Thoracoscopic Lobectomy for locally advanced cancer. Todd L. Demmy

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1 Thoracoscopic Lobectomy for locally advanced cancer Todd L. Demmy

2 5/13/15 No Disclosures

3 What is Locally Advanced? >4 cm T3 or T4 Neoadjuvant chemotherapy Ann Surg Oncol (2011) 18:

4 What is Locally Advanced? Lesion size >5 cm Strong pleural adhesions Adjacent structure involvement (parietal/mediastinal pleura, diaphragm, rib) N1 or N2 Centrally located tumors (endo- or peribronchial extension to lobar bronchus orifice) Previous chemo- or chemoradiotherapy, or previous surgery J Thorac Dis 2014;6(S6):S623-S630

CALGB 39802 Validation 4-8 cm Access Pure Video Guidance Hilar

5 CALGB Validation 4-8 cm Access Pure Video Guidance Hilar Dissection No Rib Spreading J Clin Oncol Nov 1;25(31):4993-7

Number of Pulmonary Resections Thoracoscopic 4000 Lobectomy 3500 3000 2500 STS Database: % Thoracoscopy Series

6 Number of Pulmonary Resections Thoracoscopic 4000 Lobectomy STS Database: % Thoracoscopy Series 2 Thoracotomy 39.7% 42.8% 1541 * 5/ % % < % % % 8.0% 11.6% % 26.2% Ceppa DP, et al. Ann Surg 2012 Aug 3. [Epub ahead of print] PMID:

7 VATS Experience & Reliability

8 2012 SPARCS Data Centers > 100 Lobes

9 What are the MIS Frontiers? Routine Reliability for a Center/Surgeon Training/Equipment/SOPs Routine Reliability for a Specialty Mentorship/Simulation Innovation and Expansion More challenging cases Integrating technologies/imaging Enhancing Medical Therapy

10 Fissure Division Videos section/videos/2013_video-atlasthorascopic-lobectomy.html

11 Basic Lobectomy Steps

12 Troubleshooting Guide Ann Thorac Surg 2005;79:

13 Troubleshooting Guide

Straight Curved 104 68 78 38 PA Branch Vein

14 Median (s) Curved Tip Cartridge for Thoracic Surgery STAPLER PASSAGE TIMES COMPLEX CASES Straight Curved PA Branch Vein Demmy&Mayfield,Ann Thorac Surg 2012;93:

15 What are the MIS Frontiers? Routine Reliability for a Center/Surgeon Training/Equipment/SOPs Routine Reliability for a Specialty Mentorship/Simulation Innovation and Expansion More challenging cases Integrating technologies/imaging Enhancing Medical Therapy

16 Thoracoscopic Path of One Surgeon/Program Chest wall Sleeve 2007 Pneumonectomy 1999 Lobe 1995 MIE Segmentectomy 2003 EPP 2009

17 Visualization Tools High Definition Optimal Endocameleon

18 Visualization Tools 5 mm Optimal For Sharing ports

19 Importance of Low Profile and Angles

20 Multiple retractors 00:26

21 Thermal Sealing Technology N=211 Lobes/Segments J Thorac Cardiovasc Surg 2010;140:

22 PA control - Loops #1 Silk A. Watanabe et al. / European Journal of Cardio-thoracic Surgery 31 (2007)

23 VATS WEDGE Bronchoplasty Kamiyoshihara, 2010, Interact Cardiovasc Thorac Surg 11(5):

24 Follow the Fs when you are stuck- 1 Free All Adhesions, All Lobes Find Somewhere else to work or view Pleurae and lymphatic tissue Divide more distally Fissure Division (also opens camera angles) Partially (outside in) Completely (blunt clamp technique)

25 Fissure Division Videos section/videos/2013_video-atlasthorascopic-lobectomy.html

26 Follow the Fs when you are stuck - 2 Flip order of anatomical divisions (eg. Change to Fissure Last Technique) Fill the port/access incisions ( fers ) Traction Countertraction to define anatomy (eg. Two-fer and vessel loops) Fresh planes (eg. Open pericardium) Flatten the diaphragm

