VAMLA/TEMLA. Todd L. Demmy

Transcription

1 VAMLA/TEMLA Todd L. Demmy

2 Disclosures/ Questions

3 Objectives - Staging Learn new lymphadenectomy (LA) results: Video-Assisted Mediastinal (VAMLA) Transcervical Extended Mediastinal (TEMLA) Compare with existing techniques in initial and restaging scenarios

4 Mediastinoscopy

5 VideoMed vs Traditional Med p=0.006 p= % 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Conventional Bleeding Vocal cord palsy Video p= Nodes Found Nodes Left Conventional Video Ann Thorac Surg 2011;92:

6 Wolf Scope VAMLA

7 Linder-Hürtgen Scope

8 VAMLA

9 VAMS/ VAMLA Result 8.7 grams (2 to 23.7 grams). Positive N2/N3 (32.8%) Operation time 54.1 minutes (40 to 175) Nine complications (3.98%) 1 R and 4 L recurrent laryngeal nerve palsies 2 azygos vein lacerations 1 mediastinitis 1 aortic arch bleeding (N=186) Ann Thorac Surg 2006;82:1821 7

10 VAMLA (N=144) Discovery of N2-N3 130 cases went to thoracotomy Sensitivity 100% Specificity 94% False Neg 0.9% Ann Thorac Surg 2006;82:1821 7

11 Effect on Right VATS Lobectomy European Journal of Cardio-thoracic Surgery 35 (2009)

12 Effect on Left VATS Lobectomy European Journal of Cardio-thoracic Surgery 35 (2009)

13 VAMLA - Turkey VAMLA N=44 Nodes 8.4 Complications 11.3% Video Med N=113 Nodes 7.6 (p=0.001) Complications 2.6% (p=0.04) Sensitivity and NPV better Sayar, Gen Thor and CV Surg 2011:59(12)

14 VAMLA - Turkey N status Med_scopy (n=344) VAMLA (n=89) p-value N0, no. (%) 288 (83.7) 53 (59.6) N2-3, no. (%) 56 (16.2) 36 (40.4) <.001 Specificity Sensitivity False-negative value Negative predictive value Accuracy Turna, J Thorac Cardiovasc Surg

15 VAMLA - Turkey Turna, J Thorac Cardiovasc Surg

16 VAMLA - Turkey Turna, J Thorac Cardiovasc Surg

17 VAMLA & ECM Affected Staging in 78% Sensitivity 94% Specificity 100% NPV 96% Witte, European Journal of Cardio-Thoracic Surgery (2013) 1 6 doi: /ejcts/ezt313

18 VAMLA + Extended Mediastinoscopy Suspect Left Sided Lung Cancer N=110 False False Neg Neg VAMLA ECM Witte, European Journal of Cardio-Thoracic Surgery (2013) 1 6 doi: /ejcts/ezt313

19 TEMLA - Technique 5-8cm collar incision Elevation sternum Nerves visualization All nodal stations except: J Thorac Oncol. 2007;2:

20 Retractor System RUL - Tract

21 TEMLA Setup

22 TEMLA Setup

23 TEMLA Setup

24 NIM Monitoring

25 TEMLA Zielinski Semin Thoracic Surg 22: /3

26 TEMLA Zielinski Semin Thoracic Surg 22: /3

27 PM Case 5/2013 VATS Chest Wall Resection 83 y.o male Carcinosarcoma

28 TEMLA 01:35 Zielinski Semin Thoracic Surg 22: /2

29 TEMLA 01:15 Zielinski Semin Thoracic Surg 22:

30 TEMLA 02:21 Zielinski Semin Thoracic Surg 22:

31 TEMLA Zielinski Semin Thoracic Surg 22:

32 TEMLA Zielinski Semin Thoracic Surg 22:

33 TEMLA Result (N=256) 39 nodes/case (15-85) Positive N2 (31.3%) 138 thoracotomies 5 Missed N2 Mean 24 month followup Only one locoregional recurrence 77% survival if TEMLA negative J Thorac Oncol. 2007;2:

34 TEMLA (N=698) All cases Discovery of N2-N3 Sensitivity 96.2% Specificity 100% Accuracy 99% Neg Pred Value 98.7% 445 thoracotomies after 513 negative Missed N2 in 7 (1.6%) 128 minutes (45-330) 0.7% mortality 6.6% morbidity Laryngeal nerve palsy temp/perm (2.3/0.8%) Pneumonol Alergol Pol. 2011;79(3):

35 EBUS (N=226) Confirmed by TEMLA if Negative All cases Sensitivity 89% Specificity 100% Accuracy 92.9% PPV 100% Neg Pred Value 83.5% 16 positive TEMLA of 97 Negative EBUS cases Level 7-27% of 118 nodes 4L - 24% of 34 nodes 4R - 48% of 50 nodes 5-42% of 38 nodes 6 2 of 4 nodes Eur J Cardio-thoracic Surg 35 (2009)

