Thoracoscopic Lobectomy for Locally Advanced Lung Cancer · 2017. 9. 19. · undergoing lobectomy...

Masters MITS '2016

Thoracoscopic Lobectomy for Locally

Advanced Lung Cancer

Todd L. Demmy

No Disclosures

5/13/15

Masters MITS '2016

Objectives

• Define Locally Advanced

• Advanced Min Inv results

• Review technical pearls

• Videos

Masters MITS '2016

What is Locally Advanced?

Procedural Definition

• Pneumonectomy

• Sleeve Lobectomy

• Chest Wall Resection

• Advanced exposure

Masters MITS '2016

What is Locally Advanced?

Anatomic Definition • Lesion size >5 cm

• Strong pleural adhesions

• Adjacent structure involvement

(parietal/mediastinal pleura, diaphragm, rib)

• N1 or N2

• Centrally located tumors (endo- or peri-

bronchial extension to lobar bronchus orifice)

• Previous chemo- or chemoradiotherapy, or

previous surgery

J Thorac Dis 2014;6(S6):S623-S630

Masters MITS '2016

Pischik, J Thorac Dis 2014;6(S6):S623-S630

• Lesion size >5 cm

• Dense pleural adhesions, fused fissure and severe emphysema;

• Adjacent structures involvement ( mediastinal/parietal pleura, diaphragm, rib

• N1 or N2

• Centrally located tumors extension to lobar bronchus orifice)

• Previous chemo- or chemoradiotherapy

• Previous surgery

Locally Extensive

Masters MITS '2016

Pischik, J Thorac Dis 2014;6(S6):S623-S630

Group S

(n=45)

Group E

(n=47)

P value

Average operation time (minutes) 152.0 189.0 0.093

Number of mediastinal LN (mean) 10.2 13.1 0.068

Blood loss (mean, mL) 159.0 151.0 0.890

Chest tube duration (mean, days) 3.9 5.2 0.080

Amt drained fluid/day (mean, mL) 203.5 180.5 0.638

Total amount of postop. opioids 0.8 1.1 0.398

Morbidity 5 (16.7%) 7 (21.9%) 0.443

Length of stay (mean, days) 7.1 7.9 0.353

Standard (S) vs. extended (E) indications

for VATS major pulmonary resection

Masters MITS '2016

J Thorac Cardiovasc

Surg 2013;145:514-

21

Duke Series

Central = could not be wedged

Masters MITS '2016

Duke Series

After Preoperative Chemo

Yang, European Journal of Cardio-Thoracic Surgery (2015) 1–9

Propensity Matched

Masters MITS '2016

MSK Series

Preoperative Chemo

Park, J Thorac Dis 2016;8(Suppl 4):S406-S413

Masters MITS '2016 Masters MITS '2016

Huang, J Thorac Dis 2013;5(S3):S267-S273.

VATS following

Neoadjuvant N=43 • IIA-IIIB NSCLC (IIIA:

62.8%; IIIB: 25.6%)

• 32 males (74.4%)

• 42 successful (7 hybrid)

• 28 lobectomies (9 sleeve)

• 5 bilobectomies, 5 wedge, 4

pneumonectomies.

• 160 min (130-180 min)

• EBL 253±117 mL

• Nodes 17±11

• CT 2.6 day (1-7)

• Hospital 5.4 (3-7)

• Complications 9.5%

• Mortality 2.4%

• Overall 94%, 79%,

and 65% 1, 2 & 3yr

Survival

Masters MITS '2016

Nakanishi, Ann Thorac Surg 2014;97:980–6

April 2002 and

April 2011 for

advanced-stage

NSCLC of

preoperative

stage II or greater

at a single

institution

VATS for Stage 2 or greater

Masters MITS '2016

Group A

(2002–2006)

Group B

(2006–2009)

Group C

(2009–2011)

