thoracoscopic lobectomy for t3 nsclc: chest wall, diaphragm,...

Thoracoscopic Lobectomy for Thoracoscopic Lobectomy for

T3 NSCLC: Chest Wall,

Diaphragm, Mediastinum

AATS Postgraduate CourseAATS Postgraduate Course

Thomas A. D’Amico MDThomas A. D’Amico MDProfessor of Surgery, Chief of Thoracic SurgeryProfessor of Surgery, Chief of Thoracic Surgery

Duke University Health SystemDuke University Health System

AATS Postgraduate CourseAATS Postgraduate Course

April 29, 2012April 29, 2012

DisclosureDisclosure

•• No conflicts related to this presentationNo conflicts related to this presentation

Thoracoscopic LobectomyThoracoscopic Lobectomy

Cancer Mortality in the USCancer Mortality in the USSiegel R, Siegel R, NaishadhamNaishadham D, D, JemalJemal A. A. CA Cancer J CA Cancer J ClinClin 2012;62:102012;62:10--2929

SiteSite DeathsDeaths

1.1.Lung Lung 160,340160,340

2.2.Colon/RectumColon/Rectum 51,69051,690


2.2.Colon/RectumColon/Rectum 51,69051,690

3.3.BreastBreast 39,92039,920

4.4.PancreasPancreas 37,39037,390

5.5.ProstateProstate 28,17028,170

157,170157,170

Duke ApproachDuke Approach

Thoracoscopic LobectomyThoracoscopic LobectomyDuke ApproachDuke Approach

•2 incisions: camera port + access incision (4.5 cm)

•No retractors, no rib spreading

•Anatomic hilar and mediastinal lymph node dissection


19961996--20002000 FeasibilityFeasibility

20012001--20052005 Refinement of techniqueRefinement of technique


20062006--PresentPresent Demonstration of advantagesDemonstration of advantages

Advanced techniquesAdvanced techniques

Advanced Procedures For T3 NSCLCAdvanced Procedures For T3 NSCLC

•• Larger tumorsLarger tumors

•• MediastinalMediastinal involvementinvolvement

•• Chest wall resectionChest wall resection


•• Chest wall resectionChest wall resection

•• Diaphragm resectionDiaphragm resection

•• Lobectomy Lobectomy after induction therapyafter induction therapy

Conrad Fev1 30%Conrad Fev1 30%

Thoracoscopic LobectomyThoracoscopic Lobectomy Duke Thoracic Oncology ProgramDuke Thoracic Oncology Program

KurtzKurtz


MajetteMajette


CTCT


Debona


KennedyKennedy


BoardwineBoardwine


Cote, LuanCote, Luan


HauckHauck


Rosa Watson


BlaunerBlauner


Thoracoscopic Lobectomy: T<3cm Thoracoscopic Lobectomy: T<3cm vsvs

TT>>3cm3cm

•• Thoracoscopic lobectomy for NSCLC: 916 Thoracoscopic lobectomy for NSCLC: 916 ptspts

•• T<3cm: 622 (median 2 cm) T<3cm: 622 (median 2 cm)

•• TT>>3cm: 294 (median 4.3 cm; range 33cm: 294 (median 4.3 cm; range 3--20cm)20cm)


•• TT>>3cm: 294 (median 4.3 cm; range 33cm: 294 (median 4.3 cm; range 3--20cm)20cm)

•• Patients with larger tumors were Patients with larger tumors were

•• OOlder (68.1 lder (68.1 vsvs 65.9 yrs) 65.9 yrs)

•• Worse pulmonary Worse pulmonary fxfx (FEV1 72.7% (FEV1 72.7% vsvs 75.3%)75.3%)

Thoracoscopic Lobectomy: T<3cm Thoracoscopic Lobectomy: T<3cm vsvs

TT>>3cm3cm

•• TT>>3cm: no difference in feasibility or morbidity3cm: no difference in feasibility or morbidity

