Complex Thoracoscopic Resections for Locally Advanced Lung Cancer

Complex Thoracoscopic Resections for Locally Advanced Lung Cancer Duke Thoracoscopic Lobectomy Workshop March 21, 2018 Thomas A. D Amico MD Gary Hock Professor of Surgery Section Chief, Thoracic Surgery, Duke University Medical Center Chief Medical Officer, Duke Comprehensive Cancer Institute

Consultant for Scanlan Disclosure No conflicts related to this presentation

Thoracoscopic Lobectomy is Associated with Lower Morbidity Compared to Thoracotomy Villamizar N, et al. J Thorac Cardiovasc Surg 2009; 138: 419-425 J Thorac Cardiovasc Surg 2009; 138: 419-425 Feature Thoracotomy (n=284) VATS (n=284) P At least 1 Cx 49% 31% 0.0001 Atrial Fibrillation 21% 13% 0.01 Atelectasis 12% 5% 0.006 Prolonged air leak 19% 13% 0.05 Pneumonia 10% 5% 0.05 Transfusion 13% 4% 0.02 Renal Failure 5% 1% 0.02 Cx = complication

J Thorac Cardiovasc Surg 2010: 139:366-78 Postoperative Complication Thoracotomy (n=1281) Thoracoscopy (n=1281) P Value* At least 1 Cx 35% 25% <0.0001* All Cardiovascular 13% 8% 0.0002* Atrial Arrhythmia 12% 7% 0.0004* All Pulmonary 12% 7% 0.0001* Reintubation 3% 1% 0.0046* Transfusion 5% 2% 0.0028* Cx = complication

Ann Cardiothorac Surg 2012: 1: 16-23 Meta-analysis of 3 studies with propensity matching Villamizar N, et al. J Thorac Cardiovasc Surg 2009; 138: 419 Paul S, et al et al. J Thorac Cardiovasc Surg: 2010; 139: 366 Ilonen IK et al. Acta Oncologic 2011; 50: 1126

Un-matched Relative Risk of Perioperative Morbidity Matched

Un-matched Relative Risk of All Cause Mortality Matched

A National Analysis of Long-term Survival Following Thoracoscopic vs Open Lobectomy for Stage I Non-small Cell Lung Cancer Chi-Fu Jeffrey Yang, Arvind Kumar, Jacob Klapper, Matthew Hartwig, Betty C. Tong, David Harpole, Mark Berry, Thomas A. D Amico Annals of Surgery (In Press)

A National Analysis of Long-term Survival Following Thoracoscopic vs Open Lobectomy for Stage I Non-small Cell Lung Cancer Outcomes of open vs VATS lobectomy for clinical T1-2N0M0 NSCLC in the NCDB 7,114: patients Open; 5,566 (78%) VATS: 1,548 (22%) Propensity-score matching resulted in 2 groups of patients who were well-matched by 11 common prognostic co-variates 1,464 open and 1,464 VATS

A National Analysis of Long-term Survival Following Thoracoscopic vs Open Lobectomy for Stage I Non-small Cell Lung Cancer VATS approach was associated with a shorter LOS (5 vs 6 d, p<0.001) and better 5-year survival (66.0% vs 62.5%, p=0.026) No differences in 30-day readmission rate or nodal upstaging Propensity-matched analysis: no significant differences in 5-year survival between the VATS and open groups (66.3% vs 65.8%, p=0.92)

Complex Thoracoscopic Resections Larger tumors, central tumors, N1 Lobectomy with chest wall resection Sleeve resections Pneumonectomy Lobectomy after induction therapy

Impact of T Status and N Status on Outcomes after Thoracoscopic J Thorac Cardiovasc Surg 2013;145:514-21 Lobectomy for Lung Cancer Thoracoscopic Lobectomy: 2000-2010 Total:1195 Peripheral, 3cm, and Clinical N0 329 Central tumor, or > 3 cm tumor, or Clinical N1-N3 504

75 Trends Over Time % Total Cases 50 25 Central > 3 cm Node Positive 0 1998 2000 2002 2004 2006 2008 2010 2012 Year

Risk Factors for Morbidity Complications: incidence is not related to Central location Tumor size >3cm Clinical node status Conversions Not higher for central tumors or for tumors > 3cm Higher for clinically node positive disease cn0 3.3% cn1-n3 7.2% p=0.03

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

Posterior Approach

Feasibility Of Hybrid Thoracoscopic Lobectomy And En Bloc Chest Wall Resection Eur J Cardiothorac Surg 2011; 41: 888-892 78 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

Open (n=68) Data VATS-Hybrid (n=10) Age 58.5±12.0 63.4±12.2 # ribs resected 3.2±1.1 2.6±1.1 Chest tube duration 4.4±1.6 4.3±1.5 Hospital stay 12.5±18.6 6.1±3.6 Overall morbidity 41 (60%) 4 (40%) Technical complications 23 (34%) 3 (30%) Respiratory complications 22 (32%) 2 (20%) Cardiovascular complications 20 (29%) 1 (10%) Peri-Op death 2 (3.4%) 0

Bronchoplastic Thoracoscopic Resections Safe, feasible, practiced by many surgeons Reasonable to conclude that it is oncologically equivalent to thoracotomy Is likely associated with the same outcome advantages as with thoracoscopic lobectomy, as compared to thoracotomy (not yet studied)

Performing Sleeve Lobectomy Instead of Pneumonectomy for Non-Small Lung Cancer with N1 Nodal Disease Does Not Compromise Long- Term Survival Mark F. Berry MD, Mathias Worni MD MHS, Xiaofei Wang PhD, David H. Harpole MD, Thomas A. D Amico MD, Mark W. Onaitis MD Ann Thorac Surg 2013; 97: 230-235

