SURGERY SECTION - ALTERNATE TECHNIQUES FOR SURGICAL RESECTION OF LUNG CANCER: VIDEO ASSISTED THORASCOPIC SURGERY by Scott Swanson, MD

SLIDES & TRANSCRIPTS
Tuesday, June 19

SURGERY SECTION - ALTERNATE TECHNIQUES FOR SURGICAL RESECTION OF LUNG CANCER: VIDEO ASSISTED THORASCOPIC SURGERY

Scott Swanson, MD

Slide 1: Introduction

DR. SWANSON: Thank you very much. I was asked to discuss, as Scott mentioned, alternative resection techniques. And I was going to start by going over a little bit about video assisted lobectomy, to try to show you that I think it's a feasible approach, particularly in small tumors. Also I will briefly touch on what might be the best treatment, as Valerie Rusch pointed out, for these very small tumors that have a high chance of being cured.

Slide 2: Technique of Resection

The standard has evolved, and for the non-surgeons in the audience, two of the real leaders in the field back in the fifties had somewhat of a hostile, or certainly enthusiastic discussion at one of our major meetings in 1950, where the idea of a lobectomy was somewhat heretical, and pneumonectomy at that point was standard operation. Evarts Graham said, "It might be far better to take a chance with lobectomy in such case, and make the patient less of a respiratory cripple than would be by perhaps doing a better operation, a total pneumonectomy, but leaving him so uncomfortable that life is hardly worthwhile for him." And he said that to Edward Churchill. So I think we have to keep our mind open as we go forward with these small lesions, as to what is the best operation.

Slide 3: Technical Options

Technical options include pneumonectomy, lobectomy, segmentectomy, wedge resection, and then with two approaches, either thoracotomy or thoracoscopy.

Slide 4: Open or Closed

As everyone is familiar with here, a thoracotomy is a source of pain and pulmonary dysfunction. And there is a mortality associated simply with a thoracotomy operation, presumably from the pulmonary dysfunction. A thoracoscopy is purported to have less trauma, less pain, and the real question is do you have the same surgical capability?

Slide 5: Background

Minimally invasive surgery has been a major advance in surgery, and the paradigm for that would be laproscopic cholecystectomy. Video assisted thorascopic or thoracic surgery is really considered the technique of choice for lung biopsies and lobectomy, and for pleurodesis after pneumothorax. It is still somewhat controversial for anatomic resection.

Slide 6: VATS Lobe

Why is it controversial? Well, with a variable definition as to what a VATS lobectomy really means, it could anything from a small thoracotomy, to what is called a SIS lobectomy, which simultaneous stapling of the hilum, to a true thorascopic lobectomy. There were really haven't been any adequate standard randomized trials to date, and the outcome measures aren't that well documented. There are certainly oncological concerns about this operation, however, single institution reports which suggest there is a benefit.

Slide 7: VATS Lobe

. The combined experience as of a couple of years ago was published by Rob McKenna in Chest Surgery Clinics of North America. He did a meta-analysis of 1,120 patients. The mortality rate was 0.6%. The morbidity rate was between 10-20%. And the bronchial stump leak rate was about a third of a percent. Conversion from a straight thorascopic technique to a thoracotomy occurred in 11% of the cases, and mostly it was because the surgeon didn't think he could get an adequate cancer operation. Visibility was a reason in 30%, and it was very unusual to have significant bleeding, less than 1% of the time this was the reason to convert.

Slide 8: Series

And this is a table that shows those series. Most of them range from 30 up to as high as 212 patients. You can see the range of mortality, and the length of stay.

Slide 9: QOL Data

In terms of the quality of life data from these studies, the average length of stay, or median length of stay is 5.3 days. There have been two studies that document as well as we have, the idea of pain, studied by Walker from Scotland. It showed less morphine use in a comparative study between VATS and open thoracotomy. And Giudicelli did a randomized study between muscle sparing thoracotomy and VATS approach, and showed also less pain, albeit these are small numbers, and very few in number. In terms of post-thoracotomy pain syndrome, for this meta-analysis it was found to be 2%, which is lower than we would see for a thoracotomy approach.

