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Giulia Veronesi
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ES 05 - Surgical Skills (ID 514)
- Event: WCLC 2017
- Type: Educational Session
- Track: Surgery
- Presentations: 1
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ES 05.04 - Minimally Invasive Surgery for Lung Cancer, including Robotics (ID 7602)
16:30 - 16:45 | Presenting Author(s): Giulia Veronesi
- Abstract
- Presentation
Abstract:
During the last two-three decades the surgical approach for the treatment of lung cancer had significantly changed. Compared to the traditional posterolateral thoracothomy the introduction and diffusion of a more conservative muscle sparing lateral thoracothomy has shown a first change to lesser trauma for patients, but only with the advent of mininvasive surgery we have witnessed the real change in terms of improving the quality of life and reducing perioperative pain (1). According to some review articles (2) not only perioperative outcome was improved with MIS compared to thoracotomy but also advantages in terms of oncological outcome have been reported even if it is possible that some selection bias could have played a role in the review results. Many studies have confirmed the benefits for the patients treated with MIS compared to open including reduced pain, complications, blood trasfusions and postoperative stay, and improved quality of life, ahestetic and functional results (3). Different technique have been described with different number of small incisions but all have in common that no rib spreading is performed and the dissection is done looking at the monitor. The most common videothoracoscopic techniques are: a. the Cophenaghen approach with an anterior incision of 4-6 cm in the IV intercostal space and 2 more trocars is characterised by an anterior to posterior approach to the mediastinum. This technique has been described by Heine Hansen and by Mc Kenna (4); b. the posterior approach of the Edinburgh school has been described by William Walker and reproduces the posterior approach to the hylum similar to that of the posterolateral thoracothomy (5). In this technique the utility incision is posterior, in the auscultatory triangle and usually two or three additional ports are used; c. the single port described by Gaetano Rocco and Diego Gonzales Riva with a single incision of 4-8 cm usually in the V intercostal space through which the tools and the camera are inserted (6). More recently new approaches has been described including the microlobectomy and the subxhifoid approach. Both techniques are aimed to reduce the pain of the intercostal nerve injury by avoiding the utility incision in the intercostal space. Despite all these advantages for the patients the manual vats has been embraced by a minority of thoracic surgeons and the diffusion has been very slow mainly due to technical difficulties, like the limited visual information, limited freedom of movement, unstable camera platform and poor ergonomics, and doubts on oncological radicality. To overcome videothoracoscopic technical limitations, the micromechanic and robotic sophisticated technology has been introduced with the robotic surgical systems. Natural movements of the surgeon’s hands are translated into precise instrument movements inside the patient with tremor filtration. Three dimensional view offers a visual magnification that compensate the absence of haptic feedback. The robotic surgical system is the result of a long process of development aimed at producing a natural extension of the surgeon’s eyes and hands via the intermediation of a computer. In this way, the ease of movement obtained with open surgery is summated with the advantages of the minimally invasive technique. Since 2002, when the first robotic system for surgery was introduced, robot-assisted thoracic surgery (RATS) has been adopted by an increasing number of centres around the world, and today is used in ~10% of lobectomies in the US (7, 8). Two different techniques have been described in robotic thoracic surgery, the complete portal robotic lobectomy or segmentectomy (CPRL or CPRS) maynly used by surgeons of North American, characterised by 3-4 arms technique, CO2 insufflation, posterior to anterior hilar dissection and a specimen extraction incision at the end of the procedure (9); and the Robotic Assisted Thoracoscopic Surgery (RATS), characterized by a 4-arms approach, a utility incision since the beginning, no routine CO2 insufflation and anterior to posterior hilar dissection (10). To date, no randomized trials have reported comparative data on RATS vs. VATS or thoracotomy for lung cancer. Retrospective analysis comparing RATS vs. thoracotomy have revealed advantages for the RATS approach, especially shorter hospital stays and a lower complication rate but when compared to VATS, RATS produces similar or only slightly better results, the two being minimally invasive techniques with no need for rib separation. A few studies have reported RATS to be safer than VATS, with less conversions for bleeding, less complications and lengths of stay; in others, it was associated with lower postoperative consumption of pain killers and quicker return of patients to normal activity. In addition, lymph-node upstaging has been shown to be higher with RATS than with VATS, with a similar rate as thoracotomy. The main disadvantage of RATS is the higher costs of instrumentation and surgical kits. Nevertheless, the future will probably see reductions in the costs of robotics and improvements in the instrumentation, integration with 3D imaging to improve virtual reality, and more patients benefitting from minimally invasive procedures for lung malignancies. References 1. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients a case-control study. Ann Thorac Surg 1999;68:194-200. 2. Whitson BA, et al. Thoracoscopic versus thoracotomy approaches to lobectomy: differential impairment of cellular immunity. Ann Thorac Surg 2008;86:1735-44. 3. Bendixen M, et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016;17:836-44. 4. Hansen HJ, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Surg Endosc. 2011;25:1263-9. 5. Walker WS, et al. Thoracoscopic pulmonary lobectomy. Early operative experience and preliminary clinical results. J Thorac Cardiovasc Surg. 1993;106:1111-7. 6. Gonzalez-Rivas D, et al. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections†. Eur J Cardiothorac Surg 2016;49 Suppl 1:i6-16. 7. Park BJ, et al. Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results. J Thorac Cardiovasc Surg 2006;131:54-9. 8. Cerfolio RJ, et al. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011;142:740-6. 9. Dylewski MR, et al. Pulmonary resection using a total endoscopic robotic video-assisted approach. Semin Thorac Cardiovasc Surg 2011;23:36-42. 10. Veronesi G, et al. Four-arm robotic lobectomy for the treatment of early-stage lung cancer. J Thorac Cardiovasc Surg 2010;140:19-25.
