take into account cost-effectiveness, but I like as much data as I can to help me come up with my decision. So if I have a PET that’s low grade, a needle biopsy that doesn’t show an obvious malignancy on a lesion that I’m not crazy about

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SOLITARY PULMONARY NODULES going in there for, then I’m okay with watching that patient. However, if the PET is positive, there is suspicion on the needle biopsy, that leans me more toward doing surgery. But if I have a 1-cm nodule that’s negative on PET and the needle biopsy does not show malignancy, I’m more comfortable watching that patient. DR. BAUER: I’m using it for more information. When they’re concordant, and either way, then I think it’s very useful. When they’re discordant in that the PET would technically be negative but the lesion looks like it’s growing, the accuracy of the PET is probably equal to that of flipping a quarter. So then I will take the more conservative approach. If it’s growing, then I ignore the PET scan and I take it out. Frequently, it is a cancer that was just not PET positive. DR. MARSHALL: Have you ever used any of the Bayesian calculators where they import the risk data? I find them quite interesting, because I usually have an opinion and input the information as a teaching point for students. DR. SWANSON: Do they correlate? DR. MARSHALL: Sometimes they correlate. Once, I used it with a patient. I thought her nodule was clearly a cancer but used the calculator to support my opinion. The calculator came up 100% chance of being cancer. I had actually never seen that before. DR. SWANSON: One-hundred percentage likely to be cancer? DR. MARSHALL: One-hundred percentage likely to be cancer. DR. BAUER: No is my answer to that question because for the points you’re just making. Changing a few answers minimally can dramatically change the perceived risk. And that miniscule change is within the error of people’s answers and accuracy of a variety of different things. So I find it at this point not to be useful. So I don’t even go through it because it either… DR. MARSHALL: … overestimates or under? DR. BAUER: Yes. I am concerned that it gives them a false sense of security or a fear unnecessarily. What I will use, though, is volumetric data, taking the formula that uses natural logs to calculate volumetric doubling time to days and then look at that. And if it’s falling within the range of a cancer, then that’s my evidence of support for either resecting or following closely. That’s how I use those predictors. DR. MARSHALL: I don’t use it if there’s ever growth. If it’s growing, it is resected. DR. BAUER: I just think they’re very confusing. Maybe in the future, we’ll have enough factors and

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there will be genetic information that gets put in as well. DR. FLORES: I have also found bias in the calculators. If someone is proscreening, it may give you an answer different from someone who is antiscreening. So there is still bias in there. You think, because you’re plugging in these numbers; it has got to spit out something that is just unbiased. But, no, there is bias that goes into constructing that model whether you are pro- or antiscreening.

LOBECTOMY VS LESSER RESECTION DR. MARSHALL: For, let’s say, biopsy-proven non–small cell lung cancers, an adenocarcinoma less than a centimeter in size, do you routinely perform a lobectomy vs segmentectomy? DR. BAUER: My hope is that it’s peripheral, and then they will go, hopefully, into CALGB 140503. That initiates the whole discussion of the origin lobectomy as the standard of care. If not, then we go through the conversation of potential differences in recurrence depending on what we do. But if it’s central and it has to be a lobe, then it’s a lobe.

I think if it’s under 2 cm and centered in a segment that I’d normally do, then I would talk to the patient about a segmentectomy, and if they seemed amenable, then I’d do a segment, with the caveat that you have to do a really careful node dissection in the hilum and the fissure and the mediastinum, and also you have to check your margins to make sure you’re really happy with them, and I’m good with that. DR. SWANSON, MD DR. SWANSON: I think if it’s under 2 cm and centered in a segment that I’d normally do, then I would talk to the patient about a segmentectomy, and if they seemed amenable, then I’d do a segment, with the caveat that you have to do a really careful node dissection in the hilum and the fissure and the mediastinum, and also you have to check your margins to make sure you’re really happy with them, and I’m good with that. I’ve been doing them for a while. I haven’t had more than a 3% or 4% local recurrence rate, which I