Variable Total (n = 76) n = 25 n = 25 n = 26 p Value

Complication: total 27 (35.5%) 10 (40.0%) 10 (40.0%) 7 (26.9%) 0.5281c

Air leak > 7 days 8 (10.5%) 4 (16.0%) 2 (8.0%) 2 (7.7%) 0.5525c

Sputum retention

requiring bronchoscopy

7 (9.2%) 4 (16.0%) 2 (8.0%) 1 (3.8%) 0.3140c

Pneumothorax 5 (6.6%) 1 (4.0%) 2 (8.0%) 2 (7.7%) 0.8166c

Atrial fibrillation 4 (5.3%) 2 (8.0%) 1 (4.0%) 1 (3.8%) 0.7557c

Hoarseness 4 (5.3%) 0 (0%) 2 (8.0%) 2 (7.7%) 0.3548c

Gastrointestinal disorder 2 (2.6%) 1 (4.0%) 1 (4.0%) 0 (0%) 0.5862c

Pneumonia 1 (1.3%) 1 (4.0%) 0 (0%) 0 (0%) 0.3557c

Empyema 1 (1.3%) 0 (0%) 1 (4.0%) 0 (0%) 0.3557c

Grade 3 or higher

complication

2 (2.6%) 1 (4.0%) 1 (4.0%) 0 (0%) 0.5862c



Masters MITS '2016

Group A

(2002–2006)

Group B

(2006–2009)

Group C

(2009–2011)

Variable Total (n =76) n = 25 n = 25 n = 26 p Value

Perioperative outcome Operative time (min) 327(152–590) 393 (226–590) 314 (152–512) 296 (186–588) 0.0133b

Blood loss (mL) 138 (6–1500) 255 (55–1500) 104 (20–427) 104 (6–493) 0.0012b

Conversion 2 (2.6%) 2 (8.0%) 0 (0%) 0 (0%) 0.1231c

Transfusion 2 (2.6%) 2 (8.0%) 0 (0%) 0 (0%) 0.1231c

Complete resection (R0) 70 (92.1%) 23 (92.0%) 24 (96.0%) 23 (88.5%) 0.6076c

Chest tube duration

(days)

1 (1–117) 2 (1–42) 1 (1–117) 1 (1–18) 0.6246b

Hospital stay (days) 14 (5–201) 19 (7–201) 14 (6–117) 9 (5–64) 0.1249b

Hospital mortality 2 (2.6%) 1 (4.0%) 1 (4.0%) 0 (0%) 0.5862c

Recurrence: distant/local 19 (25.0%)/11

(14.5%)

5 (20%)/5 (20%) 6 (24%)/3 (12%) 8 (31%)/3 (12%) 0.8302c



Masters MITS '2016

Group A

(2002–2006)

Group B

(2006–2009)

Group C

(2009–2011)

Variable Total (n = 76) n = 25 n = 25 n = 26 p Value

Operative procedures Lobectomy 53 (69.7%)b 15 (60.0%) 20 (80.0%) 18 (69.2%) 0.2448e

Bilobectomy 11 (14.5%) 3 (12.0%) 4 (16.0%) 4 (15.4%)

Pneumonectomy 12 (15.8%)c 7 (28.0%) 1 (4.0%) 4 (15.4%)

Nodes resected 16 (1–33) 17 (1–30) 19 (4–33) 15 (1–31) 0.6098f

adjacent organs

resected

28 (36.8%) 10 (40.0%) 10 (40.0%) 8 (30.8%) 0.7962e

PA angioplasty 5 (7.9%) 3 (16.0%) 0 (0%) 2 (7.7%) 0.2222e

Bronchoplasty 3 (3.9%)d 0 (0%) 0 (0%) 3 (11.5%) 0.0496e

Bronch coverage 8 (10.5%) 1 (4.0%) 1 (4.0%) 6 (23.1%) 0.0367e



Masters MITS '2016

Locally Advanced VATS

Masters MITS '2016

Advanced Resections

125 patients

undergoing lobectomy

for Advanced Lung

Cancer 1/1/2002-

7/31/2007 11 patients

excluded for tumors

with chest wall or

brachial plexus

invasion

114 patients in final

analysis

19 patients

“Open”

Thoracotomy Attempted VATS

22 patients

“Conversion”

73 patients

“VATS”

95 patients

attempted VATS

Successful Converted

Conversion rate = 23%

tumors ≥ 4cm

any T3 or T4 tumor

tumors requiring neoadjuvant

chemotherapy

Hennon, Ann Surg Oncol (2011)

