Transcript lung cancer - Scioto County Medical Society

THE ROLE OF VIDEO ASSISTED
THORACIC SURGERY IN THE
MANAGEMENT OF LUNG CANCER
NEPAL C. CHOWDHURY, MD
CARDIOTHORACIC & VASCULAR SURGERY
ST. MARY’S MEDICAL CENTER
OVERVIEW OF LUNG CANCER
• Background
–Epidemiology
–Significance
–Risk factors
• Goals of surgical therapy for lung cancer
• Comparison of thoracotomy vs. minimally invasive lung resections
ESTIMATED CANCER DEATHS FOR SELECTED
CANCER SITES IN US, 2007
STATE
ALL
SITES
BRAIN/
NS
BREAS
T
COLOR
ECTAL
LEUKE
MIA
LIVER
LUNG/
BRONC
HUS
LYMPH
OMA
OVARY
PANCR
EAS
PROST
ATE
OHIO
24,600
540
1,820
2,350
950
600
7,310
610
650
1,370
1,350
KENTU
CKY
9,390
150
600
860
320
220
3,450
290
220
460
310
WEST
VIRGINI
A
4,610
90
280
480
130
110
1,450
170
140
220
160
US
559,650
12,740
40,460
52,180
21,790
16,780
160,390
18,660
15,289
33,370
27,050
LUNG CANCER
Leading cause of cancer death for both men and women
More people die of lung cancer than of colon, breast and prostate
cancers combined
In 2008: about 215,020 new cases of lung cancer (NSCCA and
SCCa)1
About 161,840 will die of this disease in 20081
Overall cost of treating lung cancer exceeds $9.6 billion in the US
each year2
1.ACS: www.cancer.org
2. Medical Care v40 IV104-117, 2002
RISK FACTORS
Tobacco Smoking (responsible for > 87% of cases)
Age (>70% of people with lung ca are > 65yo)
Asbestosis (50 –90x)
Radon: naturally occurring radioactive gas that results from the
breakdown of uranium in soil and rocks
Radiation therapy to the chest
Arsenic, certain mineral exposure (silicosis, berylliosis), uranium,
gasoline
Family history (inheritance of certain DNA changes on ch 6)
CANCERS AMONG MEN
Prostate cancer (145.3)
– First among men of all races and Hispanic origin.
Lung cancer (85.3)
– Second among white (84.4), black (104.5), Asian/Pacific Islander (49.7), and
American Indian/Alaska Native (51.1) men.
– Third among Hispanic men (48.5).
Colorectal cancer (58.2)
– Second among Hispanic men (50.3).
– Third among white (57.0), black (67.6), Asian/Pacific Islander (42.0), and
American Indian/Alaska Native (32.6) men.
Note: The numbers in parentheses are the rates per 100,000 persons.
Source: U.S. Cancer Statistics Working Group.
Centers for Disease Control and Prevention, and
National Cancer Institute; 2007.
LEADING CAUSES OF CANCER DEATHS
AMONG MEN
Leading causes of cancer death among men:
Lung cancer (70.3)
– First among men of all racial and Hispanic origin.
Prostate cancer (25.4)
– Second among white (23.4), black (56.1), American Indian/Alaska Native (16.5),
and Hispanic (19.3) men.
Colorectal cancer (21.6)
– Third among men of all races and Hispanic origin.
Liver cancer
– Second among Asian/Pacific Islander men (15.1).
Note: The numbers in parentheses are the rates per 100,000 persons.
Source: U.S. Cancer Statistics Working Group.
Centers for Disease Control and Prevention, and
National Cancer Institute; 2007.
CANCERS AMONG WOMEN
Three most common cancers among women:
Breast cancer (117.7)
– First among women of all racial and Hispanic origin populations.
Lung cancer (54.2)
– 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)
women.
Colorectal cancer (42.7)
– Second among black (50.6), Asian/Pacific Islander (32.1), and Hispanic (34.2)
women.
– Third among white (41.6) and American Indian/Alaska Native women (28.7).
Note: The numbers in parentheses are the rates per 100,000 persons.
Source: U.S. Cancer Statistics Working Group.
Centers for Disease Control and Prevention, and
National Cancer Institute; 2007.
LEADING CAUSES OF CANCER DEATHS
AMONG WOMEN
Lung cancer (40.9)
– First among white (41.9), black (40.0), Asian/Pacific Islander (18.1), and
American Indian/Alaska Native (30.2) women.
– Second among Hispanic women (14.4).