Recurrences Pneumonectomy (n=52) Sleeve Lobectomy (n=35) p Distant 9 (26%) 13 (25%) 1 Local/Regional 5 (10%) 9 (26%) 0.07 Local Recurrences after Sleeve Resection 6 in mediastinal lymph nodes 2 in the ipsilateral hilum 1 in the distal bronchus

65% 3-year survival p=0.23 47% 3-year survival Pneumonectomy 52 37 27 20 13 11 Sleeve Resection 35 26 20 16 13 11

The picture can't be displayed. Thoracoscopic Lobectomy: Safe and Effective Strategy After Induction Therapy Petersen RP, D Amico TA. Ann Thorac Surg 2006; 82:214-219 Outcomes (N=97) 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) 1.00 4 (2-12) <0.001 5 (2-63) <0.01 4 (5) 0.44 1 (1) 0.10 8 (9) 0.27 2 (2) 0.59 10 (12) 0.21

Long-term Survival Following Lobectomy After Induction Therapy for NSCLC: VATS Approach Does Not Compromise Outcomes 273 patients: lobectomy after induction chemo: 70 (26%) VATS and 203 (74%) thoracotomy Compared to thoracotomy patients, VATS pts Higher stage (p=0.03) Older (p<0.001) Greater BMI (p=0.01) More CAD (p=0.008) More COPD (p=0.02) Induction RT more common in open patients

Long-term Survival Following Lobectomy After Induction Therapy for NSCLC: VATS Approach Does Not Compromise Outcomes Perioperative mortality similar between the VATS (3%) and open (4%) groups (p=0.67) 7 (2.6%) converted to thoracotomy due to bleeding (n=2) or difficulty in dissection of fibrotic tissue, adhesions (n=5) None of these conversions led to perioperative deaths

Lobectomy After Induction Therapy: VATS Approach Does Not Compromise Outcomes Univariate analysis: VATS patients had improved 3-year survival compared with thoracotomy (61% vs 43%; p=0.008) Multivariable analysis: VATS approach was associated with improved overall survival (p=0.04)

Overall Survival Stratified by Surgical Approach VATS 61% Thoracotomy 43% p = 0.01

Propensity-Matched Survival Stratified by Surgical Approach VATS 36.3% Thoracotomy 30.2% p = 0.56

Thoracoscopic Pneumonectomy Introduced with the demonstration of feasibility without the demonstration of advantages (unlike thoracoscopic lobectomy) Outcome advantages QOL, complications, compliance with adjuvant chemo are inferred Experience thus far is not as convincing as for VATS lobectomy regarding safety and efficacy

Thoracoscopic Pneumonectomy Potential Criticisms 1. Safety: inability to manage bleeding 2. Efficacy: inability to determine is sleeve lobectomy is feasible

Does Thoracoscopic Pneumonectomy for Lung Cancer Affect Survival? Nwogu CE, et al. Ann Thorac Surg 2010;89:2102-2106 Pneumonectomy for malignancy (2002-08) 70 patients: VATS 24, Open 35, Conversions 8 Complication rates similar among all 3 groups VATS: shorter LOS and less blood loss vs Open Conversion pts: longer LOS and more blood loss 30-day mortality: 1 death in VATS and open groups

Thoracoscopic Pneumonectomy: Duke 23 patients underwent attempted VATS pneumonectomy; 17 (73.9%) were completed VATS and 6 required conversion to thoracotomy There were no peri-operative mortalities Conversions were more likely to have CAD, DM, CHF, poorer pulmonary function and to have received induction chemotherapy or previous thoracic surgery

Thoracoscopic Pneumonectomy Reasons for Conversion (n=6) Anatomical hilar dissection not amenable to VATS (n=4) Pulmonary artery bleeding (n=1) Adhesions (n=1)

Thoracoscopic Pneumonectomy Outcome of Conversion: Higher blood loss (p = 0.001) VATS Open Conversions EBL (ml) 200 250 1275

Thoracoscopic Pneumonectomy Compared to 44 matched thoracotomy patients: VATS patients had shorter hospital stay (median LOS = 4 vs. 5 days, p < 0.01) Operative time, morbidity, and mortality were not significantly different Adjuvant chemotherapy was started sooner in VATS patients No differences in short or long term survival

CHEST 2014; 146(5): 1300-1309 107 consecutive pneumonectomies 2002 to 2012 Open 40 VATS 50 Conversions 17 VATS cohort had more pre-op comorbidities and were older (65 years vs 63 years, P =0.07) C-stage lower for VATS (26% vs 50% stage III, P= 0.035) P-stage was similar (25% vs 38%, P = 0.77)

CHEST 2014; 146(5): 1300-1309 VATS approach yielded similar complications with no catastrophic intraoperative bleeding Successful VATS rates rose from 50%-82% by the 2nd half of the series (P =0.001) Completion pneumonectomy cases (13.4% VATS, 7.5% open) had similar outcomes

CHEST 2014; 146(5): 1300-1309 No difference in early pain among 3 groups More patients undergoing VATS were pain-free at 1 year (53% vs 19%, P= 0.03) Conversions: longer ICU (4 vs 2 days, P= 0.01) Median survival stage I-II VATS Open Conversions 80 m 28 m 16 m

CHEST 2014; 146(5): 1300-1309

Multicenter Study of Open vs VATS Pneumonectomy for Lung Cancer 3 Institutions 401 patients VATS 155 (39%) Open 246 (61%)

Thoracoscopic Extended Resections Feasible Safe Adhere to the principle of conversion whenever patient safety or oncologic standards would be compromised

11 th Annual Masters in Minimally Invasive Thoracic Surgery September 21-22, 2018 Waldorf Astoria Orlando, Florida endo.surgery.duke.edu/courses