Dana-Farber / Brigham and Women's Cancer Center

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.

Robotic Surgery for Thoracic Lesions

Thoracic surgeons in the Center perform robotic surgery for thoracic lesions, enabling a broader range of patients to undergo minimally invasive surgical treatment. Robotic lobectomy, robotic mediastinal tumor resections, and other robotic approaches for thoracic lesions offer minimally invasive options for patients with extensive scarring, large mediastinal disease, and difficult body habitus, who may be ineligible for thoracoscopic approaches. They also offer minimally invasive treatment for patients who have had previous treatment, as well as those with recurrent disease. In addition, robotic thoracic surgery provides surgeons with three-dimensional visibility and magnification of the anatomy, along with the capability to perform very precise, finite movements.

Robotic Lobectomy procedure Video

> Click here to see a video of a robotic lobectomy procedure.

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 non-small 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, VATS 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;
  • Improved lung function.

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.

A recent retrospective analysis of 185 consecutive minimally invasive esophagectomies performed by the thoracic surgeons at the BWH Division of Thoracic Surgery determined that this effective, minimally invasive alternative to dissecting the esophagus was associated with excellent outcomes. Thirty-day and in-hospital mortality was 0.5 percent – compared with national mortality rates among the largest esophageal centers ranging from four to 10 percent for open esophagectomy. At four weeks after MIE, patients are generally back to full activity and have scars that are barely visible.

Pharyngeal Cancer Treated with Robotic Surgery 02

This image illustrates the division of the stomach to form the gastric conduit. The left portion of the stomach shows the distal esophagus and GE junction with the tumor,
as well as the proximal stomach. The right portion of the staple line designates the part of the stomach that will be used to recreate the esophagus. Staplers will be used to complete the division and separate the specimens.

Pharyngeal Cancer Treated with Robotic Surgery 01

This diagram shows the completed reconstruction. The esophagus has been resected, and the stomach has been tubularized, brought up into the chest, and attached to the remaining cervical esophagus. (Wee JO, Bizekis C, Luketich JD, “Minimally Invasive Esophagectomy” in Adult Chest Surgery text by Sugarbaker et al., McGraw-Hill Medical publisher, 2009, page 127.)

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 chemo-radiotherapy 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. “Recent reviews of our results suggest that surgery following neoadjuvant therapy has acceptable morbidity at BWH and mortality lower than many other published reports.  Based on our results, we tailor the therapy of individual patients based on their response to various agents," said Raphael Bueno, MD, Associate Chief of Thoracic Surgery at BWH and a thoracic surgeon within the Thoracic Oncology Center.

Additional studies and current endeavors include:

  • 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 Screening Trial, 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 [email protected].

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Dana-Farber President Comments on National Cancer Report

Benz, Jr., MD comments on the Annual Report to the Nation

Dana-Farber president Edward J. Benz, Jr., MD, comments on the
Annual Report to the Nation on the Status of Cancer,
citing encouraging news as well as areas where improvement is needed.

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