thoracoscopic lobectomy for t3 nsclc: chest wall, diaphragm,...
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Thoracoscopic Lobectomy for Thoracoscopic Lobectomy for
T3 NSCLC: Chest Wall,
Diaphragm, Mediastinum
AATS Postgraduate CourseAATS Postgraduate Course
Thomas A. D’Amico MDThomas A. D’Amico MDProfessor of Surgery, Chief of Thoracic SurgeryProfessor of Surgery, Chief of Thoracic Surgery
Duke University Health SystemDuke University Health System
AATS Postgraduate CourseAATS Postgraduate Course
April 29, 2012April 29, 2012
DisclosureDisclosure
•• No conflicts related to this presentationNo conflicts related to this presentation
Thoracoscopic LobectomyThoracoscopic Lobectomy
Cancer Mortality in the USCancer Mortality in the USSiegel R, Siegel R, NaishadhamNaishadham D, D, JemalJemal A. A. CA Cancer J CA Cancer J ClinClin 2012;62:102012;62:10--2929
SiteSite DeathsDeaths
1.1.Lung Lung 160,340160,340
2.2.Colon/RectumColon/Rectum 51,69051,690
Thoracoscopic LobectomyThoracoscopic Lobectomy
2.2.Colon/RectumColon/Rectum 51,69051,690
3.3.BreastBreast 39,92039,920
4.4.PancreasPancreas 37,39037,390
5.5.ProstateProstate 28,17028,170
157,170157,170
Duke ApproachDuke Approach
Thoracoscopic LobectomyThoracoscopic LobectomyDuke ApproachDuke Approach
•2 incisions: camera port + access incision (4.5 cm)
•No retractors, no rib spreading
•Anatomic hilar and mediastinal lymph node dissection
Thoracoscopic LobectomyThoracoscopic Lobectomy
19961996--20002000 FeasibilityFeasibility
20012001--20052005 Refinement of techniqueRefinement of technique
Thoracoscopic LobectomyThoracoscopic Lobectomy
20062006--PresentPresent Demonstration of advantagesDemonstration of advantages
Advanced techniquesAdvanced techniques
Advanced Procedures For T3 NSCLCAdvanced Procedures For T3 NSCLC
•• Larger tumorsLarger tumors
•• MediastinalMediastinal involvementinvolvement
•• Chest wall resectionChest wall resection
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• Chest wall resectionChest wall resection
•• Diaphragm resectionDiaphragm resection
•• Lobectomy Lobectomy after induction therapyafter induction therapy
Conrad Fev1 30%Conrad Fev1 30%
Thoracoscopic LobectomyThoracoscopic Lobectomy Duke Thoracic Oncology ProgramDuke Thoracic Oncology Program
KurtzKurtz
Thoracoscopic LobectomyThoracoscopic Lobectomy Duke Thoracic Oncology ProgramDuke Thoracic Oncology Program
MajetteMajette
Thoracoscopic LobectomyThoracoscopic Lobectomy
CTCT
Thoracoscopic LobectomyThoracoscopic Lobectomy Duke Thoracic Oncology ProgramDuke Thoracic Oncology Program
Debona
Thoracoscopic LobectomyThoracoscopic Lobectomy
KennedyKennedy
Thoracoscopic LobectomyThoracoscopic Lobectomy
BoardwineBoardwine
Thoracoscopic LobectomyThoracoscopic Lobectomy
Cote, LuanCote, Luan
Thoracoscopic LobectomyThoracoscopic Lobectomy
HauckHauck
Thoracoscopic LobectomyThoracoscopic Lobectomy
Thoracoscopic LobectomyThoracoscopic Lobectomy
Thoracoscopic LobectomyThoracoscopic Lobectomy
Rosa Watson
Thoracoscopic LobectomyThoracoscopic Lobectomy
BlaunerBlauner
Thoracoscopic LobectomyThoracoscopic Lobectomy
Thoracoscopic Lobectomy: T<3cm Thoracoscopic Lobectomy: T<3cm vsvs
TT>>3cm3cm
•• Thoracoscopic lobectomy for NSCLC: 916 Thoracoscopic lobectomy for NSCLC: 916 ptspts
•• T<3cm: 622 (median 2 cm) T<3cm: 622 (median 2 cm)
•• TT>>3cm: 294 (median 4.3 cm; range 33cm: 294 (median 4.3 cm; range 3--20cm)20cm)
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• TT>>3cm: 294 (median 4.3 cm; range 33cm: 294 (median 4.3 cm; range 3--20cm)20cm)
•• Patients with larger tumors were Patients with larger tumors were
•• OOlder (68.1 lder (68.1 vsvs 65.9 yrs) 65.9 yrs)
•• Worse pulmonary Worse pulmonary fxfx (FEV1 72.7% (FEV1 72.7% vsvs 75.3%)75.3%)
Thoracoscopic Lobectomy: T<3cm Thoracoscopic Lobectomy: T<3cm vsvs
TT>>3cm3cm
•• TT>>3cm: no difference in feasibility or morbidity3cm: no difference in feasibility or morbidity
