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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

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I have the following real or perceived conflicts of interest that relate to this presentation:

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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

Video ARPON MELANOMA MARINA

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!!!