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

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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

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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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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
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SBRT and SR NCI studies

• RTOG 0236 (n55)
• medically inoperable Median FU 24.8m
• Local failure 5
• Loco-regional failure 12.8
• Grade 3 or higher toxicity 16
• Mortality 0

• Z4032 (n222)
• 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

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RFA stage I NSCLC ToxicityHikari et al. JTCVS
201114224-30

• 50 patients -52 treatments
• CTCAE V4.0
• Grade 2 AE -12
• Grade 3 AE-6 (n3, effusion, empyema, BPF)
• 3-year overall survival 67 with median FU 37
  months

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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

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Case 1

• 60 yr woman
• Stress echo-
• EF 35
• PFTs
• FVC 1.53(49)
• FEV1 0.51(20)
• DLCO 1.22(5)

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Case 2 Stage IV cancer

• Bilateral localized lung cancers
• Negative mediastinum and metastatic work-up
• PFTs
• FVC 0.87(35)
• FEV1 0.67(39)
• DLCO (35)
• Hx tracheostomy ARDS within year of presentation

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Case 2 CT Scout
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Case 2 CT
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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

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

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RFA of central non-hilar vessel
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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

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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

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Microwave Ablation
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Microwave ablation

• Proximal amplification effect if probes are too
  close to each other (lt8mm)
• 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

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Complications after SBRT

• Mortality minimal
• One study-dose escalation had 7.14 mortality
• Fakiris Int J Rad Oncol Biol Phy 2009
• Related to high-dose SBRT to central tumors
• Bronchial stenosis airways leading to pneumonia,
  hemoptysis, resp failure
• 27.7 became O2 dependant after Rx

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Proximal Bronchial Tree Diagram
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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

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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

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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, DONT place camera
  right over blood vessel

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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

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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)

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Thankyou!