Thoracoscopic Lobectomy for Locally Advanced Lung Cancer. Masters of Minimally Invasive Thoracic Surgery Orlando September 19, 2014

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1 for Locally Advanced Lung Cancer Masters of Minimally Invasive Thoracic Surgery Orlando September 19, 2014 Thomas A. D Amico MD Gary Hock Endowed Professor and Vice Chair of Surgery Chief Thoracic Surgery Chief Medical Officer, Duke Cancer Institute

2 Disclosures No conflicts of interest related to this presentation

3 Cancer Mortality in the US Siegel R, Ma J, Zou Z, Jemal A. CA Cancer J Clin 2014;64:9 29 Site Deaths 1. Lung 160, Colon/Rectum 50, Breast 40, Pancreas 39, Prostate 29, ,810

4 Site Cancer Mortality in the US Siegel R, Ma J, Zou Z, Jemal A. CA Cancer J Clin 2014;64:9 29 Deaths 1. Lung 160, Colon/Rectum 2:150, Breast 4:140, Pancreas 4:139, Prostate 29,480 5:1 159,810

5 Lung Cancer in Non-Smokers Siegel R, Naishadham D, Jemal A. CA Cancer J Clin 2012;62:10-29 Site Deaths 1. Colon/Rectum 51, Breast 39, Pancreas 37, Lung cancer, non-smokers 30,000

6 Critical Outcome Advantages of 1. Fewer complications 2. Better compliance with adjuvant therapy 3. High-risk patients: physiologic and oncologic

7 J Thorac Cardiovasc Surg 2010: 139: Postoperative Complication Thoracotomy (n=1281) Thoracoscopy (n=1281) P Value* At least 1 Cx 35% 25% <0.0001* All Cardiovascular 13% 8% * Atrial Arrhythmia 12% 7% * All Pulmonary 12% 7% * Reintubation 3% 1% * Transfusion 5% 2% *

8 J Thorac Cardiovasc Surg 2010: 139: Postoperative Complication Thoracotomy (n=1281) Thoracoscopy (n=1281) P Value* At least 1 Cx 35% 25% <0.0001* All Cardiovascular 13% 8% * Atrial Arrhythmia 12% 7% * All Pulmonary 12% 7% * Reintubation 3% 1% * Transfusion 5% 2% *

9 Fewer Complications Result From VATS Approach To Resection Of Clinical Stage I Lung Cancer Boffa DJ et al JTCVS 2014: 148: 637 STS database queried for lobectomy for stage I lung cancer ,531 (7137 open and 4394 VATS) patients Propensity scoring: 2745 well-balanced pairs Overall complications were significantly more likely in the thoracotomy group (36%) than in the VATS cohort (30%; P <.001)

10 Fewer Complications Result From VATS Approach To Resection Of Clinical Stage I Lung Cancer Boffa DJ et al JTCVS 2014: 148: 637 Patients undergoing thoracotomy experienced significantly more pulmonary complications (21% vs 18%) atrial arrhythmias (13% vs 10%) transfusion (6% vs 4%) Operative mortality was similar (thoracotomy 1.8%, VATS 1.3%; P =.13)

11 in the Elderly High Risk Under 70 Poor PFT n=207 (22%) Over 70 Poor PFT n=135 (14%) Low Risk n=398 (42%) Over 70 Good PFT n=203 (22%)

12 Risk Factors For Morbidity After Lobectomy For Lung Cancer In Elderly Patients Berry MF, et al Ann Thorac Surg 2009; 88: Morbidity HR p value Age Thoracotomy Thoracotomy VATS p At least 1 Cx 64% 39% A-fib 28% 18% 0.04 Respiratory Cx 12% 5% 0.03 Transfusion 16% 7% 0.01 Delirium 13% 5% 0.03

13 Risk Factors For Morbidity After Lobectomy For Lung Cancer In Elderly Patients Berry MF, et al Ann Thorac Surg 2009; 88: Morbidity HR p value VATS is associated with fewer overall and Age specific complications in the elderly Thoracotomy The use of VATS Thoracotomy is twice as important VATS as age p At least 1 Cx 64% 39% in predicting complications A-fib 28% 18% 0.04 Respiratory Cx 12% 5% 0.03 Transfusion 16% 7% 0.01 Delirium 13% 5% 0.03

14 with Poor PFTs High Risk Under 70 Poor PFT n=207 (22%) Over 70 Poor PFT n=135 (14%) Low Risk n=398 (42%) Over 70 Good PFT n=203 (22%)

15 Percent Pulmonary Cx Pulmonary Complications Thoracotomy n=8439 Thoracoscopy n= Ceppa DP, et al. Ann Surg 2012;256:487-93

16 Percent Pulmonary Complications Pulmonary Complications by FEV1 FEV1 <60, p=0.02 * * Thoracotomy n=8439 Thoracoscopy n= * Ceppa DP, FEV1 et al. Ann predicted Surg 2012;256: (range)

17 Percent Pulmonary Complications Pulmonary Complications by FEV1 FEV1 <60, p=0.02 Thoracotomy n=8439 Thoracoscopy n=4531 VATS is associated with fewer overall and * * specific pulmonary complications 10 5 The use * of VATS is even more important in those with compromised pulmonary function Ceppa DP, FEV1 et al. Ann predicted Surg 2012;256: (range)

