vats lobectomy an alternative technique for early stage lung

VATS Lobectomy an VATS Lobectomy an Alternative Technique for Alternative Technique for Early Stage Lung CancerEarly Stage Lung Cancer

Michael F. Gibson, MD FACSMichael F. Gibson, MD FACS

South Carolina Cardiovascular SurgerySouth Carolina Cardiovascular SurgeryOctober 1, 2008October 1, 2008

Lung CarcinomaLung Carcinoma

Lung Cancer remains a fatal diseaseLung Cancer remains a fatal disease– The overall 5 year survival is 10-13% and has The overall 5 year survival is 10-13% and has

not changed significantly over the past 20 not changed significantly over the past 20 yearsyears

– The TNM classification is used for stagingThe TNM classification is used for staging In 1997 changes were made to the TNM system to In 1997 changes were made to the TNM system to

better stratify prognosesbetter stratify prognoses Only 25% of patients will have early stage lung Only 25% of patients will have early stage lung

cancer at time of diagnosiscancer at time of diagnosis

– NSCLC accounts for 80% of lung cancerNSCLC accounts for 80% of lung cancer– It is the most common cancer cause of death It is the most common cancer cause of death

in men and womenin men and women– 185,000 new cases per year185,000 new cases per year

Lung CancerLung Cancer

Clinical PresentationClinical Presentation Due to primary tumorDue to primary tumor

– cough, hemoptysis, wheeze, stridor, dyspnea, cough, hemoptysis, wheeze, stridor, dyspnea, post-obstructive pneumonia, pain from invasionpost-obstructive pneumonia, pain from invasion

Due to regional spread of tumorDue to regional spread of tumor– Tracheal compression, dysphagia, RLN palsy, Tracheal compression, dysphagia, RLN palsy,

Phrenic nerve palsy, SVC syndrome, Horner’s Phrenic nerve palsy, SVC syndrome, Horner’s syndrome, Pancoast syndrome, effusion, syndrome, Pancoast syndrome, effusion, tamponadetamponade

Due to metastatic spreadDue to metastatic spread– Bone pain, adrenal insufficiency, CNS symptomsBone pain, adrenal insufficiency, CNS symptoms

Paraneoplastic syndromesParaneoplastic syndromes


Diagnosis and work up for solitary lung nodule > 1cmDiagnosis and work up for solitary lung nodule > 1cm– History and PhysicalHistory and Physical

Smoking >10 yrsSmoking >10 yrs Asbestosis exposureAsbestosis exposure COPDCOPD History of prior maligacyHistory of prior maligacy

– CXRCXR Review all old films with in 2 yearsReview all old films with in 2 years No change in size likely to be benignNo change in size likely to be benign

– CT of Chest and AbdomenCT of Chest and Abdomen Anotomical location of tumorAnotomical location of tumor Mediastinal structures and lymph nodes (>1cm)Mediastinal structures and lymph nodes (>1cm)

– Pulmonary function testPulmonary function test FEV1 – 40% of predictedFEV1 – 40% of predicted

– PET – metastatic w/u and stagingPET – metastatic w/u and staging CT of Head, Bone scanCT of Head, Bone scan

– MRI MRI Preop cardiac evaluation per ACC guidelinesPreop cardiac evaluation per ACC guidelines

Pulmonary Function for Pulmonary Function for Thoracic SurgeryThoracic Surgery

Pulmonary resections lead to a Pulmonary resections lead to a permanent loss of pulmonary permanent loss of pulmonary functionfunction

The definition of “resectability” can be The definition of “resectability” can be different under different circumstancesdifferent under different circumstances

There have been a nmber of There have been a nmber of improvements in anesthesia and ICU care improvements in anesthesia and ICU care that may allow resections in previously that may allow resections in previously unresectable ptsunresectable pts

What are the real numbers? What are the real numbers?

