VATS Segmentectomy. Duke Masters Course Sept 2015

Transcription

1 VATS Segmentectomy Duke Masters Course Sept 2015 Scott J. Swanson, M.D. Director, Minimally Invasive Thoracic Surgery Brigham and Women s Hospital Chief Surgical Officer Dana Farber Cancer Institute Professor of Surgery Harvard Medical School

2 Disclosures Teach Courses for Ethicon and Covidien

3 VATS segmentectomy is equal to VATS lobectomy for small lung cancers Swanson. JTCS June 2009

4 Thoracoscopic Segmentectomy Compares Favorably with Thoracoscopic Lobectomy For Small Stage I Lung Cancers Shapiro M, Weiser T, Wisnivesky J, Chin C, Arustmyan M and Swanson SJ. JTCS June 2009

5 Thoracoscopic Segmentectomy Compares Favorably with Thoracoscopic Lobectomy For Small Stage I Lung Cancers Shapiro M, Weiser T, Wisnivesky J, Chin C, Arustmyan M and Swanson SJ. JTCS June 2009

6 Thoracoscopic Segmentectomy Compares Favorably with Thoracoscopic Lobectomy For Small Stage I Lung Cancers Shapiro, Wisnivesky,. Swanson. JTCS June 2009

7 VATS segmentectomy is equal to VATS lobectomy for small lung cancers Swanson. JTCS June 2009

8 Segmentectomy-Technique Isolation and division of appropriate segmental bronchus, artery and vein Divide fissure with stapler, cautery, other energy device or finger fracture Full node sampling/dissection Rapid intraoperative analysis of draining or sump node, if positive consider conversion to a lobectomy May include adjacent segments

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10 Case History 58 yo woman with a round 2.0 cm lesion in the right lower lobe. Needle biopsy suggested spindle cell neoplasm

11 Right lower lobe basilar lesion

12 Port Placement

13 Right VATS Medial Basilar Segmentectomy

14 Pathology Report A. SUMP NODE, LEVEL 11, RUL NODE ON ARTERY (INCLUDING FSA): One (1) lymph node, negative for tumor. B. LEVEL 12 (INCLUDING FSB): One (1) lymph node, negative for tumor. C. RLL BASILAR SEGMENTECTOMY (INCLUDING FSC1, FSC2): INFLAMMATORY MYOFIBROBLASTIC TUMOR (2.0 cm). Adjacent lung parenchyma with numerous hemosiderin-laden macrophages secondary to old hemorrhage, mild patchy chronic interstitial pneumonitis (non-specific). Immunohistochemistry performed at BWH demonstrates the following staining profile in lesional cells: Positive - ALK, CD163 Negative - CD1a, EMA, SMA, Desmin The immunohistochemical profile supports the above diagnosis. Dr. Sholl and Dr. Fletcher have reviewed selected slides and concurs with the above diagnosis. D. LEVEL 7: Six (6) lymph nodes, negative for tumor. E. 4R: Three (3) lymph nodes, negative for tumor.

15 RLL Basilar Seg- followup Pathology : completely resected 2.0 cm inflammatory myofibroblastic tumor with benign lymph nodes

16 VATS Lingula-Sparing LUL (Left Tri-segmentectomy)

17 Segmentectomy Indications Peripheral T1N0 (< 2 cm) AND Limited cardiopulmonary reserve or Synchronous lung primary tumors or Concern for metachronous primary tumors i.e. following a small contralateral lesion Lesion must be centered in the segment of interest

18 Segments Left upper division (tri-segment) Lingula Superior segment either lower lobe Composite basilar segments either lower lobe Posterior segment right upper lobe

19 New Technology- Vascular Stapler - PA

20 New Technology Vascular Stapler- Pulm Vein

21 Pre-operative 3-dimensional CT reconstruction prior to segmentectomy JTCS Chan et al 2015

22 Time trends in surgery for lung cancer in France, Morgan et al. ERJ Express Aug 2015 Assess the change in survival in pts treated surgically for NSCLC in France N = 34,006, French database- Epithor, , , , Survival increased significantly % First 2 periods, lobe better than segment Last 2 periods these were equivalent Node dissection increased OS for all Chemo, not xrt incr surv in all in 1 st 12m

23 French Lung Cancer Surgery Morgan et al ERJ Express 2015

24 French Lung Cancer Surgery Morgan et al ERJ Express 2015

25 Limited resection vs lobe for pts over 65 and with stage Ia, impact of histology Veluswamy et al JCO 2015

26 Limited resection vs lobe for pts over 65 and with stage Ia, impact of histology Veluswamy et al JCO 2015 SEER-Medicare, limited resection vs lobectomy for stage IA adeno or squamous cell cancer, age>65 27% of 2008 pts with adeno and 32% of 1139 pts with squamous cell had limited resection Not equivalent: HR adeno 1.21 HRsquamous 1.21 Segmentectomy equivalent to lobectomy for adeno ( HR 0.97) but not squamous cell

27 Importance of Lesser Resections via Minimally Invasive Approaches Pathology changed type, size and location Alternative Treatment Options SBRT Quality of life and long term considerations New primary at 2-4%/yr

28 Summary Standard surgical resection for lung cancer is evolving Currently lobectomy with lymph node dissection is the gold standard for most cancers For lesions < 2cm consideration should be given for a sublobar resection Segmentectomy is superior to wedge resection when anatomically appropriate Segmentectomy can be done via VATS New technology facilitates these operations CALGB is the best way to study this All patients who are candidates should be enrolled