27 Exposure Problems Vessel Access 00:20

28 Poor PFT VATS J Thorac Cardiovasc Surg 2011;141:459-62

29 Poor PFT VATS J Thorac Cardiovasc Surg 2011;141:459-62

30 Poor PFT VATS VATS (n = 47) Open (n = 23) p-value Pneumonia (no.) 2 (4.3%) 5 (21.7%) ARDS (no.) 0(0%) 2 (8.7%) Intubation>24 h (no.) 2 (4.3%) 2 (8.7%) Oxygen at >4 wk (no.) 6 (12.9%) 5 (21.7%) 0.49 Mean total stay (d) Mean ICU tay (d) Rehabilitation (no.) 2 (4.3%) 4 (17.4%) 0.09 Mortality (no.) 1 (2.1%) 1 (4.3%) >.999 Kachare, J Thorac Cardiovasc Surg 2011;141:459-62

31 STS VATS vs. Open OPEN, N=8439 VATS, N=4531 Ceppa, Ann Surg 2012;256:

32 What is Locally Advanced? Pneumonectomy Sleeve Lobectomy Chest Wall Resection Advanced exposure

33 VATS Pneumonectomy Longer Persistance of Severe and Moderate Pain for Open Pneumonectomy Patients might relate to survival

34 Survival May benefit advanced stages (ITT Analysis) Conversions in early pathologic stage may reduce VATS benefits

35 Hybrid VATS Sleeve Ref N Deaths Complications EBL (ml) Time HospStay Santambrogio, ??? Okada, ? ? Tse, ????? He, Pettiford, ? Yen, trach? 37? He, /

36 Complete VATS Sleeve Ref N EBL Deaths Complications (ml) Time Hosp Stay Nakanishi, Mahtabifard, / DeArmond, ?? 3 Kamiyoshihara, * Mei, ???? Li, Yu, Liu, ??? Only Plasty MULTIPLE CASE REPORTS, 14 IN THE LAST 3 YEARS

37 Bronchoplasty

38 VATS WEDGE Bronchoplasty Kamiyoshihara, 2008, Gen Thorac Cardiovasc Surg 56(9): Cm 70% direct visualization handling the needle: scooping, rotating, and turning 30% monitor confirm each needle insertion site and anastomotic line Polyurethane wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA).

39 VATS WEDGE Bronchoplasty Kamiyoshihara, 2010, Interact Cardiovasc Thorac Surg 11(5):

40 VATS WEDGE Bronchoplasty Kamiyoshihara, 2010, Interact Cardiovasc Thorac Surg 11(5):

41 First VATS Sleeve 15 yo female 5cm muscle sparing access "uneventful" course Mucoepidermoid carcinoma Santambrogio, 2002, Chest 121(2):

42 VATS Sleeve Resection Nakanishi, 2007, Ann Thorac Surg 84(1):

43 Two-Port Sleeve Case Jiao et al. Journal of Cardiothoracic Surgery 2013, 8:99.

44 Two-Port Sleeve Case Jiao et al. Journal of Cardiothoracic Surgery 2013, 8:99.

45 Uniportal Sleeve Case 55 year old, post induction therapy Gonzalez-Rivas, J Thorac Cardiovasc Surg 2013;145:1676-7

46 Uniportal Sleeve Case Gonzalez-Rivas, J Thorac Cardiovasc Surg 2013;145:1676-7

47 PD - Index Case 7/ yo female Hx breast ca Hemoptysis Inflammatory myofibroblastic tumor

48 TiKnot Device

49 Feb 2008 to Aug VATS Sleeves 7 VATS Bronchoplasty 2 VATS Sleeves with tracheoplasty 3 VATS PA/SVC resections/repairs 42 Other Bronchoplasy, PA plasty, Sleeves

50 Chest Wall Resection and Reconstruction Todd L. Demmy

51 Potential Advantages Ann Thorac Surg 2012;94: Planning/Accurate resection margins Avoid rib spreading pain Less blood loss

52 Diagnosis Superior Sulcus 2/12 No invasion 8/12 Diagnostic 4/12 Adhesions Faster start of adjuvant Hubbard, Surg Laparosc Endosc Percutan Tech 2011;21:

53 VATS for Planning Open Interactive CardioVascular and Thoracic Surgery 17 (2013) 32 35

54 Hybrid Superior Sulcus 60 yo female 7 day stay Induction XRT No complications W. Truin et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010)

55 Hybrid Thoracotomy (n = 93) VATS hybrid (n = 12) P-value Perioperative mortality 3 (3.2%) 0 1 Overall morbidity 55 (59%) 5 (42%) 0.35 Hospital stay (median) 6 (2 124) 5.5 (3 15) 0.03 Chest tube duration 4 (2 15) 3.5 (2 7) 0.44 Postop bronchoscopy 23 (25%) 3 (25%) 1 Atrial arrhythmia 24 (26%) 1 (8%) 0.3 Pneumonia 19 (20%) 1 (8%) 0.45 Post-op transfusion 16 (17%) 2 (17%) 1 Need for CT >5 days 19 (20%) 2 (17%) 1 Berry, European Journal of Cardio-Thoracic Surgery 41 (2012)

56 Hybrid Thoracotomy VATS hybrid P-value (n = 93) (n = 12) Tumour size (cm) 5.4 ± ± Number of resected 3.3 ± ± ribs Superior sulcus 34 (37%) 2 (17%) 0.21 location Pathologic stage 2 64 (69%) 12 (100%) 0.2 Reconstruction with mesh 40 (43%) 4 (33%) 0.8 Berry, European Journal of Cardio-Thoracic Surgery 41 (2012)

57 Thoracoscopic Lobe with en bloc Chest Wall Year N # ribs Author Citation Widmann Caccavale Bocage Lewis Yendamuri, Nwogu Demmy Demmy, Nwogu, Yendamuri Ann Thorac Surg Dec;70(6): Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery. 4(1):36-38, January Ann Thorac Surg Jun;89(6):S Plus assorted VATS first rib resections for TOS

58 Technique Score planned margins Divide ribs close to utility incision with standard ribcutter Divide IC muscles with energy Dissect sub-muscular plane Divide ribs away from port

59 Gigli/Rib Cutter/High Speed Burr Midas Rex Black Max

60 Methods-Retraction Wylie or similar Self-retaining systems, Bookwalter Fan-retraction

61 Case Presentation LUL Chest Wall Invasion After Chemo Before Chemo

62 Case Presentation LUL Chest Wall Invasion 0:26

63 Case Presentation LUL Chest Wall Invasion

64 Jan 2007 to December VATS lobe en Bloc 1 VATS Pneumonectomy en Bloc 1 Benign 1 Sarcoma

65 Relative Risk NSCLC with Chest Wall Invasion Challenging Disease 5% of NSCLC Technically Demanding Complex Resections Traditionally Open Reconstruction Issues Pulmonary Compromise Multimodality Therapy Day Mortality Compared to VATS Wedge VATS Lobe 1.01 Open Lobe Pneumon -ectomy 5.65 Chest Wall Lung Hu et al. Ann Thorac Surg, 2014 vol. 97(3) pp

Potential Advantages Ann Thorac Surg 2012;94:1744 7

66 Potential Advantages Ann Thorac Surg 2012;94: Planning/Accurate resection margins Avoid rib spreading pain Less blood loss

67 Methods Retrospective Analysis 47 chest wall resections VATS, 30 open Subgroup 31 patients with NSCLC 15 VATS, 16 open

68 Gigli/Rib Cutter/High Speed Burr Midas Rex Black Max

69 Similar Pathology and Stage Distribution VATS Open IIIB IB IV IB IIIA IIIA IIB IIB

70 Percent Similar Pulmonary Function FEV1 DLCO VATS Open

71 Results NSCLC Groups Variable (median) VATS (n=15) Open (n=16) p-value Age (years) Operative Time (min) EBL (ml) Ribs Resected 3 (range 1-5) 3 (range 1-5) 0.105

72 Wider Age Range for VATS

73 Variable (median) ICU (days) In Hospital (days) Results VATS (n=15) Open (n=16) p-value Reconstruction with Patch 6.7% 56.3% Neoadjuvant Chemo or ChemoRT 66.7% 62.5% Day Mortality/Major Morbidity 53.3% 87.5% 0.036

74 Conclusions Thoracoscopic chest wall resection is technically feasible expanded our case selection reduced prosthetic reconstruction It did not, however, reliably protect frail, elderly patients.