Pulmonary Function for Pulmonary Function for Thoracic SurgeryThoracic Surgery

SpirometrySpirometry– Gaensler in 1955 suggested vital capacity >2L be present before Gaensler in 1955 suggested vital capacity >2L be present before

resectionresection– Suggested parameters for FEV1 have varied from 1.5 - 1.75L for Suggested parameters for FEV1 have varied from 1.5 - 1.75L for

lobectomy and >2L for pneumonectomylobectomy and >2L for pneumonectomy– Miller recently suggested:Miller recently suggested:

FEV1 > 2L for lungFEV1 > 2L for lung > 1L for lobe> 1L for lobe > 0.6L for wedge> 0.6L for wedge

– A number of reports suggest that % is more accurateA number of reports suggest that % is more accurate Mittman suggested FEV1 be greater than 70%Mittman suggested FEV1 be greater than 70% Nagasaki and Pate, FEV1 be greater than 40%Nagasaki and Pate, FEV1 be greater than 40%

– DLCO of < 50-60% is suggested for “major resection”DLCO of < 50-60% is suggested for “major resection”– ABG’s are also used:ABG’s are also used:

PaO2 < 50 is associated with increased riskPaO2 < 50 is associated with increased risk PaCO2 > 50 is also associated with increased risk PaCO2 > 50 is also associated with increased risk

Lung CancerLung Cancer DiagnosisDiagnosis

– Sputum cytologySputum cytology– BronchoscopyBronchoscopy

Biopsy, washings, Transbronchial needle biopsy, BALBiopsy, washings, Transbronchial needle biopsy, BAL– CT guided Transthoracic FNACT guided Transthoracic FNA

Inability to determine a specific benign diagnosis in Inability to determine a specific benign diagnosis in 80%80%

Inconclusive diagonosisInconclusive diagonosis– Further investigation ( biopsy)Further investigation ( biopsy)– Radiologic follow-upRadiologic follow-up

– VATS wedge resectionVATS wedge resection Most common used techniqueMost common used technique Avoids traditional thoracotomyAvoids traditional thoracotomy 45% - 70% nodules are malignant45% - 70% nodules are malignant

– Proceed with anatomical resectionProceed with anatomical resection– MediastinoscopyMediastinoscopy

StagingStaging


PathologyPathology– Squamous Cell CaSquamous Cell Ca 30-35%30-35%– AdenocarcinomaAdenocarcinoma 30-35%30-35%

Bronchoalveolar CarcinomaBronchoalveolar Carcinoma

– Large Cell CALarge Cell CA 25%25%– Small Cell CarcinomaSmall Cell Carcinoma 15-20%15-20%– CarcinoidCarcinoid 1-2%1-2%


Stage GroupingStage GroupingStageStage TNM SubsetTNM Subset % 5yr survival % 5yr survival

Clinical/PathologicClinical/PathologicStage 0Stage 0 CISCIS

Stage IAStage IA T1N0M0T1N0M0 61 / 6761 / 67

Stage IBStage IB T2N0M0T2N0M0 38 / 5738 / 57

Stage IIAStage IIA T1N1M0T1N1M0 34 / 5534 / 55

Stage IIBStage IIB T2N0M0T2N0M0 24 / 3924 / 39

T3N0M0T3N0M0 22 / 3822 / 38

Stage IIIAStage IIIA T3N1M0T3N1M0 9 / 259 / 25

T1N2M0T1N2M0

T2N2M0T2N2M0 13 / 2313 / 23

T3N2M0T3N2M0

Stage IIIBStage IIIB T4N0M0T4N0M0 55

T4N1M0T4N1M0

T4N2M0T4N2M0

T1-T4N3M0T1-T4N3M0

Stage IVStage IV Any T Any N M1Any T Any N M1 <1<1


Staging SystemStaging SystemTxTx Tumor can not be assesed, but tumor presentTumor can not be assesed, but tumor present

T0T0 No evidence of primary tumorNo evidence of primary tumor

TisTis Carcinoma is situCarcinoma is situ

T1T1 <3cm, surrounded by lung or visceral pleura, not in main bronchus<3cm, surrounded by lung or visceral pleura, not in main bronchus

T2T2 >3cm, involves main bronchus >2cm more distal to carina, invades visceral pleura, >3cm, involves main bronchus >2cm more distal to carina, invades visceral pleura, associated with atelectasis or obstructive pneumonitis extending to hilusassociated with atelectasis or obstructive pneumonitis extending to hilus

T3T3 Any size that directly invades the following: chest wall (including superior sulcus), Any size that directly invades the following: chest wall (including superior sulcus), diaphragm, mediastinal pleura, parietal pericardium, <2cm from the carina but not diaphragm, mediastinal pleura, parietal pericardium, <2cm from the carina but not invading invading the carina, or associated atelectasis/obstructive pneumonitis involving the the carina, or associated atelectasis/obstructive pneumonitis involving the entire lungentire lung