36 Primary Staging TEMLA EBUS/EUS 623 Patients (%) TEMLA 276 Patients (%) p Sensitivity < 0.01 Specificity NPV < 0.01 PPV Prevalence < 0.01 Zielinski, J Thorac Oncol. 2013;8: )

37 Restaging TEMLA EBUS/EUS 105 Patients (%) TEMLA 78 Patients (%) p Sensitivity < 0.01 Specificity NPV < 0.01 PPV Prevalence < 0.01 Zielinski, J Thorac Oncol. 2013;8: )

38 Imprint Cytology Speeds TEMLA Jakubiak, European Journal of Cardio-Thoracic Surgery 43 (2013)

39 RPCI TEMLA N = 100 April 2009 Sept 2012 Mean age 66 Histology 38 (58.5%) Adeno 20 (30.8%) Squamous Median Hospital - 5 Median ICU - 1

40 RPCI TEMLA N = 100 Neoadjuvant chemo 55% Neoadjuvant chemorad 15% Anatomic resection Lobectomy 81.5% Pneumonectomy 7.7% Duration 115±30 min

41 RPCI TEMLA Stage Data N=100 Clinical Stage No. (%) I 3 (4.6%) II 15 (23.1%) IIIA 33 (50.8%) IIIB 6(5.2%) IV 8 (12.3%)

42 RPCI TEMLA N=100 No vascular complications Recurrent laryngeal nerve injury 3% Average 17 nodes N2 18.5% N3 4.6% Of 3 patients inaccurately classified by TEMLA, only 1 had N2 in TEMLA Accessible Nodes.

43 RPCI TEMLA N=100 N2 detection PET/CT (%) TEMLA (%) p Sensitivity Specificity PPV NPV Accuracy < 0.05

44 TEMLA/VAMLA Caveat Can create hilar fibrosis that can affect dissection later

45 Summary 1 Mediastinoscopy is safe and effective for many lung cancer scenarios but not always applied Current preference Confirmation of Nodal Status before resection in medium risk noninduction patients (+/- EBUS)

46 Summary 2 TEMLA/VAMLA Preferences (1) Induction patients: EBUS for staging, Then Chemo +/- XRT Then TEMLA/VAMLA at time of resection VATS for the Level 5,6 modes (2) Unfavorable biology patients

47 TEMLA/VAMLA Conclusions Stages patients better than thoracotomybased approaches Enhances dissection and its extra time is offset by limiting VATS lymphadenectomy Therapeutic for some tumors???

48 TEMLA improves Bronchial Mobility 01:31

49

50 Diagnostic yield of the largest reported series of restaging of NSCLC. De Waele et al. Marra et al. Herth et al. Cerfolio et al. Zielin ski et al. True positive (TP) True negative (TN) False positive (FP) False negative (FN) Overall Sensitivity (confidence intervals) (0.65, 0.72) (0.52, 0.61) (0.74, 0.77) (0.50, 0.71) (0.87, 0.96) Negative predictive value (NPV) (0.69, 0.73) (0.81, 0.85) (0.13, 0.20) (0.50, 0.71) (0.93, 0.98) Eur J Cardiothorac Surg (2009), doi: /j.ejcts

51 TEMLA Setup

52 TEMLA Setup

53 TEMLA Setup

54 RPCI TEMLA First 18/59 Concomitant operations VATS Lobe 8 Vats bilobe 2 Open lobe 2 None 2 VATS Lobe with chest wall 1 Open lobe with chest wall 1 Thoracotomy exploration 1 Pneumonectomy 1

55 RPCI TEMLA First 18/59 Complications none 10 afib 1 otitis 1 bleeding 1 pneumonia/ards 2 air leak 1 bipap 1 confusion 1

56 RPCI TEMLA First 18/59 Indications 1 N1 disease 3 Tumors > 6cm 2 Chest wall 1 Downstaged IIIB 1 Metastatic thyroid 1 Multiple lung nodules 1 T2 central 1 Indications 2 Downstaged IIIA 1 Diffuse PET avidity 1 N2 disease 1 Two primaries 1 T3 1 T4 1 Brain met/t3 1 Neoadjuvant Brain met 1

57 RPCI TEMLA Last 18/59 Node Number Node Weight (g) Station Median Range Station Median Range 2R L R L R L R L

58 TEMLA (N=21) vs. Med. (N= 20) Discovery of N2-N3 Cervical Mediastinoscopy Sensitivity 38% Neg Pred Value 67% TEMLA Sensitivity 100% Neg Pred Value 100% p = European Journal of Cardiothoracic Surgery 31 (2007) 88-94