aats skills course may 4, 2013webcast.aats.org/2013/files/saturday/20130504_101e_1330_14.00... ·...

AATS Skills Course

May 4, 2013

Thomas A. D’Amico MD

Professor and Vice Chair of Surgery

Chief Thoracic Surgery

Chief Medical Officer, Duke Cancer Institute

Thomas A. D’Amico MD Professor and Vice Chair of Surgery

Chief Thoracic Surgery Chief Medical Officer, Duke Cancer Institute

Thoracoscopic Lobectomy:

Mediastinal Lymph Node Dissection

AATS Skills Course

May 4, 2013

MLND: Thoracoscopic vs Open

Disclosure

• No conflicts related to this presentation


Oncologic Outcomes

• Ability to achieve complete resection

• Survival and other oncologic surgical outcomes

• Immunologic competence

• Compliance with adjuvant therapy

• Mediastinal lymph node dissection


Mediastinal Lymph Node Staging

• Important component of the assessment and

management of patients with NSCLC

• Although rigid standards regarding the conduct

and extensiveness of MLN staging do not exist,

current guidelines suggest that the assessment of a

minimum of three N2 nodes should be included,

in addition to the removal of regional N1 nodes


Adoption of Thoracoscopic Lobectomy

• Several factors may explain the lack of complete

adoption

• Inadequate experience during training

• Concerns regarding oncologic effectiveness

• One specific concern relates to the ability of

thoracoscopic surgery to achieve adequate staging

of the mediastinum


Mediastinal Lymph Node Dissection

• Several studies confirm equivalent lymph node

dissections


Is complete systematic nodal dissection by

thoracoscopic surgery possible? Kondo et al JTCVS 1998; 116: 651-2

• 6 patients underwent VATS lobectomy with

MLND followed by thoracotomy

• # LN by VATS lobectomy was 27-48

• Remaining LN found in 2 patients at thoracotomy

• Weight of LN tissue resected by VATS was 5.0-

16.1 g


Is complete systematic nodal dissection by

thoracoscopic surgery possible? Kondo et al JTCVS 1998; 116: 651-2

• In the 2 patients in whom remaining LN were

found at thoracotomy, the weight of the

additionally dissected tissue was 0.6 and 0.2 g

• The percentage of lymph nodes remaining was

3.5% and 2%, respectively

• Overall percentage of LN remaining after

systematic nodal dissection by VATS lobectomy

was 3.4% by #, and 1.5% by weight


Sugi et al

• Randomized trial, with 100 consecutive patients

with clinical stage IA NSCLC

• Endpoints: nodal dissection and survival

World J Surg. 2000;24 : 27-31

MLND: Thoracoscopic vs Open Duke Thoracic

Oncology

Program

Sugi World J Surg. 2000;24 : 27-31


Compared LN harvest in 350 patients with c-Stage I

NSCLC

• 191 thoracoscopic lobectomies and 159 open

lobectomies

Surgery. 2005;138:510-517.


Watanabe et al Surgery. 2005;138:510-51


Watanabe et al Surgery. 2005;138:510-517

Surgery. 2005;138:510-517.


Is VATS a feasible approach for c-N0/p-N2

NSCLC? Watanabe A et al. Eur J Cardiothorac Surg 2008;33:812-818

• 770 patients who underwent lobectomy and

MLND by VATS or thoracotomy

• 69 patients were upstaged from cN0 to pN2

NSCLC

• The rate of LN upstaging was similar between the

two groups

• The 3-year and 5-year recurrence-free survivals

were similar


Lymph Node Evaluation in VATS Lobectomy

Versus Lobectomy by Thoracotomy Denlinger C et al Ann Thorac Surg 2010;89:1730-1736

• Barnes Hospital, St. Louis: 79 VATS and 464 open lobectomy or segmentectomy

• No differences in N1 node sampling

• Fewer N2 nodes sampled with VATS vs thoracotomy (2.5 vs 3.3; p=0.004)

• Fewer station 7 lymph nodes with VATS vs thoracotomy (0.6 vs 1.2; p=0.002)

• Fewer total # nodes sampled with VATS vs thoracotomy (7.4 vs 8.9 p=0.029)

• No difference in 2-year survival: (81% vs 83%, p=0.4)


Lymph Node Evaluation by Open or VATS Approaches in

11,500 Anatomic Lung Cancer Resections Boffa DJ, et al Ann Thorac Surg 2012;94:347-353

• STS database: lobe/segment resection 2001-11

• 11,531 (7,137 open, 4,394 VATS) c-stage I

• Upstaging: Open 14%, VATS 12% (p < 0.001)

• N0 to N1 higher in open (9% vs 7%; p < 0.001)

• N0 to N2 similar (5% open, 5% VATS; p = 0.52)

• 2,745 propensity-matched pairs, N0 to N1 lower

with VATS (7% vs 9%; p = 0.002)


Prevalence of nodal upstaging (cN0 to pN1) by

participant use of VATS


Nodal Upstaging is Lower after Thoracoscopic

Lobectomy Compared with Thoracotomy for

Clinical Stage-1 Lung Cancer: A Nationwide Study Licht P et al STS January 28, 2013

• Danish Lung Cancer Registry was 2007-11

• 1675 patients: lobectomy for clinical stage-1

• VATS: 751 patients (45%)

• # of LN stations not significantly different

• Nodal upstaging: 319 (19%) significantly more

frequent after thoracotomy in both N0 to N1

upstaging (14.0%vs. 8.3%, p<0.001) and in N0 to

N2 upstaging (10.9% vs. 3.6%, p<0.001)


