We are going to change gears here. Uh, and I, um, understood the topic surgical perspectives to be a little bit more rudimentary and not necessarily geared toward. Um, in the neoadjuvant or, um, setting per se. OK, there's no question that there's been an evolution in lung cancer surgery driven by, uh, innovation, um, improved, um, effectiveness with systemic therapies, um, and yet lung cancer still remains the leading cause of cancer death. However, surgery still has a very important role, um, still offers the best chance for a cure in early staged, uh, cancers. Um, so then versus now, when I was in training, the norm was, uh, to offer patients with resectable disease, an open thoracotomy. This led to, uh, sizable incisions with some prolonged recovery. Um, the usual, uh, resection type was a lobectomy and maybe sometimes even a pneumonectomy. And oftentimes, uh, surgery, um, was performed in late stage cancers and not necessarily in the earliest, earliest. Possible stages. Now, the norm that we see as surgeons is more to offer patients, a minimally invasive approach, either a video assisted thoracic surgery or a robotic assisted approach, and this affords smaller ports, faster recovery, um, earlier ability to begin adjuvant treatment. Um, the types of resection are more tailored according to tumor type, um, and can include sublobar resections as opposed to, uh, lobectomies alone. Uh, we are seeing, um, although not enough of it, we are seeing more, uh, tumors in earlier stages. Um, it's more of a sort of an evolution by virtue of technological innovation, but also a conceptual one. We offer now patients the right surgery, um, for the right reason at the right time. So, surgeons are seeing, um, extremes of, uh, a different type of patient population than years ago. Um, we see again, the earliest stage cancers, they may be, um, part solid ground glass opacities, uh, that may represent an adenocarcinoma spectrum lesion. Um, sometimes we see multifocal disease, uh, bilateral synchronous tumors, and then we also see, um, patients with locally advanced disease, perhaps those with very bulky hilar disease that may require a pneumonectomy if, if surgery were to be offered at the outset. But these days, uh, given the remarkable, um, treatment responses that we've heard about so far and induction chemo immunotherapy, these patients can be downsized so that their tumors are resectable by a lesser lung surgery, um, lobectomy. We're also seeing an interesting, uh, group of oligometastatic disease that we had, uh, heard mentioned, uh, earlier this morning, um, in which case, um, patients may be offered consolidation therapy for local control in very, um, well selected patients. So, in general, I just wanted to, very, very, very rudimentary, from a very rudimentary standpoint, talk about 3 D's, the detection of earlier stage cancers, uh, decision making, uh, from a surgeon's standpoint, and delivery or the execution of the surgical technique. So diagnosis of early disease is critical. Um, one of the main, the major barrier as a surgeon, uh, is that most cancers upon diagnosis are found in later stages when tumors are no longer resectable. Uh, only 20% of all comers upon diagnosis are resectable. Um, lung screening, unfortunately, the uptake rate has been on the lower side in Philadelphia. It's, uh. Made it to be about 12% of those who are eligible for lung screening actually undergo, um, the screening programs throughout the state of Pennsylvania. It's at 9% and even in the top tier in other states, it's only 13 to 16%. So there's still much to be done in terms of expanding lung screening efforts with the hope of detecting earlier stage tumors. Um, these days, because of the preponderance of, uh, patients getting CT scans and other types of studies for different reasons, uh, incidental lung nodules can be identified and there are certainly routine use of AI programs to help identify these, uh, lung nodules. And, um, there are AI models whereby, um, the risk of malignancy can be predicted, and these, uh, can certainly help in identifying again, earlier stage tumors. Um, one of the challenges from a surgeon's standpoint of detecting these potentially earlier staged tumors is that with the smaller size of these nodules comes the fact that they may be non-palpable. Um, and, uh, ironically, the smaller the lesion, sometimes the more tissue is needed to be resected in order to be ensured, uh, to, to ensure that you're doing an R0 resection. If the nodule is not easily localizable, if it's not visualized, um, then you might have to take more lung tissue, which in part, uh, goes against this, um, effort to, um, spare lung parenchyma when possible. So, um, the, there has been, um, a really sort of revolutionary use of molecular imaging, um, agents, which can help visual, help surgeons visualize and localize tumors. Um, there's one that is linked to a folate receptor and in so doing, it takes the human factor, the human error out of guessing where the nodule is, um, and it enables surgeons to do more lung sparing procedures. Decision making. So the evidence and the art. Um, so the goals from a surgical standpoint, uh, in, you know, achieving an R0 resection is to, uh, the goals are to improve outcomes, uh, quicken recovery, decrease the overall risk, um, of attendant comorbidities, and to offer safer surgery, which hopefully can even expand the scope of who gets the surgery, who it gets offered. So the who, what, and the how, uh, choosing the ideal surgical candidate, oftentimes it's easy for us to tell who's a good surgical candidate. It's the question of, um, those borderline patients where it becomes a little bit more contentious, those with perhaps advanced age, borderline lung function who are then perhaps better candidates for the, uh, the competing modality of SBRT. Um, what kind of surgery is offered sublobar versus lobar resection with an eye, um, toward preserving function without compromising oncologic efficacy. And then in the how, how to improve outcomes in the preoperative, perioperative and postoperative, um, setting. Uh, there have been, uh, widespread implementation of ERRAS protocols, which stands for enhanced recovery after surgery. Um, the, uh, protocols that attend to