!"#$%&'#()*+,-)%,.%/"*$)*0+1('*2,%34%5)**'

677,(1'8)%9*,.)77,*%,.%5:,*'(1(%/"*$)*0;#1<)*7180%,.%/',%9'"-,%3)21('-%/(:,,-

Disclosure

• Scientific Consultant/Advisory Board: Johnson&Johnson

• Educational grants:

– Medtronic

– Pfizer

GeneralObjectivesSurgeryforLungCancer

• Localtreatment– Tissueforpathology– Margins– Surgicalstaging

Outline

• RoleofofsurgeryinLungCancer:– Stage1and2– Stage3

• Technicalaspects– Typeofresection– Lymphadenectomy– Minimallyinvasivesurgery

Stage1and2

Guidelines

• Resectionisthegold-standardtreatment

ACCP,2013

ESMO,2013

! &'-1.,*#1'%&'#()*%+)$178*0

! CKLID%A'81)#87%/8'$)%M

! CNED%#,%8*)'8F)#8

&:)784%DIIL%O"-PCEDQCRBCKEGK4%

>A)*'8)2%S%#,8%8*)'8)2

&:)784%DIIL%O"-PCEDQCRBCKEGK4%

TherapeuticAlternatives

• Surgery

• Lobectomy

• Segmentectomy

• StereotaxicRadiotherapy

• PercutaneousAblation

!"#$ &'#()* /8'$) 1#%U*'V1- Q/', 9'"-,%+)$178*0R+)$178*,%W,7A18'-'*%2)%&X#()*%2,%J78'2,%2)%/Y,%9'"-,

DIII%'%DICI%Q#ZDI[\IR

]>/9H%DICE

9:;&4+/)(<)+'&84(-)(=

Stage3

N2Disease

Heterogeneouspopulation

O5>H%DIIL

pN1/N2Stations8th Revision

Pathologic- R0

Pathologic- anyR

N1a vs N1b vs N2a1 vs N2a2 vs N2b Comparisons Adjusted for Histology (adeno vs others), Sex, Age

60+ , and Region. (Cox PH regression on R0 cases)

comparison HR PN1b vs N1a 1.39 0.0005

N2a1 (skip) vs N1b 0.89 0.2863N2a2 vs N2a1 (skip) 1.35 0.0007

N2b vs N2a2 1.26 0.0028N2a2 vs N1b 1.21 0.064

N1Single=N1aN1Multiple=N1bN2SingleN2(“skipmets”)=N2a1N2SingleN2+N1=N2a2N2MultipleN2=N2b

N1a vs N1b vs N2a1 vs N2a2 vs N2b Comparisons Adjusted for Histology (adeno vs others), Sex, Age

60+ , R0 Resection, and Region. (Cox PH regression on All cases)

comparison HR PN1b vs N1a 1.38 0.0005

N2a1 (skip) vs N1b 0.92 0.4331N2a2 vs N2a1 (skip) 1.37 0.0002

N2b vs N2a2 1.21 0.0117

N2a2 vs N1b 1.26 0.0197

Locat ion and Number of Pos Sta tions N1-N2 Any R

0%

20%

40%

60%

80%

100%

0 2 4 6YEARS AFTER RESECTION

1. N1 Si ngle2. N1 Multi ple3. N2 Si ngle4. N2 Si ngle+N15. N2 Multi ple N2

Events / N438 / 1135153 / 325261 / 602304 / 582462 / 796

MSTNR60.967 .043 .938 .0

60 Month 58% 50% 52% 41% 36%

Locat ion and Number of Pos Sta tions N1-N2 R0

0%

20%

40%

60%

80%

100%

0 2 4 6YEARS AFTER RESECTION

1. N1 Si ngle2. N1 Multi ple3. N2 Si ngle4. N2 Si ngle+N15. N2 Multi ple N2

Events / N415 / 1089146 / 306230 / 549271 / 540403 / 711

MSTNR60.970 .946 .040 .0

60 Month 59% 50% 54% 43% 38%

Asamura Hetal.JThorac Oncol.2015

="12)-1#)7

U5/H%DICI

ESMO2013

DIIK

!,?)(8,F09#)"F,#)(8,F0

SD:StablediseaseOR:objectiveresponse

TechnicalAspects

TypeofResection

• Lobectomy is the gold-standard

• Segmentectomy (preferred) or wedge resection in patients with:

• Poor pulmonary reserve or major comorbidity• Peripheral nodule < 2cm and:

• AIS histology• >50% ground-glass appearance• Long doubling time >400 days

Why Lobectomy?

Wedge resectionSegmentectomyLobectomy

1++234*%5' ,6%$ .DD:EFGHF.:IF00

! &-1#1('-%8*1'-B%DNL%A'81)#87B

! 5C%^I%!"#$%&'#()*%Q1#8*',A)*'81<)%78'$1#$R

! 5e,%6*F7B

! !,?)(8,F0

! /"?-,?'* *)7)(81,#

!>"8(,F)7B

! !,('-%+)("**)#()

! _17)'7)G.*))%7"*<1<'-

1++234*%5' ,6%$ .DD:EFGHF.:IF00

!1F18)2%+)7)(81,#% !,?)(8,F0

J<)#8^,4%,.%9'81)#87

+'8)%QA)*%A)*7,#`0R

^,4%,.%9'81)#87

+'8)%QA)*%A)*7,#`0R% A%f'-")%

+)("**)#()%Q)T(-"21#$%7)(,#2%A*1F'*0R E[ I4CIC DE I4I\L I4ID?