Slide 10: Oncologic Issues

What about the oncologic issues I mentioned? Survival is usually done in a retrospective manner and in a single institution, but in McKenna's series he believes that it demonstrates better results than a comparative group of open thoracotomies. Kaseda from Japan showed a 94% four year survival for stage 1 lung cancer. Port site recurrence issues, that some people are worried about. We presented our data that showed one port site recurrence out of 475 thorascopic resections for malignancy. There is new data coming online as we speak about the potential immunologic benefit. Walker, in an early series in 1996, showed that there is less C reactive protein and IL6 levels seen in the thorascopic approach, and enhanced monocyte and neutrophils function. There are more and more studies that are looking into this.

Slide 11: VATS Lobectomy

This is the graph of the survival from McKenna's series. The top line is the stage I data, and the bottom line is the stage IIIA data.

Slide 12: Current Study

Currently, we have a CALGB study, which is an Intergroup study that is to standardized the definition of VATS lobectomy. It's a multi-institution study. It is phase II feasibility study, and it's obviously prospective. We are measuring the success rate, or conversion rate with a prospective group of patients who aim to have a VATS lobectomy. Also, what is the morbidity and mortality, and a second endpoint is cancer recurrence and survival in this phase II trial. It will close next month, and it will accrue about 135 patients. We plan to open a phase III trial in the winter of this year.

Slide 13: Technique Standardization

The technique is standardized to include no rib spreading. Certainly, if quality of life and pain are reasons to consider this approach, we think that the pain is probably related to the spreading of the ribs. You can have up to an 8-centimeter axis incision simply to get the lobe out of the chest. It averages typically about 5 centimeters. And there is standard individual hilar dissection, and standard node sampling or dissection. Surgeons must be credentialed in both VATS surgery and then in VATS lobectomy. We have had a couple of national courses now, and plan to have another one in the fall to help teach the technique to make it safe and standard.

Slide 14: Port Placement and Incision

I'm going to briefly show you a few video clips, to show the technique, to show you that it really is feasible. [Video Clip] This is a picture of the port placement. And the head of the bed is at the top of the page, the feet at the bottom. This is the scapula. This would be the axis incision in the fourth interspace anteriorly. Here would be the camera port in the seventh interspace. And here is another port posteriorly. [Video Clip] And this is a video clip just illustrating that.

Slide 15: Port Placement and Incision

Here is the head of the bed, the feet, the lateral decubitus position. This is the posterior port, the tip of scapula, the access incision, and the camera port. [Video Clip] This is going to be a right upper lobectomy.

Slide 16: Dissection and Division

We dissect out the anterior hilum. This is the superior pulmonary vein with a clamp bringing a tie around it. This is a technique we use to do this safely which involves a phalange to a catheter that helps us get a three dimensional feeling for a two dimensional situation. [Video Clip]

Slide 17: Dissection and Division

The head of the bed is up here, the feet are here. This is medially, this is the heart beating, the lung here being retracted posteriorly. The surgeon is dissecting out the anterior hilum, the upper pulmonary vein. I'm not sure how well that's projecting, but you can see the two branches to the upper lobe. The middle lobe branch is here. The surgeon can both look through the access incision, and this is coming up from the camera incision, which is on the screen. So by going back and forth, you can get an idea of more three dimensions.

Slide 18: Dissection and Division

This is the upper vein. Here is the middle lobe vein. I'm not sure how well this projects, but in reality it's very well seen.

Slide 19: Dissection and Division

Here is a clamp coming around the upper vein. I'll just show you a brief clip of how we divide this vein. [Video Clip] This is that red rubber catheter I showed you earlier, which can be placed over the endoscopic stapler. And by having a phalanged end, it allows us to know that the stapler is going to fit comfortably around the space we are going to place it before pushing it through. And you see that being applied here to the upper vein. This can all be done in a very controlled fashion, in a similar way to how it would be done in an open technique.

Slide 20: Dissection and Division

Following the vein, we then go on to do the artery. This is the truncus anterior branch, the posterior recurrent branch. The lung is being brought posteriorly.

