wie und warum entscheidet der Chirurg - Klinik für Radio

19.12.16
“Oligo-Metastasierung als Chance zur Kombination
von zielgerichteter lokaler und systematischer
Therapie” - Symposium 2016, UniversityHospital Zurich
Offene versus thorakoskopische
Operation – wie und warum
entscheidet der Chirurg
Prof. Dr. Walter Weder, Klinikdirektor
Klinik für Thoraxchirurgie, UniversitätsSpital Zürich
Improving survival for NSCLC
1
19.12.16
3
Thoracic surgical treatment
Medical problem  surgical solution 
Lung cancer
lobectomy +
lymphadenectomy
approach
thoracotomy
VATS
Sternotomy
Thymoma
Radical thymectomy
RATS
2
19.12.16
Anterolateral Thoracotomy
Median Sternotomy
3
19.12.16
Clamshell incision
Evolution in minimal invasive thoracic surgery
Jacobeus 1910
Videoendoscopy
Late 1980‘s
robotic surgery
2000
4
19.12.16
48-year-old female with NSCLC
01/2008
Oligometastatic NSCLC
01/2008
48-year-old female with bilateral synchronous NSCLC and isolated brain metastasis
 Poorly differentiated NSCLC left upper lobe ypT2, ypN2, pM1
(BRA)
 Adenocarcinoma right upper lobe ypT2, ypNo, Mx
 Craniotomy with extirpation of brain metastasis
 3 cycles cis/gem + 3 cycles carbo/gem
 Lobectomy left upper lobe + mediastinal lymphadenectomy, VATS
 Segmentectomy right upper lobe + mediastinal lymphadenectomy, open
5
19.12.16
Follow-up PET-CT (4 years later)
04/2012
06/2012
 Local recurrence of third primary in apical segment right lower lobe
 Segmentectomy + local radiotherapy (60gy)
01/2016
 No
evidence of disease
6
19.12.16
58-year-old female
2010 presenting with dyspnoe
Tumor infiltrating the
left lower lung vein
with tumorcone
into the left atrium
Extended pneumonectomy with atrium resection on
cardiopulmonary bypass
Central adenocarcinoma
- pT4 pN0 (0/24) cM0
 2011 presenting with solitary
cerebellum metastases
 Radiotherapy of the metastases
with 10 x 3= 30 Gy
7
19.12.16
12/2015: patient in good performance status, no reccurence
Survival of surgical T4-NSCLC after induction
ypT0-3, N=15
ypT4, N=34
Induction: chemotherapy (n=38), chemoradiation (n=10), radiation (n=1)
Collaud S., Weder W. et al. In Press.
8
19.12.16
71-year-old male
squamous cell carcinoma, Stage IIIA (cT3 N1M0);
locally advanced
Preoperative imaging
9
19.12.16
Intraoperative situation
Right pulm. artery
V. azygos
V. cava sup.
Right Lung
Aorta
Pericardium
Folienmaster USZ 4:3, EN
19.12.
16
1
9
Final pathology:
ypT4 (carina) ypN2 (ATS 9) M0; IIIB
X-Ray before demission
Aorta
Pericardium
10
19.12.16
Videoassisted thoracoscopic surgery VATS
NSCLC Stage II
70-year-old smoker (20py)
11
19.12.16
Follow-up
 First postoperative day: drain removed
 Fifth postoperative day: discharged
pT2, pN1 (23), cM0
X-ray at discharge
12
19.12.16
Safety and efficacy of VATS vs. Open lobectomy
in early NSCLC
 Meta-analysis of 21 eligible comparative studies
1,391 VATS, 1,250 open
 No differences in prolonged air leak, arrhythmia, pneumonia and mortality
 No difference in loco regional recurrence
 Superiority of VATS lobectomy in systemic recurrence and 5-year mortality
Local Recurrence
Study
RR (random)
95 % CI
Weight
%
Sugi et al2
Koizumi et al10
Sakuraba et al17
Subtotal (95 % CI)
Total events: 6 (VATS), 8 Open
0.001
0.01
44.54
40.42
15.05
100.00
0.1
Favors VATS
1
10
100
RR
(random)
1.08
0.36
0.67
0.64
95 % CI
0.23 to 5.11
0.07 to 1.83
0.04 to 10.44
0.23 to 1.82
1000
Favors Open
Yan, JCO, May 2009
13
19.12.16
VATS lobectomy is cost effective
Casali, EJCTS 2009
Open lobectomy versus VATS

Mortality
VATS
open
0.8 – 1.8%
1.2 – 2.9%

Morbidity
VATS
open
9 – 19%
28 – 38%

delayed adj.
Chemotherapy
VATS
open
18%
58%
14
19.12.16
15
19.12.16
Surgical Mortality for clinical stage I-II NSCLC:
Current series from specialized centres
Author,
Year
Patients
Stage
Approach
Mortality
Stephens,
2013
307
Clinical I
VATS
0.3%
Burt,
2014
6802
Clinical I-IIIA
VATS
0.8%
Okada,
2014
634
Clinical I
Open
0%
Nasir,
2014
316
Clinical I-II
Robotic
0.3%
Weder,
2015
>400
Clinical I-II
VATS
0%
16