the role of video assisted thoracic surgery in the management of lung cancer nepal c. chowdhury, md...

THE ROLE OF VIDEO ASSISTED THE ROLE OF VIDEO ASSISTED THORACIC SURGERY IN THE THORACIC SURGERY IN THE

MANAGEMENT OF LUNG CANCERMANAGEMENT OF LUNG CANCER

NEPAL C. CHOWDHURY, MDNEPAL C. CHOWDHURY, MD

CARDIOTHORACIC & VASCULAR SURGERYCARDIOTHORACIC & VASCULAR SURGERY

ST. MARY’S MEDICAL CENTERST. MARY’S MEDICAL CENTER

OVERVIEW OF LUNG CANCEROVERVIEW OF LUNG CANCER

•• BackgroundBackground

––EpidemiologyEpidemiology

––SignificanceSignificance

––Risk factorsRisk factors

•• Goals of surgical therapy for lung cancerGoals of surgical therapy for lung cancer

•• Comparison of thoracotomy vs. minimally invasive lung resectionsComparison of thoracotomy vs. minimally invasive lung resections

ESTIMATED CANCER DEATHS FOR ESTIMATED CANCER DEATHS FOR SELECTED CANCER SITES IN US, 2007SELECTED CANCER SITES IN US, 2007

STATESTATE ALL ALL SITESSITES

BRAIN/ BRAIN/ NSNS

BREASTBREAST COLORCOLORECTALECTAL

LEUKELEUKEMIAMIA

LIVERLIVER LUNG/ LUNG/ BRONCBRONCHUSHUS

LYMPHLYMPHOMAOMA

OVARYOVARY PANCRPANCREASEAS

PROSTPROSTATEATE

OHIOOHIO 24,60024,600 540540 1,8201,820 2,3502,350 950950 600600 7,3107,310 610610 650650 1,3701,370 1,3501,350

KENTUKENTUCKYCKY

9,3909,390 150150 600600 860860 320320 220220 3,4503,450 290290 220220 460460 310310

WEST WEST VIRGINIVIRGINIAA

4,6104,610 9090 280280 480480 130130 110110 1,4501,450 170170 140140 220220 160160

USUS 559,650559,650 12,74012,740 40,46040,460 52,18052,180 21,79021,790 16,78016,780 160,390160,390 18,66018,660 15,28915,289 33,37033,370 27,05027,050

LUNG CANCERLUNG CANCER

Leading cause of cancer death for both men and womenLeading cause of cancer death for both men and women

More people die of lung cancer than of colon, breast and prostate More people die of lung cancer than of colon, breast and prostate cancers combinedcancers combined

In 2008: about 215,020 new cases of lung cancer (NSCCA and In 2008: about 215,020 new cases of lung cancer (NSCCA and SCCa)SCCa)11

About 161,840 will die of this disease in 2008About 161,840 will die of this disease in 200811

Overall cost of treating lung cancer exceeds $9.6 billion in the US Overall cost of treating lung cancer exceeds $9.6 billion in the US each yeareach year22

1.ACS: www.cancer.org1.ACS: www.cancer.org

2. Medical Care v40 IV104-117, 20022. Medical Care v40 IV104-117, 2002

RISK FACTORSRISK FACTORS

Tobacco Smoking (responsible for > 87% of cases)Tobacco Smoking (responsible for > 87% of cases)Age (>70% of people with lung ca are > 65yo)Age (>70% of people with lung ca are > 65yo)Asbestosis (50 –90x)Asbestosis (50 –90x)Radon: naturally occurring radioactive gas that results from the Radon: naturally occurring radioactive gas that results from the breakdown of uranium in soil and rocks breakdown of uranium in soil and rocks Radiation therapy to the chestRadiation therapy to the chestArsenic, certain mineral exposure (silicosis, berylliosis), uranium, Arsenic, certain mineral exposure (silicosis, berylliosis), uranium, gasolinegasolineFamily history (inheritance of certain DNA changes on ch 6)Family history (inheritance of certain DNA changes on ch 6)

CANCERS AMONG MENCANCERS AMONG MEN

Prostate cancer (145.3) Prostate cancer (145.3) – First among men of all races and Hispanic origin. First among men of all races and Hispanic origin.