•• Multivariable analysis predictors of morbidity: Multivariable analysis predictors of morbidity:
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• Multivariable analysis predictors of morbidity: Multivariable analysis predictors of morbidity:
–– Age (odds ratio 1.06 per year, p<0.0001)Age (odds ratio 1.06 per year, p<0.0001)
–– FEV1 (odds ratio 1.25, p<0.0001)FEV1 (odds ratio 1.25, p<0.0001)
–– Prior chemotherapy (odds ratio 2.45, Prior chemotherapy (odds ratio 2.45,
p=0.005)p=0.005)
–– CHF (odds ratio 2.14, p=0.03)CHF (odds ratio 2.14, p=0.03)
Thoracoscopic LobectomyThoracoscopic Lobectomy
Thoracoscopic Lobectomy: Safe and Thoracoscopic Lobectomy: Safe and
Effective Strategy After Induction Therapy Effective Strategy After Induction Therapy Petersen RP, D’Amico TA. Ann Thorac Surg 2006;Petersen RP, D’Amico TA. Ann Thorac Surg 2006; 82:21482:214--219219
•• 97 consecutive patients who underwent 97 consecutive patients who underwent
induction therapy followed by lobectomyinduction therapy followed by lobectomy
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• 85 thoracotomy, 12 thoracoscopy85 thoracotomy, 12 thoracoscopy
Thoracoscopic Lobectomy: Safe and Effective Thoracoscopic Lobectomy: Safe and Effective
Strategy After Induction Therapy Strategy After Induction Therapy Petersen RP, D’Amico TA. Ann Thorac Surg 2006;Petersen RP, D’Amico TA. Ann Thorac Surg 2006; 82:21482:214--219219
OutcomeOutcome
VATSVATS
N=12 (%)N=12 (%)
ThoracotomyThoracotomy
N=85 (%)N=85 (%) pp--valuevalue
Complete ResectionComplete Resection
Chest tube durationChest tube duration
12 (100)12 (100)
2 (22 (2--3)3)
85 (100)85 (100)
4 (24 (2--12)12)
1.001.00
<0.001<0.001
Thoracoscopic LobectomyThoracoscopic Lobectomy
Chest tube durationChest tube duration
LOSLOS
3030--Day mortalityDay mortality
HemorrhageHemorrhage
PneumoniaPneumonia
Respiratory failureRespiratory failure
Atrial fibrillationAtrial fibrillation
2 (22 (2--3)3)
3 (23 (2--6)6)
0 (0)0 (0)
1 (8)1 (8)
0 (0)0 (0)
0 (0)0 (0)
0 (0)0 (0)
4 (24 (2--12)12)
5 (25 (2--63)63)
4 (5)4 (5)
1 (1)1 (1)
8 (9)8 (9)
2 (2)2 (2)
10 (12)10 (12)
<0.001<0.001
<0.01<0.01
0.440.44
0.100.10
0.270.27
0.590.59
0.210.21
100%
75%
50%
KaplanKaplan--Meier SurvivalMeier Survival
Thoracoscopic LobectomyThoracoscopic Lobectomy Duke Thoracic Oncology ProgramDuke Thoracic Oncology Program
0 5 10 15 20 25
MonthsMonths
25%
0%
log-rank test p-value=0.64
---- VATS Not met
Thoracotomy 24 months
Median Survival (28 months overall)
Thoracoscopic LobectomyThoracoscopic Lobectomy
Does Thoracoscopic Pneumonectomy for Does Thoracoscopic Pneumonectomy for
Lung Cancer Affect Survival?Lung Cancer Affect Survival?Nwogu CE, et al. Nwogu CE, et al. Ann Thorac Surg 2010;89:2102Ann Thorac Surg 2010;89:2102--21062106
•• Pneumonectomy for malignancy (2002Pneumonectomy for malignancy (2002--08)08)
•• 70 patients: VATS 24, Open 35, Conversions 870 patients: VATS 24, Open 35, Conversions 8
•• VATS: shorter LOS and lessVATS: shorter LOS and less blood lossblood loss
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• VATS: shorter LOS and lessVATS: shorter LOS and less blood lossblood loss
•• Conversion Conversion ptspts: longer LOS and more blood : longer LOS and more blood
lossloss
•• ComplicationComplication rates similar among all 3rates similar among all 3 groupsgroups
•• 3030--day mortality: 1 day mortality: 1 death in VATS death in VATS and open and open
groupsgroups
CTCT
Thoracoscopic LobectomyThoracoscopic Lobectomy
Chest wallChest wall
Thoracoscopic LobectomyThoracoscopic Lobectomy
Hybrid Approach to Chest Wall TumorsHybrid Approach to Chest Wall Tumors
•• Thoracoscopic hilar dissection and ligationThoracoscopic hilar dissection and ligation
•• Small counter incision centered over lesionSmall counter incision centered over lesion
•• Chest wall resection and specimen removal Chest wall resection and specimen removal