75 Case Presentation LUL Chest Wall Invasion

76 Less Variation for VATS Despite Older Patients Pneumonectomy Neuro? Other Emergency Colon ischemia

77 Variable (median) ICU (days) In Hospital (days) Results VATS (n=15) Open (n=16) p-value Reconstruction with Patch 6.7% 56.3% Neoadjuvant Chemo or ChemoRT 66.7% 62.5% Day Mortality/Major Morbidity 53.3% 87.5% 0.036

78 Outcomes (1) Variable (median) VATS (n=15) Age (years) 76 (range 73-90) Operative Time (min) 500 EBL (ml) 450 Ribs Resected 3 (range 1-5) ICU (days) 2 In Hospital (days) 7

79 Patch Preparation 2mm PTFE Cut to same size as specimen + 1 cm Prepunch perimeter to make intracorporeal suturing easier

80 Body Wall Anchoring Carter-Thomason Needle

81 Case Presentation RLL Chest Wall Invasion

82 VATS RLL PTFE Reconstruction 2:20

83 Outcomes (2) Hospital Deaths Ages 73, Emerg Superior Sulcus Spinal compress - SIRS 83, Colon ischemia with cardiac mets 90, Stroke 77, Respiratory failure

84 VATS Brachytherapy

85 Summary Highly selected cases of primary or T3 lung cancer may be appropriate VATS resection candidates.? short-term recovery benefits Not for all frail patients Cooperative study is needed

Locally Extensive Lesion size >5 cm Dense pleural adhesions, fused fissure and severe emphysema; Adjacent structures involvement ( mediastinal/parietal pleura, diaphragm,

86 Locally Extensive Lesion size >5 cm Dense pleural adhesions, fused fissure and severe emphysema; Adjacent structures involvement ( mediastinal/parietal pleura, diaphragm, rib N1 or N2 Centrally located tumors extension to lobar bronchus orifice) Previous chemo- or chemoradiotherapy Previous surgery Pischik, J Thorac Dis 2014;6(S6):S623-S630

87 Standard (S) vs. extended (E) indications for VATS major pulmonary resection Group S (n=45) Group E (n=47) P value Average operation time (minutes) Number of mediastinal LN (mean) Blood loss (mean, ml) Chest tube duration (mean, days) Amt drained fluid/day (mean, ml) Total amount of postop. opioids Morbidity 5 (16.7%) 7 (21.9%) Length of stay (mean, days) Pischik, J Thorac Dis 2014;6(S6):S623-S630

88 Duke Series Central = could not be wedged J Thorac Cardiovasc Surg 2013;145:514-21

89 VATS following Neoadjuvant N=43 IIA-IIIB NSCLC (IIIA: 62.8%; IIIB: 25.6%) 32 males (74.4%) 42 successful (7 hybrid) 28 lobectomies (9 sleeve) 5 bilobectomies, 5 wedge, 4 pneumonectomies. 160 min ( min) EBL 253±117 ml Nodes 17±11 CT 2.6 day (1-7) Hospital 5.4c (3-7) Complications 9.5% Mortality 2.4% Overall 94%, 79%, and 65% 1, 2 & 3yr Survival Huang, J Thorac Dis 2013;5(S3):S267-S273.

