thoracic surgery innovations. innovations vats lvrs chemotherapy radiotherapy pet small cell n2...
TRANSCRIPT
Thoracic SurgeryInnovations
Innovations
• VATS• LVRS• Chemotherapy• Radiotherapy• PET• Small Cell• N2• Stents & Lasers• Stapler In Oesophagogastrectomy• Epidural• SVC stents
VATS
• Sympathectomy• Pleurectomy• Lobectomy• Biopsy
– mass– lung
Pneumothorax
Pleurectomy
• VAT
• Muscle sparing
• Mini
• Full Thoracotomy
VAT Lobectomy
Biopsy Lung / Pleura
LVRS
LVRS
LVRS• Criteria
• Dyspnoeic on daily activities• Age < 75• No bullae > 5cm• Generalised emphysema with regional heterogeneity• TLC > 125%• FEV1 < 30 %• PaCO2 < 50 mmHg, PaO2 > 40 mmHg on air• No CAD or Pulmonary hypertension• Steroid < 15 mg/day
LVRS
• Unilateral / Bilateral
• Thoracotomy / Sternotomy / VAT
• Role of Physio
Chemotherapy and Radiotherapy
• Preoperative Neoadjuvant
• Operative
• Postoperative Adjuvant
Chemotherapy• Numerous agents
• Adjuvant
– Stage II (T2N0)– ? Role in N2 disease– All oat cell
• Neoadjuvant
• Stage IIIA (N2)– If respond are resected– No residual tumour at surgery means prolonged survival– Experimental
Radiotherapy
• External beam external rays– Single / multiple beam / Fraction No
• Brachy local ie intra bronchial– Interstitial directly into tumour– Intra cavity in bronchus
• Adjuvant Postoperative
• Neoadjuvant Preoperative
Radiotherapy• Primary treatment
– Stage 1 and 2 – Refuse or unfit for surgery– Failure 30 % stage 1 (T1N0), 70% stage 2 (T2N0)– 5 year survival 5 to 40%
• Adjuvant for N1 / N2
– Reduces rate local recurrence– Survival unchanged– ? Role in +Ve resection margins
Radiotherapy• Neoadjuvant
– T3 Pancoast prior to surgery
• Palliative
– Symptomatic relief– Pain, haemoptysis, bronchial, SVC obstruction– Bone met pain
• Brachytherapy
– Local application high local dose
Chemotherapy and Radiotherapy
• Adjuvant• Neoadjuvant
• Sequential / concurrent / alternating
• Good performance status• Not standard practice
• May increase risk surgery
PET
• 2-(fluorine-18) fluo-2-deoxy-D-glucose (18-FDG)
• 18-FDG competes with glucose for facilitated transport into tumour cells and also competes with glucose for phosphorylation by hexokinase
• Positive and negative predictive power
Small Cell Lung Cancer
Small Cell
All need :
Mediasteinoscopy
CT head
Bone scan
Pre operative N2
• Young patients
• Pre op chemo downstage
• No evidence
Stents & Lasers
Malignant terminal conditions that are inoperable
Benign inoperable conditions
Tracheal obstruction-malignant - Pre and post Nd:Yag laser
Left main bronchus extensive
squamous cell carcinoma
Metal stent in left main
Stapler In Oesophagogastrectomy
Epidural
• Pain• Poor PFTs• Cardiac history
• Contraindications– Low risk– On anticoagulants– Consent– Anatomical– Infective
SVC Stents
Any
Questions
?
Next Week
2nd March
Inotropes
ITU seminar room