VATS Segmentectomy AATS Focus on Lung Cancer Boston Nov 2012

1. VATS SegmentectomyAATS Focus on Lung CancerBostonNov 2012 Scott J. Swanson, M.D. Professor of Surgery Harvard Medical School Director of Minimally Invasive Thoracic Surgery Brigham and Women’s Hospital

2. Disclosures • I have no conflicts for this talk • I serve as a consultant to Covidien and Ethicon

3. Segmental Lung Resection History • Evarts Graham (St Louis) reported the first successful pneumonectomy for lung cancer using a tourniquet technique in 1933 • Belsey and Churchill (Boston, 1939) – suggested segmentectomy was a reasonable option for bronchiectasis • Bonfil-Roberts and Claggett (NY, Minneapolis, 1972) reported that segmentectomy was reasonable for small lung cancers • Currently lobectomy with lymph node dissection is the gold standard for surgical treatment of lung cancer

4. Technical Options Pneumonectomy Lobectomy Segmentectomy Wedge Thoracotomy vs Thoracoscopy

5. Best Operation Evolving - 1930 -50 = pneumonectomy 1950-2009 – lobectomy Issues Small lesions - subcentimeter Detected by screening 80-90% survival with resection (sublobar) 20% - new lung primary in 10 yrs Lobectomy vs segmentectomy/wedge

6. Standard for Surgical Resection of Lung Cancer Standard has evolved! Evarts Graham to Edward Churchill, AATS 1950 “It might be far better to take a chance with LOBECTOMY in such case and make the patient less of a respiratory cripple than he would be by perhaps doing a better operation, a total PNEUMONECTOMY but leaving him so uncomfortable that life is hardly worth while for him”

8. SegmentectomyTechnique Isolation, division and suture of appropriate segmental bronchus, artery and vein May include up to 2 adjacent segments

9. Segmentectomy History Churchill and Belsey (1939) – Bronchiectasis Overholt + Langer (1947) - TB/Bronchiectasis Bonfils-Roberts + Clagett (1972) -Carcinoma

11. Segmentectomy – Jensik 1979 N=168 for peripheral Stage I Mortality < 2% Prolonged air leak 6% Survival 53% at 5 years Local recurrence = 10%

12. Segmentectomy vs Lobectomy Read, 1990 244 patients, T1N0 NSCLC Mortality= 2.9% (no difference) 5% yr survival = 78% ( cancer deaths no diff.) Local recurrence 8.2% Lobectomy = 11.5% Segmentectomy = 4.4%

13. Segmentectomy vs Lobectomy for Stage I lung cancer Warren and Faber JTCS 1994 • N = 173 Stage I NSCLC pts 1980-1988 • Segmentectomy - 68 • Lobectomy – 105 • 169/173 pts for followed for 5 yrs • No survival difference for tumors < 3.0 cm • For entire group there was a difference in local regional recurrence • Segmentectomy 15/66 (22.7%) • Lobectomy 5/103 (4.9%)

14. Lung Cancer Study GroupSublobar rxn vs Lobectomy Randomized trial for T1 N0 247 patients No difference in periop morbidity and mortality Except 5% prolonged ventilator dependence in lobectomy group Late pulmonary function similar though data incomplete 5 year survival –p = 0.09 (trend favoring lobectomy) Local recurrence: 2.4x with segmentectomy/wedge Second primaries= 5% Ginsberg and Rubinstein Ann Thor Surg 1995

15. Lobectomy vs. Sublobar ResectionLCSG Trial Ginsberg et al Ann Thorac Surg 1995;60:615-623 Ginsberg and Rubinstein Ann Thor Surg 1995

16. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study Okada et al JTCS 2006 • 1992-2001, comparative study, 3 institutions, peripheral < 2cm nsclc • N = 305 sublobar resection, 262 lobectomies • Median f/u > 5yr • Recurrence and survival rates no different • Pulmonary function better for sublobar pts • Conclusion – sublobar resection is a reasonable treatment option for pts with 2 cm or less nsclc even if low risk

