Minimally Invasive Thoracic Surgery Delivers Significant Patient Benefits
Brigham and Women’s Hospital is home to one of the largest Divisions of Thoracic Surgery worldwide. The team of 13 attending thoracic surgeons actively participates in the Thoracic Oncology Center and performs more than 3,500 procedures each year. Many of these procedures, including some of the most complex techniques, are completed using minimally invasive, image-guided approaches. “Compared with conventional procedures, newer minimally invasive and image-guided techniques in thoracic surgery not only provide a much faster recovery with less pain and risk of complications but also improved outcomes,” said Scott J. Swanson, MD, Center Director of the Thoracic Oncology Center and Chief Surgical Officer at Dana-Farber/ Brigham and Women’s Cancer Center.
Video-assisted Thoracoscopic Surgery
Thoracic surgeons in the Center have vast experience in video-assisted thoracoscopic surgery (VATS) lobectomies, thymectomies, esophagectomies, and metastasectomies, as well as innovative endoscopic and image-guided procedures. Between 80 and 90 percent of all lobectomies are performed using VATS. Dr. Swanson was the Principal Investigator of the first prospective multi-institution study (CALGB 39802) supporting the technical feasibility and safety of VATS lobectomy for the treatment of early non-small cell lung cancer (Journal of Clinical Oncology, Vol 25, No 31 (November 1), 2007: 4993-4997.).
In a comparative review of 39 studies with an aggregate of 3,256 thoracotomy patients and 3,114 VATS patients, thoracic surgeons in the Center determined that, compared with thoracotomy, VATS lobectomy appears to favor lower morbidity and improved survival rates for early-stage nonsmall cell lung cancer. VATS lobectomy was associated with shorter chest tube duration, shorter length-of-hospital stay, and improved survival at four years post resection compared with thoracotomy (Ann Thorac Surg. 2008 Dec;86(6):2008- 16; discussion 2016-8.).
In addition to a faster rate of recovery, VATS also offers:
- More rapid delivery of adjuvant therapy – Full doses of postoperative chemotherapy often can be provided sooner;
- Options for patients considered ineligible for traditional surgery, including patients with limited pulmonary and cardiac reserves;
- Fewer complications and shorter length-of-stay;
- Improved lung function.
Image-guided Diagnostic and Therapeutic Techniques
Thoracic surgeons in the Center are among few in the country to offer a comprehensive range of image-guided diagnostic and therapeutic techniques. In addition to VATS, techniques include:
- Navigational bronchoscopy uses real-time electromagnetic guidance to improve navigation within the lung parenchyma and offers diagnostic benefits over standard flexible bronchoscopy. This technique is valuable in performing biopsies of peripheral lung lesions and mediastinal lymph nodes for the staging of lung cancer, as well as in placing fiducial catheters to aid stereotactic radiotherapy;
- Endobronchial ultrasound (EBUS) enables visualization of the tissue beyond the bronchial wall, including lymph nodes and lesions outside of the bronchial airways. This technique also enables simultaneous diagnosis and lung cancer staging;
- Radiofrequency ablation is performed percutaneously under CT guidance and offers treatment for patients who are not surgical candidates or patients with unresectable tumors, as well as palliative care for patients with lung metastasis.
Evaluating Outcomes of Surgery and Chemoradiation
Thoracic surgeons together with radiation and medical oncologists in the Center have conducted studies evaluating outcomes of patients undergoing surgery and chemoradiation for lung cancer. Findings include:
- Outcomes of pneumonectomy after induction chemoradiotherapy in patients with locally advanced non-small cell lung cancer (Cancer, March 1, 2008;Vol 112: No 5: 1106-1113.) showed benefits of trimodality therapy and a low associated mortality compared to that observed in other centers;
- Brain metastases constitute the most common site of recurrence in stage IIIA non-small cell lung cancer patients downstaged to N0 disease (J Clin Oncol, 2005;23:1530- 1537.). Aggressive therapies to control brain metastases can lead to long-term survival, and future studies focusing on prophylaxis of brain metastases or more aggressive treatment may improve the outcome of these patients;
- Patients with stage IIIA N2-positive non-small cell lung cancer whose nodal disease is eradicated after neoadjuvant therapy and surgery have significantly improved cancer-free survival. Based on our results, we tailor the therapy of individual patients based on their response to various agents.
