VATS Mediastinal VATS Mediastinal Lymph Node DissectionLymph Node Dissection

AATS Focus on Lung CancerAATS Focus on Lung CancerBoston Boston

Nov 2012Nov 2012

Scott J. Swanson, M.D.Director Minimally Invasive Thoracic Surgery

Brigham and Women’s HospitalProfessor of Surgery

Harvard Medical School

Disclosures

• I have no conflicts for this talk

• I serve as a consultant to Covidien and Ethicon

Most Important Principles of Most Important Principles of Surgical Management of Surgical Management of

Non-Small Cell Lung CancerNon-Small Cell Lung Cancer

• Clear Surgical Margin

• Sampling/Dissection of Lymph Nodes

Lymph Node Sampling versus Lymph Node Sampling versus Dissection is ControversialDissection is Controversial

• Presentation of Z0030 trial at AATS 2010 suggested no added benefit to dissection after careful sampling in early stage lung cancer

• However careful sampling is of critical importance for staging and possible improvement in outcome

• Data suggests inadequate sampling is associated with worse outcome

Ludwig MS et al. Postoperative survival and the number of lymph nodes sampled during resection of node-negative NSLC. Chest 2005. 1545-50.

Wolf AS, Richards WG, Jaklitsch MT, Gill R, Chirieac LR, Colson YL, Mohiuddin K, Mentzer SJ, Bueno R, Sugarbaker DJ and Swanson SJ. Lobectomy versus sublobar resection for small (2 cm or less) non-small cell lung cancers. Ann Thorac Surg. 2011 Nov;92:1819-23.

Methods for AssessmentMethods for Assessment• CXR• Chest CT scan• CT/PET• EBUS/EUS• Mediastinoscopy• VAMLA• Open lymphadenectomy• Sentinel node sampling

Technique of Mediastinal Technique of Mediastinal Lymph Node DissectionLymph Node Dissection

• Right Paratracheal – clear all tissue from SVC to trachea and from upper lobe bronchus to the subclavian artery

• Left Aorto-Pulmonary Window –clear all tissue from phrenic nerve to the descending aorta and from the left upper lobe bronchus to the subclavian artery

• Subcarinal- clear out all tissue bordered by the right and left bronchi and pericardium

VATS left subcarinal LND

Left VATS AP Window LND

Right VATS Paratracheal LND

Right VATS subcarinal LND

Mediastinal Node DissectionMediastinal Node Dissection

• Either VATS or thoracotomy for exposure

• Data for local recurrence and survival shows no difference between these techniques

• 2 meta- analyses raise possibility of VATS superiority

Shapiro M, Weiser TS, Wisnivesky JP, Chin, Arustamyan M and Swanson SJ. JTCS 2009Whitson BA, Groth SS, Duval S, Swanson SJ and Maddaus M. Ann Thorac Surg 2008Yan TD, Black D, Bannon PG, McCaughan BC. J. Clin Onc 2009

Standard ApproachStandard Approach• CT/PET• Various algorithms but most have mediastinoscopy• Question true utility of mediastinoscopy/mediastinal

staging for early peripheral lung cancer with negative CT/PET scan of mediastinum

• There may be a VATS alternative which is oncologically sound and saves operative time and morbidity related to mediastinoscopy

One approachOne approach• For outer half lung cancer with negative CT/PET scan in the

mediastinum

• Begin VATS lobectomy with ipsilateral mediastinal node evaluation (N2)

– For right sided tumors – 2R, 4R, 7, 8, 9

– For left sided tumors – 5,6, 7, 8, 9

• Evaluate by rapid section, if (+) stop and go to induction therapy prior to lobectomy

• In my experience this is less than 5%

• Potential downside is skip to N3 with negative N2 which would have been picked up on mediastinoscopy – I have not seen this i.e. in following pts none have recurred in contralateral mediastinum or false negative frozen section result

Right VATS ipsilateral mediastinal LN assessment

ConclusionsConclusions

• VATS lymphadenectomy is easy to accomplish and effective

• Lymph node assessment and treatment is of the utmost importance in moving the treatment of lung cancer forward

• Technologies such as VATS, EBUS/EUS and mediastinoscopy are critical in this endeavor