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• AdvantagesAdvantages
–– Smaller incision overallSmaller incision overall
–– Precise dissectionPrecise dissection
–– No rib spreading No rib spreading
–– No scapular retraction/rotatiNo scapular retraction/rotationon
Posterior ApproachPosterior Approach
Thoracoscopic LobectomyThoracoscopic Lobectomy
Posterior ApproachPosterior Approach
Thoracoscopic LobectomyThoracoscopic Lobectomy
Feasibility Of Hybrid Feasibility Of Hybrid ThoracoscopicThoracoscopic
LobectomyLobectomy--En Bloc Chest Wall Resection En Bloc Chest Wall Resection Berry MF, et al. Berry MF, et al. EurEur J J CardiothoracCardiothorac SurgSurg 2011; 41: 2011; 41: 888888--892892
•• 78 patients: lobectomy and chest wall resection78 patients: lobectomy and chest wall resection
•• 68 patients: resection via thoracotomy68 patients: resection via thoracotomy
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• 10 patients: hybrid thoracoscopic approach10 patients: hybrid thoracoscopic approach
•• PrePre--op, periop, peri--op, and outcome variables assessed op, and outcome variables assessed
using standard descriptive statisticsusing standard descriptive statistics
•• All patients underwent complete resection with All patients underwent complete resection with
negative marginsnegative margins
DataDataOpen (n=68)Open (n=68)
VATSVATS--Hybrid Hybrid
(n=10)(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
Thoracoscopic LobectomyThoracoscopic Lobectomy
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%)
Respiratory complications 22 (32%) 2 (20%)
Cardiovascular
complications20 (29%) 1 (10%)
Peri-Op death 2 (3.4%) 0
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• Oncologically equivalent to open lobectomy, Oncologically equivalent to open lobectomy,
perhaps superior (compliance with adjuvant perhaps superior (compliance with adjuvant
chemo)chemo)
•• More differentially beneficial than any other More differentially beneficial than any other
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• More differentially beneficial than any other More differentially beneficial than any other
minimally invasive procedure vs open alternativeminimally invasive procedure vs open alternative
•• Associated with fewer postoperative Associated with fewer postoperative
complicationscomplications
•• Even more advantageous for high risk patientsEven more advantageous for high risk patients
•• Applicable in locally advanced disease as wellApplicable in locally advanced disease as well
Thoracoscopic Lobectomy: The FutureThoracoscopic Lobectomy: The Future
•• Higher proportion of early stage patients, Higher proportion of early stage patients,
which will increase based on screening trialwhich will increase based on screening trial
•• Application to the highest risk patients: age, Application to the highest risk patients: age,
Thoracoscopic LobectomyThoracoscopic Lobectomy
•• Application to the highest risk patients: age, Application to the highest risk patients: age,
pulmonary function, performance statuspulmonary function, performance status
•• Application to patients with advanced Application to patients with advanced
disease: Stage II, Stage III after induction disease: Stage II, Stage III after induction
therapytherapy
Masters in Minimally Invasive Thoracic SurgeryMasters in Minimally Invasive Thoracic Surgery
September September 2020––22, 201222, 2012
OrlandoOrlando, Florida, Florida
Thoracoscopic LobectomyThoracoscopic Lobectomy
Registration/InformationRegistration/Information::
endo.surgery.duke.edu/coursesendo.surgery.duke.edu/courses
CoCo--sponsored by the American Association for Thoracic sponsored by the American Association for Thoracic
SurgerySurgery
Thoracoscopic LobectomyThoracoscopic Lobectomy
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