•• Multivariable analysis predictors of morbidity: Multivariable analysis predictors of morbidity:


•• Multivariable analysis predictors of morbidity: Multivariable analysis predictors of morbidity:

–– Age (odds ratio 1.06 per year, p<0.0001)Age (odds ratio 1.06 per year, p<0.0001)

–– FEV1 (odds ratio 1.25, p<0.0001)FEV1 (odds ratio 1.25, p<0.0001)

–– Prior chemotherapy (odds ratio 2.45, Prior chemotherapy (odds ratio 2.45,

p=0.005)p=0.005)

–– CHF (odds ratio 2.14, p=0.03)CHF (odds ratio 2.14, p=0.03)

Thoracoscopic Lobectomy: Safe and Thoracoscopic Lobectomy: Safe and

Effective Strategy After Induction Therapy Effective Strategy After Induction Therapy Petersen RP, D’Amico TA. Ann Thorac Surg 2006;Petersen RP, D’Amico TA. Ann Thorac Surg 2006; 82:21482:214--219219

•• 97 consecutive patients who underwent 97 consecutive patients who underwent

induction therapy followed by lobectomyinduction therapy followed by lobectomy


•• 85 thoracotomy, 12 thoracoscopy85 thoracotomy, 12 thoracoscopy

Thoracoscopic Lobectomy: Safe and Effective Thoracoscopic Lobectomy: Safe and Effective

Strategy After Induction Therapy Strategy After Induction Therapy Petersen RP, D’Amico TA. Ann Thorac Surg 2006;Petersen RP, D’Amico TA. Ann Thorac Surg 2006; 82:21482:214--219219

OutcomeOutcome

VATSVATS

N=12 (%)N=12 (%)

ThoracotomyThoracotomy

N=85 (%)N=85 (%) pp--valuevalue

Complete ResectionComplete Resection

Chest tube durationChest tube duration

12 (100)12 (100)

2 (22 (2--3)3)

85 (100)85 (100)

4 (24 (2--12)12)

1.001.00

<0.001<0.001


Chest tube durationChest tube duration

LOSLOS

3030--Day mortalityDay mortality

HemorrhageHemorrhage

PneumoniaPneumonia

Respiratory failureRespiratory failure

Atrial fibrillationAtrial fibrillation

2 (22 (2--3)3)

3 (23 (2--6)6)

0 (0)0 (0)

1 (8)1 (8)

0 (0)0 (0)

0 (0)0 (0)

0 (0)0 (0)

4 (24 (2--12)12)

5 (25 (2--63)63)

4 (5)4 (5)

1 (1)1 (1)

8 (9)8 (9)

2 (2)2 (2)

10 (12)10 (12)

<0.001<0.001

<0.01<0.01

0.440.44

0.100.10

0.270.27

0.590.59

0.210.21

100%

75%

50%

KaplanKaplan--Meier SurvivalMeier Survival


0 5 10 15 20 25

MonthsMonths

25%

0%

log-rank test p-value=0.64

---- VATS Not met

Thoracotomy 24 months

Median Survival (28 months overall)

Does Thoracoscopic Pneumonectomy for Does Thoracoscopic Pneumonectomy for

Lung Cancer Affect Survival?Lung Cancer Affect Survival?Nwogu CE, et al. Nwogu CE, et al. Ann Thorac Surg 2010;89:2102Ann Thorac Surg 2010;89:2102--21062106

•• Pneumonectomy for malignancy (2002Pneumonectomy for malignancy (2002--08)08)

•• 70 patients: VATS 24, Open 35, Conversions 870 patients: VATS 24, Open 35, Conversions 8

•• VATS: shorter LOS and lessVATS: shorter LOS and less blood lossblood loss


•• VATS: shorter LOS and lessVATS: shorter LOS and less blood lossblood loss

•• Conversion Conversion ptspts: longer LOS and more blood : longer LOS and more blood

lossloss

•• ComplicationComplication rates similar among all 3rates similar among all 3 groupsgroups