Lung cancer (85.3) Lung cancer (85.3) – Second among white (84.4), black (104.5), Asian/Pacific Islander (49.7), and Second among white (84.4), black (104.5), Asian/Pacific Islander (49.7), and

American Indian/Alaska Native (51.1) men. American Indian/Alaska Native (51.1) men. – Third among Hispanic men (48.5). Third among Hispanic men (48.5).

Colorectal cancer (58.2) Colorectal cancer (58.2) – Second among Hispanic men (50.3). Second among Hispanic men (50.3). – Third among white (57.0), black (67.6), Asian/Pacific Islander (42.0), and Third among white (57.0), black (67.6), Asian/Pacific Islander (42.0), and

American Indian/Alaska Native (32.6) men. American Indian/Alaska Native (32.6) men.

Note: The numbers in parentheses are the rates per 100,000 Note: The numbers in parentheses are the rates per 100,000 persons.persons.

Source: U.S. Cancer Statistics Working Group. Source: U.S. Cancer Statistics Working Group. Centers for Disease Control and Prevention, and Centers for Disease Control and Prevention, and National Cancer Institute; 2007.National Cancer Institute; 2007.

LEADING CAUSES OF CANCER DEATHS LEADING CAUSES OF CANCER DEATHS AMONG MENAMONG MEN

Leading causes of cancer death among men:Leading causes of cancer death among men:

Lung cancer (70.3) Lung cancer (70.3) – First among men of all racial and Hispanic origin. First among men of all racial and Hispanic origin.

Prostate cancer (25.4) Prostate cancer (25.4) – Second among white (23.4), black (56.1), American Indian/Alaska Native (16.5), Second among white (23.4), black (56.1), American Indian/Alaska Native (16.5),

and Hispanic (19.3) men. and Hispanic (19.3) men.

Colorectal cancer (21.6) Colorectal cancer (21.6) – Third among men of all races and Hispanic origin. Third among men of all races and Hispanic origin.

Liver cancer Liver cancer – Second among Asian/Pacific Islander men (15.1). Second among Asian/Pacific Islander men (15.1).



CANCERS AMONG WOMENCANCERS AMONG WOMEN

Three most common cancers among women:Three most common cancers among women:

Breast cancer (117.7) Breast cancer (117.7) – First among women of all racial and Hispanic origin populations. First among women of all racial and Hispanic origin populations.

Lung cancer (54.2) Lung cancer (54.2) – Second among white (55.5) and American Indian/Alaska Native (35.3) women. Second among white (55.5) and American Indian/Alaska Native (35.3) women. – Third among black (50.4), Asian/Pacific Islander (26.9), and Hispanic (26.7) Third among black (50.4), Asian/Pacific Islander (26.9), and Hispanic (26.7)

women. women.

Colorectal cancer (42.7) Colorectal cancer (42.7) – Second among black (50.6), Asian/Pacific Islander (32.1), and Hispanic (34.2) Second among black (50.6), Asian/Pacific Islander (32.1), and Hispanic (34.2)

women. women. – Third among white (41.6) and American Indian/Alaska Native women (28.7). Third among white (41.6) and American Indian/Alaska Native women (28.7).



LEADING CAUSES OF CANCER DEATHS LEADING CAUSES OF CANCER DEATHS AMONG WOMENAMONG WOMEN

Lung cancer (40.9) Lung cancer (40.9) – First among white (41.9), black (40.0), Asian/Pacific Islander (18.1), and First among white (41.9), black (40.0), Asian/Pacific Islander (18.1), and

American Indian/Alaska Native (30.2) women. American Indian/Alaska Native (30.2) women. – Second among Hispanic women (14.4). Second among Hispanic women (14.4).

Breast cancer (24.4) Breast cancer (24.4) – First among Hispanic women (15.7). First among Hispanic women (15.7). – Second among white (23.8), black (32.3), Asian/Pacific Islander (12.6), and Second among white (23.8), black (32.3), Asian/Pacific Islander (12.6), and

American Indian/Alaska Native (15.0) women. American Indian/Alaska Native (15.0) women.

