Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
Thank you for viewing this presentation.
We would like to remind you that this
material is the property of the author.
It is provided to you by the ERS for your
personal use only, as submitted by the
author.
2016 by the author
PG5 How to reach peripheral solitary nodules
Minimally-Invasive Surgery
Laureano Molins, M.D. Ph.D., FETCS
Chief, Thoracic Surgery
Hospital Clínic & Sagrat Cor University Hospitals
Associate Professor of Surgery
Barcelona University, Spain.
• ERS 2016, London, 3rd Sept, 2016
Conflict of interest disclosure
I have no real or perceived conflicts of interest that relate to this presentation.
I have the following real or perceived conflicts of interest that relate to this presentation:
This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent ofthis disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providersof any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which theycan make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence thepresentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of thespeaker’s presentation. Drug or device advertisement is forbidden.
Perioperative identification of pulmonary
nodules
• GCCB-S: 4,24 cm. NEED TO CHANGE!
VATS RESECTION OF PULMONARY NODULE
• If negative FNA and still suspicious or resection
is indicated
Specificity: 100%. Low operative mortality
Difficulties in identification because of size and
localization. Need of mini thoracotomy for digital
palpation.
Perioperative indentificaction of a
pulmonary nodule
- Digital palpation
- Intraoperatory ultrasonography
- Metylen blue injection
- CT-guided Microcoil localization
- Bronchoscopic Navigation
- CT-guided hookwire localization
Results:
Chest tube removal:
a) 1 hour after LB: 135 patients (92.4%)
b) 4-24 hour after: 9 patients (6.2%)
c) 48 hour after: 2 patients (1.4%)
Median stay: 1.2 days (range: 0-7)
Outpatient procedures (Since 2001):
32 (50% of all VATS-LB in this period)
480 patients
EXPERIENCE WITH CT-GUIDED HOOK WIRE FOR
LOCALIZATION OF SMALL PULMONARY NODULES PRIOR
TO VIDEOTHORACOSCOPIC RESECTION
Laureano Molins1-2, E. Mauri3, M. Sánchez4, J. Fibla 2, JM. Gimferrer 2,
P. Arguis4, JM. Mier2, A. Gomez-Caro2, M. Catalan2, JM. Sancho5, J. Ramírez6
Cir Esp. 2013; 91(3):184-188.
1 Thoracic Surgery, Hospital Clínic, Barcelona, Spain2 Thoracic Surgery, Hospital Universitari Sagrat Cor (HUSC), Barcelona, Spain
3 Diagnostic Imaging (CRC Sagrat Cor). HUSC, Barcelona, Spain4 Radiology Dept., Hospital Clínic, Barcelona, Spain5 Pathology Dept., HUSC, Barcelona, Spain6 Pathology Dept., Hospital Clínic, Barcelona, Spain
Abstract MO14.05
November 2004 – January 2011
• 55 CT guided hookwire in PN before VATS
• 52 patients, 3 double placement
• Diagnostic Imaging Service
• Drs. Eduard Mauri, Cristina Simón, H. Sagrat Cor
• Marcelo Sánchez, Pedro Arguis, Ivan Völlmer, H. Clinic
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
• 52 PATIENTS (55 RESECTED NODULES)
44 Solitary Pulmonary Nodules 8 Multiple Nodules (> 2) 3 Double Nodules (in different lobes)
• SIZE: 0.5-20 mm• Mean: 9.57 mm• 37 nodules < 10 mm• 9 nodules defined as GGO
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
METHODS
Admission 1-2 hours prior surgery to the short-stayfacility
• Transfer to the Radiology department to CTplacement of the hook wire.
• Transfer to the OR
• SURGERY: VATS wedge resection + frozen section:
- If (-) or M1: done +/- sampling
- If lung ca: lobectomy if indicated
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
HE*40 Lymph node with
antracosis and reactive adenitis Large cell ca
METHODS
• Recovery room 20-40 min prior to transferred back
• Chest X-ray performed & revised by surgeon.
• Discharge from the short-stay facility 4-6 h. aftersupervision by nursing staff (contacted the morningafter and visited in one week)
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
RESULTS
* A videothoracoscopic resection was carried outin all but two cases without need of extending theincisions of ports.