Breast cancer (24.4)
– First among Hispanic women (15.7).
– Second among white (23.8), black (32.3), Asian/Pacific Islander (12.6), and
American Indian/Alaska Native (15.0) women.
Colorectal cancer (15.2)
– Third among women of all races and Hispanic origin (15.2).
Note: The numbers in parentheses are the rates per 100,000 persons.
Source: U.S. Cancer Statistics Working Group.
Centers for Disease Control and Prevention, and
National Cancer Institute; 2007.
COMPARATIVE NO OF DEATH PER YEAR
STAGING
Tx: unable to visualize tumor
Tis
T0: no evidence of primary
T1 < 3 cm, surrounded by parenchyma
T2: > 3cm in size, or
or assoc. atelectasis / pneumonitis / in the lobar bronchus, but 2 cm distal to the carina or
invading visceral pleura
T3 invades the chest wall or pericardium, parietal pleura without involving intrathoracic major
structures, within 2 cm of the carina, atelectasis / pneumonitis of whole lung
T4: invasion of intrathoracic structures, or satellite nodule in the same lobe, malignant pleural or
pericardial effusion
NX
N0
N1: ipsilateral hilar LN
N2: ipsilateral mediastinal or subcarinal
N3: contralateral mediastinal / hilar, supraclavicular
Mx
Mo
M1 including additional nodule in ipsilateral different lobe
STAGING
NEW RECOMMENDATION BY IASLC
Tx: unable to visualize tumor
Tis
T0: no evidence of primary
T1 < 3 cm, surrounded by parenchyma
T1a: <2 cm
T1b: 2-3 cm
T2: > 3cm in size,
T2a: 3-5 cm
T2b: 5-7 cm
(Tumor > 7 cm : T3)
or assoc. atelectasis / pneumonitis / in the lobar bronchus, but 2 cm distal to the carina or invading visceral pleura
T3: > 7 cm (T2)
or satellite nodule in the same lobe (T4)
or invades the chest wall or pericardium, parietal pleura without involving intrathoracic major structures, within 2
cm of the carina, atelectasis / pneumonitis of whole lung
T4: invasion of thoracic structures, or satellite nodule in the different ipsilateral lobe (M1a)
NX
N0
N1: ipsilateral hilar LN
N2: ipsilateral mediastinal or subcarinal
N3: contralateral mediastinal / hilar, supraclavicular
Mx
Mo
M:
M1a: Pleural and Pericardial dissemination
M1b: Distant metastases
Molecular staging in Stage I lung cancer: p53, Angiogenesis VIII, erbB-2, and rb (Ann Thorac Surg 2008; 85: S737-42)
International association for study of lung cancer
STAGE OF LUNG CANCER AT DIAGNOSIS
NCI: SEER cancer statistics review 1973-2002
POSTSURGICAL SURVIVAL
based on TNM subsets
MOUNTAIN, 1997
NARUKE, 1988
STAGE
TNM
N
5- Yr Survival
N
5- Yr Survival
1A
T1N0M0
511
67.0
245
75.5
1B
T2N0M0
549
57.0
241
57.0
IIA
T1N1M0
76
55.0
66
52.5
IIB
T2N1M0
288
39.0
153
40.0
T3N0M0
87
38.0
106
33.3
T3N1M0
55
25.0
85
39.0
Any N2M0
344
23.0
368
15.1
IIIA
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 CANCER
AIM:
Complete removal of tumor, and all associated lymphatic drainage
Minimize risk of tumor spillage
En bloc resection of invaded structures is preferable to discontinuous
resection
Patient’s safety
Should have less postoperative complications
PFT
Jeng-Shing Wang. Pulmonary Function Tests in preoperative pulmonary evaluation. Resp Med 2004; 98: 598-605
TYPES OF SURGICAL LOBECTOMY
Standard posterolateral thoracotomy
Limited thoracotomy
Muscle sparing thoracotomy
VATS lobectomy
CONVENTIONAL THORACOTOMY
30-40 cm incision, cutting of muscles, and spreading of ribs
VATS 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 LOBECTOMY
SUGGESTED ADVANTAGES
Less postoperative pain
Preservation of pulmonary funtion
Blunted inflammatory cytokine response
Shorter chest tube duration
Shorter length of stay
Reduced overall cost
Early return to full activity
? Adjuvant Rx better tolerated
INDICATIONS OF VATS LOBECTOMY
Stage 1 lung cancer
A few cases of benign disease
(Bronchiectasis, Giant bullae)
Elderly patients with a poor performance status
CONTRAINDICATIONS OF VATS LOBECTOMY
Absolute
Inability to achieve complete resection
–T3 or T4 tumors
–N2 or N3 disease
Inability to obtain single lung ventilation
Large Tumor > 5 cm (too large to remove through utility incision)
Relative
Conditions that compromise the safety of dissection
-- Pre-op chemotherapy / radiation therapy or both
-- Presence of hilar lympnadenopathy complicating dissection
-- Presence of extensive adhesions
Invasion of extra-pulmonary structure
Tumors visible at bronchoscopy
CONCERNS
Is it safe? So far no intra-operative death or major complication
Visualization:
Is it complete cancer operation?