Colorectal cancer (15.2) Colorectal cancer (15.2) – Third among women of all races and Hispanic origin (15.2). Third among women of all races and Hispanic origin (15.2).



COMPARATIVE NO OF DEATH PER YEARCOMPARATIVE NO OF DEATH PER YEAR

STAGINGSTAGING

Tx: unable to visualize tumorTx: unable to visualize tumorTisTisT0: no evidence of primaryT0: no evidence of primaryT1 < 3 cm, surrounded by parenchymaT1 < 3 cm, surrounded by parenchymaT2: > 3cm in size, or T2: > 3cm in size, or or assoc. atelectasis / pneumonitis / in the lobar bronchus, but 2 cm distal to the carina or or assoc. atelectasis / pneumonitis / in the lobar bronchus, but 2 cm distal to the carina or invading visceral pleura invading visceral pleura T3 invades the chest wall or pericardium, parietal pleura without involving intrathoracic major T3 invades the chest wall or pericardium, parietal pleura without involving intrathoracic major structures, within 2 cm of the carina, atelectasis / pneumonitis of whole lungstructures, within 2 cm of the carina, atelectasis / pneumonitis of whole lungT4: invasion of intrathoracic structures, or satellite nodule in the same lobe, malignant pleural or T4: invasion of intrathoracic structures, or satellite nodule in the same lobe, malignant pleural or pericardial effusionpericardial effusion

NXNXN0N0N1: ipsilateral hilar LNN1: ipsilateral hilar LNN2: ipsilateral mediastinal or subcarinalN2: ipsilateral mediastinal or subcarinalN3: contralateral mediastinal / hilar, supraclavicularN3: contralateral mediastinal / hilar, supraclavicular

MxMxMoMoM1 including additional nodule in ipsilateral different lobeM1 including additional nodule in ipsilateral different lobe

STAGINGSTAGINGNEW RECOMMENDATION BY IASLCNEW RECOMMENDATION BY IASLC

Tx: unable to visualize tumorTx: unable to visualize tumorTisTisT0: no evidence of primaryT0: no evidence of primaryT1 < 3 cm, surrounded by parenchymaT1 < 3 cm, surrounded by parenchyma T1a: <2 cmT1a: <2 cm

T1b: 2-3 cmT1b: 2-3 cmT2: > 3cm in size, T2: > 3cm in size, T2a: 3-5 cmT2a: 3-5 cm

T2b: 5-7 cmT2b: 5-7 cm(Tumor > 7 cm : T3)(Tumor > 7 cm : T3)

or assoc. atelectasis / pneumonitis / in the lobar bronchus, but 2 cm distal to the carina or invading visceral or assoc. atelectasis / pneumonitis / in the lobar bronchus, but 2 cm distal to the carina or invading visceral pleura pleura T3: > 7 cm (T2)T3: > 7 cm (T2)or satellite nodule in the same lobe (T4)or satellite nodule in the same lobe (T4)or invades the chest wall or pericardium, parietal pleura without involving intrathoracic major structures, within 2 or invades the chest wall or pericardium, parietal pleura without involving intrathoracic major structures, within 2 cm of the carina, atelectasis / pneumonitis of whole lungcm of the carina, atelectasis / pneumonitis of whole lungT4: invasion of thoracic structures, or satellite nodule in the different ipsilateral lobe (M1a)T4: invasion of thoracic structures, or satellite nodule in the different ipsilateral lobe (M1a)

NXNXN0N0N1: ipsilateral hilar LNN1: ipsilateral hilar LNN2: ipsilateral mediastinal or subcarinalN2: ipsilateral mediastinal or subcarinalN3: contralateral mediastinal / hilar, supraclavicularN3: contralateral mediastinal / hilar, supraclavicular

MxMxMoMoM:M: M1a: Pleural and Pericardial disseminationM1a: Pleural and Pericardial dissemination