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SOLITARY PULMONARY NODULES think is similar to lobectomy. So I’m not convinced it’s a problem. But you always have the caveat, we don’t have the randomized data yet. I’m more worried that most of those are cured and they’re going to get another cancer and it may not be in a good spot and it might require a lobe. Now they’re one lobe down. So that’s my bigger concern for these small adenocarcinomas that are curable. DR. FLORES: I have shifted. In the year 2000, I was doing lobectomies for everything. Then over the past decade, I’ve gone to doing segmentectomies and wedge resections for smaller lesions. When you look at the randomized trial where lobectomy became the standard, that was just based on x-rays. That was not based on CT scans. Now I think we’re seeing a different disease than what we were seeing back then. So I do think that limited resection will probably have somewhat of a higher recurrence rate than lobectomy based on all the data that’s out there. However, I think when you highly select your patients and take into account multiple factors, you can minimize the patients. I don’t think your resection, if you have a local recurrence, is based on your technique. I think if you have a recurrence, it was a result of selection, based on whether you should have done a wedge on that or not, and hindsight is 20 of 20. But it’s not that hard to do a wedge resection or a segmentectomy. I don’t think that you can blame it on technique whenever you have a local recurrence. I think it was the decision to do a limited resection that you need to go back and look at and say, “Okay, what other factors here should have pointed me to doing a lobectomy?” But as with Scott and Tom, I’ve leaned more toward doing limited resections for smaller lesions. What is interesting is that we just did a pilot study that is going to be published in Chest where we looked at various factors, SUV, histology, etc, and we found that it had no bearing on whether there was a local recurrence rate, and that was a small population, about 80 patients. There are many things we do that may or may not work. Is it an invasive adenocarcinoma? Is there lymphatic invasion? There were a bunch of different things that we looked into to say, “Okay, do a lobectomy here, do a wedge resection here or a segment here.” And in our pilot study, we found that none of those factors mattered. Now, when we get more numbers, we’ll be able to say whether that holds true. But I think that many of us do think that way. We look at multiple factors to decide whether to do our lobe vs our limited risk action. DR. BAUER: The CALGB 140503 trial, though, is important, because I think there are a lot of people

still doing open thoracotomies, and if you’re a VATS surgeon, then you can do VATS segmentectomies, but for a large portion of our population that’s providing care to these patients, it’s going to be important to be able to state whether a wedge resection is an adequate operation with a lymph node sampling or if you’re going to have to do a lobe or in which patients do you need to. And that’s why I’m committed to doing the trial, because I think it hopefully is going to change how we provide care for these patients. That won’t prevent you from obviously doing a segmentectomy. It will give you more evidence to say that’s a good thing, which we probably already agree it is. DR. SWANSON: I don’t want to be miscommunicating. I think the trial is a great trial and we should complete it, for sure. DR. BAUER: And we’re getting there. So pretty soon we will have that answer. And the I-ELCAP group did look, and others have as well, in the current era with a good wedge resection, the overall survival doesn’t appear to be different. So that’s where I get my equipoise for doing the trial. And I’m able to justify doing the lobe because that is the standard, even though these other nonrandomized trials would suggest it’s as good. So I think it’s easy to have equipoise toward either arm of the trial. So hopefully, we will have our answer in the next 2 years. THE ROLE OF THE ROBOT FOR NODULES DR. MARSHALL: Do you think the robot offers any advantage for pulmonary resection over VATS in the management of solitary pulmonary nodules? DR. FLORES: The robot doesn’t have a human finger to palpate it. DR. SWANSON: There is this idea that somehow there are certain people that can’t do VATS that can do robotics. I don’t believe that, but if that’s true, then there is a value to it. Otherwise I, at this point, don’t see that the technology of VATS vs robotics prevents or facilitates a lymph node dissection or a certain kind of operation any better or worse, and I don’t see that the outcomes in terms of pain, length of stay, and morbidity are any better or any worse. All I see right now is a cost difference, at the moment, but it’s in evolution. DR. BAUER: You lose all haptics. So to be able to appreciate the nodule and do a lesser-thanlobectomy operation right now, it’s counterproductive. Now, if they’re able to integrate the CT scans and some virtual imaging or infrared technology or some other mechanism that you can see where the nodule is, maybe. But right now, no.

