Pulmonary laser resections: Technical aspects and results in colorectal cancer Bernward Passlick Professor of Thoracic Surgery Dept. of Thoracic Surgery University of Freiburg Germany
Pulmonary laser resections 1. Background 2. Significance of R0 resections 3. Laser technique 4. Results 5. Conclusions
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
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
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. R1 2.49 < 0.0001 Histology (Melanoma vs. Epithelial) 3.26 < 0.0001 DFI (</> 36 months) 0.60 0.01 Sex, Age, number of metastases, type of surgery, uni- vs. bilateral, nodal status not significant Casiraghi M. et al., JTO, 2011; 6; 1373
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
Technique of pulmonary metastasectomy: Peripheral Metastases Klinik und Poliklinik für Allgemein- Viszeral- und Thoraxchirurgie Wedge resection: VATS or Thoracotomy
Technique of pulmonary metastasectomy: Central Metastases Anatomical resection? Dissection? Breast cancer: Metastases in the left upper lobe
Technique of pulmonary metastasectomy: Multiple peripheral metastases (Colon Cancer)
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
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., 38 115-7 (1999)
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)
Curative resection of Lung Metastases: Safety Margin (Colorectal cancer) Welter,S. et al.,, J Thorac Cardiovasc Surg 2011;141:1218-22
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
Laser supported metastasectomy Right Middle Lobe Adenoid-cystic carcinoma: multiple lesions bilateral
Laser supported metastasectomy Germ cell tumor: presice resection, double lesion, RLL
Closure of a superficial defect after laser metastasectomy Right Middle lobe Germ cell tumor: multiple lesions
Closure of a deep defect after laser metastasectomy Right Lower lobe Germ cell tumor: multiple lesions
Laser supported metastasectomy Radiological findings 3 weeks after right sided Laser supported metastasectomy
Postoperative Complications (initial series): Conventional (n=239) vs. Laser-supported Technique (n=61) Chest drain >7d Redrainage Pneumonia Empyema Others Mortality Wedge, anatomical n=239 3 1.3% 7 2.9% 6 2.5% 3 1.3% 27 11.3% 0 Laser assisted n=61 0 0.0% 1 1.6% 7 11.5% 1 1.6% 4 6.6% 0 p value 0.38 0.58 0.02 0.82 0.28 Antibiotics (Cefuroxim) for 3 days postoperatively
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
Correlation between the number of metastases and completeness of resections (Renal cell carcinoma) Laser metastasectomy Murthy et al. Ann. Thorac. Surg., 2005; 79, 996
Lung metastases at the University of Freiburg: Spectrum of primary tumors: 2008-2014 (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
Laser supported resection of lung metastases in colorectal cancer patients Freiburg data - 2008-14: 211 patients with lung metastases from colorectal cances - 75 with/136 without Laser support - 189 Thoracotomy/ 22 VATS - 138 Unilateral/ 75 Bilateral
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) 7.5 3.5 57 56
Laser supported resection of lung metastases in colorectal cancer patients Freiburg data
Colorectal cancer Systematic Review: 51 publications Publications Number of patients 5 year survival Single lung metastases Multiple lung metastases 25 2227 54% 15 1516 37% CEA normal 11 1159 43% CEA elevated 11 1159 22% Fiorentina, F., et al.: J R Soc Med., 2010:103, 60-66
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