18 Facilitates the Delivery of Adjuvant Chemotherapy Petersen R, et al. Ann Thorac Surg 2007; 83: Ann Thorac Surg 2007; 83: patients: Lobectomy + Adjuvant Chemo Thoracotomy N=43 Thoracoscopic N=57 p-value Any delayed chemo doses 58% 18% <0.001 Any reduced chemo doses 49% 26% % of planned regimen 40% 61% 0.03

19 21 comparative studies: 2 randomized Morbidity, mortality, recurrence, 5-year mortality

20 Systematic Review and Meta-Analysis of Randomized and Nonrandomized Trials on Safety and Efficacy of VATS Lobectomy VATS Lobectomy No significant difference in locoregional recurrence (P= 0.24) Reduced systemic recurrence rate (P=0.03) Improved 5-year mortality rate (P =0.04)

21 All-Cause Mortality

22 Ann Cardiothorac Surg 2012: 1: Meta-analysis of 3 studies with propensity matching 1. Villamizar N, et al. J Thorac Cardiovasc Surg 2009; 138: Paul S, et al. J Thorac Cardiovasc Surg: 2010; 139: Ilonen IK et al. Acta Oncologic 2011; 50: 1126

23 Un-matched Relative Risk of Perioperative Morbidity Matched

24 Un-matched Relative Risk of All Cause Mortality Matched

25 Thoracoscopic Approach To Lobectomy For Lung Cancer Does Not Compromise Oncologic Efficacy Berry MF, D'Amico TA, et al. Ann Thorac Surg 2014 (in press) 1087 patients: 610 VATS, 477 thoracotomy Multivariable analysis, worse survival associated: 1. Pathologic stage (HR 1.45/stage, p<0.0001) 2. Thoracotomy approach (HR 1.22, p=0.01) 3. Increasing age (HR 1.02 per year, p<0.0001)

26 Survival of all patients by operative approach

27 Thoracoscopic Approach To Lobectomy For Lung Cancer Does Not Compromise Oncologic Efficacy Berry MF, D'Amico TA, et al. Ann Thorac Surg 2014 (in press) In a propensity matched cohort of 560 patients (311 VATS, 249 thoracotomy), worse survival associated with Increasing age (HR 1.02 per year, p=0.01) Pathologic stage (HR 1.44, p<0.0001) Male gender (HR 1.29, p=0.01)

28 Survival of propensity matched patients by operative approach

29 Number and % of Pulmonary Resections 4000 STS Database: % 42.8% * 5/ Thoracoscopy Series2 Thoracotomy Series1 39.7% % 45% % <10% 17.4% % 8.0% % % 26.2% Year Ceppa DP, et al. Ann Surg 2012;256:487-93

30 Advanced Procedures Larger tumors Lobectomy after induction therapy Chest wall resection Pneumonectomy Sleeve resection

31 Impact of T Status and N Status on Outcomes after Thoracoscopic J Thorac Cardiovasc Surg 2013;145: Lobectomy for Lung Cancer : Total:1195 Peripheral, 3cm, and Clinical N0 329 Central tumor, or > 3 cm tumor, or Clinical N1-N3 504

32 % Total Cases Trends Over Time Central > 3 cm Node Positive Year

33 Risk Factors for Morbidity Complications: incidence is not related to Central location Tumor size >3cm Clinical node status Conversions Not higher for central tumors or for tumors > 3cm Higher for clinically node positive disease cn0 3.3% cn1-n3 7.2% p=0.03

34 Hybrid Approach to Chest Wall Tumors Thoracoscopic hilar dissection and ligation Small counter incision centered over lesion Chest wall resection and specimen removal Advantages Smaller incision overall Precise dissection No rib spreading No scapular retraction/rotation

35 Posterior Approach

36 Posterior Approach

37 Feasibility Of Hybrid Thoracoscopic Lobectomy And En Bloc Chest Wall Resection Eur J Cardiothorac Surg 2011; 41: patients: lobectomy and chest wall resection 68 patients: resection via thoracotomy 10 patients: hybrid thoracoscopic approach Pre-op, peri-op, and outcome variables assessed using standard descriptive statistics All patients underwent complete resection with negative margins

38 Open (n=68) Data VATS-Hybrid (n=10) Age 58.5± ±12.2 # ribs resected 3.2± ±1.1 Chest tube duration 4.4± ±1.5 Hospital stay 12.5± ±3.6 Overall morbidity 41 (60%) 4 (40%) Technical complications 23 (34%) 3 (30%) Respiratory complications 22 (32%) 2 (20%) Cardiovascular complications 20 (29%) 1 (10%) Peri-Op death 2 (3.4%) 0

39 : Safe and Effective Strategy After Induction Therapy Petersen RP, D Amico TA. Ann Thorac Surg 2006; 82: Outcomes (N=97) Complete Resection Chest tube duration LOS 30-Day mortality Hemorrhage Pneumonia Respiratory failure Atrial fibrillation VATS N=12 (%) 12 (100) 2 (2-3) 3 (2-6) 0 (0) 1 (8) 0 (0) 0 (0) 0 (0) Thoracotomy N=85 (%) p-value 85 (100) (2-12) < (2-63) < (5) (1) (9) (2) (12) 0.21

40 60 month Overall Survival

41 Oncologically equivalent to open lobectomy Perhaps superior (compliance with adjuvant chemo) More differentially beneficial than any other minimally invasive procedure vs open alternative Advantages in safety and quality of life Even more advantageous for complex patients (high-risk) and complex resections (locally advanced disease)

42 Video 56 yo woman with progressive shortness of breath CT: Thoracoscopic tumor Lobectomy left upper lobe/distal left main bronchus

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