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P1.07 - Immunology and Immunotherapy (ID 693)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Immunology and Immunotherapy
- Presentations: 1
- Moderators:
- Coordinates: 10/16/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P1.07-032 - 28-Color, 30 Parameter Flow Cytometry to Dissect the Complex Heterogeneity of Tumor Infiltrating T Cells in Lung Cancer (ID 10160)
09:30 - 09:30 | Author(s): Giulia Veronesi
- Abstract
Background:
Defining the phenotypic, molecular and functional characteristics of tumor infiltrating leukocytes advances our understanding of how the immune system is defective in fighting cancer and may thus lead to the identification of new therapeutic targets to be exploited in the clinic. Considerable heterogeneity is found at the tumor site in terms of leukocyte populations and cellular subsets which may retain pro- or anti-cancer potential. Such heterogeneity can only be addressed by more powerful single cell technologies.
Method:
We used 30-parameter single cell flow cytometry to define the memory differentiation, activation, tissue-residency, exhaustion and transcription factor profile of millions of single T cells infiltrating human lung adenocarcinomas.
Result:
We revealed that PD-1[high] exhausted T cells were enriched at the tumor site compared to the peripheral blood or to the non-tumoral portion of the lung from the same patient, were mainly confined to the CD69+ tissue-resident memory compartment and expressed high levels of the transcription factor T-bet and the activation marker HLA-DR. Conversely, these PD-1[high] cells were nearly absent from the early-differentiated, circulating memory compartment identified by CCR7+ expression. Bona fide naïve T cells, as identified by the simultaneous expression of 5 markers, were virtually absent at the tumor site. The exhausted T cells also lacked markers of terminally-differentiated senescent T cells, which in turn are CD57+ T-bet[low]Eomes[high], thereby suggesting that exhaustion and senescence are divergent differentiation states.
Conclusion:
We anticipate that such high-content single cell profiling will identify patient-specific subpopulations capable to correlate with disease progression and clinical/metabolic parameters.
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P1.16 - Surgery (ID 702)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Surgery
- Presentations: 1
- Moderators:
- Coordinates: 10/16/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P1.16-027 - Robotic Surgery, VATS, and Open Surgery for Early Stage Lung Cancer: Comparison of Costs and Outcomes at a Single Institute (ID 10227)
09:30 - 09:30 | Author(s): Giulia Veronesi
- Abstract
Background:
Robotic surgery is increasingly used to resect lung cancer. However costs are high. We compared costs and outcomes for robotic surgery, video-assisted thoracic surgery (VATS), and open surgery, to treat non-small-cell lung cancer (NSCLC).
Method:
We retrospectively assessed 103 consecutive patients given lobectomy or segmentectomy for clinical stage I or II NSCLC. Three surgeons could choose VATS or open, the fourth could choose between all three techniques. Between-group differences were assessed by Fisher’s exact, two-way analysis of variance, and Wilcoxon-Mann-Whitney test. P values <0.05 were considered significant.
Result:
Twenty-three patients were treated by robot, 41 by VATS, and 39 by open surgery. Age, physical status, pulmonary function, comorbidities, stage, and perioperative complications did not differ between the groups. Pathological tumor size was greater in the open than VATS and robotic groups (P=0.025). Duration of surgery was 150, 191 and 116 minutes, by robotic, VATS and open approaches, respectively (p<0001). Significantly more lymph node stations were removed (p<0.001), and median length of stay was shorter (4, 5 and 6 days, respectively; p<0.001) in the robotic than VATS and open groups. Estimated costs were 82%, 69% and 68%, respectively, of the regional health service reimbursement for robotic, VATS and open approaches.
Conclusion:
Robotic surgery for early lung cancer was associated with shorter stay and more extensive lymph node dissection than VATS and open surgery. Duration of surgery was shorter for robotic than VATS. Although the cost of robotic thoracic surgery is high, the hospital makes a profit.
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WS 02 - IASLC Symposium on the Advances in Lung Cancer CT Screening (Ticketed Session SOLD OUT) (ID 631)
- Event: WCLC 2017
- Type: Symposium
- Track: Radiology/Staging/Screening
- Presentations: 3
- Moderators:
- Coordinates: 10/14/2017, 09:00 - 18:15, F201 + F202 (Annex Hall)
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WS 02.01 - Welcome to the Special Symposium (ID 10583)
09:00 - 09:10 | Presenting Author(s): Giulia Veronesi
- Abstract
- Presentation
Abstract not provided
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WS 02.02 - Session 1: Status of Lung Cancer Screening in USA and Europe (ID 10584)
09:10 - 09:10 | Presenting Author(s): Giulia Veronesi
- Abstract
Abstract not provided
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WS 02.04 - Lung Cancer Screening Status in Europe (ID 10621)
10:10 - 10:40 | Presenting Author(s): Giulia Veronesi
- Abstract
- Presentation
Abstract not provided
Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