M1b: Distant metastasesM1b: Distant metastases

Molecular staging in Stage I lung cancer: p53, Angiogenesis VIII, erbB-2, and rb (Ann Thorac Surg 2008; 85: S737-Molecular staging in Stage I lung cancer: p53, Angiogenesis VIII, erbB-2, and rb (Ann Thorac Surg 2008; 85: S737-42)42)

International association for study of lung cancerInternational association for study of lung cancer

STAGE OF LUNG CANCER AT DIAGNOSISSTAGE OF LUNG CANCER AT DIAGNOSIS

NCI: SEER cancer statistics review 1973-2002

POSTSURGICAL SURVIVAL POSTSURGICAL SURVIVAL based on TNM subsetsbased on TNM subsets

MOUNTAIN, 1997MOUNTAIN, 1997 NARUKE, 1988NARUKE, 1988

STAGESTAGE TNMTNM NN 5- Yr Survival5- Yr Survival NN 5- Yr Survival5- Yr Survival

1A1A T1N0M0T1N0M0 511511 67.067.0 245245 75.575.5

1B1B T2N0M0T2N0M0 549549 57.057.0 241241 57.057.0

IIAIIA T1N1M0T1N1M0 7676 55.055.0 6666 52.552.5

IIBIIB T2N1M0T2N1M0 288288 39.039.0 153153 40.040.0

T3N0M0T3N0M0 8787 38.038.0 106106 33.333.3

IIIAIIIA T3N1M0T3N1M0 5555 25.025.0 8585 39.039.0

Any N2M0Any N2M0 344344 23.023.0 368368 15.115.1

Mountain CF: Revisions in the International System for Staging Lung Cancer. Chest 111:1710-1717, 1997; Mountain CF, Dressler CM: Regional lymph node classification for lung cancer staging. Chest 111:1718-1723, 1997; and Naruke T, Tomoyuki G, Tsuchiya R, Suemasa K: Prognosis and survival in resected lung carcinoma based on the new international staging system. J Thorac Cardiovasc Surg 96:440-447, 1988.

SURGICAL THERAPY OF LUNG CANCERSURGICAL THERAPY OF LUNG CANCER

AIM:AIM:

Complete removal of tumor, and all associated lymphatic drainageComplete removal of tumor, and all associated lymphatic drainage

Minimize risk of tumor spillageMinimize risk of tumor spillage

En bloc resection of invaded structures is preferable to discontinuous En bloc resection of invaded structures is preferable to discontinuous resectionresection

Patient’s safetyPatient’s safety

Should have less postoperative complicationsShould have less postoperative complications

PFTPFT

Jeng-Shing Wang. Pulmonary Function Tests in preoperative pulmonary evaluation. Resp Med 2004; 98: 598-605

TYPES OF SURGICAL LOBECTOMYTYPES OF SURGICAL LOBECTOMY

Standard posterolateral thoracotomyStandard posterolateral thoracotomy

Limited thoracotomyLimited thoracotomy

Muscle sparing thoracotomyMuscle sparing thoracotomy

VATS lobectomyVATS lobectomy

CONVENTIONAL THORACOTOMYCONVENTIONAL THORACOTOMY

30-40 cm incision, cutting of muscles, and spreading of ribs

VATS LOBECTOMYVATS LOBECTOMY

•Incisions: 3-4 without rib spreading•Anatomic lobectomy using individual hilar dissection & node sampling or dissection•Lobes are removed in a bag through one port enlarged up to 6 cm

VATS LOBECTOMYVATS LOBECTOMYSUGGESTED ADVANTAGESSUGGESTED ADVANTAGES

Less postoperative painLess postoperative pain

Preservation of pulmonary funtionPreservation of pulmonary funtion

Blunted inflammatory cytokine responseBlunted inflammatory cytokine response

Shorter chest tube durationShorter chest tube duration

Shorter length of stayShorter length of stay

Reduced overall costReduced overall cost

Early return to full activityEarly return to full activity

? Adjuvant Rx better tolerated? Adjuvant Rx better tolerated

INDICATIONS OF VATS LOBECTOMYINDICATIONS OF VATS LOBECTOMY

Stage 1 lung cancerStage 1 lung cancer

A few cases of benign disease A few cases of benign disease

(Bronchiectasis, Giant bullae)(Bronchiectasis, Giant bullae)

