VATS Lobectomy an Alternative Technique for Early Stage Lung ...

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VATS Lobectomy an Alternative Technique for Early Stage Lung ...

  1. 1. VATS Lobectomy an Alternative Technique for Early Stage Lung Cancer Michael F. Gibson, MD FACS South Carolina Cardiovascular Surgery October 1, 2008
  2. 2. Lung Carcinoma <ul><li>Lung Cancer remains a fatal disease </li></ul><ul><ul><li>The overall 5 year survival is 10-13% and has not changed significantly over the past 20 years </li></ul></ul><ul><ul><li>The TNM classification is used for staging </li></ul></ul><ul><ul><ul><li>In 1997 changes were made to the TNM system to better stratify prognoses </li></ul></ul></ul><ul><ul><ul><li>Only 25% of patients will have early stage lung cancer at time of diagnosis </li></ul></ul></ul><ul><ul><li>NSCLC accounts for 80% of lung cancer </li></ul></ul><ul><ul><li>It is the most common cancer cause of death in men and women </li></ul></ul><ul><ul><li>185,000 new cases per year </li></ul></ul>
  3. 3. Lung Cancer <ul><li>Clinical Presentation </li></ul><ul><ul><ul><li>Due to primary tumor </li></ul></ul></ul><ul><ul><ul><ul><li>cough, hemoptysis, wheeze, stridor, dyspnea, post-obstructive pneumonia, pain from invasion </li></ul></ul></ul></ul><ul><ul><ul><li>Due to regional spread of tumor </li></ul></ul></ul><ul><ul><ul><ul><li>Tracheal compression, dysphagia, RLN palsy, Phrenic nerve palsy, SVC syndrome, Horner’s syndrome, Pancoast syndrome, effusion, tamponade </li></ul></ul></ul></ul><ul><ul><ul><li>Due to metastatic spread </li></ul></ul></ul><ul><ul><ul><ul><li>Bone pain, adrenal insufficiency, CNS symptoms </li></ul></ul></ul></ul><ul><ul><ul><li>Paraneoplastic syndromes </li></ul></ul></ul>
  4. 4. Lung Cancer <ul><li>Diagnosis and work up for solitary lung nodule > 1cm </li></ul><ul><ul><li>History and Physical </li></ul></ul><ul><ul><ul><li>Smoking >10 yrs </li></ul></ul></ul><ul><ul><ul><li>Asbestosis exposure </li></ul></ul></ul><ul><ul><ul><li>COPD </li></ul></ul></ul><ul><ul><ul><li>History of prior maligacy </li></ul></ul></ul><ul><ul><li>CXR </li></ul></ul><ul><ul><ul><li>Review all old films with in 2 years </li></ul></ul></ul><ul><ul><ul><li>No change in size likely to be benign </li></ul></ul></ul><ul><ul><li>CT of Chest and Abdomen </li></ul></ul><ul><ul><ul><li>Anotomical location of tumor </li></ul></ul></ul><ul><ul><ul><li>Mediastinal structures and lymph nodes (>1cm) </li></ul></ul></ul><ul><ul><li>Pulmonary function test </li></ul></ul><ul><ul><ul><li>FEV1 – 40% of predicted </li></ul></ul></ul><ul><ul><li>PET – metastatic w/u and staging </li></ul></ul><ul><li>CT of Head, Bone scan </li></ul><ul><ul><li>MRI </li></ul></ul><ul><li>Preop cardiac evaluation per ACC guidelines </li></ul>
  5. 5. Pulmonary Function for Thoracic Surgery <ul><li>Pulmonary resections lead to a permanent loss of pulmonary function </li></ul><ul><ul><ul><li>The definition of “resectability” can be different under different circumstances </li></ul></ul></ul><ul><ul><ul><li>There have been a nmber of improvements in anesthesia and ICU care that may allow resections in previously unresectable pts </li></ul></ul></ul><ul><ul><ul><li>What are the real numbers? </li></ul></ul></ul>