90 VATS for Stage 2 or greater April 2002 and April 2011 for advanced-stage NSCLC of preoperative stage II or greater at a single institution Nakanishi, Ann Thorac Surg 2014;97:980 6

91 VATS for Stage 2 or greater Group A ( ) Group B ( ) Group C ( ) Variable Total (n = 76) n = 25 n = 25 n = 26 p Value Complication: total 27 (35.5%) 10 (40.0%) 10 (40.0%) 7 (26.9%) c Air leak > 7 days 8 (10.5%) 4 (16.0%) 2 (8.0%) 2 (7.7%) c Sputum retention 7 (9.2%) 4 (16.0%) 2 (8.0%) 1 (3.8%) c requiring bronchoscopy Pneumothorax 5 (6.6%) 1 (4.0%) 2 (8.0%) 2 (7.7%) c Atrial fibrillation 4 (5.3%) 2 (8.0%) 1 (4.0%) 1 (3.8%) c Hoarseness 4 (5.3%) 0 (0%) 2 (8.0%) 2 (7.7%) c Gastrointestinal disorder 2 (2.6%) 1 (4.0%) 1 (4.0%) 0 (0%) c Pneumonia 1 (1.3%) 1 (4.0%) 0 (0%) 0 (0%) c Empyema 1 (1.3%) 0 (0%) 1 (4.0%) 0 (0%) c Grade 3 or higher complication 2 (2.6%) 1 (4.0%) 1 (4.0%) 0 (0%) c Nakanishi, Ann Thorac Surg 2014;97:980 6

92 VATS for Stage 2 or greater Group A ( ) Group B ( ) Group C ( ) Variable Total (n =76) n = 25 n = 25 n = 26 p Value Perioperative outcome Operative time (min) 327( ) 393 ( ) 314 ( ) 296 ( ) b Blood loss (ml) 138 (6 1500) 255 ( ) 104 (20 427) 104 (6 493) b Conversion 2 (2.6%) 2 (8.0%) 0 (0%) 0 (0%) c Transfusion 2 (2.6%) 2 (8.0%) 0 (0%) 0 (0%) c Complete resection (R0) 70 (92.1%) 23 (92.0%) 24 (96.0%) 23 (88.5%) c Chest tube duration 1 (1 117) 2 (1 42) 1 (1 117) 1 (1 18) b (days) Hospital stay (days) 14 (5 201) 19 (7 201) 14 (6 117) 9 (5 64) b Hospital mortality 2 (2.6%) 1 (4.0%) 1 (4.0%) 0 (0%) c Recurrence: distant/local 19 (25.0%)/11 (14.5%) 5 (20%)/5 (20%) 6 (24%)/3 (12%) 8 (31%)/3 (12%) c Nakanishi, Ann Thorac Surg 2014;97:980 6

93 VATS for Stage 2 or greater Group A ( ) Group B ( ) Group C ( ) Variable Total (n = 76) n = 25 n = 25 n = 26 p Value Operative procedures Lobectomy 53 (69.7%) b 15 (60.0%) 20 (80.0%) 18 (69.2%) e Bilobectomy 11 (14.5%) 3 (12.0%) 4 (16.0%) 4 (15.4%) Pneumonectomy 12 (15.8%) c 7 (28.0%) 1 (4.0%) 4 (15.4%) Nodes resected 16 (1 33) 17 (1 30) 19 (4 33) 15 (1 31) f adjacent organs 28 (36.8%) 10 (40.0%) 10 (40.0%) 8 (30.8%) e resected PA angioplasty 5 (7.9%) 3 (16.0%) 0 (0%) 2 (7.7%) e Bronchoplasty 3 (3.9%) d 0 (0%) 0 (0%) 3 (11.5%) e Bronch coverage 8 (10.5%) 1 (4.0%) 1 (4.0%) 6 (23.1%) e Nakanishi, Ann Thorac Surg 2014;97:980 6

94 Locally Advanced VATS

95 Advanced Resections 11 patients excluded for tumors with chest wall or brachial plexus invasion 125 patients undergoing lobectomy for Advanced Lung Cancer 1/1/2002-7/31/ patients in final analysis tumors 4cm any T3 or T4 tumor tumors requiring neoadjuvant chemotherapy Attempted VATS Successful 95 patients attempted VATS Thoracotomy Conversion rate = 23% Converted Hennon, Ann Surg Oncol (2011) 18: patients VATS 22 patients Conversion 19 patients Open

96 Advanced VATS Resections- Survival Overall Disease-free Hennon, Ann Surg Oncol (2011) 18: tumors 4cm any T3 or T4 tumor tumors requiring neoadjuvant chemotherapy

97 Advanced resections Stage III (7 th Ed) Survivals OS DFS

98 RPCI Local Advanced Ann Surg Oncol (2011) 18:

RPCI Local Advanced Characteristic VATS (n = 95) Open (n = 19) P value Operative, median (range) EBL (ml) 200 (20 1600) 150 (50 1000) 0.3667 Time (min) 231 (96 574) 202 (105 317) 0.

