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

Transcription

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

2 5/13/15 No Disclosures

3 Objectives Define Locally Advanced Advanced Min Inv results Review technical pearls Videos

4 What is Locally Advanced? Procedural Definition Pneumonectomy Sleeve Lobectomy Chest Wall Resection Advanced exposure

5 What is Locally Advanced? Anatomic Definition 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

6 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

7 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

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

9 Duke Series After Preoperative Chemo Propensity Matched Yang, European Journal of Cardio-Thoracic Surgery (2015) 1 9

10 MSK Series Preoperative Chemo Park, J Thorac Dis 2016;8(Suppl 4):S406-S413

11 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 5.4 (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.

12 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

13 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

14 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

15 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

16 Locally Advanced VATS

17 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

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

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

20 RPCI Local Advanced UPDATE

21 RPCI Local Advanced UPDATE

22 RPCI Local Advanced VATS (n=224) UPDATE 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

23 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

24 RPCI Local Advanced UPDATE

25 RPCI Local Advanced UPDATE VATS (n=224) Conversio n (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)

26 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

27 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) < Path Stage > 1 62% 92% 54%

28 Visualization Tools High Definition ANGLED Optimal Endocameleon

29 Visualization Tools 5 mm Optimal For Sharing ports

30 Common 3D Systems today Viking ConMed.com Olympus ENDOEYE Flex 3D Laparoscopy bbraun.com

31 Importance of Low Profile and Angles

32 Multiple retractors 00:26

33 Lymph Node Grasping No Grasp - Metal Endoscopic Sucker -- Liu et al. BMC Surgery (2015) 15:38

34 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:

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

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

37 PA control - Bulldogs

38 PA control - Bulldogs Dong, J Thorac Dis 2014;6(12):

39 PA control - Bulldogs Dong, J Thorac Dis 2014;6(12):

40 PA control - Bulldogs Dong, J Thorac Dis 2014;6(12):

41 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)

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

43 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

44 Exposure Problems Vessel Access 00:20

45 Left Lower Lobe

46 Left Lower Lobe

47 Bronchoplasty

48 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).

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

50 Complete VATS Sleeve Ref N EBL Deaths Complications (ml) Time Hosp Stay Nakanishi, Mahtabifard, / Li, Yu, Wang, Shao, Huang(He),

51 Complete VATS Sleeve Ref N Technique Nakanishi, Interrupted + Running Mahtabifard (Mckenna) Interrupted 000 Vicryl Li, running memb, inter cart Yu, Interrupted switched to running Wang, incision, 3.0 prolene running Shao, Running Prolene Huang(He), Prolene, running memb, inter cart

52 VATS Sleeve He Team - GuangzhouUniversity Lobe Number RUL 59 RML 7 RLL 8 LUL 34 LLL 10 Huang (He), J Thorac Dis 2016;8(3):

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

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

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

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

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

58 Uniportal Sleeve Review Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6 i16

59 Uniportal Sleeve Review Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6 i16

60 Diego-Rivas, European Journal of Cardio- Thoracic Surgery 49 (2016) i6 i16

61 Uniportal Sleeve Review Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6 i16

62 Diego-Rivas, European Journal of Cardio- Thoracic Surgery 49 (2016) i6 i16

63 Carinal Resection RUL Sleeve Lin, J Thorac Dis 2015;7(10):

64 Carinal Resection RUL Sleeve Squamous cell Lin, J Thorac Dis 2015;7(10):

65 TiKnot Device

66 V-loc Device

67 LUL Sleeve Lobectomy 2:30

68 Traction Sutures Xu, J Thorac Dis 2013;5(S3):S298-S300.

69 Double Sleeve Liu, European Journal of Cardio-Thoracic Surgery 46 (2014)

70 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

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

72 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

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

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

75 Case Presentation LUL Chest Wall Invasion After Chemo Before Chemo

76 Case Presentation LUL Chest Wall Invasion 0:26 0:26

77 Methods Retrospective Analysis 47 chest wall resections VATS, 30 open Subgroup 31 patients with NSCLC 15 VATS, 16 open Hennon, Ann Thorac Surg Jun;99(6):

78 Similar Pathology and Stage Distribution VATS Open IIIB IB IV IB IIIA IIIA IIB IIB Hennon, Ann Thorac Surg Jun;99(6):

79 Percent Similar Pulmonary Function FEV1 DLCO VATS Open

80 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) Hennon, Ann Thorac Surg Jun;99(6):

81 Wider Age Range for VATS Hennon, Ann Thorac Surg Jun;99(6):

82 Variable (median) ICU (days) In Hospital (days) Reconstruction with Patch Results VATS (n=15) Open (n=16) p-value % 56.3% Neoadjuvant Chemo or ChemoRT 66.7% 62.5% Day Mortality/Major Morbidity 53.3% 87.5% Hennon, Ann Thorac Surg Jun;99(6):

83 Less Variation for VATS Despite Older Patients Pneumonectomy Neuro? Other Emergency Colon ischemia Hennon, Ann Thorac Surg Jun;99(6):

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

85 Body Wall Anchoring Carter-Thomason Needle

86 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

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

88 VATS Brachytherapy Pract Radiat Oncol May 7. pii: S (16) doi: /j.prro

89 VATS Brachytherapy Video

90 VATS Brachytherapy Video

91

92 Troubleshooting Guide Ann Thorac Surg 2005;79:

93 Troubleshooting Guide

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

95 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:

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

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

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

99 Case Presentation RLL Chest Wall Invasion

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

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

102 VATS Pneumonectomy Longer Persistance of Severe and Moderate Pain for Open Pneumonectomy Patients might relate to survival Chest Nov;146(5):

103 Survival Chest Nov;146(5): May benefit advanced stages (ITT Analysis) Conversions in early pathologic stage may reduce VATS benefits