T4T4 Any size that directly invades the following: mediastinum, heart, great vessels, Any size that directly invades the following: mediastinum, heart, great vessels, trachea, trachea, esophagus, vertebral body, carina, malignant pleural or pericardial effusion, esophagus, vertebral body, carina, malignant pleural or pericardial effusion, or satellite tumor or satellite tumor nodule within the ipsilateral primary tumor of the lungnodule within the ipsilateral primary tumor of the lung

NxNx Regional nodes can not be evaluatedRegional nodes can not be evaluated

N0N0 No regional node metastasisNo regional node metastasis

N1N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar nodes, intrapulmonary nodesMetastasis to ipsilateral peribronchial and/or ipsilateral hilar nodes, intrapulmonary nodes

N2N2 Metastasis to ipsilateral mediastinal and/or subcarinal nodesMetastasis to ipsilateral mediastinal and/or subcarinal nodes

N3N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene or supraclavicular nodesscalene or supraclavicular nodes

MxMx Metastasis can not be assessedMetastasis can not be assessed

M0M0 No distant metastasisNo distant metastasis

M1M1 Distant metastasis presentDistant metastasis present

Lung CancerLung CancerLymph Node Map (Naruki)Lymph Node Map (Naruki)

N2 Nodes (all N2 nodes lie within the mediastinal pleural envelope)N2 Nodes (all N2 nodes lie within the mediastinal pleural envelope)11 Highest MediastinalHighest Mediastinal Above the upper rim of the brachiocephalic v.Above the upper rim of the brachiocephalic v.22 Upper ParatrachealUpper Paratracheal Above upper Ao and below brachiocephalic v.Above upper Ao and below brachiocephalic v.33 Pre & RetrotrachealPre & Retrotracheal 3A and 3P3A and 3P44 Lower ParatrachealLower Paratracheal Right: between upper margin of Ao & main broncRight: between upper margin of Ao & main bronc

Left: between upper margin of Ao & main broncLeft: between upper margin of Ao & main bronc55 Subaortic (A-P Wind)Subaortic (A-P Wind) Lateral to ligamentum & prox to 1st LPA Lateral to ligamentum & prox to 1st LPA

branchbranch66 Para-aorticPara-aortic Anterior and lateral to the ascending AoAnterior and lateral to the ascending Ao77 SubcarinalSubcarinal Caudal to the carinaCaudal to the carina88 ParaesophagealParaesophageal Adjacent to the wall of the esophagusAdjacent to the wall of the esophagus99 Pulmonary LigamentPulmonary Ligament Inferior pulmonary ligamentInferior pulmonary ligament

N1 Nodes (all N1 nodes are distal to the mediastinal pleural reflection)N1 Nodes (all N1 nodes are distal to the mediastinal pleural reflection)1010 HilarHilar Proximal lobar nodesProximal lobar nodes1111 InterlobarInterlobar Between lobar bronchiBetween lobar bronchi1212 LobarLobar Adjacent to distal lobar bronchiAdjacent to distal lobar bronchi1313 SegmentalSegmental Adjacent to segmental bronchiAdjacent to segmental bronchi1414 SubsegementalSubsegemental Around subsegmental bronchiAround subsegmental bronchi

Naruke Lymph Node MapNaruke Lymph Node Map

Thoracotomy TechniqueThoracotomy Technique

Standard posterior lateral Standard posterior lateral thoracotomythoracotomy– Serratus spearing thoracotomySerratus spearing thoracotomy

Shear 5Shear 5thth or 6 or 6thth rib rib Perform anatomical lung resectionPerform anatomical lung resection Lymph node dissectionLymph node dissection Chest tube placement and closureChest tube placement and closure

ThoracotomyThoracotomy

VATS Lobectomy VATS Lobectomy TechniqueTechnique

ContraindicationsContraindications– Intolerance of single lung ventilationIntolerance of single lung ventilation– Tumor size >6cm (T2)Tumor size >6cm (T2)– Significant hilar lymphadnopathy (N2)Significant hilar lymphadnopathy (N2)– Tumor involvement of chest or Tumor involvement of chest or

mediastinum (T3)mediastinum (T3) Most limitations are due to Most limitations are due to

anatomical considerationsanatomical considerations

VATS Lobectomy VATS Lobectomy Technique Technique

2 cm incision 62 cm incision 6thth ICS midclavicular line ICS midclavicular line 5mm port site 85mm port site 8thth ICS midaxillary line ICS midaxillary line

– 30 degree scope30 degree scope Utility incision 4 cm - 6 cmUtility incision 4 cm - 6 cm