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SOLITARY PULMONARY NODULES DR. FLORES: I think that’s something that’s a very personal decision. I personally used the robot a lot at the beginning when we were starting out with VATS lobectomies; we were also doing robotic lobectomies. Later, midway, when I was very comfortable with doing VATS, I still played with the robot and did resections that way as well. I personally have not found the robot to add anything to VATS resections at this point. But you have to take into account that technology is evolving, and maybe one day something will change where you will say, “Okay, this is the way to go.” But right now, the only thing I found that it adds is time. DR. BAUER: And money. DR. FLORES: And money. I don’t think it’s something we should put away. I think it’s something we need to keep looking at and find out if 1 day that changes, because progress takes baby steps. Initially, we were putting scopes in the chest with both lungs being ventilated. Then 1 lung is collapsed and then you can do VATS wedge resections. The next thing we are doing is VATS lobectomies. So it has to happen in baby steps, and right now I just don’t think the robot is the be-all and end-all, but you never know where it’s going to evolve to. DR. BAUER: I think the best answer was when Cerf presented yesterday the quote, “It’s too big, it’s too expensive, it will never work,” and that was a quote that someone had made about the automobile and airplanes.

STAGING AND NODULES: EBUS? MEDIASTINOSCOPY? WHEN? DR. MARSHALL: How about the use of mediastinoscopy vs EBUS for staging the mediastinum? DR. SWANSON: I think EBUS is a great tool. I think you have to be good at it and know what your own outcomes are. We tend to do EBUS if it’s negative and we’re suspicious to follow it up with a mediastinoscopy right then and there. If it’s positive, then we stop. In other words, is one N2 node enough to get started with your induction protocol or do you want to sample 3 or 4? I think that is locally different for everyone. I think most of the time if we find an N2 node positive, they’re going to go on induction, and whether you come back, you can do a repeat EBUS or a mediastinoscopy and sort out whether they’re a good candidate for surgery at that point. DR. BAUER: So, if you find the N2, are you trying to do N3 nodes to rule out IIIb disease or only if they’re positive on PET or CT scan? What do you do with that?

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DR. SWANSON: Our radiation oncologists change their fields if it’s N3 or N2. So we have been looking for that. DR. BAUER: Trying to get negative nodes to prove… DR. SWANSON: … that they’re not N3. DR. BAUER: Or if the CT scan and PET scan are okay, you assume it to be only N2? DR. SWANSON: It’s an interesting question. I think if your PET is lighting up some lymph nodes and not others and you biopsy some and they’re positive, then maybe you can assume the others aren’t, but we’ll still attempt to aspirate the contralateral side. DR. MARSHALL: And are you doing your own EBUS or do you send it to your pulmonologist? DR. SWANSON: Painfully, yes. DR. MARSHALL: And do you perform it in the OR? DR. SWANSON: We do it in the OR, yes. DR. MARSHALL: Dr. Flores? DR. FLORES: I think it brings up a couple of different points. From a technical standpoint, in my opinion, if you can do an EBUS and get the nodes, that’s better than putting the patient through a mediastinoscopy to get it. Now, many will feel mediastinoscopy is not a big procedure; you can go ahead and do it. We reported on 3500 mediastinoscopies where 11 had to be opened for bleeding. So there is that small risk of having an issue with the mediastinoscopy that an EBUS avoids. The bigger question is, do you need to biopsy those lymph nodes? If you have a negative PET scan and a 1-cm lesion, do all patients need the preoperative mediastinoscopy? I found it very different from surgeon to surgeon. There are some surgeons who still perform mediastinoscopy on everybody, and then there are some now, with a negative PET, who will not do it. Of course, the data has changed with preoperative chemotherapy vs postoperative chemotherapy. In the old days, and Harvey was a pioneer with this, there was a big push toward doing chemotherapy presurgery. Now I think the data suggest you can go either way; you can give it afterwards as well. So is there as much of a push to get that diagnosis ahead of time? My own bias, if you can do it by EBUS, fine, but I have no issue with doing a mediastinoscopy as well. But for the majority of my practice for early stage, I don’t do presurgical staging. I’ll just go there and then assess the lymph nodes at the time of surgery. DR. BAUER: I did some EBUS. I think it’s better to concentrate the effort. And so for right now, my partner does all of them for us or the pulmonologists do.