18:3732–3736

Masters MITS '2016

Advanced VATS Resections- Survival

tumors ≥ 4cm

any T3 or T4 tumor

tumors requiring neoadjuvant chemotherapy

Hennon, Ann Surg Oncol

(2011) 18:3732–3736

Overall Disease-free

Masters MITS '2016

Advanced resections

Stage III (7th Ed) Survivals

OS DFS

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RPCI Local Advanced –

UPDATE

Masters MITS '2016

VATS

(n=224)

Conversion

(n=55)

Open

(n=37)

p value

Age (year) 67.09.5 65.811.1 70.916.0 0.08

Sex (M/F) 116/108 28/27 18/19 0.32

Preop

comorbidities

DM 44 (19.6%) 13 (23.6%) 4 (10.8%) 0.11

CAD/MI 74 (33.0%) 11 (20.0%) 8 (21.6%) < 0.05

CHF 14 (6.3%) 5 (9.1%) 0 0.07

HTN 117 (52.2%) 36 (65.5%) 17 (45.9%) 0.05

CKD 15 (6.7%) 1 (1.8%) 0 < 0.05

DVT/PE 9 (4.0%) 0 1 (2.7%) 0.16

COPD 77 (34.4%) 17 (30.9%) 7 (18.9%) 0.07

Other

malignancy

67 (29.9%) 21 (38.2%) 10 (27.0%) 0.15


UPDATE

Masters MITS '2016

VATS

(n=224)

Conversion

(n=55)

Open

(n=37)

p value

Pulmonary

function

FEV1 (%) 77.621.0 77.820.8 75.615.7 0.74

DLCO (%) 73.721.6 69.818.8 69.920.3 0.85

Neoadjuvant 95 (42.4%) 18 (32.7%) 21 (56.8%) < 0.05

Chemotherapy 74 (33.0%) 14 (25.5%) 11 (29.7%) 0.19

Chemoradiation 21 (9.4%) 4 (7.3%) 10 (27.0%) < 0.01


UPDATE

Masters MITS '2016


UPDATE

Masters MITS '2016

VATS

(n=224)

Conversio

n (n=55)

Open

(n=37)

p value

Cancer type

Adenocarcinoma 110 (49.1%) 28 (50.9%) 18 (48.6%) 0.33

Squamous cell

carcinoma

79 (35.3%) 20 (36.4%) 12 (32.4%) 0.32

Large cell carcinoma 11 (49.1%) 1 (1.8%) 2 (5.4%) 0.21

Others 24 (10.7%) 6 (10.9%) 5 (13.5%) 0.30

Size of tumor (cm) 4.152.10 4.402.33 4.732.39 0.29


UPDATE

Masters MITS '2016

VATS

(n=224)

Conversion

(n=55)

Open

(n=37)

p value

Operative data EBL (ml) 290.0341.6 671.0619.3 419.6314.1 < 0.001

OR time (min) 312.4126.7 373.0134.5 307.3125.3 < 0.01

Enbloc resection 42 (18.8%) 10 (18.2%) 15 (40.5%) < 0.01 Sublobar resection 23 (10.3%) 3 (5.5%) 4 (10.8%) 0.19

Bilobectomy 6 (2.7%) 1 (1.8%) 2 (5.4%) 0.21 Chest wall 8 (3.6%) 4 (7.3%) 9 (24.3%) < 0.001

Adjacent structure 5 (2.2%) 2 (3.6%) 0 0.18 R1 resection 9 (4.0%) 5 (9.1%) 0 < 0.05

Bronchial margin 6 (2.7%) 3 (5.5%) 0 0.11 Pleura / chest wall 2 (0.9%) 1 (1.8%) 0 0.24

Pericardium/mediastinum 1 (0.4%) 1 (1.8%) 0 0.16

R2 resection 1 (0.4%) 1 (1.8%) 1 (3.4%) 0.12

Total LNs 15.412.4 14.411.3 15.79.5 0.86

Positive LNs 0.71.8 1.52.5 1.53.4 < 0.01


UPDATE

Masters MITS '2016

VATS

(n=224)

Conversion

(n=55)