17. Schema and patient profile Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study Okada et al JTCS 2006

18. Results Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study Okada et al JTCS 2006

19. Post-operative pulmonary function Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study Okada et al JTCS 2006

20. Segmentectomy Indications Peripheral T1N0 AND Limited cardiopulmonary reserve Synchronous lung primary tumors Marginal pulmonary reserve and concern for metachronous primary tumors i.e. following a small contralateral lesion

21. Segments Left upper division (tri-segment) Lingula Superior segment either lower lobe Composite basilar segments either lower lobe Posterior segment right upper lobe

22. Segmentectomyvs wedge rxn • Segmentectomy • Better deep margin (El Sharif et al Ann Surg Onc 2007) • Better nodal evaluation/clearance • Wedge resection • Adequate for peripheral (subpleural), small (1 cm) lesions when margin is wide (diameter of lesion or more) • If lesion straddles segmental boundary (i.e. between lingula and upper division)

23. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally invasive approachAtkins et al. Ann Thorac Surg 2007 • Retrospective review • 77 consecutive segmentectomy, pts 2000-2006 • Thoracoscopic (TS) (n=48) or thoracotomy (n=29) • 27/48 TS and 12/29 open for primary lung cancer • No conversions • Similar operative variables between groups • Similar outcomes but hospital stay was less among TS pts – 6.8 vs 4.3d p=0.03 • 30 d mortality 6.9% for open group and 0% for TS • Long term survival better for TS group (p=0.0007)

24. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally invasive approach Atkins et al (D’Amico) Ann Thorac Surg 2007

25. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally invasive approach Atkins et al (D’Amico) Ann Thorac Surg 2007

26. ThoracoscopicSegmentectomy Compares Favorably with ThoracoscopicLobectomy For Small Stage I Lung Cancers Shapiro, Wisnivesky, …. Swanson. JTCS June 2009

27. ThoracoscopicSegmentectomy Compares Favorably with ThoracoscopicLobectomy For Small Stage I Lung Cancers Shapiro, Wisnivesky, …. Swanson. JTCS June 2009

28. ThoracoscopicSegmentectomy Compares Favorably with ThoracoscopicLobectomy For Small Stage I Lung Cancers Shapiro, Wisnivesky, …. Swanson. JTCS June 2009

29. ThoracoscopicSegmentectomy Compares Favorably with ThoracoscopicLobectomy For Small Stage I Lung Cancers Shapiro, Wisnivesky, …. Swanson. JTCS June 2009

30. ThoracoscopicSegmentectomy Compares Favorably with ThoracoscopicLobectomy For Small Stage I Lung Cancers Shapiro, Wisnivesky, …. Swanson. JTCS June 2009

31. ThoracoscopicSegmentectomy Compares Favorably with ThoracoscopicLobectomy For Small Stage I Lung Cancers Shapiro, Wisnivesky, …. Swanson. JTCS June 2009

32. RLL medial and anterior basilar segmental resection 58 yo woman with a round 2.0 cm lesion in the right lower lobe. Needle biopsy suggested spindle cell neoplasm

33. Right lower lobe basilar lesion

34. Right Basilar Segmentectomy

35. RLL Basilar Seg- followup • Pathology : completely resected 2.0 cm inflammatory myofibroblastic tumor with benign lymph nodes

36. VATS RLL composite basilar sgementectomy for small lung cancer 68 yo woman who had a left upper lobectomy following neoadjuvant chemoradiation therapy for stage IIIa lung cancer 7 yrs earlier Developed a slowly growing vague 2 cm lesion in base of right lower lobe

37. Right Lower Composite Basilar Segmentectomy

38. Conclusion Standard surgical resection for lung cancer is evolving Currently lobectomy with lymph node dissection is the gold standard For lesions < 2cm consideration should be given for a sublobar resection Segmentectomy is superior to wedge resection when anatomically appropriate Segmentectomy can be done via VATS CALGB 140503 is the best way to study this All patients who are candidates should be enrolled