Elderly patients with a poor performance statusElderly patients with a poor performance status

CONTRAINDICATIONS OF VATS LOBECTOMYCONTRAINDICATIONS OF VATS LOBECTOMY

AbsoluteAbsoluteInability to achieve complete resectionInability to achieve complete resection

––T3 or T4 tumorsT3 or T4 tumors––N2 or N3 diseaseN2 or N3 disease

Inability to obtain single lung ventilationInability to obtain single lung ventilationLarge Tumor > 5 cm (too large to remove through utility incision)Large Tumor > 5 cm (too large to remove through utility incision)

RelativeRelativeConditions that compromise the safety of dissectionConditions that compromise the safety of dissection

-- Pre-op chemotherapy / radiation therapy or both-- Pre-op chemotherapy / radiation therapy or both-- Presence of hilar lympnadenopathy complicating -- Presence of hilar lympnadenopathy complicating

dissectiondissection-- Presence of extensive adhesions-- Presence of extensive adhesions

Invasion of extra-pulmonary structureInvasion of extra-pulmonary structureTumors visible at bronchoscopyTumors visible at bronchoscopy

CONCERNSCONCERNS

Is it safe? So far no intra-operative death or major complicationIs it safe? So far no intra-operative death or major complication

Visualization:Visualization:

Is it complete cancer operation?Is it complete cancer operation?

Any advantages over conventional thoracotomy?Any advantages over conventional thoracotomy?

CONCERNS CONCERNS contd.contd.

Post-operative pain: usually less (has been shown in many publicationsPost-operative pain: usually less (has been shown in many publications

Post-operative pulmonary functionPost-operative pulmonary function

Effect on inflammatory response:Effect on inflammatory response:

Quality of lifeQuality of life



Discharge independence after thoracoscopic lobectomy



Outpatient support, including home health care, rehabilitation, nursing home care, or death, required for 200 consecutive thoracic surgery patients by age group at Roswell

Park Cancer Institute preceding the video-assisted thoracic surgery (VATS) lobectomy preference era

VATS LOBECTOMY VS OPEN LOBECTOMYVATS LOBECTOMY VS OPEN LOBECTOMY

Operative time: (227Operative time: (227++47 min vs 19647 min vs 196++64 min)64 min)

Mean blood loss: (150Mean blood loss: (150++126 ml vs 300 126 ml vs 300 ++192 ml; P = 0.0089)192 ml; P = 0.0089)Demmy et al Demmy et al Ann thorc surg Ann thorc surg

1999;681999;68

Days in hospital: (5.3Days in hospital: (5.3++3.7days vs 12.23.7days vs 12.2++11.1 days; 11.1 days; P = 0.02)P = 0.02)

Chest tube duration: (4.0Chest tube duration: (4.0++2.8 days vs 8.32.8 days vs 8.3++8.9 days; 8.9 days; P = 0.06)P = 0.06)

OTHER CONCERNSOTHER CONCERNS

Risk and management of intra-operative bleedingRisk and management of intra-operative bleeding

Tumor recurrence in the incisionTumor recurrence in the incision

Adequacy of cancer operationAdequacy of cancer operation

VATS LOBECTOMY: EXPERIENCE WITH 1,100 CASESVATS LOBECTOMY: EXPERIENCE WITH 1,100 CASESMcKenna RJ et al, ATS 2006; 81McKenna RJ et al, ATS 2006; 81

••Retrospective review of 1100 VATS lobectomies performed from Retrospective review of 1100 VATS lobectomies performed from 1992-20041992-2004••Diagnoses:Diagnoses:

––Primary lung cancer:Primary lung cancer: 10151015––Benign lung disease:Benign lung disease: 5353––Pulmonary metastases or lymphoma:Pulmonary metastases or lymphoma: 3232

