thoracoscopic sleeve resection and ... - duke university · duke cancer institute ... lobectomy: a...

Thoracoscopic Sleeve Resection

and Pneumonectomy

Thomas A. D’Amico MD Gary Hock Professor of Surgery

Chief Thoracic Surgery, Chief Medical Officer Duke Cancer Institute

8th Masters of Minimally Invasive Thoracic Surgery

Orlando

September 25, 2015

Thoracoscopic Lobectomy

Disclosures

Consultant for Scanlan Instruments

No conflicts of interest related to this presentation


Video-assisted thoracic surgery sleeve

lobectomy: a case series Mahtabifard A, et al. Ann Thorac Surg. 2008;85:S729-32

• 13 patients, no conversions

• Median operative time 167 minutes

• ICU stay 0-4 days

• Median hospital stay 3 days (2-8 days)

• No complications in 9 patients (69%)

• Morbidity in 4 patients: Atrial fibrillation,

reintubation, anastomotic stricture, and bronchial

tear requiring repair


Does Thoracoscopic Pneumonectomy for

Lung Cancer Affect Survival? Nwogu CE, et al. Ann Thorac Surg 2010;89:2102-2106

• Pneumonectomy for malignancy (2002-08)

• 70 patients: VATS 24, Open 35, Conversions 8

• VATS: shorter LOS and less blood loss

• Conversion pts: longer LOS and more blood loss

• Complication rates similar among all 3 groups

• 30-day mortality: 1 death in VATS and open

groups

Performing Sleeve Lobectomy Instead of

Pneumonectomy for Non-Small Lung Cancer with

N1 Nodal Disease Does Not Compromise Long-

Term Survival

Mark F. Berry MD, Mathias Worni MD MHS, Xiaofei

Wang PhD, David H. Harpole MD, Thomas A. D’Amico

MD, Mark W. Onaitis MD

Ann Thorac Surg 2013; 97: 230-235


Recurrences

Local Recurrences after Sleeve Resection

– 6 in mediastinal lymph nodes

– 2 in the ipsilateral hilum

– 1 in the distal bronchus

Pneumonectomy

(n=52)

Sleeve Lobectomy

(n=35)

p

Distant 9 (26%) 13 (25%) 1

Local/Regional 5 (10%) 9 (26%) 0.07

Thoracoscopic Lobectomy Pneumonectomy 52 37 27 20 13 11 Sleeve Resection 35 26 20 16 13 11

65% 3-year survival

47% 3-year survival

p=0.23

Does Pneumonectomy Have a Role in the

Treatment of Stage IIIA

Non-Small Cell Lung Cancer?

Shah AA, Worni M, Kelsey CR, Onaitis MW, D'Amico

TA, Berry MF. Does pneumonectomy have a role in the

treatment of stage IIIA non-small cell lung cancer? Ann

Thorac Surg Ann Thorac Surg 2013; 95:1700-1707

Southern Thoracic Surgical Association

November 10, 2012


Patient Characteristics

Variable N=55

Age (years) 62 ± 12

Gender (male) 64%

FEV1 (% predicted) 64 ± 18

DLCO (% predicted) 72 ± 20

Smoking history 91%

Pack year history of smokers 50 ± 27

Coronary artery disease 15%

Diabetes 16%


Pre-Surgery Staging and Treatment

Induction Therapy 31%

Preoperative chemotherapy 7%

Preoperative chemoradiation 24%

Chemotherapy regimens

Carboplatin + Navelbine 6

Carboplatin + Taxol 4

Cisplatin + Docetaxel 2

Other 5

Staging Techniques N=55

Chest CT 100%

PET 75%

Brain MRI/CT 49%

Mediastinoscopy 89%


Perioperative Outcomes

Perioperative Mortality 9%

Induction vs. No induction 18% vs 5% (P=0.17)

Any Complication 58%

Blood product transfusion 29%

Atrial fibrillation 20%

Need for postoperative bronchoscopy 11%

Vocal cord paralysis 11%

Bronchopleural fistula 7%

Pneumonia 7%

Length of hospital stay (median [25th, 75th) 5 (5,7)

Recurrence 31%


Pathology

Right Pneumonectomy 38%

Tumor Size (cm) 5.8 ± 3.1

Histology

Squamous Cell Carcinoma 62%

Adenocarcinoma 16%

Large Cell 7%

Other 15%

TNM Stage

T3-4N0-1 58%

T1-T3N2 42%

R0 Resection 93%


Adjuvant Therapy

Radiation 11%

Chemotherapy 29%

Unknown if chemotherapy given 13%

Reason for no adjuvant chemotherapy N=32

Early death 8

Poor performance status 6

Progressive disease 5

Physician decision 4

Patient preference 3

Postop complication 3

Unknown 3


Overall Survival

Median: 16.5

months

3-year: 36%

5-year: 29%

Risk Factors HR P

Age (>60 vs <60) 3.49 0.001

N2 vs N0-1 1.03 0.94

Induction Treatment 2.32 0.03

Adjuvant Treatment 0.39 0.02


Survival Stratified by N2 Status

P=0.59


Survival Compared to Other Series

First author Periop

Mortality

Median Survival

(months)

3-Year

Survival

5-Year

Survival

Albain 26% 18.9 36% 22%

Van Meerbeeck 7% 13.4 12%

Stefani 7.6% 25.9 23%

Paul 3.2% 22%

Weder 3%* 23 43% 38%

Steger 6.4% 26 33%

This series 9% 16.5 36% 29%

* 90 day


Conclusions

Long-term survival after pneumonectomy for stage

IIIA NSCLC is acceptable

Pneumonectomy may not be appropriate after

induction therapy

Patient selection and operative technique that limit

perioperative morbidity and allow adjuvant

chemotherapy use are critical to optimizing

outcomes


Video

56 yo woman with progressive shortness of breath

CT: tumor left upper lobe/distal left main bronchus

thoracoscopic sleeve resection and ... - duke university · duke cancer institute ... lobectomy: a...

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