Lungebevarende resektioner ved lungecancer metode og resultater

Transcription

1 Dept. of Cardiothoracic Surgery Lungebevarende resektioner ved lungecancer metode og resultater Henrik Jessen Hansen Dept. of Cardiothoracic Surgery RT 2152, The National University Hospital. Copenhagen, Denmark University of Copenhagen 1

2 Does this really need a lobectomy, University of Copenhagen 2

3 Årsrapporten 2004, University of Copenhagen 3

4 Årsrapporten 2017, University of Copenhagen 4

5 30 dages dødelighed ved forskellige kirurgi typer, University of Copenhagen 5

6 Sleeve lobectomy, University of Copenhagen 6

7 Bronkial sleeve af ve. hovedbronkus, University of Copenhagen 7

8 Current status Lobectomy is the golden standard Pneumonectomy is associated with high mortality and morbidity Sleeve lobectomy is an attractive alternative in central tumors Much interest about sublobar resections, University of Copenhagen 8

9 Resections in the age of screening, University of Copenhagen 9

10 What is the natural history of subsolid nodules?, University of Copenhagen 10

11 What management? WR = wedge resection, Seg= Segmental Resection, Lob = Lobectomy, University of Copenhagen 11

12 Questions to sublobar resection The type of resection Is it oncologically equel Is there a patient benefit in parenchyma sparring resections, University of Copenhagen 12

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14 RCT LOBECTOMY VS SUBLOBAR RESECTION LUNG CANCER STUDY GROUP TRIAL (1995) Ginsberg et al, Ann Thorac Surg 1995;60: , University of Copenhagen 14

15 RCT LOBECTOMY VS SUBLOBAR RESECTION LUNG CANCER STUDY GROUP TRIAL (1995) Ginsberg et al, Ann Thorac Surg 1995;60: , University of Copenhagen 15

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17 Sublobar resections for lung cancer? We do have a good and well documented procedure VATS Lobectomy Sublobar resections a bad idea end of show But Let us have a look at the paper, University of Copenhagen 17

18 , University of Copenhagen 18

19 , University of Copenhagen 19

20 8th edition Every cm counts, University of Copenhagen 20

21 , University of Copenhagen 21

22 Subsolid nodules: Lobectomy or sublobar resection?, University of Copenhagen 22

23 JAPANESE CLASSIFICATION OF SUBSOLID NODULES: 3 CATEGORIES, University of Copenhagen 23

24 , University of Copenhagen 24

25 Lymph node metastasis in clinical stage IA peripheral lung cancer CONCLUSIONS: The rate of metastasis to the lymph nodes is very low in clinical stage IA peripheral lung cancer patients. Patients with a dominant GGO component on CT might be the suitable candidates for lung segmentectomy because of almost no lymph node metastasis. Careful selection should be made for the patients with tumor size 2cm who had metastasized nodes in non-tumor bearing segment when considering segmentectomy. If the resected tumor had micropapillary or solid component, the lobectomy might be considered. Wang L et al. Lung Cancer Oct;90(1):41-6.

26 Early/small adeno-carcinoma and sublobar resections, University of Copenhagen 26

27 , University of Copenhagen 27

28 2015 VATS anatomical lung resection profile - Copenhagen, University of Copenhagen 28

29 Lingula sparring lobectomy

30 Histology NSCLC 55 NSCLC + former lobe 18 Carcinoid 6 Metastatic 95 Benign 13, University of Copenhagen 30

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32 DATABASE STUDY

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34 Ungoing studies CALGB JCOG0802/WJOG4607L, University of Copenhagen 34

35 Lung segmentectomy: does it offer a real functional benefit over lobectomy? Anatomical segmentectomy has been implemented to offer better pulmonary function preservation than lobectomy. the assumption that reducing the resected lung volume may enhance the possibility of further resections in the case of a second primary lung cancer has provided an additional substantial incentive to perform segmentectomy. the development of this procedure was the intent to propose surgical treatment to patients with impaired lung function. Indeed, based on early published studies, the use of segmentectomy in these patients was recommended as an alternative to lobectomy by several task forces, University of Copenhagen 35

36 Lung segmentectomy: does it offer a real functional benefit over lobectomy? Questions: How big is the loss of function in reality - both postoperatively and over time Improvement over time Method of surgery: Open or VATS Number of segments to be resected What about patients with poor preoperative lung function Does the differences have any clinical impact, University of Copenhagen 36

37 , University of Copenhagen 37

38 , University of Copenhagen 38

39 when evaluating the difference between lobectomy and segmentectomy, the delay after surgery should be considered. Within 2 months after surgery, the mean loss of FEV1 ranged from 17% to 29% of initial value after lobectomy (mean 25%) and from 9% to 24% after segmentectomy (mean 18%) Beyond 12 months, the mean FEV1 loss ranged from 8% to 13% of initial value after lobectomy (mean 11%) and from 2% to 7% after segmentectomy (mean 5%) Within 2 months after surgery, the difference between lobectomy and segmentectomy was 3 10% of initial FEV1, whereas after 12 months, this difference ranged from 4% to 7% of initial FEV1, University of Copenhagen 39

40 Lung segmentectomy: does it offer a real functional benefit over lobectomy? Conclusions The published studies show that the long-term reduction ( 12 months) in lung function induced by segmentectomy is very small, and a little smaller than that induced by lobectomy. However, this tiny difference may benefit lung cancer patients who may need subsequent lung resections. Within the 2 months after surgery, lung function reduction is mild to moderate, but also a little smaller than that induced by lobectomy. However, PFT monitoring within the early days after VATS segmentectomy, days that are critical determinants of post-operative morbidity, needs to be assessed. Two issues remain to be addressed: whether VATS segmentectomy may preserve lung function better than VATS lobectomy in patients with poor lung function, and whether this may translate into a lowering of the functional limit for surgery, University of Copenhagen 40

41 Avoid pneumonectomies if possible Use sleeve resections VATS lobectomy should be the surgery of choice by early stage NSCLC and sufficient lung function Wait to the randomized studies are published on segments Wedge resection is a NO GO, University of Copenhagen 41

42 VATS segmentectomies is a acceptable option in patients with NSCLC and: poor lung function older than 70 with several small lesions in different lobes GGO The lesion has to be < 2cm and the free margin > than the lesion Both N1 and N2 lymph nodes has to be removed according to guidelines., University of Copenhagen 42

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