Additional studies and current endeavors include:
- Comparison of lobectomy and segmentectomy – The Center is one of few in New England to participate in a national, Phase III trial evaluating outcomes in patients undergoing either lobectomy or segmentectomy for the treatment of stage IA non-small cell lung cancer. The trial aims to determine the amount of lung tissue needed to be removed in order to cure patients with early lung cancer. While participating centers may choose to perform each procedure using a minimally invasive or open technique, surgeons in the Center perform the vast majority of these procedures using a minimally invasive approach. A retrospective review of patients who underwent thoracoscopic segmentectomy or lobectomy for clinical stage I non–small cell lung cancer determined that thoracoscopic segmentectomy was a safe option for experienced thoracoscopic surgeons treating patients with small stage I lung cancers. No significant difference in oncologic outcome was seen between thoracoscopic segmentectomy and thoracoscopic lobectomy, and lymph node dissection could be performed as effectively during segmentectomy as lobectomy (The Journal of Thoracic and Cardiovascular Surgery, Volume 137, Issue 6, June 2009, Pages 1388-1393.).
- Computed tomography benefits in lung cancer screening – The Thoracic Oncology Center also is establishing a screening clinic for lung cancer in an effort to promote earlier diagnosis and improved outcomes. Specialists in the Center were part of the National Lung Cancer Screening Trial (NLST), a randomized trial comparing the effects of lung cancer screening using low-dose computed tomography (CT) imaging and chest X-ray on lung cancer mortality among current and former heavy smokers. Initial results of the study found that lung cancer screening using CT imaging resulted in more than a 20 percent decrease in lung cancer mortality compared with chest X-ray.
- Real-time Image-guided Lymphatic Mapping and Nodal Targeting in Lung Cancer – While accurate nodal staging is a key factor in treatment planning in non-small cell lung cancer, a reliable method of sentinel lymph node mapping for lung cancer has not been identified to date. Preclinical research conducted through the Thoracic Oncology Center has demonstrated the feasibility of an intraoperative optical imaging technology that uses safe, invisible, near-infrared (NIR) fluorescent light for thoracic nodal mapping (Seminars in Thoracic and Cardiovascular Surgery. 2009; 21(4):309-15.). Led by Principal Investigator Yolonda Colson, MD, PhD, Director of the Women’s Lung Cancer Program, the Thoracic Oncology Center is now enrolling eligible patients in an NCI-sponsored Phase I/II clinical trial evaluating the efficacy of this imaging platform in sentinel lymph node identification during surgery for early-stage lung cancer. For more information regarding study participation, please contact Principal Investigator Yolonda Colson, MD, PhD, at (617) 732-6648 or firstname.lastname@example.org.
Minimally Invasive Esophagectomy: A Revolutionary Advance in Esophageal Cancer Treatment
Thoracic surgeons in the Center perform among the highest volume of resections for esophageal cancer in the nation, and the vast majority of these procedures are completed using complex minimally invasive approaches, including minimally invasive esophagectomy (MIE). MIE offers patients a much faster rate of recovery with less pain and long-term complications, including pneumonia, and is associated with a very low mortality rate. Neo-adjuvant treatment with chemotherapy and radiation are provided to patients with locally advanced esophageal cancers to improve outcomes. In a retrospective analysis of 116 consecutive esophagectomies utilizing a completely thoracoscopic mobilization of the esophagus, thoracic surgeons in the Center determined that this effective, minimally invasive alternative to dissecting the esophagus was associated with a low mortality of less than one percent. Thirtyday and in-hospital mortality was 0.9 percent – compared with national mortality rates among the largest esophageal centers ranging from four to ten percent for open esophagectomy. At four weeks after MIE, patients are back to full activity and have scars that are barely visible.
David J. Sugarbaker, MD
Chief, Thoracic Surgery
Scott J. Swanson, MD
Chief Surgical Officer, Dana-Farber/Brigham and Women’s Cancer Center;
Center Director, Thoracic Oncology Center;
Director, Minimally Invasive Thoracic Surgery
Raphael Bueno, MD
Associate Chief, Thoracic Surgery
Yolonda Colson, MD, PhD
Director, Women’s Lung Cancer Center
Jon O. Wee, MD
Co-Director, Minimally Invasive Thoracic Surgery
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This page was last modified on 10/19/2011