* No complications like hemorrage
or simptomatic pneumothorax
were observed
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
ML RLL
Double
placement
LLLLUL
RESULTS
52 / 55 Hook wires found in place (94,5%)
3 / 55 found outside (different model in 2)
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
HOSPITAL STAY
52 PATIENTS
• RANGE: 4-72h (mean: 25h)
-19 patients (36,5%): 4h: Outpatient program
-15 patients (28,8%): 24h (9 drain, 6 outside Bcn)
- 1 patient (1,9%): 72h (air leak)
-17 patients (32,7%): after 5 days (Lobectomy)
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
52 PATIENTS / 55 NODULES
• 35 oncologic patients
26 (+) 13 Lung
4 Colon
2 Breast
3 Melanoma
4 Other (Parotid, tipical carcinoid, endometrium, urothelial)
9 (-) 2 Hamartoma
1 Chronic Pneumonia
1 Intraparenchimal lymph node
1 Adenomatous hyperplasia
3 Inflammatory infiltrate
1 Sarcoidosis
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
52 PATIENTS / 55 NODULES
• 17 non-oncologic patients
12 (+) 9 Single: Bronchogenic Ca.
3 Double: Adenoca ML / Large Cell RLL
Bronchiol LUL / Bronchiol LLL
Adenoca RUL / Adenoca RLL
5 (-) 3 Hamartomas
1 Fibrous nodule
1 tuberculous nodule
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
CONCLUSIONS
* The perioperative identification of the small-sized pulmonary nodules enables a resectionthrough VATS without the need of having toextend the incision or the practice of a minithoracotomy for palpation of the nodule.
* The introduction of a CT-guided hook wire is, inexpert hands, a very safe and effective procedurethat can be carried out in an outpatient surgeryprogramme.
Experience with CT-guided hook wire for localization of small pulmonary nodules prior to videothoracoscopic resection
VATS vs Thoracotomy
LOBECTOMY STILL THE
STANDARD OF CARE IN THE
SURGICAL TREATMENT OF
NSCLC…
VATS
Current evidence
Postoperative benefits Gopaldas RR, Bakaeen FG, Dao TK, et al. Video-assisted thoracoscopic versus open
thoracotomy. lobectomy in a cohort of 13,619 patients. Ann Thorac Surg. 2010;89:1563-70
Whitson BA, Groth SS, Duval SJ, et al. Surgery for early-stage non-small cell lung cancer: a
systematic review of the video-assisted thoracoscopic surgery versus thoracotomy
approaches to lobectomy. Ann Thorac Surg. 2008;86:2008-16; discussion 16-8
Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of
randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27:2553-62.
Oncologic efficacy .Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than
open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg.
2010;139:366-78.
Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer:
Diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians evidence-
based clinical practice guidelines. Chest. 2013;143:e278S-e313S.
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) non-small cell lung cancer,
version 4.2015. Available from: http://www.nccn.org/professionals/physician_glos/PDF/nscl.pdf. Accessed
February 11, 2015.
Sleeve Lobectomy
Sleeve Lobectomy
Minimally invasive approaches
Parenchyma-sparing resections
VATS Lobectomy
vs Thoracotomy
Fewer complications Hoksch1
Less pain Walker2
Better quality of life Sugiura3
Better PFTs Nakata4
Less pneumonia Whitson5
Earlier recovery Demmy6
Easier for octogenarians McVay7
1. Zentralbl Chir. 2003;128:106-110. 2. Semin Thorac Cardiovasc Surg. 1998;10:291. 3. Surg Laparosc
Endosc. 1999;9:403-410. 4. Ann Thorac Surg. 2000;70:938-941. 5. Ann Thor Surg. 2007;83:1965-1970.
6. Ann Thorac Surg. 1999;68:194-200. 7. Am Surg. 2005;71:791-793.
VATS vs Thoracotomy
Patients received > 75% of
their planned chemotherapy
regimen:
• 61% after VATS
• 40% after thoracotomy
Peterson et al. Ann Thor Surg. 2007;83:1245-1249.
Limited thoracotomy
1995-1998VATS
1999-
Retrospective study for comparison
between VATS and limited thoracotomy
For clinical stage I NSCLC
Nomori H, et al. Ann Thorac Surg, 2001
Numbers of resected lymph nodes
In VATS and limited thoracotomy
Site VATS Limited thoracotomy Difference
Right 31 31 p=0.89
Left 28 27 p=0.79
Assessment of node dissection for clinical stage I primary lung cancer by VATS*
Atsushi Watanabe, et al.