+)("**)#()%Q1#(-"21#$%7)(,#2%A*1F'*0R ND I4CCD ED I4ILK I4ILK?

!,(,*)$1,#'-%*)("**)#()2 DC I4IgI [ I4IDI I4II[(

^,#-,('-%*)("**)#()2 CL I4IN[ C\ I4IEL I4gLD%Q^/R(

_)'8:%Qe18:%('#()*R EI I4ILE DC I4INK I4IKN?

_)'8:%Q'--%('"7)7R N[ I4CCL E[ I4I[K I4I[[?

!,(,*)$1,#'-%*)("**)#()2 DC I4IgI [ I4IDI I4II[(

^,#-,('-%*)("**)#()2 I4gLD%Q^/R

1++234*%5' ,6%$ .DD:EFGHF.:IF00

/"?-,?'* *)7)(81,#%17%'77,(1'8)2%e18:%'%25-2)(&($')&"?&%"#$%&()#4(()+#)

&,#(-"71,#

!,?)(8,F0%17%8:)%$,-2G78'#2'*2

1++234*%5' ,6%$ .DD:EFGHF.:IF00

! J#*,--F)#8B%-'8)%CK[I7H%)'*-0%CKKI7! &5%/('#! /8'$1#$%F)8:,27

^)e%(:'--)#$)7

! /F'--%#,2"-)7

! J-2)*-0%A'81)#87

! =*,"#2G$-'77%,A'(181)7

J8&%"B)#'"*=&()$%%=&+)#)88$(=C

Smallnodules

N=2090(688sublobar resection)Propensitymatchedscores

! N%O'A'#)7)%M#7818"81,#7! +)8*,7A)(81<)%DII\GDICI! /8'$)%M6%Q)T(-"2)2%+C`D%)%F"-81A-)%8"F,*7R

! ==>%A*)2,F1#'#()%Qh\IiR

3-year

RetrospectiveStageIAOrginal set:800(lobectomy)

392(sublobar)

ClinicaltrialACOSOGZ4032

Segmentectomyvs.Wedgeresection

TechnicalAspects

Lymphadenectomy

Nodifferenceincomplicationrate

RandomizedclinicaltrialLinfadenectomy XSamplingResectable TNMc I-IIIAN=471ResectedLy:

SND:9.45MLS:3.63

TechnicalAspects

MinimallyInvasiveSurgery

!)77%1#<'71<)%A*,()2"*)

MinimallyinvasiveLobectomy

U'#(, 2)%2'2,7%(,F%D[LLC%('7,7H%A'*)'F)#8, (,F%9*,A)#7180G7(,*)7

VATSLobectomy:BrazilianExperience(VATSBrazil)

RicardoMingarini TerraDarcyRibeiroPintoFilhoSergioTadeuPereiraThamaraKazantzis

PauloManuelPego-Fernandes

InstitutionsSociedadeBrasileiradeCirurgiaTorácica

FaculdadedeMedicinadaUniversidadedeSãoPaulo- DisciplinadeCirurgiaTorácica

9'81)#87

><)*'--%#ZL[g

M#(-"2)2 A'81)#87ZgNKEIG2'0%F,*8'-180

#ZNK\

JT(-"2)2 2") 8,F1771#$ 2'8'

#ZCEL

C[%7"*$),#7CN%M#7818"81,#7

5)**'%+3H%DICg

DemographyAge (n=646), mean ± DP(mín-max)

61,7 ± 14,7(3-87)

Gender (n=649), n (%)MaleFemale

295 (45,5)354 (54,5)

Diagnosis (n=631), n (%)NeoplasiaBenign

522 (82,7)111 (17,3)

Smoking (n=648), n(%)Non-smokerSmokerEx-smoker

191 (29,5)269 (41,5)188 (29,0)

Comorbidities, nCOPDCAD CHFDM

(n= 628)(n=649)(n=649)(n=602)

234 (37,2)70 (10,8)22 (3,4)85 (14,2)

Resultados VATS Brasil

ESTS STS SID Premier

Mortalidade em 30 dias, %

2,0 1,0 0,94 1,1 2,7

Complicações pós operatórias, %

19,1 29,1 26,23 43,6 9,47

Tempo int, Mediana Média (DP)

4

6,75 (23,4)

6

7,8 (5,8)

4

5

4

5,83 (5,03) !

30-dayMortality

Complications

Admissiontime

Results

TerraRM,2016

SID– StateInpatientDatabase

/M_%m /8'8)%M#A'81)#8%_'8'?'7)

9'*)'F)#8, A,* A*,A)#7180G7(,*)7

Lung lobectomy in lung cancer patients VATS vs. Robotics: Randomized study

Ricardo Mingarini Terra, Pedro Henrique Xavier Nabuco de Araujo, Leticia Leone Lauricella, Alberto Jorge Monteiro Del Vega, Paulo Manuel Pego-Fernandes, Fabio Biscegli Jatene

Serviço de Cirurgia Torácica do Instituto do Câncer do Estado de São Paulo - ICESPDisciplina de Cirurgia Torácica - Departamento de Cardiopneumologia – Faculdade de Medicina da USP

5:'#b%0,"n+1('*2,%34%5)**'

*F8)**'o",-4(,F4?*