What is the appropriate management for a patient undergoing Minimally Invasive Lung Oncologic Surgery (MILOS)?

Management of Minimally Invasive Lung Oncologic Surgery (MILOS)

Video-assisted thoracic surgery (VATS) is the recommended approach for minimally invasive lung cancer resection, as it causes less postoperative pain than open surgery while providing similar long-term oncologic outcomes. 1

Patient Selection and Preoperative Assessment

Pulmonary Function Testing

• Perform preoperative pulmonary function testing with diffusion capacity (DLCO) to assess surgical risk:
  • If both predicted postoperative (PPO) FEV1 and PPO DLCO are >60% predicted: proceed with surgery 1
  • If either PPO FEV1 or PPO DLCO is <60% but both are >30% predicted: perform low-technology exercise test (stair climb or shuttle walk test) 1
  • If either PPO FEV1 or PPO DLCO is <30% predicted: perform cardiopulmonary exercise test (CPET) with measurement of maximal oxygen consumption (VO₂max) 1

Exercise Testing Thresholds

• If patient walks <25 shuttles (<400m) on shuttle walk test or climbs <22m on stair climbing test: perform CPET 1
• If VO₂max <10 mL/kg/min or <35% predicted: consider sublobar resection or non-operative options 1
• For VO₂max between 10-15 mL/kg/min: increased mortality risk expected 1

Surgical Approach

Resection Extent

• Lobectomy is the standard surgical approach for most lung cancers 1
• Sublobar resection (segmentectomy or wedge resection) should be considered for:
  • Patients with impaired pulmonary reserve
  • Note: Sublobar resection has higher local recurrence rate and 5-10% decrease in long-term survival compared to lobectomy 1

Lymph Node Management

• Systematic lymph node dissection is essential for accurate staging 1
• The therapeutic value of radical lymphadenectomy remains uncertain 1

Special Considerations

Oligometastatic Disease

• For patients with 1-3 synchronous metastases: consider systemic therapy and local consolidative therapy (surgery or high-dose RT) 1
• For solitary lesions in the contralateral lung: treat as synchronous secondary primary tumors with curative-intent therapy when possible 1
• For limited metachronous metastases: radical local therapy (surgery or high-dose RT) may be offered 1

Neoadjuvant Therapy

• For patients who undergo neoadjuvant therapy: repeat pulmonary function testing with diffusion capacity after completion of therapy 1
• For patients with stage IIIA disease: consider multimodality treatment including surgery and adjuvant chemotherapy 1

Elderly Patients

• Age alone should not be a contraindication to surgery 1
• Careful assessment of comorbidities is more important than chronological age
• For elderly patients with significant comorbidities and small tumors (<4cm): radiotherapy may be considered as an alternative to surgery 2

Perioperative Management

Smoking Cessation

• Tobacco dependence treatment is strongly recommended for all patients who are actively smoking 1
• Smoking cessation provides both short-term perioperative and long-term survival benefits

Pulmonary Rehabilitation

• For high-risk patients (as defined by the functional algorithm): preoperative or postoperative pulmonary rehabilitation is recommended 1

Complications Management

• Mortality following resection should not exceed 4% for lobectomy and 8% for pneumonectomy 1
• For pneumothorax following transbronchial procedures: chest tube insertion may be required, with surgical intervention for persistent air leaks 3

Follow-up

• Close monitoring every 6-12 weeks after initial therapy is recommended to allow for early detection of recurrence and initiation of second-line therapy 1
• Surveillance should include regular imaging and clinical assessment

Multidisciplinary Approach

• Management of patients with locally advanced disease should be discussed at multidisciplinary meetings involving physicians, surgeons, and oncologists 1
• For stage IIIA disease, participation in prospective trials of multimodality treatment is strongly recommended 1

MILOS represents an evolution in lung cancer surgery that balances oncologic principles with minimizing surgical trauma. The approach should be tailored based on tumor characteristics, patient functional status, and institutional expertise.