Open

(n=37)

p value

Adjuvant therapy Chemotherapy 81 (36.2%) 22 (40.0%) 10 (27.0%) 0.16

Chemoradiation 10 (4.5%) 6 (10.9%) 3 (8.1%) 0.07

Radiation therapy 9 (4.0%) 1 (1.8%) 0 0.13 Time to start (days) 50.520.7 53.413.4 61.418.4 0.07

Postoperative outcomes Distal metastasis 38 (17.0%) 15 (27.3%) 11 (29.7%) < 0.05

Brain 24 (10.7%) 6 (10.9%) 5 (13.5%) 0.30 Spine 6 (2.7%) 3 (5.5%) 2 (5.4%) 0.17 Others 8 (3.6%) 6 (10.9%) 4 (10.8%) < 0.05

Recurrence 63 (28.1%) 22 (40.0%) 15 (40.5%) < 0.05 Overall survival (mon) 41.227.8 32.627.2 36.234.8 0.10

Disease-free survival (mon) 36.128.4 25.721.9 31.434.7 < 0.001

Path Stage > 1 62% 92% 54%


UPDATE

Masters MITS '2016

Visualization Tools

High Definition ANGLED Optimal Endocameleon™

Masters MITS '2016

Visualization Tools

5 mm Optimal For Sharing ports

Masters MITS '2016

Common 3D Systems today

Olympus ENDOEYE Flex

3D Laparoscopy

Viking ConMed.com

bbraun.com

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Importance of Low Profile and Angles


Multiple retractors

00:26

Masters MITS '2016

Lymph Node Grasping

No Grasp - Metal Endoscopic Sucker -- Liu et al. BMC Surgery (2015) 15:38


Curved Tip Cartridge for Thoracic Surgery

PA Branch Vein

104

78 68

38

Med

ian (

s)

STAPLER PASSAGE TIMES

COMPLEX CASES

Straight Curved

Demmy&Mayfield,Ann Thorac Surg 2012;93:1280-1284

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Thermal Sealing Technology N=211

Lobes/Segments

J Thorac Cardiovasc Surg

2010;140:1168-73

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PA control - Loops

A. Watanabe et al. / European Journal of

Cardio-thoracic Surgery 31 (2007) 129—131

•#1 Silk

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PA control - Bulldogs

Masters MITS '2016

PA control - Bulldogs

Dong, J Thorac Dis 2014;6(12):1855-1860

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Follow the “Fs” when you

are stuck- 1

• Free All Adhesions, All Lobes

• Find Somewhere else to work or view

– Pleurae and lymphatic tissue

– Divide more distally

• Fissure Division (also opens camera angles)

– Partially (outside in)

– Completely (blunt clamp technique)

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Fissure Division Videos

• http://www.ctsnet.org/sections/video

section/videos/2013_video-atlas-

thorascopic-lobectomy.html

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Follow the “Fs” when you

are stuck - 2

• Flip order of anatomical divisions (eg.

Change to Fissure Last Technique)

• Fill the port/access incisions (“fers”)

– Traction – Countertraction to define

anatomy (eg. “Two-fer” and vessel

loops)

• Fresh planes (eg. Open pericardium)

• Flatten the diaphragm


Exposure Problems Vessel Access

00:20

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Left Lower Lobe

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Bronchoplasty

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VATS WEDGE Bronchoplasty

Kamiyoshihara, 2008, Gen Thorac Cardiovasc Surg 56(9):

476-478.

• 5-8 Cm

• 70% direct visualization

• handling the needle:

scooping, rotating, and

turning

• 30% monitor

• confirm each needle

insertion site and

anastomotic line

• Polyurethane wound retractor

(Applied Medical, Rancho

Santa Margarita, CA, USA).

Masters MITS '2016


Kamiyoshihara, 2010, Interact Cardiovasc Thorac Surg 11(5):

693-695.

