Pulmonary laser resections: Technical aspects and results in colorectal cancer
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1 Pulmonary laser resections: Technical aspects and results in colorectal cancer Bernward Passlick Professor of Thoracic Surgery Dept. of Thoracic Surgery University of Freiburg Germany
2 Pulmonary laser resections 1. Background 2. Significance of R0 resections 3. Laser technique 4. Results 5. Conclusions
3 Colorectal Cancer Lung: Second most site of metastases 20% will have pulmonary metastases after curative resection (Germany: >5000/year) Untreated: 5-year survival <5 % Phil et al., 1987 Van Schaik et al., 2009 Pfannschmidt et al., 2003 Murata et al., 1998 Mitry et al., 2010
4 Curative resection of lung metastases: Prognostic factors Type of primary tumor Disease free interval Number of metastases Completeness of resection International Registry of Lung metastases 1997; n= 5206 patients
5 Curative resection of lung metastases: Significance of different prognostic factors Multivariate Analysis of prognostic factors after pulmonary metastasectomy (n=575) Prognostic factors HR p-value R0 vs. R < Histology (Melanoma vs. Epithelial) 3.26 < DFI (</> 36 months) Sex, Age, number of metastases, type of surgery, uni- vs. bilateral, nodal status not significant Casiraghi M. et al., JTO, 2011; 6; 1373
6 Curative resection of lung metastases: Prognostic factors Unchangeable factors: Type of primary tumor Disease free interval Can be influenced: Number of metastases which are resectable Completeness of resection
7 Technique of pulmonary metastasectomy: Peripheral Metastases Klinik und Poliklinik für Allgemein- Viszeral- und Thoraxchirurgie Wedge resection: VATS or Thoracotomy
8 Technique of pulmonary metastasectomy: Central Metastases Anatomical resection? Dissection? Breast cancer: Metastases in the left upper lobe
9 Technique of pulmonary metastasectomy: Multiple peripheral metastases (Colon Cancer)
10 Surgery for lung metastases Operative Techniques Wedge (Atypical-) resection Anatomical resection: - Segmentectomy, Lobectomy, Pneumonectomy Dissection of the lung tissue: - Ultrasound dissection - Electro cauterization - Laser dissection
11 Technical Improvement of Pulmonary Laser Surgery Standard Nd:YAG-Laser Modification of the wave length 1064 nm Modified ND:YAG-Laser 1318 nm Vaporisation and coagulation simultaneously Rolle and Eulerich, Acta Chir. Hunga., (1999)
12 Laser dissection of lung parenchyma: How does it work? Histological evaluation: Vaporisation zone Three zones: Vaporisation zone Coagulation zone (necrosis) Hyperemia zone Hyperemia zone 5 mm Coagulation zone Photo: Dept. of Pathology, University Hospital of Freiburgof Freiburg, 2009 Recommended technique for metastasectomy: 3 mm safety margin + 5 mm coagulation zone (Rolle A. et al. Ann Thorac Surg 2002, J Thorac Cardiovasc Surg 2006)
13 Curative resection of Lung Metastases: Safety Margin (Colorectal cancer) Welter,S. et al.,, J Thorac Cardiovasc Surg 2011;141:
14 Curative Resection of Lung Metastases: Innovative Laser System Limax 60/ Limax 120: 120 W or 60 W of power Diode pumped Nd:YAG-Laser Integrated smoke evacuator Integrated gas flow Simple to operate
15 Laser supported metastasectomy Right Middle Lobe Adenoid-cystic carcinoma: multiple lesions bilateral
16 Laser supported metastasectomy Germ cell tumor: presice resection, double lesion, RLL
17 Closure of a superficial defect after laser metastasectomy Right Middle lobe Germ cell tumor: multiple lesions
18 Closure of a deep defect after laser metastasectomy Right Lower lobe Germ cell tumor: multiple lesions
19 Laser supported metastasectomy Radiological findings 3 weeks after right sided Laser supported metastasectomy
20 Postoperative Complications (initial series): Conventional (n=239) vs. Laser-supported Technique (n=61) Chest drain >7d Redrainage Pneumonia Empyema Others Mortality Wedge, anatomical n= % 7 2.9% 6 2.5% 3 1.3% % 0 Laser assisted n= % 1 1.6% % 1 1.6% 4 6.6% 0 p value Antibiotics (Cefuroxim) for 3 days postoperatively
21 How many metastases can/should be resected? Variables: Location of the metastases Type of Primary tumor (i.e. breast cancer sarcoma) Lung function Co-morbidity Surgical technique
22 Correlation between the number of metastases and completeness of resections (Renal cell carcinoma) Laser metastasectomy Murthy et al. Ann. Thorac. Surg., 2005; 79, 996
23 Lung metastases at the University of Freiburg: Spectrum of primary tumors: (n=555) 4% 4% 2% colorectal carcinoma 5% renal cell carcinoma 6% 5% 7% 38% melanoma breast cancer sarkoma head and neck carcinoma lung cancer ovarian/endometrial/cervical 7% bone tumors germ c ell t umors 8% 14% thyroid cancer
24 Laser supported resection of lung metastases in colorectal cancer patients Freiburg data : 211 patients with lung metastases from colorectal cances - 75 with/136 without Laser support Thoracotomy/ 22 VATS Unilateral/ 75 Bilateral
25 Laser supported resection of lung metastases in colorectal cancer patients Freiburg data Laser supported (n=75) Standrad resections (n=136) Number of metastases resected (mean) Median Survival (months)
26 Laser supported resection of lung metastases in colorectal cancer patients Freiburg data
27 Colorectal cancer Systematic Review: 51 publications Publications Number of patients 5 year survival Single lung metastases Multiple lung metastases % % CEA normal % CEA elevated % Fiorentina, F., et al.: J R Soc Med., 2010:103, 60-66
28 Pulmonary laser resections of lung metastases Conclusions R0 resection is the most important prognostic factor in pulmonary metastasectomy Laser supported resections seem to be a good tool to provide resectability even with multiple or centrally located lesions The morbidity is not significantly influenced
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