each phase of, um, surgery in the perioperative setting and otherwise. So, who is, um, my, my slide got a little, uh, morphed, but, um, who is a good surgical candidate? These days, there are, um, more widespread use of, um, validated risk calculators. This is an example of a risk calculator from the Society of Thoracic Surgeons, uh, General Thoracic Surgery database. Um, it, uh, allows one to easily input data and get more objective measures of. operative mortality, estimated morbidity and mortality risk, um, at a at a fairly granular level, and it helps just, it helps surgeons to standardize, uh, treatments, holds them accountable. Um, there are these risk calculators, uh, that are professional society driven, but also, um, there's, you know, many prospective databases that just again, uh, encourage standardization of risk assessment. At the end of the day, who, uh, uh, surgical candidacy is based on lung function, and assessment of cardiopulmonary reserve, um, performance status, and there are, you know, increasing uses of other indices, although there are no strict consensus frailty index, for example. Um, what surgery to perform? So, um, this is just, the, uh, diagram is just to remind, uh, the non-surgeons of what these different types of surgeries involve. A wedge resection is just a haircut of the lung, taking a very peripheral, uh, piece of lung tissue. A segmental resection is an anatomic, um, resection. whereby the airway, the blood vessels, uh, to that specific part of the lung are, um, dissected and, um, a delineation by, by virtue of perfusion. No perfusion is, is decided upon before resection is completed. Lobectomy is a standard anatomic resection of one of the five lobes in the lungs, and a pneumonectomy is the complete lung removal of one lung. So the lung cancer study group, it's been 30 years since the results were published and this established, this was a randomized control trial that established lobectomy as the standard of care. Um, since then, there have been, um, at least a couple of, uh, Surgical randomized control trials which have now established that there is a role for sublobar resection either by virtue of wedge resection or segmentectomy, um, that sublobar resection is not inferior for tumors that are 2 centimeters or smaller, um, especially those at the periphery of the lung, um, that are, uh, verifiably N 0. And, um, especially for those um tumors that may have this ground glass opacity as opposed to pure solid nature. So how to optimize, uh, surgical outcomes we made mention of the ERS protocols, uh, just a reminder for me to plug in that, um, it's really important to engage every member of the extended team taking care of these, um, cancer patients, um, to the level of nutrition optimization, you know, there's a. Uh, big movement toward immuno nutrition, optimizing, enhancing protein synthesis, pre-habbing patients, especially when patients, uh, are undergoing these sequential treatments of induction or neoadjuvant treatment followed by surgery, we have the opportunity to, um, make them potentially healthier in the process, um, all with an eye toward enhancing the safety profile of surgery. Uh, so, our decision making from the surgeon's standpoint has become more evidence-based and less art, but there's no question that at the end of the day, it comes down to clinical judgment, um, as has been alluded to, um, previously. So the execution of the surgical technique, we live in a very exciting time, um, driven by, uh, the, um, robotic surgery innovations. There are many modalities of advanced imaging that have also helped in operative planning, especially as we drill down to trying to preserve lung parenchyma while achieving, um, the goal at hand, which is our zero section. Um, there are also, um, groups, uh, throughout the world that are doing uni portal surgery. So taking the standard 4 incisions, uh, required for robotic surgery, uh, to 1, and then, um, telesurgery, role of AI. I mean, we're not yet automated, but we're getting very close to it. Um, just a reminder that, um, the incisions for minimally invasive surgery, um, to the right, you see the, the, uh, 4 robotic incisions with an assistant port for retrieval of the specimen versus the traditional open thoracotomy incision, shorter length of stay, better quality of life, um, quicker recovery. And the surgical robot, this is the most recent iteration of the, um, surgical platform that is most, um, rampantly used. Uh, it's called the DV5 enhanced optics, precision, increased haptic feedback, all wonderful things with a smaller footprint to allow, um, more routine use, um, by surgeons. So 3D mapping, I just wanted to give a representative picture. There are, um, Platforms that allow, uh, inputting CT, um, scan data. And in to the right, you can see the PN there's the the pulmonary nodule, which is a ground glass nodule, not to be palpate, not palpable, not visualized, uh, through the visceral pleura. And the PN is also configured on the left in that 3D map, um, but it allows sort of drilling down to the actual vessels that need to be, um, dissected and divided and allows just precision. This is just a headline. These headlines are, are a dime a dozen, but robotic surgery. This is an example of a cardiac surgeon in street clothes doing, um, cardiac coronary bypass, um, graft surgery from hundreds of miles away. Um, it is a tele-surgery that is, um, brings access to, um, patients who may not be able to, you know, go to major, major centers with all of the, um, all of the benefits. And then emerging technologies. Most of what I've discussed has been, is, is routinely used, but, you know, here is an Android, a humanoid that is being taught how to do a lung resection. Um, Uh, this is, it is, it's a real thing, maybe not in this country as yet, but it's coming, um, and then the right is another surgical platform for robotics, uh, using a uni portal approach. So just a summary, detection of earlier stage lung cancer is, is critical. Uh, there's much to be done about expanding lung screening efforts. Um, uh, clinical judgment is critical and, uh, engage every part of your, uh, extended team. Uh, we live an amazing time. Thank you.
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