  6. 6. Pulmonary Function for Thoracic Surgery <ul><li>Spirometry </li></ul><ul><ul><li>Gaensler in 1955 suggested vital capacity >2L be present before resection </li></ul></ul><ul><ul><li>Suggested parameters for FEV1 have varied from 1.5 - 1.75L for lobectomy and >2L for pneumonectomy </li></ul></ul><ul><ul><li>Miller recently suggested: </li></ul></ul><ul><ul><ul><li>FEV1 > 2L for lung > 1L for lobe > 0.6L for wedge </li></ul></ul></ul><ul><ul><li>A number of reports suggest that % is more accurate </li></ul></ul><ul><ul><ul><li>Mittman suggested FEV1 be greater than 70% </li></ul></ul></ul><ul><ul><ul><li>Nagasaki and Pate, FEV1 be greater than 40% </li></ul></ul></ul><ul><ul><li>DLCO of < 50-60% is suggested for “major resection” </li></ul></ul><ul><ul><li>ABG’s are also used: </li></ul></ul><ul><ul><ul><li>PaO2 < 50 is associated with increased risk </li></ul></ul></ul><ul><ul><ul><li>PaCO2 > 50 is also associated with increased risk </li></ul></ul></ul>
  7. 7. Lung Cancer <ul><li>Diagnosis </li></ul><ul><ul><li>Sputum cytology </li></ul></ul><ul><ul><li>Bronchoscopy </li></ul></ul><ul><ul><ul><li>Biopsy, washings, Transbronchial needle biopsy, BAL </li></ul></ul></ul><ul><ul><li>CT guided Transthoracic FNA </li></ul></ul><ul><ul><ul><li>Inability to determine a specific benign diagnosis in 80% </li></ul></ul></ul><ul><ul><ul><li>Inconclusive diagonosis </li></ul></ul></ul><ul><ul><ul><ul><li>Further investigation ( biopsy) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Radiologic follow-up </li></ul></ul></ul></ul><ul><ul><li>VATS wedge resection </li></ul></ul><ul><ul><ul><li>Most common used technique </li></ul></ul></ul><ul><ul><ul><li>Avoids traditional thoracotomy </li></ul></ul></ul><ul><ul><ul><li>45% - 70% nodules are malignant </li></ul></ul></ul><ul><ul><ul><ul><li>Proceed with anatomical resection </li></ul></ul></ul></ul><ul><ul><li>Mediastinoscopy </li></ul></ul><ul><ul><ul><li>Staging </li></ul></ul></ul>
  8. 8. Lung Cancer <ul><li>Pathology </li></ul><ul><ul><li>Squamous Cell Ca 30-35% </li></ul></ul><ul><ul><li>Adenocarcinoma 30-35% </li></ul></ul><ul><ul><ul><li>Bronchoalveolar Carcinoma </li></ul></ul></ul><ul><ul><li>Large Cell CA 25% </li></ul></ul><ul><ul><li>Small Cell Carcinoma 15-20% </li></ul></ul><ul><ul><li>Carcinoid 1-2% </li></ul></ul>
  9. 9. Lung Cancer <ul><li>Stage Grouping </li></ul><ul><ul><li>Stage TNM Subset % 5yr survival Clinical/Pathologic </li></ul></ul><ul><ul><li>Stage 0 CIS </li></ul></ul><ul><ul><li>Stage IA T1N0M0 61 / 67 </li></ul></ul><ul><ul><li>Stage IB T2N0M0 38 / 57 </li></ul></ul><ul><ul><li>Stage IIA T1N1M0 34 / 55 </li></ul></ul><ul><ul><li>Stage IIB T2N0M0 24 / 39 </li></ul></ul><ul><ul><li>T3N0M0 22 / 38 </li></ul></ul><ul><ul><li>Stage IIIA T3N1M0 9 / 25 </li></ul></ul><ul><ul><li>T1N2M0 </li></ul></ul><ul><ul><li>T2N2M0 13 / 23 </li></ul></ul><ul><ul><li>T3N2M0 </li></ul></ul><ul><ul><li>Stage IIIB T4N0M0 5 </li></ul></ul><ul><ul><li>T4N1M0 </li></ul></ul><ul><ul><li>T4N2M0 </li></ul></ul><ul><ul><li>T1-T4N3M0 </li></ul></ul><ul><ul><li>Stage IV Any T Any N M1 <1 </li></ul></ul>
  10. 10. Lung Cancer <ul><li>Staging System </li></ul><ul><ul><li>Tx Tumor can not be assesed, but tumor present </li></ul></ul><ul><ul><li>T0 No evidence of primary tumor </li></ul></ul><ul><ul><li>Tis Carcinoma is situ </li></ul></ul><ul><ul><li>T1 <3cm, surrounded by lung or visceral pleura, not in main bronchus </li></ul></ul><ul><ul><li>T2 >3cm, involves main bronchus >2cm more distal to carina, invades visceral pleura, associated with atelectasis or obstructive pneumonitis extending to hilus </li></ul></ul><ul><ul><li>T3 Any size that directly invades the following: chest wall (including superior sulcus), diaphragm, mediastinal pleura, parietal pericardium, <2cm