Masters MITS '2016

Complete VATS Sleeve

Ref N Deaths Complications EBL (ml) Time Hosp Stay

Nakanishi, 2007 5 0 1 265 600 10

Mahtabifard, 2008 13 0 4/13 250 167 3

Li, 2013 11 0 0 180 178 9

Yu, 2014 9 0 0 390 203 21

Wang, 2014 15 0 0 170 183 7

Shao, 2016 6 0 0 110 182 9.2

Huang(He), 2016 118 1 2 71 124 5.1

Masters MITS '2016

Complete VATS Sleeve

Ref N Technique Nakanishi, 2007 5 Interrupted + Running

Mahtabifard (Mckenna) 2008 13 Interrupted 000 Vicryl

Li, 2013 11 running memb, inter cart

Yu, 2014 9 Interrupted switched to running

Wang, 2014 15 2 incision, 3.0 prolene running

Shao, 2016 6 Running Prolene

Huang(He), 2016 118 3.0 Prolene, running memb, inter cart

Masters MITS '2016

VATS Sleeve

He Team - GuangzhouUniversity

Lobe Number

RUL 59

RML 7

RLL 8

LUL 34

LLL 10

Huang (He), J Thorac Dis 2016;8(3):553-574

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VATS Sleeve Resection

Nakanishi, 2007, Ann Thorac Surg 84(1): 191-195.

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Two-Port Sleeve Case

Jiao et al. Journal of Cardiothoracic Surgery 2013, 8:99.

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Uniportal Sleeve Case

Gonzalez-Rivas, J Thorac Cardiovasc Surg 2013;145:1676-7

55 year old, post induction therapy

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Uniportal Sleeve Case

Gonzalez-Rivas, J Thorac Cardiovasc Surg 2013;145:1676-7

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Uniportal Sleeve Review

Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6–i16

Masters MITS '2016

Diego-Rivas,

European Journal

of Cardio-

Thoracic Surgery

49 (2016) i6–i16

Masters MITS '2016

Uniportal Sleeve Review

Diego-Rivas, European Journal of Cardio-Thoracic Surgery 49 (2016) i6–i16

Masters MITS '2016

Diego-Rivas,

European Journal

of Cardio-

Thoracic Surgery

49 (2016) i6–i16

Masters MITS '2016

Carinal Resection RUL

Sleeve

Lin, J Thorac Dis 2015;7(10):1861-1864

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Carinal Resection

RUL Sleeve – Squamous cell

Lin, J Thorac Dis 2015;7(10):1861-1864

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TiKnot Device

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V-loc Device

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LUL Sleeve Lobectomy

2:30

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Traction Sutures

Xu, J Thorac Dis 2013;5(S3):S298-S300.

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Double Sleeve

Liu, European Journal of Cardio-Thoracic Surgery 46

(2014) 493–495


NSCLC with Chest Wall Invasion Challenging Disease

• 5% of NSCLC

• Technically Demanding

Complex Resections

• Traditionally Open

Reconstruction Issues

• Pulmonary Compromise

• Multimodality Therapy

Hu et al. Ann Thorac Surg, 2014 vol. 97(3) pp. 973-9.

1.01 1.57

5.97 5.65

0

1

2

3

4

5

6

7

Rel

ati

ve

Ris

k

90 Day Mortality Compared to VATS Wedge

VATS

Lobe

Open

Lobe

Pneumon

-ectomy

Chest Wall

Lung

Masters MITS '2016

Chest Wall Potential Advantages

Ann Thorac Surg 2012;94:1744 –7

• Planning/Accurate resection

margins

• Avoid rib spreading pain

• Less blood loss

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• Score planned margins

• Divide ribs close to utility incision with standard rib-cutter

• Divide IC muscles with energy

• Dissect sub-muscular plane

• Divide ribs away from port

Technique

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Gigli/Rib Cutter/High Speed Burr