Open Lobectomy for Early Stage Lung Carcinoma

Achieves a Superior Lymph Node Dissection

Compared to Thoracoscopic Lobectomy Merritt RE et al STS January 28, 2013

• 130 pts lobectomy c-stage I-II NSCLC-54% open

• Mean # LN in open group was significantly

higher (15.4 vs. 9.8, p=0.002)

• Upstaging: Open 28.5% vs VATS 10% [p=0.02]

• Kaplan-Meier 3-year survival was similar

between the groups


Hypothesis

There is no difference in the efficacy of

mediastinal lymph node assessment whether

lobectomy is performed with a Thoracoscopic

approach or with an Open approach


Patients and Methods

• NCCN NSCLC Database: Web-based database

of patients who received primary treatment for

NSCLC since 2007 at 8 of the 21 NCCN

institutions

• Efficacy of MLN assessment analyzed in patients

who underwent lobectomy: VATS vs Open

Ann Thorac Surg 2011;92:226-232


Patients and Methods

The # and location of all N1 and N2 lymph node

stations resected was analyzed by approach

1. The # of N2 LN stations resected

2. The % of patients with >3 MLN stations resected

3. The total # of lymph nodes (N1+N2)

4. The degree of upstaging and downstaging


Results

• 2007 -2010: 4215 patients with NSCLC

• 851 pts underwent lobectomy for c-Stage I-III

• 388 evaluable pts underwent lobectomy:

199 Thoracoscopic and 189 Open

• There was no difference in age, sex, co-

morbidities, performance status, or histology


# N2 Lymph Nodes: Open Vs VATS

Median Mean

Open 3 2.9

VATS 3 3.2 p=0.12

# of LN Stations

# o

f P

atie

nts


At Least 3 N2 Lymph Node Stations

# N2

Stations

Open Thoracoscopic P value

N % N %

<3 77 42% 67 34% 0.12

>3 107 58% 130 66%


Total Lymph Nodes (N1+N2): Open vs VATS

Median Mean

Open 4 4.4

VATS 4 4.8 p=0.06

# of LN Stations

# o

f P

atie

nts


Upstaging Thoracoscopic Pathologic N: Up-Staging

Clinical N N0 N1 N2 Total

N0 152 11 4 171

N1 4 3 1 8

N2 4 0 10 14

Open Pathologic N: Up-Staging


N0 122 10 11 145

N1 3 11 2 17

N2 4 2 17 23

9%

14%; P=.15


Downstaging Thoracoscopic Pathologic N: Down-Staging


N0 152 11 4 171

N1 4 3 1 8

N2 4 0 10 14

Open Pathologic N: Down-Staging


N0 122 10 11 145

N1 3 11 2 17

N2 4 2 17 23

29%

26%; P=1.0


Summary

• The majority of patients who underwent

lobectomy by either a Thoracoscopic or Open

approach had at least 3 MLN stations assessed

• There was no difference in

1. # of N2 LN stations resected

2. % of patients with >|3 MLN stations assessed

3. Total # of LN stations (N1 + N2) by approach

4. Degree of upstaging or downstaging


• 21 comparative studies: 2 randomized

• Morbidity, mortality, recurrence, 5-year mortality

http://jco.ascopubs.org/cgi/doi/10.1200/JCO.2008.18.2733


Systematic Review and Meta-Analysis of

Randomized and Nonrandomized Trials on Safety

and Efficacy of VATS Lobectomy

• VATS did not demonstrate any significant

difference in locoregional recurrence (P= 0.24)

• VATS associated with reduced systemic

recurrence rate (P=0.03) and an improved 5-year

mortality rate of VATS (P =0.04)


All-Cause Mortality


• Meta-analysis of 3 studies with propensity

matching

• Villamizar N, et al. J Thorac Cardiovasc Surg

2009; 138: 419

• Paul S, et al et al. J Thorac Cardiovasc Surg:

2010; 139: 366

• Ilonen IK et al. Acta Oncologic 2011; 50: 1126

Ann Cardiothorac Surg 2012: 1: 16-23


Relative Risk of All Cause Mortality Un-matched

Matched


Randomized Trial of MLNS vs MLND During

Pulmonary Resection for N0-1 NSCLC: Results of

the ACOSOG Z0030 trial Darling GE, et al. J Thorac Cardiovasc Surg. 2011;141:662-670

• 1,111 patients randomized intraoperatively after

MLNS performed (555 MLNS, 556 MLND)

• In the MLND group, only 20 patients (3.8%) were

found to have occult N2 disease

MLNS MLND P value

Deaths 214 (42.9%) 217 (41.3%) NS

Median Survival 8.1 years 8.5 years p=0.531

Time to recurrence 5.7 years 6.1 years p=0.655


In Order To Avoid Complete MLND

1. T<3cm

2. Appropriate preoperative mediastinal lymph

node assess including EBUS or mediastinoscopy

3. Complete hilar dissection

4. Frozen section negative on all 10, 11, and N2

lymph nodes


Summary

• There is no difference in the efficacy of MLN

assessment whether lobectomy is performed by

thoracoscopy or thoracotomy

• Concerns about the efficacy of MLN resection

should not limit the adoption of thoracoscopic

lobectomy


Duke Approach Anterior superior

iliac crest

Thoracoscopic Lobectomy: Duke Approach

2 incisions: Camera port (1 cm) + Access incision (4.5 cm)


Duke Approach

Thoracoscopic Lobectomy: Duke Approach

2 incisions: Camera port (1 cm) + Access incision (4.5 cm)

Anterior superior

iliac crest

aats skills course may 4, 2013webcast.aats.org/2013/files/saturday/20130504_101e_1330_14.00... ·...

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