Slide 21 Dissection and Division

Hopefully, this is reminiscent from your old anatomy lab for anyone who is not a surgeon. [Video Clip] This is the artery being dissected. And that is a suction device that just helps keep the field clear. [Video Clip] I'll skip through this for the sake of time. [Video Clip]

Slide 22: Dissection and Division

Finally after this, we divide the bronchus, which can be done by bringing the stapler through the posterior port, or it can be brought up through the camera port, which you will see in this clip. The right angle clamp going around the upper lobe bronchus, a self-tie being brought around it, and then the same technique using the phalange catheter to safely pass the endo-GI stapler that can be seen here. And again, one can see that this is a standard-type operation, with hilar dissection just as we do in an open technique. There is simply no difference. We test inflate the lung, just as we do in an open technique, to make sure air flow is unobstructed. Then we divide the bronchus. We then go on to create the fissure. Now if you do it in this technique where you get all the structures first, an incomplete fissure becomes irrelevant, and not a problem. Some of the earlier techniques, it was a contraindication to a VATS lobectomy, but using this technique, it's not. [Video Clip]

Slide 23: Nodal Sampling

Then following that, we can do a node sampling or dissection. Here is a set of nodes being resected from the peribronchial area, again just as we do in an open technique.
[Video Clip] This is one area that has had some controversy associated with it. Can we do an adequate node sampling? Here is a posterior view of the hilum. This is the right upper lobe stump, the bronchus intermedius. And there is a node here that will be harvested by the surgeon in just a minute. And I think the answer is certainly yes, for anyone who does these operations, that it can be done. [Video Clip]

Slide 24: Specimen Removal

Then the specimen is placed in a bag, and it just needs to be a fairly heavy bag, so it doesn't rip on the way out. But other than that, it is fairly easy to get it out through a small incision.

Slide 25: Specimen Removal

The lung is mostly filled with air, and it does collapse well. [Video Clip] This is the surgical bed when we are done, and the specimen, which again, is a standard lobe. The surgeon will show you the tumor here in just a second.

Slide 26: Best Operation

So you can see from a view like that, that it's a fairly straightforward thing to do. And I think we'll show with our phase II study that it is feasible. And I think the question really will be is it better? And also as Valerie Rusch pointed out, is a lobectomy going to be necessary? I think the data for this would be the lung cancer study group data that Valerie nicely presented. And against it would be some of the early segmentectomy data from Jensik and Reed and Warren and others. Our experience with small nodules, doing mostly either segmentectomies or wedge resections showing a 90% cancer-free five year survival. And the point about a 10% rate of second lung primary cancers at 10 years that Dr. Martini's studies showed that Dr. Rusch pointed out earlier, are all reasons to consider doing a lesser operation.

Slide 27: Wedge vs Lobectomy

As Valerie pointed out, the lung cancer study group was a T1 N0 247 patients. There was no difference in morbidity and mortality, other than there was a 5% prolonged ventilatory dependence in the lobectomy group. Late pulmonary function was similar, although the data was incomplete. Only two-thirds had long-term follow-up. Five-year survival favored the lobectomy group. Local recurrence was clearly higher with the segmentectomy group. And in that study it was a 5% incidence of second primaries.

Slide 28: Graph

This is a graph of our survival of 40 patients who had 1 centimeter or less non-small cell lung cancers, the N of 9 here is the anatomic resection, either segment or lobe, and 31 had wedges. This was not a significant difference, however, the numbers are small.

Slide 29: Required Information

So the best operation, I think we need some more information. We are going to need data about nodal patterns. There is a 5-10% incidence of skip mets. And I think Mike Liptay is going to give us some very exciting information about sentinel node, and whether that can help us with this. We have heard earlier about biologic behavior of some of these different tumors. Is there is a way to identify them up front? A genetic analysis with microarray type analysis. We have done some of that work in stage I cancers that we're getting ready to publish, that would suggest there are four or five patterns in stage I adenocarcinomas that can be identified using this type of genetic footprint. Also biomarker analysis, all of that will be very helpful to tell which are the bad tumors, and which aren't the bad ones. And I think we may need to consider a randomized study of say a segmentectomy versus lobectomy for these 1 centimeter or less tumors.

Slide 30: Summary

So in summary, a VATS lobectomy will be feasible for these early stage lung cancers, and I think we need to determine whether it's going to be better. The correct operation is not obvious for the small tumors. And I think the current standard still is and should be a lobectomy with lymph node sampling or dissection. I do think we need to consider segmentectomy with the same lymph node sampling or dissection, and perhaps look at a study. Along the way we've got to clearly look at sentinel nodes, biomarkers, and genetic analyses. Thanks very much.