Seminars in Thoracic and Cardiovascular Surgery最新文献

Image-guided thermal ablation (IGTA) applied to pulmonary pathology is an alternative to surgery in high-risk patients with stage I non-small cell lung cancer (NSCLC). Its application to lung neoplasm was first introduced in 2001 and has been implemented to treat metastatic disease to the lung or in select medically inoperable patients with peripheral stage I NSCLC. IGTA may also be an alternative to treat stage I NSCLC in non-operable patients with interstitial lung disease in whom a radiation modality is deemed too high risk. There are 3 methods of delivery: radiofrequency ablation (RFA), microwave ablation and cryoablation. Observational series and some prospective trials have shown safety and efficacy across all three modalities. Despite accumulating experience, there are no large randomized clinical trials comparing the outcomes of lung IGTA to alternative locoregional therapies (e.g. stereotactic body radiotherapy or sublobar pulmonary resection) for the treatment of stage I NSCLC. Because IGTA is a local therapy, a higher risk of locoregional recurrence is inherently understood as compared with anatomic resection. In the literature, primary tumor control after RFA ranges from 47-90% and is dependent on tumor size and proximity to bronchovascular structures. Local failure ranges from 10-47%, and tumors ≥ 3 cm have the highest rate of local recurrence. The most prevalent side effects are pneumothorax and reactive pleural effusion; hemorrhage is uncommon. Of note, observational series show no significant loss of lung function after IGTA. This expert review contextualizes limitations, complications and outcomes of IGTA in patients with stage I NSCLC.

Objective: A significant proportion of patients with stage I non-small cell lung cancer (NSCLC) are considered at high risk for complications or mortality after lobectomy. The American Association for Thoracic Surgery (AATS) previously published an expert consensus document detailing important considerations in determining who is at high risk. The current objective was to evaluate treatment options and important factors to consider during treatment selection for these high-risk patients.

Methods: After systematic review of the literature, treatment options for high-risk patients with stage I NSCLC were reviewed by an AATS expert panel. Expert consensus statements and vignettes pertaining to treatment selection were then developed using discussion and a modified Delphi method.

Results: The expert panel identified sublobar resection, stereotactic ablative radiotherapy (SABR), and image-guided thermal ablation (IGTA) as modalities applicable in the treatment of high-risk patients with stage I NSCLC. The panel also identified lung-nodule-related factors that are important to consider in treatment selection. Using this information, the panel formulated 14 consensus statements and 5 vignettes illustrating clinical scenarios.

Conclusions: This article summarizes important factors to consider in treatment selection using these modalities, which are applicable in high-risk patients with stage I NSCLC. The choice of which modality (sublobar resection, SABR, or IGTA) is optimal in high-risk patients with stage I NSCLC is complex, but a surgical approach is generally favored when deemed safe. SABR and IGTA are reasonable options in select patients. SABR is more commonly used than IGTA and is likely the next-best choice. A multi-disciplinary review of patient and tumor characteristics is essential for achieving an optimal decision. The clinical treatment decision should also take patient perspectives, preferences, and quality of life into consideration.

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