February - 20208In My OpinionPaul Chomiak, MD, Director, Thoracic Surgical Oncology, Sarasota Memorial Health Care SystemByLung cancer is an epidemic in our country. Historically, most patients do not think of seeking care for lung conditions until they experience symptoms. Lung cancer patients are customarily diagnosed in an advanced stage that requires multidisciplinary chemotherapy, radiation therapy, and possibly immunotherapy. The success of cancer treatment relies on having an opportunity to screen and identify asymptomatic patients with an early stage of cancer that has a higher chance for cure. Other cancer screening programs that screen patients for breast cancer, colon cancer, and prostate cancer have been successfully implemented for decades. Today, according to the American Cancer Society, more people die from lung cancer than from those cancers combined.The National Lung Cancer Trial demonstrated convincing evidence that validated the use of low dose non-contrast screening in high risk individuals. Most accredited multidisciplinary cancer centers now offer robust lung cancer screening programs. Recent trials have demonstrated a reduction in lung cancer associated mortality through lung cancer screening.The growing use of lung cancer screening also has identified an increasing incidence of ground glass opacification (GGO) reported in up to 63% of all screening studies. Though historically a GGO was considered to represent an inflammatory lung disease, GGO may also represent a lung cancer. Hence the increased incidence of GGO identified on lung cancer screening studies is resulting in a clinical concern.Often incidentally identified lung nodules may be further risk stratified with the use of a PET/CT. Routine use of a PET/CT to evaluate GGO's is considered by some authors as inappropriate due to unacceptable reported false negative rates. Accurate histologic biopsy of a GGO is difficult secondary to its architecture. CT guided biopsies of GGO dominant lesions demonstrate a diagnostic yield between 35% - 80% depending on the lesion size. However, GGO biopsy diagnostic accuracy was enhanced utilizing a combined technique of endobronchial ultrasound with a virtual navigation bronchoscopy.For patients identified with pure GGO, an interval course of observation with a repeat CT scan may be appropriate. However, intervention should be offered if the pure GGO increases in size or there is identification of a solid component in the GGO. Patients who have previously undergone a lung resection for lung cancer and develop a new pure GGO should be offered intervention versus observation due to an increased risk of tumor recurrence.Due to the documented range of false negative biopsy results for GGO lesions, many physicians are recommending to proceed with upfront surgical resection that can offer both diagnosis and therapeutics in one single setting. Various thoracic surgical approaches can be offered depending on the location and size of the GGO. Historically, a traditional thoracotomy was utilized to offer the opportunity for manual palpation of the lung to identify small nodules. However, pure GGO lesions are difficult to localize with manual palpation. Minimal invasive approaches such as da Vinci robotic surgery or video assisted thoracoscopic surgery (VATS) currently lack "ONE-STOP SHOP": UTILIZING MONARCH ROBOTIC BRONCHOSCOPY AND DA VINCI ROBOTIC SURGERY TO DIAGNOSE AND TREAT GROUND GLASS OPACIFICATION (GGO) LUNG CANCER
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