Conversion to thoracotomy:Conversion to thoracotomy: 2828––Optimal resection:Optimal resection: 77––Bleeding:Bleeding: 66––Tumor size:Tumor size: 33– – Adhesions:Adhesions: 44––Other:Other: 77

PREOPERATIVE AND POSTOPERATIVE PREOPERATIVE AND POSTOPERATIVE STAGING OF 1015 PATIENTS (VATS)STAGING OF 1015 PATIENTS (VATS)

STAGESTAGE PREOPERATIVEPREOPERATIVE POSTOPERATIVEPOSTOPERATIVE

IAIA

IBIB

IIAIIA

IIBIIB

IIIAIIIA

IIIBIIIB

IVIV

653 (59.4%)653 (59.4%)

313 (28.5%)313 (28.5%)

14 (1.3%)14 (1.3%)

12 (0.9%)12 (0.9%)

23 (2.2%)23 (2.2%)

00

00

561 (51%)561 (51%)

248 (22.5%)248 (22.5%)

50 (4.5%)50 (4.5%)

28 (2.5%)28 (2.5%)

109 (9.9%)109 (9.9%)

17 (1.5%)17 (1.5%)

2 (0.2%)2 (0.2%)

COMPLICATIONS AFTER VATS ANATOMIC COMPLICATIONS AFTER VATS ANATOMIC RESECTIONRESECTION

No intra-operative deathsNo intra-operative deathsPeri-operative deaths (n=9) Peri-operative deaths (n=9)

--Respiratory failure (3), PE (3), MI (2) mesenteric infarction --Respiratory failure (3), PE (3), MI (2) mesenteric infarction (1)(1)

Complications 15.3%Complications 15.3%– – Air leak:Air leak: 5656– – Afib:Afib: 3232– – Serous drainage: 14Serous drainage: 14– – Readmission:Readmission: 1313– – MI:MI: 1010– – Empyema:Empyema: 44– – BPF:BPF: 33

Blood transfusions required in 4.1%Blood transfusions required in 4.1%

5 YR SURVIVAL RATES AFTER 5 YR SURVIVAL RATES AFTER OPEN VS VATS LOBECTOMYOPEN VS VATS LOBECTOMY

Mountain et al, Chest: 111: 1710, 1997Mountain et al, Chest: 111: 1710, 1997Rami-porta et al, Lung Ca: 29: 113, 2000Rami-porta et al, Lung Ca: 29: 113, 2000

McKenna et al ATS: 81: 421, 2006McKenna et al ATS: 81: 421, 2006

MOUNTAINMOUNTAIN RAMI-PORTARAMI-PORTA MCKENNAMCKENNA

STAGESTAGE N %N % N %N % N %N %

IAIA

IBIB

IIAIIA

IIBIIB

IIIAIIIA

IIIBIIIB

IVIV

511 67%511 67%

549 57%549 57%

76 55%76 55%

375 38%375 38%

399 26%399 26%

1030 4%1030 4%

1427 1%1427 1%

235 58%235 58%

817 50%817 50%

31 66%31 66%

290 42%290 42%

389 25%389 25%

138 28%138 28%

27 28%27 28%

497 76%497 76%

245 75%245 75%

245 56%245 56%

59 72%59 72%

108 33%108 33%

17 17%17 17%

VATS LOBECTOMYVATS LOBECTOMYSUMMARYSUMMARY

Safe, oncologically effective strategySafe, oncologically effective strategy

Demonstrated feasibilityDemonstrated feasibility

Demonstrated advantages:Demonstrated advantages:

1. Less pain and analgesic requirement1. Less pain and analgesic requirement

2. Preserved pulmonary function2. Preserved pulmonary function

3. Less postoperative morbidity3. Less postoperative morbidity

4. Less chest tube drainage and shorter length of 4. Less chest tube drainage and shorter length of staystay

5. Early return to full activity5. Early return to full activity

the role of video assisted thoracic surgery in the management of lung cancer nepal c. chowdhury, md...

Documents

men prostate cancer

liver cancer

breast cancer

cancer statistics

colorectal cancer

hispanic men

national cancer institute

estimated cancer deaths