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SOLITARY PULMONARY NODULES It’s hard to know how many are being done unnecessarily, because it depends who sees the patient as to what the workup is and if they’re getting EBUSs when we probably would not have with a negative CT and negative PET. But with our multidisciplinary team, that usually prevents that process and it keeps everybody honest, and so that has really been important and I think that has us doing less unnecessary EBUSs. And if we’re concerned because the PET and CT are discordant, then we’ll do some form of staging, and usually it’s a preoperative EBUS, not in the OR, so that we know what we’re going to be doing and then proceed. And the benefit is that if we have to go back and do something and I want to do a mediastinoscopy in the future, I’m not having to do a redo. They had an EBUS, they got treated, and I can either do another EBUS or a mediastinoscopy in the future if we want to. DR. SWANSON: I think it’s a technology that I didn’t really like to use at first and now that I’ve done more of it, it’s getting more interesting and I’m learning how to read ultrasounds, and I think that will translate into other uses. There was a chest wall invasion question today. Once you start to look at ultrasound pictures, then you can think of ways you’re going to use it in other areas of chest disease. I think that’s a secondary gain, but if you don’t force yourself to do it, you never get comfortable with it and it becomes painful. It’s a little like VATS; once you cross over, it becomes fun and easy and interesting. So I do think we need to keep embracing some of these new technologies.

REOPERATIVE NODULE SURGERY DR. MARSHALL: Does a history of a previous thoracotomy change how you will manage the patient? DR. BAUER: It doesn’t really to me, because I’ve done enough redo VATS on people that have had thoracotomies and have had previous VATS. So I will still do what I think is the right thing to do and I will still start with a VATS. In a majority of the time, it’s actually easier, I learned, to take down adhesions with a VATS than it is to try and do a thoracotomy and be looking with your head on the shoulder or the hip of the patient trying to take down adhesions. DR. FLORES: When they have had a prior thoracotomy and it’s one of those smaller, questionable lesions, I really like to have a needle biopsy to show me something. Because when you go in there and you start dissecting, sometimes you can cause little hematomas here or there as you’re dissecting out the adhesions and you may lose it.

DR. BAUER: I agree. That’s where I’m usually not getting a biopsy, on a straightforward, nonoperated patient. Because it’s going to be more involved, I’m much more inclined to get a needle biopsy. DR. SWANSON: I think taking down adhesions, that is pretty straightforward. So that doesn’t slow me down too much, but it depends on what the lesion is and whether you get a needle first. It depends on the lesion more than the prior thoracotomy. FAMILY HISTORY, RADON, MINIMAL SMOKERS, AND NODULE SURGERY DR. MARSHALL: And do you think a family history of lung cancer impacts how you will manage the patient? DR. BAUER: It doesn’t for me. It adds another aspect to the conversation we have ahead of time. At our institution, I’m doing a clinical project looking at family history with our genetic counselors and how that plays into the odds ratio and does it impact and to what degree. But right now, until I get that answer, because it may also have everything to do with smoking and not the family history of some genetic predisposition, that’s pure behavioral that is the association there.

In a majority of the time, it’s actually easier, I learned, to take down adhesions with a VATS than it is to try and do a thoracotomy and be looking with your head on the shoulder or the hip of the patient trying to take down adhesions. DR. BAUER, MD DR. FLORES: I can’t ignore it. If a patient has a family history and they’re coming to me and they’re concerned about their family history of having a lung cancer, I don’t know see how I could not get a screening CT on that patient. I know there are strict guidelines, United States Preventative Task Force, etc, but when you have that patient sitting in front of you, all those numbers go out the window. That patient has a history in their family of having a lung cancer, they probably have some other environmental exposure, secondhand smoke, etc. I just don’t see how you can deny a patient like that a screening CT scan.

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SOLITARY PULMONARY NODULES DR. MARSHALL: Do you think we’re doing less radon testing than we were before? I see a fair number of patients and when I talk to them about radon testing, none of them have ever considered it.