Dept of Thoracic and Cardiovascular Surgery, Sapporo Medical University, Japan
Eur J Thorac Cardiovasc Surg 2005;27:745–752
VATS LobectomyComplications
• 932 (84.7%) patients had no complications
• The remaining 168 patients had 1 or more of the complications
• Blood transfusion 45/1100 (4.1%)
McKenna et al. Ann Thorac Surg. 2006;81:421-425.
VATS Lobectomy
• Video-Assisted Thoracic Surgery
Lobectomy: Report of CALGB 39802—A
Prospective, Multi-Institution Feasibility
Study.
• Swanson SJ, Herndon J, D'Amico TA, et al.
J Clin Oncol 2007;25:4993-7.
Results of CALGB 39802
• 128 patients with clinical Stage I lung cancer.
• 96/111 (87%) had successful VATS lobectomy.
• Median operative time 130 minutes (47-428).
• Median chest tube duration of 3 days.
• Mortality: 2/97 (2%)
• Demonstrated safety and feasibility in multi-
institutional trial.
Thomas A. D’Amico, M.D.
Long-Term Outcomes of Thoracoscopic Lobectomy
Thorac Surg Clin 2008; 18:259-262
McKenna et al. Ann Thorac Surg. 2006;81:421-425.
T2N0M0 n=40
5 year survival rate : 78%
0
.2
.4
.6
.8
1
0 20 40 60 80 100 120 140
T1N0M0 n=153
5 year survival rate :91%
Survival after VATS Lobectomy
for pathological Stage 1 NSCLC
1999-2005 (n=193)
MOhtsuka T, Nomori H, et al. CHEST, 2004
•65: Lung Ca. Squam: 29 ADK: 33 BAC: 3
pTNM:
• Stage I : 55: Ia: T1N0: 35
Ib: T2N0: 20
• Stage II : 7: IIa:T1N1: 4
IIb:T2N1: 3
• Stage IIIa: 3 T1N2: 2 No 90 days Mortality
T2N2: 1 PAL: 3 patients
• Tumor Size (mean) 2,5 (1-6) Reinterventions 2 (PAL& hemoth)
•3: Carcinoid Tumor FUP: 5 deaths (3 ca)
•3: M1
•1: Inflamatory
72 VATS LOBECTOMY
Hospital Clínic
5 year SURVIVAL: 76%
VATS
Rigshospitalet, Copenhaghen
Hospital Clínic, Barcelona
VATS
Operating room set-up
VATS
Operating room set-up
One monitor placed on each side of the table
The surgeon and the assistant are positioned on the anterior side
The scrub nurse is opposite to the assistant
VATS
Port placement
VATS
Instrumentation╸ Thoracoscope
VATS
Instrumentation╸ Trocars
VATS
Instrumentation╸ Hand instruments
VATS
Instrumentation╸ Device for tissue cauterization
VATS
Instrumentation╸ Staplers
Emerging concept
“Small lung cancer”
• The routine use of computed tomography (CT) in clinical practice and in some screening programmes increased the number of small peripheral lung cancers, both in the form of solid or partially solid lesions, and ground glass opacities (GGOs) for which a lobectomy seems excessive.
Sublobar resection in NSCLC
• Why not to follow a similar evolution than other cancer surgeries...?
• Anatomic Segmentectomy: resection of one or more pulmonary segments with the corresponding bronchovascular elements.
• Non-Anatomic Segmentectomy or atipical segmentectomy or Wedge Resection: without following the bronchovascular elements.
Lobectomy vs Limited Resection Time to death (from any cause) by treatment
0
20
40
60
80
100
120
0 12 24 36 48 60 72 84 9610
812
0
% S
urv
ival
Lobectomy
Limited Resection
logrank p=0.088 (one-tailed)
Ginsberg and Rubinstein
Ann Thorac Surg 1995
Overall Survival – UPMC series
2-, 3-, and 5-Year Overall Survival:
Segmentectomy: 79%, 69%, 46%
Lobectomy: 68%, 59%, 47%
Landreneau et al. 1995
Recurrence-Free Survival - UPMC
Recurrence-Free Survival Stage-for-Stage:
IA- p=0.15 IB- p=0.16
Landreneau et al. 1995
Conclusions UPMC
Segmentectomy may be associated with decreased blood
loss and operative times compared with lobectomy.