from the carina but not invading the carina, or associated atelectasis/obstructive pneumonitis involving the entire lung </li></ul></ul><ul><ul><li>T4 Any size that directly invades the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina, malignant pleural or pericardial effusion, or satellite tumor nodule within the ipsilateral primary tumor of the lung </li></ul></ul><ul><ul><li>Nx Regional nodes can not be evaluated </li></ul></ul><ul><ul><li>N0 No regional node metastasis </li></ul></ul><ul><ul><li>N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar nodes, intrapulmonary nodes </li></ul></ul><ul><ul><li>N2 Metastasis to ipsilateral mediastinal and/or subcarinal nodes </li></ul></ul><ul><ul><li>N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene or supraclavicular nodes </li></ul></ul><ul><ul><li>Mx Metastasis can not be assessed </li></ul></ul><ul><ul><li>M0 No distant metastasis </li></ul></ul><ul><ul><li>M1 Distant metastasis present </li></ul></ul>
  11. 11. Lung Cancer <ul><li>Lymph Node Map (Naruki) </li></ul><ul><li>N2 Nodes (all N2 nodes lie within the mediastinal pleural envelope) </li></ul><ul><li>1 Highest Mediastinal Above the upper rim of the brachiocephalic v. </li></ul><ul><li>2 Upper Paratracheal Above upper Ao and below brachiocephalic v. </li></ul><ul><li>3 Pre & Retrotracheal 3A and 3P </li></ul><ul><li>4 Lower Paratracheal Right: between upper margin of Ao & main bronc </li></ul><ul><li>Left: between upper margin of Ao & main bronc </li></ul><ul><li>5 Subaortic (A-P Wind) Lateral to ligamentum & prox to 1st LPA branch </li></ul><ul><li>6 Para-aortic Anterior and lateral to the ascending Ao </li></ul><ul><li>7 Subcarinal Caudal to the carina </li></ul><ul><li>8 Paraesophageal Adjacent to the wall of the esophagus </li></ul><ul><li>9 Pulmonary Ligament Inferior pulmonary ligament </li></ul><ul><li>N1 Nodes (all N1 nodes are distal to the mediastinal pleural reflection) </li></ul><ul><li>10 Hilar Proximal lobar nodes </li></ul><ul><li>11 Interlobar Between lobar bronchi </li></ul><ul><li>12 Lobar Adjacent to distal lobar bronchi </li></ul><ul><li>13 Segmental Adjacent to segmental bronchi </li></ul><ul><li>14 Subsegemental Around subsegmental bronchi </li></ul>
  12. 12. Naruke Lymph Node Map
  13. 13. Thoracotomy Technique <ul><li>Standard posterior lateral thoracotomy </li></ul><ul><ul><li>Serratus spearing thoracotomy </li></ul></ul><ul><li>Shear 5 th or 6 th rib </li></ul><ul><li>Perform anatomical lung resection </li></ul><ul><li>Lymph node dissection </li></ul><ul><li>Chest tube placement and closure </li></ul>
  14. 16. Thoracotomy
  15. 17. Thoracotomy
  16. 18. Thoracotomy
  17. 19. Thoracotomy
  18. 20. Thoracotomy
  19. 21. VATS Lobectomy Technique <ul><li>Contraindications </li></ul><ul><ul><li>Intolerance of single lung ventilation </li></ul></ul><ul><ul><li>Tumor size >6cm (T2) </li></ul></ul><ul><ul><li>Significant hilar lymphadnopathy (N2) </li></ul></ul><ul><ul><li>Tumor involvement of chest or mediastinum (T3) </li></ul></ul><ul><li>Most limitations are due to anatomical considerations </li></ul>
  20. 22. VATS Lobectomy Technique <ul><li>2 cm incision 6 th ICS midclavicular line </li></ul><ul><li>5mm port site 8 th ICS midaxillary line </li></ul><ul><ul><li>30 degree scope </li></ul></ul><ul><li>Utility incision 4 cm - 6 cm </li></ul><ul><ul><li>No rib spreading (increases post op pain) </li></ul></ul><ul><li>Mediastinal lymph node dissection </li></ul><ul><li>Additional port placed post. 5 th ICS </li></ul><ul><li>CT placement and closure </li></ul>
