diagnostic thoracoscopy (vats) in lung cancer

8/14/2019 Diagnostic Thoracoscopy (VATS) in Lung Cancer

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Role ofRole of

DiagnosticDiagnosticThoracoscopy inThoracoscopy in

Lung CancerLung Cancer

managementmanagementDR L.M.DarlongDR L.M.Darlong

MS (AIIMS)MS (AIIMS)Fellow Thoracic Surg (Seoul )Fellow Thoracic Surg (Seoul )


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Lung Cancer DiagnosticTool

Sputum & Blood Analysis

Bronchoscopy & Biopsy

Bronchoscopic Brushing Bronchial Lavage

Tracheobronchial Needle

Aspiration/Biopsy Bronchoscopic /Transesophageal

USG


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Imaging TechniquesImaging Techniques

CXRCXR CECT ChestCECT Chest MRIMRI PET ScanPET Scan Monoclonal Antibody ScanMonoclonal Antibody Scan Antisense Oligonucleotides and theAntisense Oligonucleotides and the

Imagene ConceptImagene Concept Accuracy of Radiological Assesment for SPNAccuracy of Radiological Assesment for SPN

Misclassified as benign in 25% - 40% Misclassified as benign in 25% - 40%

Malignant nodulesMalignant nodules ( Gurney JW etal ,( Gurney JW etal ,Radiology 1993 )Radiology 1993 )


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Invasive TechniquesInvasive Techniques

FNAC ( CT / USG guided )

CT guided FNAC ( False ve < 22% ,inadequate 18% )

Mediastinoscopy & Mediastinotomy Scalene & Supraclavicular node Biopsy

Thoracentesis

Thoracoscopy


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History - ThoracoscopyHistory - Thoracoscopy

1920s,- Developed to facilitate1920s,- Developed to facilitate --

Drainage of PleuralDrainage of Pleural EmpyemaEmpyema --

Lysis of Tubercular adhesionLysis of Tubercular adhesion

Recent PopularityRecent Popularity -Improved-ImprovedVideo-opticsVideo-optics -Improved-Improved

instrumentationinstrumentation -Limits incisional-Limits incisional

painpain


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Diagnostic ThoracoscopyDiagnostic Thoracoscopy

Lung Cancer Lung Cancer Tissue Diagnosis under directTissue Diagnosis under direct

visionvision

Cancer StagingCancer Staging

Assesment of RessectibilityAssesment of Ressectibility


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Tissue Diagnosis LungTissue Diagnosis Lung

CancerCancer Thoracoscopy has prompted earlier referral toThoracoscopy has prompted earlier referral to

establish a diagnosisestablish a diagnosis

Indeterminate Pulmonary LesionIndeterminate Pulmonary Lesion - Failure of- Failure of

Bronchoscopy / FNABBronchoscopy / FNAB

Undefined Peripherally located lesionsUndefined Peripherally located lesions

Centrally located nodules of lower lobe -Centrally located nodules of lower lobe -

interlobar fissure extend to the stem ofinterlobar fissure extend to the stem of

pulmonary arterypulmonary artery


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Limitation Central upper lobe lesionLimitation Central upper lobe lesion

Thoracoscopic intraoperative USG Preop imagingThoracoscopic intraoperative USG Preop imagingshows lesion to be to small / too deep from pleuralshows lesion to be to small / too deep from pleuralsurfacesurface

Thoracoscopic localization of pulmonary noduleThoracoscopic localization of pulmonary noduleUSG guided 100%USG guided 100% Radio guided 80%Radio guided 80% FingerFingerPalpation 73%Palpation 73% (Davide Sortini etal 2003, A(Davide Sortini etal 2003, ASortini etal 2002 , S Motsumota etal 2004 )Sortini etal 2002 , S Motsumota etal 2004 )


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ThoracoscopicThoracoscopicFNACFNAC- Ideal for suspected small- Ideal for suspected small

PeripheralPeripheral nodulesnodules

- Avoids- AvoidsDiagnostic Wedge ExcisionDiagnostic Wedge Excision

- Lobectomy for cancer in- Lobectomy for cancer in

same sittingsame sitting - Alternative to- Alternative topreop percutaneous FNApreop percutaneous FNA


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Thoracoscopic Staging Thoracoscopic Staging

Lung CancerLung Cancer Usually performed at the time DefinitiveUsually performed at the time Definitive

treatment plannedtreatment planned

Evaluation of Pleural spaces ,Evaluation of Pleural spaces ,

Pulmonary Hilum , nodes not accessiblePulmonary Hilum , nodes not accessibleby Mediastinoscopyby Mediastinoscopy