99 RPCI Local Advanced Characteristic VATS (n = 95) Open (n = 19) P value Operative, median (range) EBL (ml) 200 ( ) 150 ( ) Time (min) 231 (96 574) 202 ( ) Length of stay (days), median (range) ICU 1 (0 23) 1 (1 7) Hospital 4 (2 30) 5 (3 21) Adjuvant treatment Patients, n (%) 35 (37.2) 1 (5.3) Time to start (days) 49.5 (29 83) 45 (45) Complication, n (%) Arrhythmia 17 (17.9) 4 (21.1) Transfusion 12 (16) 14 (34.1) Empyema 3 (3.2) 1 (5.3) Pneumonia 21 (22.1) 4 (21.1) Myocardial infarction 3 (3.2) Prolonged air leak 17 (17.9) 1 (5.3) Bronchopleural fistula 1 (1.1) Death 1 (1.1) Any complication 37 (38.9) 7 (36.8) Ann Surg Oncol (2011) 18: VATS video-assisted thoracoscopic surgery, EBL estimated blood loss, ICU intensive care unit

100 RPCI Local Advanced UPDATE

101 RPCI Local Advanced UPDATE

102 RPCI Local Advanced UPDATE VATS (n=224) Conversion (n=55) Open (n=37) p value Age (year) Sex (M/F) 116/108 28/27 18/ Preop comorbidities DM 44 (19.6%) 13 (23.6%) 4 (10.8%) 0.11 CAD/MI 74 (33.0%) 11 (20.0%) 8 (21.6%) < 0.05 CHF 14 (6.3%) 5 (9.1%) HTN 117 (52.2%) 36 (65.5%) 17 (45.9%) 0.05 CKD 15 (6.7%) 1 (1.8%) 0 < 0.05 DVT/PE 9 (4.0%) 0 1 (2.7%) 0.16 COPD 77 (34.4%) 17 (30.9%) 7 (18.9%) 0.07 Other malignancy 67 (29.9%) 21 (38.2%) 10 (27.0%) 0.15

103 RPCI Local Advanced UPDATE VATS (n=224) Conversion (n=55) Open (n=37) p value Pulmonary function FEV1 (%) DLCO (%) Neoadjuvant 95 (42.4%) 18 (32.7%) 21 (56.8%) < 0.05 Chemotherapy 74 (33.0%) 14 (25.5%) 11 (29.7%) 0.19 Chemoradiation 21 (9.4%) 4 (7.3%) 10 (27.0%) < 0.01

104 RPCI Local Advanced UPDATE VATS (n=224) Conversion (n=55) Open (n=37) p value Preoperative stage IB 52 (23.2%) 7 (12.7%) 7 (18.9%) 0.08 IIA 39 (17.4%) 13 (23.6%) 3 (8.1%) 0.06 IIB 49 (21.9%) 9 (16.4%) 9 (24.3%) 0.21 IIIA 73 (32.6%) 22 (40.0%) 15 (40.5%) 0.16 IIIB 2 (0.9%) 2 (3.6%) 1 (2.7%) 0.11 IV 9 (4.0%) 2 (3.6%) 2 (5.4%) 0.31 Pathologic stage IA 32 (14.3%) 2 (3.6%) 3 (8.1%) < 0.05 IB 72 (32.1%) 8 (14.5%) 11 (29.7%) < 0.05 IIA 44 (19.6%) 22 (40.0%) 4 (10.8%) < IIB 38 (17.0%) 8 (14.5%) 8 (21.6%) 0.24 IIIA 29 (12.9%) 11 (20.0%) 9 (24.3%) 0.05 IIIB 0 2 (3.6%) 0 < 0.01 IV 9 (4.0%) 2 (3.6%) 2 (5.4%) 0.31