– No rib spreading (increases post op pain)No rib spreading (increases post op pain) Mediastinal lymph node dissectionMediastinal lymph node dissection Additional port placed post. 5Additional port placed post. 5thth ICS ICS CT placement and closureCT placement and closure

VATS LobectomyVATS Lobectomy

Thoracotomy vs VATSThoracotomy vs VATS

Why do VATS Lobectomy ?Why do VATS Lobectomy ? HospitalizationHospitalization Post operative PainPost operative Pain RecoveryRecovery Oncologic comparisonOncologic comparison CALGB 39802 (2007)CALGB 39802 (2007)

– Prospective, multi-Institutions feasibility studyProspective, multi-Institutions feasibility study– 127 patients127 patients– Standardized definition of VATS LobectomyStandardized definition of VATS Lobectomy– MeasuredMeasured

SuccessSuccess Morbitity and mortalityMorbitity and mortality Cancer recurrence and survivalCancer recurrence and survival

Hospitalization VATSHospitalization VATS

Shorter hospital stayShorter hospital stay Shorter chest tube durationShorter chest tube duration

– 1-2 days1-2 days Earlier return to full activitiesEarlier return to full activities Less painLess pain Faster recovery for high risk and Faster recovery for high risk and

frail patientsfrail patients

VATS VATS Post operative painPost operative pain

Epidural less duration or no epiduralEpidural less duration or no epidural Less use of analgesicsLess use of analgesics Less sleep disturbancesLess sleep disturbances Lower incidence of post Lower incidence of post

thoracotomy pain syndromethoracotomy pain syndrome Most patients off all pain meds by Most patients off all pain meds by

POD # 7POD # 7

VATS RecoveryVATS Recovery

POD #7, 14 studies show improved POD #7, 14 studies show improved PaO2, Pox, FEV1 and FVCPaO2, Pox, FEV1 and FVC

Better 6 min walk testBetter 6 min walk test May have short and Long term quality May have short and Long term quality

of life improvementof life improvement Quicker return to preoperative activityQuicker return to preoperative activity

– VATS 2.5 moVATS 2.5 mo– Thoracotomy 7.8 moThoracotomy 7.8 mo

Decreased shoulder dysfunctionDecreased shoulder dysfunction

Oncological ComparisonOncological ComparisonVATS vs ThoracotomyVATS vs Thoracotomy

No difference in lymph node No difference in lymph node dissectiondissection

No difference in survival curvesNo difference in survival curves– Some studies report trends in Some studies report trends in

increased survivalincreased survival– VATS approach does not compromise VATS approach does not compromise

patient survivalpatient survival

Survival Survival VATS vs. ThoracotomyVATS vs. Thoracotomy

Oncological ComparisonOncological Comparison

VATS SurvivalVATS Survival– McKenna, 2006McKenna, 2006 Stage I, 75% Stage I, 75%

5 yr5 yr– Solaini, 2001Solaini, 2001 Stage I, 90% 5yrStage I, 90% 5yr– Walker, 2003Walker, 2003 Stage I, 78% 5yrStage I, 78% 5yr

Port site recurrencePort site recurrence– Swanson ACCP, 98Swanson ACCP, 98 0.2%0.2%

ConclusionConclusion VATS Lobectomy is a safe procedureVATS Lobectomy is a safe procedure Fewer complicationFewer complication Proven advantagesProven advantages

– Small incisionSmall incision– Decreased painDecreased pain– Decreased LOSDecreased LOS– Decreased CT outputDecreased CT output– Decreased blood loss (transfusions)Decreased blood loss (transfusions)– Preservation of pulmonary functionPreservation of pulmonary function– Earlier return to normal activitiesEarlier return to normal activities

No oncological compromise when looking at 5 year No oncological compromise when looking at 5 year survival datasurvival data

Evidence based medicine suggest VATS lobectomy has Evidence based medicine suggest VATS lobectomy has advantages over thoracotomyadvantages over thoracotomy

So what does this all So what does this all mean?mean?

Currently only 20% of lung Currently only 20% of lung resections are performed by VATS resections are performed by VATS lobectomy world widelobectomy world wide

VATS lobectomy is now part of VATS lobectomy is now part of fellowship most training programsfellowship most training programs

This approach is likely to become This approach is likely to become standard of care for lobectomystandard of care for lobectomy

Why not !Why not !

vats lobectomy an alternative technique for early stage lung

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