So surgical approach is after new adjuvant therapy, um just wanted to, obviously, the patients uh who are to be considered in this uh context, ought to have already met with the surgeon and then, you know, been decided to be operable. So, what are the goals of surgical resection? Um One to com a complete resection which we call an R zero resection. Um A second priority is to spare lung pereny when possible. Um So to avoid pneumonectomy if at all feasible. Uh So if that means doing a what we call a bronchial slee resection um or a pulmonary arterioplasty that should ought that ought to be considered uh with an aim toward preserving all uninvolved lung. Um complete nodal dissection. Uh Part of the course, promote good surgical principles, healthy tissue, no tension. Um and then avoid uh inter operative catastrophes. So what makes surgery difficult after neoadjuvant treatment? And it's all because of the great treatment response lended by these um neoadjuvant regimens, treatment response leads to fibrosis. And uh because the tumors that um the patients with the tumors that uh for which um new adjuvant treatments are advised, um these tumors are often bulky, they can be centrally located. Um They may be immediately adherent plus minus invading into great vessels, the pulmonary artery um into major airways. Um and this leads to an absence of usual tissue planes that separate critical structures. And ultimately, um in addition to enhancing the the difficulty in maneuvering the lung tissue, um it just leads to increased tissue, uh increased technical complexity, uh and higher chance for complications. The most fearsome of which is catastrophic inter operative bleeding from the P A. So, um this main surgical approaches consist of open surgery thot, uh which um spreads the ribs versus minimally invasive approaches, which consist of robotic and video assisted thoracic surgery or vats approaches. It's been long established that minimally invasive surgery after new adjuvant treatment is safe and feasible. Of course, that's in highly selected patient populations. The benefits of mental invasive lung surgery. Just one slide to talk about that. It's less tissue trauma. There's usually lower blood loss during these types of surgeries, less incisional pain, smaller scars, fewer complications like pneumonia because the pain is less. So patients are not splinting as much, potentially overall, shorter length of stay in uh uncomplicated cases. In a foster return to normal activity. A foster return to the oncologist for further discussions of treatment. Uh usual robotic um after robotic surgery, the length of stay can be um 2 to 3 days. Uh after a thot toy, it can be 5 to 8 days while it might, might not make um that much of a difference to the provider, it certainly makes a big difference to the patient and patients families. Um The approach ultimately depends on the surgeon's skill set, expertise and judgment. And um of course, the surgeon is, ought to choose that with which she or he is most comfortable with. So minimal invasive approach. Aside, the surgery needs to get done according to the tenants that we already discussed, complete resection, nole dissection, safe um uh surgery. And um while these are steps that are usually taken for any routine lung resection in the case, uh in cases after neoadjuvant treatment, we pay heightened attention to um preoperative optimization as well as operative planning with the or team and anesthesia. So, um we have a huddle in the more and, and before the case, we talk about um our backup plans, especially if we're proceeding with an initially minimally invasive approach. Um Certainly the case for invasive hemodynamic monitoring during the surgery, uh We're ready with uh crossed units of blood just in case um of catastrophic bleeding. And there are certain operative maneuvers uh that the surgeons may preemptively take and circling the main P A before proceeding with higher dissection. Um of course, just safe and meticulous dissection. And while these are um things that we routinely do, we just pay special attention on account of the fibrosis that uh can result from um neoadjuvant treatment. Um The optimal timing of surgery after neoadjuvant treatment is a hot topic. Uh obviously, treatment leads to the new adjuvant treatment leads to inflammation which then over time uh becomes fibrotic. Um So when is the best time to operate in order to encounter the optimal situation with minimal fibrosis, minimal risk for conversion from a minimally invasive approach to a thoracotomy and minim minimal risks for bleeding. Um And the proposed best time is before six weeks. It's actually as soon as possible, but be at least before six weeks previously, when our neoadjuvant treatments were mainly chemo radiation. Um the conventional interval to uh to time of surgery was 6 to 8 weeks to give the patients an adequate break to recover from their induction treatment. Um and sort of rally before surgery ought to be done. But um in this case, what the proposed optimal timing is is about 2 to 4 weeks after their last um systemic treatment, then they undergo the surgery and they recover hopefully over the course of 4 to 6 weeks before being considered for adjuvant. I just want to spend the next few slides um showing um imaging from patients uh who have uh who I've operated on the last couple of months. And it's just to say that the radiographic imaging is deceptive and it can never adequately represent what the pa the pathologic response will be. So this is a 65 year old who had uh three a disease um uh A PDL one less than 1% and ultimately underwent four cycles of carbo PM PM, um had robotic surgery. But, you know, the, the two, the mass was still present and yet had path cr another patient uh who had a really bulky uh central tumor in the right upper lobe, um PDL one greater than 90%. And this is the pre and the post induction treatment. Um, pictures again on the left is the um imaging on diagnosis. And on the right is that which immediately preceded surgery. This patient underwent four cycles of CISplatin PM PM and ultimately had um 5% viable tumor in the surgical specimen. But the mass was still sizable at the time of surgery. Uh and another patient uh who had a big tumor, big bulky paratracheal uh adenopathy, squamous cell cancer. PPDL 1 50%. Uh on the left is his initial imaging. On the right is um his i his pet from immediately before surgery. At which time there was a complete radiologic response. I really deliberated about whether I ought to put this 58 year old. Um you know, a construction worker through surgery had four cycles of carbo paclitaxel and pem Pemba zab. And ultimately, um still had a 40% viable tumor in what was radiographically nearly absent disease. So, in summary, at present, there are no reliable predictors of complete path cr uh in the absence of such surgery ought to be done safely. Um, in order to guide further treatment and for prognosis, a minimally invasive approach ought to be considered if at all possible. But of course, that depends on the surgeons, um, level of comfort and expertise and it's best to consider surgery as early as possible. Um, in order to minimize um the uh consequences of, of the fibrosis from the treatment. Thank you.
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