But I think the bigger issue is the nonsmoking population in younger women; you can’t say you fit any screening guidelines, but they come in knowing about it and hearing about it. DR. SWANSON, MD DR. BAUER: I think that’s probably a geographic area, and so in our area, it is tested frequently when people are selling houses and has become kind of the standard. But if you’re in a geography that isn’t prone to having radon, then they’re probably not routinely tested in the houses, and you probably don’t need to test. DR. SWANSON: I think the radon issue seems less important than it did, for some reason. But I think the bigger issue is the nonsmoking population in younger women; you can’t say you fit any screening guidelines, but they come in knowing about it and hearing about it. And often there’s one patient you’re operating on, they have their sister or some friend, and they’re saying, well, I don’t smoke either. Does that mean I need to worry? DR. BAUER: We did have a great trial for that with the Flight Attendant Medical Research Institute, that was part of ELCAP, and they were doing a secondhand smoke exposure screening program and trying to be able to identify are there factors. The individuals that work in a very smokey environment—and these environments, fortunately, are becoming much, much less frequent with the many clean indoor air acts. But there are a lot of patients that probably are at risk. You grow up with your parents smoking with

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the windows up in the car, you’ve got a high exposure rate. In the current era, it’s hard absent a trial to offer them any form of screening. They end up getting a lot of CT scans for other reasons. DR. MARSHALL: Given the number of patients I see that either had a minimal amount of smoking history or none but still present with ground-glass opacities or lung cancers, I wonder if our data was off. Of course, lung cancer arose in the majority of people who smoked but that was the majority of the population. I seem to be seeing more of these ground-glass opacities and I’m not sure they’re related to smoking per se. Are they going to all become lung cancers? DR. BAUER: The GGOs may not but I think the solid lung cancers probably were related to smoking. And so if you drive down the rate of smoking, I think we’re probably going to drive down—we’re seeing areas where they’re decreasing the smoking rates that the lung cancer rate is actually falling. DR. MARSHALL: Certainly, particularly in men. DR. BAUER: Yes. So I think the solid lung cancer that we’re really worried about will become less frequent as smoking goes down. And then the more screening we do or more CT scans, then these other less invasive processes are probably going to be discovered. DR. SWANSON: But there is some factor that has changed that has led to non–smoking-related cancers, and what it is we don’t know. Are we on the cusp of some other exposure or environmental process or hormonal? In my lifetime early, 20 years ago, I rarely saw a nonsmoking cancer. Now I see one a month, easy. Something is different. DR. MARSHALL: Just like the epidemiology of other cancers, it changes with time. We have what we think is the cause, but I’m not sure we actually really know what is involved in the development of all these lung cancers. Even the switch from squamous to adenocarcinoma histology, as in esophageal cancer. We ascribe what we think is obvious reason, but actually proof is lacking. Who knows if we’re right.

Seminars in Thoracic and Cardiovascular Surgery  Volume 26, Number 2

SOLITARY PULMONARY NODULES Discussant Profiles Dr. M. Blair Marshall is chief of thoracic surgery and professor of surgery at MedStar Georgetown University Hospital and Georgetown University School of Medicine. She specializes in minimally invasive approaches to the management of thoracic pathology including non–small cell lung cancer.

Dr. Scott J. Swanson is a professor of surgery at Harvard Medical School and the director of the Minimally Invasive Thoracic Surgery (MITS) Program at Brigham and Women’s Hospital, chief surgical officer of the Dana-Farber Cancer Institute. He is also the Thoracic Oncology Disease Center Leader for the Dana-Farber Cancer Institute/ Brigham and Women’s Thoracic Oncology Program. As part of the Brigham and Women’s Hospital Thoracic Surgery Program, Dr. Swanson is involved with all aspects of lung disease including workup and treatment of advanced lung cancer and COPD. Dr. Swanson chaired and published the results of the first cooperative cancer group protocol that examined the use of minimally invasive lobectomy for lung cancer (CALGB 39802, JCO Nov 2007). He coedited The Atlas of Minimally Invasive Thoracic Surgery, which was published early in 2011 (Elsevier). He also is the coeditor of the Sabiston and Spencer Surgery of the Chest, Ninth Edition, which will be published late in 2014. Dr. Swanson’s clinical focus is in the area of thoracic oncology, including lung, esophageal, and pleural malignancies as well as malignancies of the mediastinum, including thymomas. His research compliments the existing, extensive divisional strength focused on the biology of thoracic malignancy. Dr. Swanson directed the Third Biennial International Minimally Invasive Thoracic Surgery Summit that was held at Harvard Medical School in October 2011. Dr. Swanson received his MD from Harvard Medical School and completed his residency at Brigham and Women’s Hospital.

