T3 NSCLC: Chest Wall, Diaphragm, Mediastinum

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1 for T3 NSCLC: Chest Wall, Diaphragm, Mediastinum AATS Postgraduate Course April 29, 2012 Thomas A. D Amico MD Professor of Surgery, Chief of Thoracic Surgery Duke University Health System

2 Disclosure No conflicts related to this presentation

3 Site Cancer Mortality in the US Siegel R, Naishadham D, Jemal A. CA Cancer J Clin 2012;62: Deaths 1.Lung 160,340 2.Colon/Rectum 51,690 3.Breast 39,920 4.Pancreas 37,390 5.Prostate 28, ,170

4 Duke Approach 2 incisions: camera port + access incision (4.5 cm) No retractors, no rib spreading Anatomic hilar and mediastinal lymph node dissection Duke Approach

5 Feasibility Refinement of technique 2006-Present Demonstration of advantages Advanced techniques

6 Advanced Procedures For T3 NSCLC Larger tumors Mediastinal involvement Chest wall resection Diaphragm resection Lobectomy after induction therapy

7 Conrad Fev1 30% Duke Thoracic Oncology Program

8 Kurtz Duke Thoracic Oncology Program

9 Majette

10 CT Duke Thoracic Oncology Program

11 Debona

12 Kennedy

13 Boardwine

14 Cote, Luan

15 Hauck

16

17

18 Rosa Watson

19 Blauner

20 : T<3cm vs T>3cm Thoracoscopic lobectomy for NSCLC: 916 pts T<3cm: 622 (median 2 cm) T>3cm: 294 (median 4.3 cm; range 3-20cm) Patients with larger tumors were Older (68.1 vs 65.9 yrs) Worse pulmonary fx (FEV1 72.7% vs 75.3%)

21 : T<3cm vs T>3cm T>3cm: no difference in feasibility or morbidity Multivariable analysis predictors of morbidity: Age (odds ratio 1.06 per year, p<0.0001) FEV1 (odds ratio 1.25, p<0.0001) Prior chemotherapy (odds ratio 2.45, p=0.005) CHF (odds ratio 2.14, p=0.03)

22

23 : Safe and Effective Strategy After Induction Therapy Petersen RP, D Amico TA. Ann Thorac Surg 2006; 82: consecutive patients who underwent induction therapy followed by lobectomy 85 thoracotomy, 12 thoracoscopy

24 : Safe and Effective Strategy After Induction Therapy Petersen RP, D Amico TA. Ann Thorac Surg 2006; 82: Outcome 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) 4 (2-12) 5 (2-63) 4 (5) 1 (1) 8 (9) 2 (2) 10 (12) 1.00 <0.001 <

25 100% Kaplan-Meier Survival 75% 50% 25% 0% Median Survival (28 months overall) ---- VATS Not met Thoracotomy 24 months Months log-rank test p-value=0.64 Duke Thoracic Oncology Program

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27 Does Thoracoscopic Pneumonectomy for Lung Cancer Affect Survival? Nwogu CE, et al. Ann Thorac Surg 2010;89: Pneumonectomy for malignancy ( ) 08) 70 patients: VATS 24, Open 35, Conversions 8 VATS: shorter LOS and less blood loss Conversion pts: longer LOS and more blood loss Complication rates similar among all 3 groups 30-day mortality: 1 death in VATS and open groups

28 CT

29 Chest wall

30 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

31 Posterior Approach

32 Posterior Approach

33 Feasibility Of Hybrid Thoracoscopic Lobectomy-En Bloc Chest Wall Resection Berry MF, et al. 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

34 Data Open (n=68) 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%) Respiratory complications 22 (32%) 2 (20%) Cardiovascular complications 20 (29%) 1 (10%) Peri-Op death 2 (3.4%) 0

35 Oncologically equivalent to open lobectomy, perhaps superior (compliance with adjuvant chemo) More differentially beneficial than any other minimally invasive procedure vs open alternative Associated with fewer postoperative complications Even more advantageous for high risk patients Applicable in locally advanced disease as well

36 : The Future Higher proportion of early stage patients, which will increase based on screening trial Application to the highest risk patients: age, pulmonary function, performance status Application to patients with advanced disease: Stage II, Stage III after induction therapy

37 Masters in Minimally Invasive Thoracic Surgery September 20 22, 22, 2012 Orlando, Florida Registration/Information: endo.surgery.duke.edu/courses Co-sponsored by the American Association for Thoracic Surgery

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