What is the optimal perioperative management for a patient with squamous cell carcinoma (SCC) of the lung undergoing surgery?

Perioperative Management of Squamous Cell Carcinoma of the Lung

All patients with squamous cell carcinoma of the lung being considered for surgical resection must undergo multidisciplinary team evaluation including a thoracic surgeon, medical oncologist, radiation oncologist, and pulmonologist to optimize perioperative outcomes and survival. 1

Preoperative Assessment Algorithm

Mandatory Multidisciplinary Evaluation

• Patients anatomically suitable for resection but with multiple adverse medical factors require formal multidisciplinary discussion before proceeding to surgery, as this approach increases resection rates and improves adherence to treatment guidelines 1
• Multidisciplinary evaluation is associated with improved pathologic diagnosis rates, increased receipt of appropriate therapy, and shorter intervals from diagnosis to treatment 1

Nutritional Status Assessment

Routine preoperative assessment must include body mass index (BMI) and serum albumin measurement, as poor nutrition increases postoperative complications including poor wound healing and infection 1

Risk factors indicating increased perioperative complications include:

• BMI <18.5 (IDEC grade I malnutrition) 1
• Ideal body weight <90% 1
• Triceps skin fold thickness <25th centile 1
• Low serum albumin 1

Age Considerations

Age alone should never be used as a contraindication to surgery - the increased surgical risk in elderly patients reflects underlying comorbidities rather than chronologic age 1

• Approximately 30-35% of lung resection candidates are >70 years old 1
• Cardiopulmonary fitness of elderly patients must be fully evaluated without age-based prejudice 1
• Factors including tumor stage, life expectancy, performance status, and comorbidities should guide surgical candidacy, not age 1

Staging Requirements

CT scanning is mandatory for staging all patients with squamous cell NSCLC who are surgical candidates to assess primary tumor extent (T stage) and regional lymph node involvement (N stage) 1

• Plain radiography should use high voltage (>125 kV) for adequate penetration through tumor and mediastinum 1
• Chest evaluation with CT or PET-CT is required to exclude distant metastases 1

Surgical Approach Selection

Standard Resection Options

Lobectomy remains the standard surgical approach for squamous cell carcinoma, with acceptable mortality of ≤4% 1

• Pneumonectomy carries higher mortality (≤8% acceptable) and should be reserved for tumors requiring this extent of resection 1
• Expected 5-year survival rates post-resection: T1-2N0 50-70%, T1-2N1 35-50%, T1-2N2 20-30% 1

Sublobar Resection Considerations

Sublobar resection (wedge or segmentectomy) is appropriate only for patients with impaired pulmonary reserve or tumors ≤2 cm, with the understanding that local recurrence rates are higher (14-23% vs. standard lobectomy) and long-term survival decreased by 5-10% 1, 2

• For squamous cell carcinoma >2 cm and ≤3 cm, lobectomy demonstrates superior lung cancer-specific survival compared to sublobectomy 2
• Sublobectomy may be adequate for tumors ≤2 cm, especially in patients unable to tolerate lobectomy 2

Minimally Invasive Approaches

Video-assisted thoracic surgery (VATS) reduces postoperative pain while achieving similar long-term survival to open resection, and should be utilized when technically feasible 1

• VATS demonstrates similar perioperative morbidity and mortality to open resection 1
• VATS can be used immediately before standard resection to detect unsuspected irresectability and reduce open-and-close thoracotomy rates 1

Bronchoplastic Techniques

Bronchoplastic resection is appropriate for patients with impaired pulmonary reserve and selected patients with advanced endobronchial lesions, providing parenchymal-sparing options 1, 3

• Limited bronchoplasty provides excellent results for endobronchial tumors of nodular or polypoid type with suspected deep invasion 3
• Sleeve lobectomy may be considered for advanced tumors with massive invasion outside the bronchial wall without lymph node metastases 3

Lymph Node Management

Systematic mediastinal lymph node assessment is mandatory during resection for accurate staging, though the extent (sampling vs. systematic dissection vs. block dissection) remains surgeon-dependent 1

• Accurate nodal staging is essential for comparison of results and determining need for adjuvant therapy 1
• No survival benefit has been demonstrated for block dissection over systematic dissection in prospective trials 1

Risk Threshold Discussion

Patient preference regarding maximal acceptable surgical risk must be explored preoperatively, including discussion of perioperative mortality, morbidity, and long-term functional disability 1

Alternative nonsurgical treatments should be discussed when surgical risk is deemed unacceptably high:

• Conventional radiotherapy 1
• Stereotactic radiotherapy 1
• Radiofrequency ablation 1

Critical Pitfalls to Avoid

Do not proceed with surgery without formal multidisciplinary discussion in patients with multiple adverse medical factors, as this increases perioperative complications and may miss opportunities for more appropriate nonsurgical therapy 1

Do not dismiss surgery based solely on advanced age - elderly patients with good cardiopulmonary fitness can achieve excellent outcomes 1

Do not perform sublobar resection for squamous cell carcinoma >2 cm unless pulmonary reserve absolutely precludes lobectomy, as this significantly increases local recurrence and decreases survival 1, 2

Do not accept operative mortality exceeding 4% for lobectomy or 8% for pneumonectomy - higher rates indicate need for improved patient selection or surgical technique 1