Download Minimally Invasive Approaches to Surgery for Lung and Esophageal

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Thoracic O n c o l o g y
Minimally Invasive Approaches to
Surgery for Lung and Esophageal
Cancer
Mark K. Ferguson, MD
Professor, Section of Cardiac and Thoracic Surgery
Department of Surgery
University of Chicago
(773) 702-3551
[email protected]
for surgery, among whom 10,000 to 20,000
patients will have early stage cancer possibly
amenable to VATS resection. The feasibility
and efficacy of VATS resection are being
studied in a multi-institutional setting under
the auspices of the Cancer and Leukemia
Study Group B (CALGB) through a protocol
that outlines the appropriate conduct of such
operations.
Video-assisted thoracic surgery (VATS) was
introduced in the late 1980s to facilitate lung
Surgery
biopsy, pleural procedures, and a variety of
anesthetic with the patient in a lateral
is
performed
under
a
general
other small operations that traditionally were
decubitus position, employing single lung
done through an open thoracotomy. Since then,
ventilation to permit collapse of the lung being
the scope of VATS has expanded to include
operated on. Access to the chest is gained
more major procedures such as resection of
through three ports measuring up to 10 mm
mediastinal tumors, thoracic spine surgery,
and a single accessory incision measuring up to
and operations for benign esophageal disease.
8 cm long, which permits use of some standard
surgical instruments and allows removal of the
During the past 5 years, a few pioneers have
resected lobe at the conclusion of the operation.
used VATS techniques to perform lobectomy
An anatomic dissection is performed, ligating
and esophagectomy for cancer. These efforts
all vessels and the bronchus individually,
have been controversial because of concerns
and a standard dissection is performed of hilar
over whether use of these techniques provides
and mediastinal lymph nodes to provide
an adequate cancer operation and because
staging information.
initial
reports
indicated
there
was
no
advantage to using the minimally invasive
Early published results suggest that VATS
techniques with regard to length of hospital
operations can be performed safely in patients
stay
postoperative
with lung cancer, complications are infrequent,
complications. Recent reports suggest that the
and duration of hospitalization is decreased
instrumentation and surgical techniques have
compared with what is required for standard
improved to such an extent that such
open lung resections.1 In addition, inter-
operations now can be performed with the
mediate-term survival appears to be equivalent
expectation of improved patient outcomes and
to historical results for more traditional
without compromising accepted standards of
operations.2
or
the
incidence
of
surgical cancer care.
Our medical center is one of few to begin
LUNG CANCER
screening patients for lung cancer using rapid,
It is estimated that about 165,000 new cases of
low-dose spiral computed tomographic scans.
lung cancer will be diagnosed in 2000. Of these
The new VATS techniques will enhance our
patients, fewer than 40 percent will be eligible
ability to care for people with suspected very
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early stage lung cancers, providing minimally
mobilization of the stomach and distal
invasive means to both diagnose and treat
esophagus, while the proximal esophagus is
these individuals.
dissected bluntly through a cervical incision.
This is similar to the transhiatal technique
ESOPHAGEAL CANCER
for open esophagectomy, and the same
The incidence of cancer of the esophagus and
controversies attend its use, including whether
gastroesophageal junction is difficult to
the extent of lymph node and soft tissue
estimate accurately owing to differences among
resection are adequate. In some cases a hand-
investigators as to how to categorize some of
assist technique is employed, in which the
these tumors, but is between 14,000 and 18,000
operating surgeon passes his or her hand into
new cases annually. In the United States,
the abdomen through a special laparoscopy
adenocarcinomas of the esophagogastric junc-
port, providing the ability to palpate tissues
tion are increasing in frequency more rapidly
and retract organs by hand to facilitate
than any other solid tumor. Most patients with
dissection. The other technique involves the
FIGURE.