Confirm contra lateral lung metastasisConfirm contra lateral lung metastasis

T2 Lesion which could be staged as T3T2 Lesion which could be staged as T3

on CTon CT

Confirm T status Clinical T3 or doubtfulConfirm T status Clinical T3 or doubtful

casescases


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Clinical N2 stage Inaccessible byClinical N2 stage Inaccessible by

MediastinoscopyMediastinoscopy

Carcinomas of the Lower Lobe due toCarcinomas of the Lower Lobe due to

possible invasion of nodes 8 , 9possible invasion of nodes 8 , 9( Robert etal 1999 )( Robert etal 1999 )

N0 , N1 High False Negative ratesN0 , N1 High False Negative rates

Undiagnosed Pleural effusionUndiagnosed Pleural effusion Suspected pleural metastasisSuspected pleural metastasis


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Micro metastasis in Adenocarcinoma with normalMicro metastasis in Adenocarcinoma with normalsize lymph nodessize lymph nodes

Complimentary to Mediastinoscopy for N stagingComplimentary to Mediastinoscopy for N stagingLevel 5 , 6 ( AP Window )Level 5 , 6 ( AP Window ) Level 7 ( PosteriorLevel 7 ( Posteriorsubcarinal )subcarinal ) Level 8 (Para esophageal )Level 8 (Para esophageal ) Level 9Level 9( Inferior Pulmonary Ligament )( Inferior Pulmonary Ligament )

Surgical staging has 100 % specificity , highSurgical staging has 100 % specificity , highsensitivity and minimal morbiditysensitivity and minimal morbidity (Passlick B(Passlick Betal , Lung Cancer 2003 )etal , Lung Cancer 2003 )


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Currently Surgical Stagingrecommended by Majority ofscientific societies for patients

with apparently ressectableNSCLC

CT Scan sensitivity for staging


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Assesment ofAssesment of

Resectibility LungResectibility Lung

CancerCancer Criteria for IrresectibilityCriteria for IrresectibilityMassive extranodal N2 diseaseMassive extranodal N2 disease

Bilateral lymph node involvementBilateral lymph node involvement

Extensive Pericardial invasionExtensive Pericardial invasionSuperior Vena Cava involvementSuperior Vena Cava involvement

Esophageal invasionEsophageal invasion

Extensive chest wall involvementExtensive chest wall involvement ( > 3( > 3ribs )ribs )

Tumor invasion of arteryTumor invasion of artery

Pleural DisseminationPleural Dissemination


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Centrally located primary tumor withCentrally located primary tumor with

intrapericardial extension ( Clinical T4intrapericardial extension ( Clinical T4

))

Direct examination of Pericardial sacDirect examination of Pericardial saccontentcontent

Avoids exploratory thoracotomyAvoids exploratory thoracotomy

4.7% Wain etal , 8.3% Rovario etal ,4.7% Wain etal , 8.3% Rovario etal ,

5% H Asamura etal. (Not significant5% H Asamura etal. (Not significant

but still a benefit of Thoracoscopy)but still a benefit of Thoracoscopy)


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Thoracoscopy -Thoracoscopy -

LimitationsLimitations Single lung VentilationSingle lung Ventilation Pleural AdhesionsPleural Adhesions

Contra lateral hemithorax notContra lateral hemithorax notaccessibleaccessible

Negative Thoracoscopy does notNegative Thoracoscopy does not

rule out a Thoracotomy till arule out a Thoracotomy till aHistologic diagnosis establishedHistologic diagnosis established


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Considered to be Final in -Considered to be Final in -

Nodule BiopsyNodule Biopsy

StagingStaging

RessectabilityRessectabilityEvaluationEvaluation


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ConclusionConclusion

Combined with mediastinoscopy may accuratelyCombined with mediastinoscopy may accurately

determinedetermine- Presence or absence of N2,N3- Presence or absence of N2,N3

DiseaseDisease -Identify T3,T4 & Thoracic M1-Identify T3,T4 & Thoracic M1

Assures the indicated therapeutic treatmentAssures the indicated therapeutic treatment

Valid alternative to Cervical mediastinoscopyValid alternative to Cervical mediastinoscopy

Avoids exploratory thoracotomyAvoids exploratory thoracotomy

diagnostic thoracoscopy (vats) in lung cancer

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