Black Max™ Midas Rex™

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Methods-Retraction

• Wylie or similar

• Self-retaining systems,

Bookwalter

• Fan-retraction

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Case Presentation

LUL Chest Wall Invasion

After Chemo Before Chemo

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Case Presentation

LUL Chest Wall Invasion

0:26 0:26

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Methods

Retrospective Analysis

• 47 chest wall resections

– 2007-2013

– 17 VATS, 30 open

• Subgroup 31 patients with NSCLC

– 15 VATS, 16 open

Hennon, Ann Thorac Surg. 2015 Jun;99(6):1929-34


Similar Pathology and

Stage Distribution

IB

IIB

IIIA

IIIB

VATS

IB

IIB

IIIA

IV

Open


Masters MITS '2016

Similar Pulmonary Function

0

20

40

60

80

100

FEV1 DLCO

Per

cen

t

VATS

Open

Masters MITS '2016

Results – NSCLC Groups

Variable

(median) VATS

(n=15) Open

(n=16) p-value

Age (years) 76 56 0.003

Operative Time

(min) 500 410 0.167

EBL (mL) 450 525 0.441

Ribs Resected 3 (range 1-5) 3 (range 1-5) 0.105


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Wider Age Range for

VATS


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Results

Variable (median) VATS

(n=15) Open

(n=16) p-value

ICU (days) 2 6 0.028

In Hospital (days) 7 13 0.002

Reconstruction with Patch 6.7% 56.3% 0.001

Neoadjuvant Chemo or

ChemoRT 66.7% 62.5% 0.594

90-Day Mortality/Major

Morbidity 53.3% 87.5% 0.036


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Less Variation for VATS

Despite Older Patients Pneumonectomy

Emergency Colon ischemia

Neuro ? Other


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Patch Preparation

• 2mm PTFE

• Cut to same size as specimen

+ 1 cm

• Prepunch perimeter to make

intracorporeal suturing easier

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Body Wall Anchoring

Carter-Thomason Needle

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Summary

• Highly selected cases of primary or

T3 lung cancer may be appropriate

VATS resection candidates.

• ? short-term recovery benefits

• Not for all frail patients

• Cooperative study is needed

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Conclusions

• Thoracoscopic chest wall resection is

technically feasible

– expanded our case selection

– reduced prosthetic reconstruction

• It did not, however, reliably protect

all frail, elderly patients.

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VATS Brachytherapy

Pract Radiat Oncol. 2016 May 7. pii: S1879-8500(16)30048-0. doi:

10.1016/j.prro.2016.04.006.

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VATS Brachytherapy Video

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Troubleshooting Guide

• Ann Thorac Surg 2005;79:1744 –53

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Troubleshooting Guide

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Ann Surg Oncol (2011) 18:3732–3736

RPCI Local Advanced

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0

500

1000

1500

2000

2500

3000

3500

4000

1 2 3 4 5 6 7 8 9 10

19 160

252

527 747

966

1234

1497

2058

979

4

21 22

69

138

343

617

986

1541

790

Series

2

17.4%

15.6%

44.7

42.8%

39.7%

33.3%

26.2%

11.6%

8.0% 11.6%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Thoracoscopy

Thoracotomy

Nu

mb

er

of

Pu

lmo

na

ry R

es

ec

tio

ns

* 5/2010

STS Database: %

Thoracoscopic Lobectomy 45%

<10

%

Ceppa DP, et al. Ann Surg 2012 Aug 3. [Epub ahead of print] PMID: 22868367

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STS VATS vs. Open

Ceppa, Ann Surg 2012;256: 487–493

OPEN, N=8439

VATS, N=4531

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VATS for Planning Open

Interactive CardioVascular and Thoracic Surgery 17 (2013) 32–35

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Kamiyoshihara, 2010, Interact Cardiovasc Thorac Surg 11(5):

693-695.

Masters MITS '2016

Case Presentation

RLL Chest Wall Invasion

Masters MITS '2016


Kamiyoshihara, 2010, Interact Cardiovasc

Thorac Surg 11(5): 693-695.

Masters MITS '2016

PD - Index Case 7/2013

• 58 yo female

• Hx breast ca

• Hemoptysis

• Inflammatory

myofibroblastic

tumor

Masters MITS '2016

VATS Pneumonectomy

Longer Persistance

of Severe and

Moderate

Pain for Open

Pneumonectomy

Patients

might relate to

survival

Chest. 2014 Nov;146(5):1300-9.

Masters MITS '2016

Survival

May benefit

advanced stages

(ITT Analysis)

Conversions in early

pathologic stage may reduce

VATS benefits

Chest. 2014 Nov;146(5):1300-9

Thoracoscopic Lobectomy for Locally Advanced Lung Cancer · 2017. 9. 19. · undergoing lobectomy...

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