Minimally invasive
approaches to
lung resection for
cancer include the
use of three
standard 10 mm
ports and a single
small utility
incision.
these cancers are candidates for either curative
use of thoracoscopy for dissection of the
or palliative surgery. The role of chemotherapy
esophagus under direct vision, followed by
and radiotherapy, either as a neoadjuvant
laparoscopic mobilization of the stomach for
treatment or in the postoperative setting,
reconstruction. This permits any degree of soft
remains unproven.
tissue and lymph node dissection the surgeon
desires, and is amenable to the performance of
Persistent
arguments
regarding
surgical
therapy include the appropriate approach to
future randomized studies of the appropriate
extent of surgery for esophageal cancer.
resection (open thoracotomy versus transhiatal
approach), the correct amount of soft tissue
Advantages of minimally invasive esophageal
resection, and the optimal extent of lym-
surgery include decreased pain, faster return
phadenectomy. No prospective trials have been
to full activity, and a resultant greater patient
performed that adequately address these
enthusiasm for surgery. Initial reports indicate
issues. Now, new minimally invasive ap-
that these procedures can be performed safely
proaches to esophageal resection are adding to
in carefully selected patients.3 Early results
these ongoing controversies.
suggest a decrease in hospital stay and the
incidence
Two
minimally
invasive
approaches
to
esophagectomy have been described. One
technique includes a laparoscopic approach for
UNIVERSITY OF CHICAGO
MEDICAL CENTER
of
postoperative
complications
compared with standard open techniques.4
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REFERENCES
1. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward
frail and high-risk patients: A case-control study. Ann Thorac Surg.
1999;68:194-2000.
2. McKenna RJ Jr., Wolf RK, Brenner M, Fischel RJ, Wurnig P. Is
lobectomy by video-assisted thoracic surgery an adequate cancer
operation? Ann Thorac Surg. 1998;66:1903-1908.
3. Law S, Fok M, Chu KM, Wong J. Thoracoscopic esophagectomy for
esophageal cancer. Surgery. 1997;122:8-14.
4. Watson DI, Jameison GG, Devitt PG. Endoscopic cervico-thoracoabdominal esophagectomy. J Am Coll Surg. 2000;190:372-378.
Pediatric
H E M AT O L O G Y / O N C O L O G Y
Augmented Berlin Frankfort
Munster Therapy for High-Risk
Acute Lymphoblastic Leukemia
least 10 years of age and those younger patients
with a white cell count of at least 50,000 are
considered high risk. Patients are further
stratified according to their initial response to
James B. Nachman, MD
Professor of Clinical Pediatrics
Department of Pediatrics
Section of Hematology/Oncology
University of Chicago
(773) 702-6808
[email protected]
chemotherapy.
By the late 1980s, it became clear that although
the outcome for most of these children improved
with the use of intensive chemotherapy after the
induction of remission, approximately 30
In the late 1950s, childhood acute lymphoblastic
percent of these high-risk patients eventually
leukemia (ALL) invariably was a fatal illness.
would experience relapse. Numerous studies
Children with this disease died as a result of
have demonstrated that a rapid response to
either bleeding or infection because the bone
initial chemotherapy is an important prognostic
marrow was completely replaced with malig-
factor in childhood ALL.1-6 German investigators6
nant lymphoblasts. As we enter the new
observed that patients with fewer than 1000
millennium, the cure rate for childhood ALL,
blasts/mm3 in the peripheral blood after a 7-day
even for those patients with high-risk
ALL and a slow response to initial
chemotherapy,
is
now
ap-
course of prednisone had significantly
NUMEROUS
better
event-free
survival
than
patients with at least 1000
STUDIES HAVE
blasts/mm3. Similarly, the
DEMONSTRATED THAT A
ability to cure patients with RAPID RESPONSE TO INITIAL Children’s Cancer Group, a
ALL is one of the major success
national research cooperative
CHEMOTHERAPY IS AN
stories of modern medicine. The
in which the University of
IMPORTANT PROGNOSTIC
treatment principles derived
Chicago Children’s Hospital is a
FACTOR IN CHILDHOOD
from the study of ALL have
participant,
reported that
ACUTE LYMPHOBLASTIC
been generalized to other forms of
children with high-risk ALL who
LEUKEMIA.
proximately 80 percent. The
leukemia and other types of cancer
as well.
showed 25 percent blasts or less in
the bone marrow on day 7 had a better
outcome from initial chemotherapy than those
Children with ALL who are at least 1 year of age
with more than 25 percent blasts.4
are divided into two risk groups based on age
and white blood cell count. Standard-risk
In an attempt to improve the outcome for
patients are between the ages of 1 and 9 years
children with high-risk ALL and a slow response
and have a white blood cell count of less than
to initial therapy, the Children’s Cancer Group
50,000 at the time of diagnosis. All patients at
developed a strategy of augmented, intensive