Dr. Raja M. Flores is the Chairman of the Department of Thoracic Surgery, Mount Sinai Health System, and Steven and Anne Ames Professor of Cardiothoracic Surgery at the Mount Sinai Medical Center. After earning an undergraduate degree in biochemistry from New York University, Dr. Flores attended the Albert Einstein College of Medicine, receiving his medical degree in 1992. He then spent 5 years at Columbia-Presbyterian Medical Center pursuing his general surgery internship and general surgery residency. He then completed a thoracic oncology clinical research fellowship at Brigham and Women’s Hospital/Dana Farber Cancer Institute/CALGB in Boston and his cardiothoracic surgery

residency at Brigham and Women’s Hospital, Harvard Medical School. He also received a Masters in Biostatistics from Columbia University. Dr. Flores is a recognized leader in the field of thoracic surgery for his pioneering efforts in the treatment of mesothelioma. He has established VATS lobectomy, a minimally invasive approach using 3 small incisions, as the gold standard in the surgical treatment of lung cancer. He published 2 sentinel studies validating its oncological effectiveness by demonstrating equivalent survival and recurrence rates with fewer complications and shorter hospital stays when compared with standard thoracotomy. Dr. Flores implemented the current program for this procedure at Memorial SloanKettering Cancer Center. He was lead investigator in a multicenter trial of neoadjuvant alimta-cisplatin, extrapleural pneumonectomy, and high-dose radiation, which is designed to improve outcomes. In 2013, Mount Sinai merged with Continuum Health Partners to create the Mount Sinai Health System, the largest integrated health system in the New York metropolitan region. To support the significant expansion of thoracic surgery efforts across the system, Mount Sinai leaders created an independent Mount Sinai Health System Department of Thoracic Surgery with a focus on issues specific to lung and esophageal disease and malignant and nonmalignant tumors of the chest. The department is separate from other surgical units and departments throughout the system, enabling specific focus and attention to lung disease. Dr. Flores currently has one of the largest VATS lobectomy experiences in the world. He has published and has presented these data at numerous national and international meetings. Dr. Flores’ additional research interests are based on numerous past projects relating to the multimodality management of malignant pleural mesothelioma, as well as innovative surgical techniques in minimally invasive thoracic surgery for lung cancer. He has led a number of major studies, including clinical trials of neoadjuvant gemcitabine and cisplatin followed by extrapleural pneumonectomy and high-dose radiation. Dr. Flores is also the principle investigator of the Libby Epidemiology Research Program, a $4.8 million RO1 grant funded by the Agency for Toxic Substances and Disease Registry (ATSDR). The major goals of the research are to address questions regarding the health consequences of asbestos exposure (Libby Amphibole). Dr. Flores is a member of numerous medical and surgical societies and serves on several editorial boards.

Dr. Bauer currently serves as the chief of thoracic surgery for the Helen F. Graham Cancer Center and Research Institute at Christiana Care Health System and directs the Weekly CMEapproved Thoracic Oncology Multidisciplinary. He is an associate professor of surgery at Jefferson Medical College and adjunct assistant professor of biologic sciences at the University of Delaware. In the past, Dr. Bauer has served on several committees within The Alliance (formerly CALGB). He has served as national PI and lead in many clinical trials locally. Our thoracic surgery section has been very involved in basic science and translational research related to thoracic malignancies as well as lung cancer screening research through IELCAP for many years.

Seminars in Thoracic and Cardiovascular Surgery  Volume 26, Number 2

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