•• 3030--day mortality: 1 day mortality: 1 death in VATS death in VATS and open and open

groupsgroups

CTCT


Chest wallChest wall


Hybrid Approach to Chest Wall TumorsHybrid Approach to Chest Wall Tumors

•• Thoracoscopic hilar dissection and ligationThoracoscopic hilar dissection and ligation

•• Small counter incision centered over lesionSmall counter incision centered over lesion

•• Chest wall resection and specimen removal Chest wall resection and specimen removal


•• AdvantagesAdvantages

–– Smaller incision overallSmaller incision overall

–– Precise dissectionPrecise dissection

–– No rib spreading No rib spreading

–– No scapular retraction/rotatiNo scapular retraction/rotationon

Posterior ApproachPosterior Approach


Feasibility Of Hybrid Feasibility Of Hybrid ThoracoscopicThoracoscopic

LobectomyLobectomy--En Bloc Chest Wall Resection En Bloc Chest Wall Resection Berry MF, et al. Berry MF, et al. EurEur J J CardiothoracCardiothorac SurgSurg 2011; 41: 2011; 41: 888888--892892

•• 78 patients: lobectomy and chest wall resection78 patients: lobectomy and chest wall resection

•• 68 patients: resection via thoracotomy68 patients: resection via thoracotomy


•• 10 patients: hybrid thoracoscopic approach10 patients: hybrid thoracoscopic approach

•• PrePre--op, periop, peri--op, and outcome variables assessed op, and outcome variables assessed

using standard descriptive statisticsusing standard descriptive statistics

•• All patients underwent complete resection with All patients underwent complete resection with

negative marginsnegative margins

DataDataOpen (n=68)Open (n=68)

VATSVATS--Hybrid Hybrid

(n=10)(n=10)

Age 58.5±12.0 63.4±12.2

# ribs resected 3.2±1.1 2.6±1.1

Chest tube duration 4.4±1.6 4.3±1.5


Chest tube duration 4.4±1.6 4.3±1.5

Hospital stay 12.5±18.6 6.1±3.6

Overall morbidity 41 (60%) 4 (40%)

Respiratory complications 22 (32%) 2 (20%)

Cardiovascular

complications20 (29%) 1 (10%)

Peri-Op death 2 (3.4%) 0


•• Oncologically equivalent to open lobectomy, Oncologically equivalent to open lobectomy,

perhaps superior (compliance with adjuvant perhaps superior (compliance with adjuvant

chemo)chemo)

•• More differentially beneficial than any other More differentially beneficial than any other


•• More differentially beneficial than any other More differentially beneficial than any other

minimally invasive procedure vs open alternativeminimally invasive procedure vs open alternative

•• Associated with fewer postoperative Associated with fewer postoperative

complicationscomplications

•• Even more advantageous for high risk patientsEven more advantageous for high risk patients

•• Applicable in locally advanced disease as wellApplicable in locally advanced disease as well

Thoracoscopic Lobectomy: The FutureThoracoscopic Lobectomy: The Future

•• Higher proportion of early stage patients, Higher proportion of early stage patients,

which will increase based on screening trialwhich will increase based on screening trial

•• Application to the highest risk patients: age, Application to the highest risk patients: age,


•• Application to the highest risk patients: age, Application to the highest risk patients: age,

pulmonary function, performance statuspulmonary function, performance status

•• Application to patients with advanced Application to patients with advanced

disease: Stage II, Stage III after induction disease: Stage II, Stage III after induction

therapytherapy

Masters in Minimally Invasive Thoracic SurgeryMasters in Minimally Invasive Thoracic Surgery

September September 2020––22, 201222, 2012

OrlandoOrlando, Florida, Florida


Registration/InformationRegistration/Information::

endo.surgery.duke.edu/coursesendo.surgery.duke.edu/courses

CoCo--sponsored by the American Association for Thoracic sponsored by the American Association for Thoracic

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thoracoscopic lobectomy for t3 nsclc: chest wall, diaphragm,...

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