Anatomic segmentectomy is associated with similar
recurrence rates compared with lobectomy, with no impact on
disease-free survival.
Anatomic segmentectomy can be performed safely with
acceptable morbidity (18.3%) and mortality (0.9%)
Margin: Tumor ratios <1 are associated with an increased
rate of recurrence..
Landreneau et al. 1995
Favorable Criteria for Anatomic Segmentectomy UPMC
• Small Tumors: < 2 cm in diameter
• Peripheral location (outer 1/3)
• Pathologic Margin > 1 cm (Margin/Tumor ratio>1)
• Age >75
• Marginal pulmonary function
• Ground glass opacities
Anatomic Segmentectomy
Landrenaeau et al. 1995
Background – VATS Segmentectomy
● Ohtsuka et al. (2004) - VATS segmentectomy (n=8)
- low peri-operative morbidity, acceptable recurrence rates
● Iwasaki et al. (2004) - VATS segmentectomy (n=40) for Stage I/II
lung cancer
- Equivalent survival compared with VATS lobes (n=100)
● Houk et al. (2004) – VATS trisegmentectomy (n=13)
- No mortality or recurrence at 13.5 months
● Shiraishi et al. (2004) – VATS=34 vs. Open=25
- ↑ Op times, ↓ length of stay
● Atkins et al. (2007) – VATS=48 vs. Open=29
- ↓ length of stay
VATS Segmentectomy (n=104)
Open Segmentectomy
(n=121)
Sig.
(P Value)
NED 87 (83.7%) 92 (76.0%) 0.19
Recurrence Locoregional
Distant
17 (16.3%)
5 (4.8%)
12 (11.5%)
29 (24.0 %)
12 (4.9%)
16 (13.2%)
0.10
0.14
0.84
Follow-Up 16.2 28.2 0.005
Recurrence Patterns – UPMC
series
Landreneau et al 2008
Recurrence-Free Survival - UPMC
VATS Segmentectomy
VATS segmentectomy is associated with
decreased LOS and pulmonary complications.
VATS anatomic segmentectomy is associated with
a similar recurrence rate compared with open
segmentectomy, with no impact on disease-free or
overall survival.
VATS anatomic segmentectomy can be performed
safely with acceptable morbidity and mortality
WE STILL HAVE TO SAY LOBECTOMY… VATS IS AS
STANDARD AS OPEN BUT MORE AND MORE USED
Sublobar resection for lung cancer is still a
controversial issue, specially, in T1aN0 disease.
Prospective clinical trial may resolve this issue.
Actually, Both US and Japan have ongoing
prospective phase III trials in order to establish the
standard procedure for small NSCLC.
What is a standard procedure for
NSCLC?
3rd European Lung Cancer Conference 2012
Ran
dom
ize
Peripheral carcinoma, <=2 cmNegative hilar node
Lobectomy
Segmentectomy
Endpoints: Primary: OSSecondary: pulmonary function
Sample size: 1,100/485
JCOG0802/WJOG4607L; Phase III Randomized Trial between Lobectomy and Limited Resection for Part-solid GGO – Solid T1a disease
Non-inferiority design
Stratified factors;
Institute, Gender,
Histology (Ad vs, Non-ad),
Solid or non-solid
PI: Asamura H. (JCOG) & Okada M (WJOG)
Since Aug. 2009
Ran
dom
ize
Peripheral carcinoma, <=2 cmNegative hilar node
Lobectomy
Sublobar resection
(segmentectomy/ wedge)
Endpoints: Primary: DFSSecondary: OS, pulmonary function
Sample size: 908
CALGB140503-Intergroup; Phase III Randomized Trial between Lobectomy and Sublobar Resection for Small-sized carcinoma
Non-inferiority design
Stratified factors;
Tumor size,
Histology (Sq vs. non-sq)?,
Smoking status
PI: Altorki N
Since Sep. 2007
Take home messagesSurgical Treatment of Early Stage Lung Cancer
• Use VATS when possible.
• As for the surgical intervention; American and Japanese
studies are ongoing.
At the moment,
• More than 20mm mixed GG adenocarcinoma
(C/T rate=50% or more) ; lobectomy.
• 20mm or less mixed GG adenocarcinoma (C/T rate=50%
or less); sublobar resection may be considerable.
• Surgical procedures depend on location, size, CT
findings (density, C/T rate) and/or frozen pathological
findings.
Thank you for your
attention!!!