  21. 23. VATS Lobectomy
  22. 24. VATS Lobectomy
  23. 25. VATS Lobectomy
  24. 26. Thoracotomy vs VATS
  25. 27. Why do VATS Lobectomy ? <ul><li>Hospitalization </li></ul><ul><li>Post operative Pain </li></ul><ul><li>Recovery </li></ul><ul><li>Oncologic comparison </li></ul><ul><li>CALGB 39802 (2007) </li></ul><ul><ul><li>Prospective, multi-Institutions feasibility study </li></ul></ul><ul><ul><li>127 patients </li></ul></ul><ul><ul><li>Standardized definition of VATS Lobectomy </li></ul></ul><ul><ul><li>Measured </li></ul></ul><ul><ul><ul><li>Success </li></ul></ul></ul><ul><ul><ul><li>Morbitity and mortality </li></ul></ul></ul><ul><ul><ul><li>Cancer recurrence and survival </li></ul></ul></ul>
  26. 28. Hospitalization VATS <ul><li>Shorter hospital stay </li></ul><ul><li>Shorter chest tube duration </li></ul><ul><ul><li>1-2 days </li></ul></ul><ul><li>Earlier return to full activities </li></ul><ul><li>Less pain </li></ul><ul><li>Faster recovery for high risk and frail patients </li></ul>
  27. 29. VATS Post operative pain <ul><li>Epidural less duration or no epidural </li></ul><ul><li>Less use of analgesics </li></ul><ul><li>Less sleep disturbances </li></ul><ul><li>Lower incidence of post thoracotomy pain syndrome </li></ul><ul><li>Most patients off all pain meds by POD # 7 </li></ul>
  28. 30. VATS Recovery <ul><li>POD #7, 14 studies show improved PaO2, Pox, FEV1 and FVC </li></ul><ul><li>Better 6 min walk test </li></ul><ul><li>May have short and Long term quality of life improvement </li></ul><ul><li>Quicker return to preoperative activity </li></ul><ul><ul><li>VATS 2.5 mo </li></ul></ul><ul><ul><li>Thoracotomy 7.8 mo </li></ul></ul><ul><li>Decreased shoulder dysfunction </li></ul>
  29. 31. Oncological Comparison VATS vs Thoracotomy <ul><li>No difference in lymph node dissection </li></ul><ul><li>No difference in survival curves </li></ul><ul><ul><li>Some studies report trends in increased survival </li></ul></ul><ul><ul><li>VATS approach does not compromise patient survival </li></ul></ul>
  30. 32. Survival VATS vs. Thoracotomy
  31. 33. Oncological Comparison <ul><li>VATS Survival </li></ul><ul><ul><li>McKenna, 2006 Stage I, 75% 5 yr </li></ul></ul><ul><ul><li>Solaini, 2001 Stage I, 90% 5yr </li></ul></ul><ul><ul><li>Walker, 2003 Stage I, 78% 5yr </li></ul></ul><ul><li>Port site recurrence </li></ul><ul><ul><li>Swanson ACCP, 98 0.2% </li></ul></ul>
  32. 34. Conclusion <ul><li>VATS Lobectomy is a safe procedure </li></ul><ul><li>Fewer complication </li></ul><ul><li>Proven advantages </li></ul><ul><ul><li>Small incision </li></ul></ul><ul><ul><li>Decreased pain </li></ul></ul><ul><ul><li>Decreased LOS </li></ul></ul><ul><ul><li>Decreased CT output </li></ul></ul><ul><ul><li>Decreased blood loss (transfusions) </li></ul></ul><ul><ul><li>Preservation of pulmonary function </li></ul></ul><ul><ul><li>Earlier return to normal activities </li></ul></ul><ul><li>No oncological compromise when looking at 5 year survival data </li></ul><ul><li>Evidence based medicine suggest VATS lobectomy has advantages over thoracotomy </li></ul>
  33. 35. So what does this all mean? <ul><li>Currently only 20% of lung resections are performed by VATS lobectomy world wide </li></ul><ul><li>VATS lobectomy is now part of fellowship most training programs </li></ul><ul><li>This approach is likely to become standard of care for lobectomy </li></ul><ul><li>Why not ! </li></ul>

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