105 RPCI Local Advanced UPDATE VATS (n=224) Conversion (n=55) Open (n=37) p value Cancer type Adenocarcinoma 110 (49.1%) 28 (50.9%) 18 (48.6%) 0.33 Squamous cell carcinoma 79 (35.3%) 20 (36.4%) 12 (32.4%) 0.32 Large cell carcinoma 11 (49.1%) 1 (1.8%) 2 (5.4%) 0.21 Others 24 (10.7%) 6 (10.9%) 5 (13.5%) 0.30 Size of tumor (cm)

106 RPCI Local Advanced UPDATE VATS (n=224) Conversion (n=55) Open (n=37) p value Operative data EBL (ml) < OR time (min) < 0.01 Enbloc resection 42 (18.8%) 10 (18.2%) 15 (40.5%) < 0.01 Sublobar resection 23 (10.3%) 3 (5.5%) 4 (10.8%) 0.19 Bilobectomy 6 (2.7%) 1 (1.8%) 2 (5.4%) 0.21 Chest wall 8 (3.6%) 4 (7.3%) 9 (24.3%) < Adjacent structure 5 (2.2%) 2 (3.6%) R1 resection 9 (4.0%) 5 (9.1%) 0 < 0.05 Bronchial margin 6 (2.7%) 3 (5.5%) Pleura / chest wall 2 (0.9%) 1 (1.8%) Pericardium/mediastinum 1 (0.4%) 1 (1.8%) R2 resection 1 (0.4%) 1 (1.8%) 1 (3.4%) 0.12 Total LNs Positive LNs < 0.01

107 RPCI Local Advanced VATS (n=224) UPDATE Conversion (n=55) Open (n=37) p value Length of days Ventilation ICU Hospital < 0.05 Complications Arrhythmia 44 (19.6%) 12 (21.8%) 10 (27.0%) 0.21 Bleeding 13 (5.8%) 13 (23.6%) 6 (16.2%) < Empyema 4 (1.8%) 2 (3.6%) 3 (8.1%) < 0.05 Pneumonia 23 (10.3%) 16 (29.1%) 6 (16.2%) < Air leak 26 (11.6%) 6 (10.9%) 4 (10.8%) 0.34 MI 2 (8.9%) 1 (1.8%) Periop death 2 (8.9%) 1 (1.8%) 1 (2.7%) 0.22 BPF 2 (8.9%) 0 2 (5.4%) < 0.05 Re-operation 4 (1.8%) 2 (3.6%) 7 (18.9%) < Others 40 (17.9%) 17 (30.9%) 12 (32.4%) < 0.05

108 RPCI Local Advanced UPDATE VATS (n=224) Conversion (n=55) Open (n=37) p value Adjuvant therapy Chemotherapy 81 (36.2%) 22 (40.0%) 10 (27.0%) 0.16 Chemoradiation 10 (4.5%) 6 (10.9%) 3 (8.1%) 0.07 Radiation therapy 9 (4.0%) 1 (1.8%) Time to start (days) Postoperative outcomes Distal metastasis 38 (17.0%) 15 (27.3%) 11 (29.7%) < 0.05 Brain 24 (10.7%) 6 (10.9%) 5 (13.5%) 0.30 Spine 6 (2.7%) 3 (5.5%) 2 (5.4%) 0.17 Others 8 (3.6%) 6 (10.9%) 4 (10.8%) < 0.05 Recurrence 63 (28.1%) 22 (40.0%) 15 (40.5%) < 0.05 Overall survival (mon) Disease-free survival (mon) < 0.001

109 Conclusions Thoracoscopic locally advanced resections are feasible and arise from ongoing acquisition of MIS skills As minimally invasive reliability rates rise, differences with open oncologic quality metrics may fall. Relative benefits over open, possibly shorter operations still requires study.

110

Thoracoscopic Lobectomy for Locally Advanced Lung Cancer. Todd L. Demmy

Thoracoscopic Lobectomy for Locally Advanced Lung Cancer Todd L. Demmy 5/13/15 No Disclosures Objectives Define Locally Advanced Advanced Min Inv results Review technical pearls Videos What is Locally