Any advantages over conventional thoracotomy?
CONCERNS contd.
Post-operative pain: usually less (has been shown in many publications
Post-operative pulmonary function
Effect on inflammatory response:
Quality of life
Pain control at 3 weeks after video assisted thoracic surgery (VATS) lobectomy
Demmy T. L. et al.; Ann Thorac Surg 2008;85:S719-728S
Copyright ©2008 The Society of Thoracic Surgeons
Discharge independence after thoracoscopic lobectomy
Demmy T. L. et al.; Ann Thorac Surg 2008;85:S719-728S
Copyright ©2008 The Society of Thoracic Surgeons
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
Demmy T. L. et al.; Ann Thorac Surg 2008;85:S719-728S
Copyright ©2008 The Society of Thoracic Surgeons
VATS LOBECTOMY VS OPEN LOBECTOMY
Operative time: (227+47 min vs 196+64 min)
Mean blood loss: (150+126 ml vs 300 +192 ml; P = 0.0089)
Demmy et al Ann thorc surg 1999;68
Days in hospital: (5.3+3.7days vs 12.2+11.1 days; P = 0.02)
Chest tube duration: (4.0+2.8 days vs 8.3+8.9 days; P = 0.06)
OTHER CONCERNS
Risk and management of intra-operative bleeding
Tumor recurrence in the incision
Adequacy of cancer operation
VATS LOBECTOMY: EXPERIENCE WITH 1,100 CASES
McKenna RJ et al, ATS 2006; 81
•Retrospective review of 1100 VATS lobectomies performed from
1992-2004
•Diagnoses:
–Primary lung cancer: 1015
–Benign lung disease: 53
–Pulmonary metastases or lymphoma: 32
Conversion to thoracotomy: 28
–Optimal resection:
7
–Bleeding:
6
–Tumor size:
3
– Adhesions:
4
–Other:
7
PREOPERATIVE AND POSTOPERATIVE
STAGING OF 1015 PATIENTS (VATS)
STAGE
PREOPERATIVE
POSTOPERATIVE
IA
IB
IIA
IIB
IIIA
IIIB
IV
653 (59.4%)
313 (28.5%)
14 (1.3%)
12 (0.9%)
23 (2.2%)
0
0
561 (51%)
248 (22.5%)
50 (4.5%)
28 (2.5%)
109 (9.9%)
17 (1.5%)
2 (0.2%)
COMPLICATIONS AFTER VATS ANATOMIC
RESECTION
No intra-operative deaths
Peri-operative deaths (n=9)
--Respiratory failure (3), PE (3), MI (2) mesenteric infarction (1)
Complications 15.3%
– Air leak:
56
– Afib:
32
– Serous drainage: 14
– Readmission: 13
– MI: 10
– Empyema:
4
– BPF: 3
Blood transfusions required in 4.1%
5 YR SURVIVAL RATES AFTER
OPEN VS VATS LOBECTOMY
Mountain et al, Chest: 111: 1710, 1997
Rami-porta et al, Lung Ca: 29: 113, 2000
McKenna et al ATS: 81: 421, 2006
MOUNTAIN
RAMI-PORTA
MCKENNA
STAGE
N
%
N
N
IA
IB
IIA
IIB
IIIA
IIIB
IV
511
549
76
375
399
1030
1427
67%
57%
55%
38%
26%
4%
1%
235
817
31
290
389
138
27
%
58%
50%
66%
42%
25%
28%
28%
497
245
245
59
108
17
%
76%
75%
56%
72%
33%
17%
VATS LOBECTOMY
SUMMARY
Safe, oncologically effective strategy
Demonstrated feasibility
Demonstrated advantages:
1. Less pain and analgesic requirement
2. Preserved pulmonary function
3. Less postoperative morbidity
4. Less chest tube drainage and shorter length of stay
5. Early return to full activity