Lung Cancer:Lung Cancer:an overview & discussion of an overview & discussion of

minimally invasive surgical therapyminimally invasive surgical therapy

Conrad Massimo Vial, MD

Director of Cardiothoracic SurgeryMills Peninsula Health System

Tumor

T1 T2 T3 T4

Nodes

N0

N1

N2

N3

IA IB IIB IIIB

IIIB IIIB IIIB IIIB

IIIA IIIA IIIA IIIB

IIA IIB IIIA IIIB

Stage IV = M1Stage IIIB and IV generally unresectable

Lung Cancer

5-yr survival for treated NSCLC according to

surg-path state:

Stage I: ≈ 70%

Stage II: ≈ 50%

Stage III: ≈ 20%

Minimally Invasive Lung Minimally Invasive Lung Cancer OperationsCancer Operations

Video Assisted Thoracoscopic (VATS) Video Assisted Thoracoscopic (VATS) LobectomyLobectomy

& & Lung Sparing OperationsLung Sparing Operations

The Traditional ApproachOpen Thoracotomy

Video Assisted Thoracoscopy (VATS)

VATS Lobectomy

Results in the Literature

• Advantages of VATS Approach . . .Advantages of VATS Approach . . .– Less postoperative painLess postoperative pain– Shorter length of stayShorter length of stay

•Reduced air leaks/length of chest tube Reduced air leaks/length of chest tube placementplacement

•Reduced overall hospital costReduced overall hospital cost

– Faster recovery/return to normal activitiesFaster recovery/return to normal activities– Better postoperative pulmonary functionBetter postoperative pulmonary function– More likely to complete postoperative More likely to complete postoperative

chemotherapychemotherapy

Literature Summary

• VATS lobectomy offers advantages VATS lobectomy offers advantages over conventional thoracotomy over conventional thoracotomy without compromise of short term or without compromise of short term or long term outcomelong term outcome

• VATS lobectomy can become a cost VATS lobectomy can become a cost effective alternative to open effective alternative to open lobectomy in the treatment of lobectomy in the treatment of operable NSCLCoperable NSCLC

Lung Sparing OperationsLung Sparing Operations

Bronchoplasties & Sleeve ResectionsBronchoplasties & Sleeve Resections

Definition of Bronchoplastic Techniques

Sleeve Sleeve LobectomyLobectomy

vsvs

Bronchial Sleeve Bronchial Sleeve ResectionResection

AA

Results in the LiteratureResults in the Literature

• 30 day mortality for all bronchoplastic 30 day mortality for all bronchoplastic procedures is 8%procedures is 8%

• Mortality for sleeve lobectomy is 5%Mortality for sleeve lobectomy is 5%• Mortality for sleeve pneumonectomy is Mortality for sleeve pneumonectomy is

20 – 25%20 – 25%• Mortality rates double or triple in the Mortality rates double or triple in the

presence of;presence of;– Poor pulmonary function (FEVPoor pulmonary function (FEV11< 50% < 50%

predicted)predicted)– Pulmonary hypertensionPulmonary hypertension– Severe coronary artery diseaseSevere coronary artery disease

What are we doing?What are we doing?What are our results?What are our results?

Conrad M Vial, MDConrad M Vial, MDTomomi Oka, MDTomomi Oka, MD

Program in CT Surgery Program in CT Surgery Overall Volume & Outcomes 2008-Overall Volume & Outcomes 2008-

20102010

TOTAL CASES = 1216

MORTALITY = 0.7%

MAJOR MORBIDITY = 3.9%

CARDIAC CASES = 529

MORTALITY = 1.5%

MAJOR MORBIDITY = 6.2%

THORACIC CASES = 687

MORTALITY = 0.4%

MAJOR MORBIDITY = 2.8%

Diversity & Complexity of Diversity & Complexity of Major Thoracic OperationsMajor Thoracic Operations

Diversity & Complexity of Diversity & Complexity of Major Thoracic Lung OperationsMajor Thoracic Lung Operations

Bronchoplasty and/or Sleeve

Resectionn=15

Thoracoscopic Lobectomy

n=107

STS NATIONAL DATABASESTS NATIONAL DATABASEInfluence of Functional Score in Influence of Functional Score in

Resections for Lung CancerResections for Lung Cancer

ZUBROD ZUBROD SCORESCORE MORTALITYMORTALITY LOS > 14 LOS > 14

DAYSDAYS COMPLICATIONSCOMPLICATIONS

00 1.3%1.3% 4.8%4.8% 32%32%

11 1.8%1.8% 6.8%6.8% 35%35%

22 3.5%3.5% 12%12% 41%41%

33 7%7% 14%14% 46%46%

44 16%16% 21%21% 51%51%

STS NATIONAL DATABASESTS NATIONAL DATABASEInfluence of FEVInfluence of FEV11 in Resections for in Resections for

Lung CancerLung Cancer

Preop FEVPreop FEV11 MORTALITYMORTALITY LOS > 14 DAYSLOS > 14 DAYS COMPLICATIONSCOMPLICATIONS

> 80% pred> 80% pred 1.1%1.1% 4%4% 30%30%

61-79% pred61-79% pred 2%2% 8%8% 39%39%

< 60% pred< 60% pred 2%2% 9%9% 41%41%

Diversity & Complexity of Diversity & Complexity of Major Thoracic Operations for Major Thoracic Operations for

Lung CaLung Ca

Bronchoplasty and/or Sleeve

Resectionn=15

Thoracoscopic Lobectomy

n=107

CRUDE BenchmarkingCRUDE Benchmarking“Best Case” vs Non-risk adjusted“Best Case” vs Non-risk adjusted

Best Case Lung Ca Best Case Lung Ca Resection STS ScenarioResection STS Scenario MortalityMortality

LOS LOS

> 14 > 14 daysdays

ComplicationsComplications

Preop FEVPreop FEV11 > >80% pred 80% pred

& &

Zubrod Score 0Zubrod Score 0

~1.2%~1.2% ~4%~4% ~30%~30%

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