Complications; Best Ways to avoid and how to handle difficult ones Session II; Small lung tumors

1. Complications; Best Ways to avoid and how to handle difficult onesSession II; Small lung tumors Hiran C Fernando FRCS, FACS Chief Thoracic Surgery Boston Medical Center, Boston University

2. Presenter DisclosureHiran C Fernando FRCSThe following relationships exist related to this presentation: CSA Medical ( Role Consultant; Not relevant to presentation Galil (Role Consultant; Not relevant to presentation

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4. Small Cancers; High-risk operable patients What is the best therapy? SBRT/ ablation surgery Mortality & morbidity; worse QOL issues initially worse Tumor completely resected Lymph nodes can be addressed More attractive to patients Less initial mortality & morbidity But: may have viable cancer remaining Lymph nodes not addressed

5. SBRT and SR; NCI studies • RTOG 0236 (n=55) • medically inoperable Median FU 24.8m • Local failure 5% • Loco-regional failure 12.8% • Grade 3 or higher toxicity 16% • Mortality ; 0% • Z4032 (n=222) • High-risk operable • Median FU TBD • Local failure (TBD) • Loco-regional failure (TBD) • Grade 3 or higher toxicity 27.9% (30 days) • Mortality 1.4%

6. RFA stage I NSCLC; ToxicityHikari et al. JTCVS 2011;142:24-30 • 50 patients -52 treatments • CTCAE V4.0 • Grade 2 AE -12% • Grade 3 AE-6% (n=3, effusion, empyema, BPF) • 3-year overall survival 67% with median FU 37 months

7. Patient selection • Critical to select patients appropriately to optimize chances oncological success and minimize morbidity • Consider tumor location; • Peripheral 1/3, middle 1/3, inner 1/3 • Proximity to blood vessels, airway, relationship to fissure

8. Case 1 • 60 yr woman • Stress echo- • EF 35% • PFT’s • FVC 1.53(49%) • FEV1 0.51(20%) • DLCO 1.22(5%)

9. Case 2; Stage IV cancer • Bilateral localized lung cancers • Negative mediastinum and metastatic work-up • PFT’s • FVC 0.87(35%) • FEV1 0.67(39%) • DLCO (35%) • Hx tracheostomy ARDS within year of presentation

10. Case 2; CT Scout

11. Case 2; CT

12. Issues with Thermal ablation • RFA; • Deployable probes with multiple tines • Direction deployment different • Straight probes • Heat synch effect protective • Microwave • Straight probes • Heat synch effect less, so risk injury higher • Can burn chest wall

13. RITA XL Valleylab RFA Technical Considerations LeVeen (Bost. Scient.) Slide and Illustrations courtesy of David Lu, M.D.

14. RFA technical considerations • Consider proximity to large blood vessels • Consider how probe deploys in relation to vessels • Do not ablate close to PA /PV at hilum • OK to ablate close to non-hilar blood vessel

15. RFA of central non-hilar vessel

16. Initial RFA Experience at UPMC • One early mortality • Central nodule (metastatic carcinoma) treated with RFA • Following this had HDR-endobronchial brachytherapy for endbronchial disease • massive hemoptysis 19 days post RFA

17. Mortality after RFA • 2008; reviewed mortalities from FDA database • Some cases preventable • Resp arrest during concious sedation (pt with sleep apnea, COPD and CAD) • PA injury during needle advancement , massive hemoptysis (pulmonologist consulted…..) • Prior pneumonectomy- patient d/c ‘d and represented with hemothorax • Prior pneumonectomy; Pneumothorax- hemlich valve placed and discharged, readmitted with resp failure

18. Microwave Ablation

19. Microwave ablation • Proximal amplification effect if probes are too close to each other (<8mm) • Oval burn that propogates proximally along antenna. • Can burn skin/soft tissue • Inject saline into soft tissue at probe insertion sites, measure skin temperature during ablation • Caution-close to blood vessels

20. Complications after SBRT • Mortality minimal • One study-dose escalation had 7.14% mortality • FakirisInt J Rad OncolBiolPhy 2009 • Related to high-dose SBRT to central tumors • Bronchial stenosis airways leading to pneumonia, hemoptysis, respfailure • 27.7% became O2dependant after Rx

21. Proximal Bronchial Tree Diagram

22. Challenges with VATS wedge • Greatest challenge is identifying small lesions/GGO • Hookwire with methylene blue • Nav bronch-dye marking • Radiology coils • Dividing thick lung tissue and risk air-leaks • Compress tissue first with long clamp (Landreneau Masher) • Consider “Black load tristapler” or “Ethicon Echelon”

23. Challenges with VATS segmentectomy • Same challanges as lobectomy • Vessel and bronchial dissection as well as incomplete fissure • Same tricks as VATS lobe • Lymph node dissection, silk-ties, low-profile stapler (multifire), reticulating staplers, consider energy devices, clips or ties for small vessels

24. Bleeding during VATS segmentectomy • Sponge stick ready all the time • If bleeding apply pressure and wait if controlled. • Get team ready to convert (assistant, anesthesia, lines, blood in room, nurses • However may not need to convert • When reexamine bleeding site, DON’T place camera right over blood vessel

25. Challenges with Brachytherapy • Ideally sew mesh on re-expanded lung • Usually not feasible with VATS • Therefore check re-expansion as mesh can constrict lung and need to be readjusted • Consider clamp trial before removing chest-tube, to minimize need for new tube placement after chest-tube removal

26. Short, obese patients • Can be challenging as even with lung collapse, there is minimal space between chest wall and lung • Hard to move instruments in intercostal spaces • Probably best patients for robotic procedures (but also most challenging if bleeding occurs)

27. Thankyou!