A decade ago, a lung cancer diagnosis left both patients and physicians with few options. Today, while surgery remains the gold standard, the approach to this treatment has changed. Thoracic surgeons at South Nassau Communities Hospital are forging innovative surgical ground and safeguarding patients’ lungs.
According to the American Cancer Society, 221,130 new cases of lung cancer will be diagnosed in 2011. Almost 17,000 cases of esophageal cancer will be diagnosed, and, though the incidence rate is extremely low, patients with these types of cancers can develop tumors within and around the heart. Before 2004, Long Island residents with disease of the chest cavity made the long trek to Manhattan for consultations, treatments and follow-up care.
With the arrival of Shahriyour Andaz, M.D., FACS, FRCS, Director of Thoracic Oncology at South Nassau Communities Hospital and associate professor in the Department of Surgery at Hofstra University, two principles of thoracic care on Long Island have shifted significantly. Patients now have an alternative to Manhattan medicine, and with the investment in advanced technologies at South Nassau Communities Hospital, they also have an alternative to traditional open chest surgery.
“In the past, surgeons would make a large incision to cut the ribs and access the chest. That was a painful operation, so we’ve moved away from major incisions to doing smaller and smaller cuts,” says Dr. Andaz. “Now, 80% to 90% of all the cancer we take out is done through small, minimally invasive incisions.”
A Renaissance of Surgical Technique
The robotic da Vinci Surgical System offers Dr. Andaz and his colleagues in the thoracic oncology program the visualization and maneuverability necessary to promote minimally invasive approaches to technically demanding procedures. The three-dimensional views and flexibility of robotic hands, which are carefully controlled by the surgeon, facilitate the delicate dissection of blood vessels and the resection of the lungs’ lobes through centimeter-long incisions.
In the case of a video-assisted thoracoscopy, which allows the surgeon to evaluate the chest cavity for lung cancer or remove a tissue sample for further analysis, the da Vinci Surgical System has supplanted the need for an open chest thoracotomy. Dr. Andaz makes two or three small incisions between the ribs, and the lung is deflated to allow for a greater space between the lung and chest wall. That vantage point provides access to the lung for an endoscope, which Dr. Andaz uses to view and sample any potentially malignant tumor on the lung. The sample is then sent to the laboratory for pathological testing.
While the da Vinci Surgical System is utilized for general, gynecologic, kidney, prostate and urologic procedures, the technology allowed Dr. Andaz to become the first health care provider on Long Island to perform a robotic thymectomy and robotic bilobectomy in 2010 and 2011, respectively.
Operating Across the Aisle
“Most surgeons will not do a bilobectomy for central tumors — the type of tumor that straddles the airway and involves blood vessels stuck to the tumor,” says Dr. Andaz. “The da Vinci can help with the tedious process of dissecting those blood vessels.”
The complexity of a bilobectomy is grounded in the need to remove both the lower and middle lobes of the lung — leaving only the upper lobe — to ensure that wide enough margins are created and no cancer cells are left behind. In addition, the complex network of blood vessels stretching over the fissures in the lungs poses a challenge in cleanly resecting the necessary portions of the lung.
To begin, the attending anesthesiologist puts the patient under and slowly deflates one lung. Dr. Andaz then makes four 2-centimeter-long incisions in the chest wall and guides the da Vinci Surgical System’s robotic arms into the chest through the incisions, allowing him to concentrate on excising the lower lobe. The precise instrumentation divides the blood vessels and pulmonary vein from the lung tissue without disrupting the blood flow to the heart.
Next, Dr. Andaz exposes the fissure between the lower and middle lobes to allow for visualization of the pulmonary artery. With the three-dimensional da Vinci Surgical System camera, he is able to safely encircle and divide the branches leading to the lower lobe. After removing the lower lobe tissue, Dr. Andaz begins dissecting the pulmonary artery branches to the middle lobe. That separation allows him to dissect and divide the bronchus to the middle and lower lobes.
Dr. Andaz explains that the ability to remove both the lower and middle lobes of the lung can often depend on how much reserve a patient has in his or her lungs. The resection of one lobe diminishes lung function by 10% to 15%; the loss of two lobes results in a 20% to 25% reduction in total capacity; and the removal of all three lobes — the entire right lung — equals a 40% to 50% loss of the combined lung capacity. All surgical candidates undergo pulmonary function testing before being cleared for robotic surgery.
After the final tissue resection, Dr. Andaz retracts the da Vinci Surgical System’s arms and closes the incisions while the anesthesiologist carefully re-inflates the lung. Patients typically remain in the inpatient unit at South Nassau Communities Hospital for four to five days.
Tackling the Thymus Gland
Just as the da Vinci Surgical System has allowed Dr. Andaz and his colleagues to move away from the open chest thoracotomy, the technology has opened up new avenues for removing the thymus gland. The traditional procedure involved splitting the sternum with a major incision to access the chest cavity. Dr. Andaz can perform a robotic thymectomy instead, which approaches the organ — located in a tight space between the heart and the breastbone — through small incisions placed on the side of the patient.
“Usually, as a person ages, the thymus gland — like the tonsils — becomes smaller and almost disappears,” says Dr. Andaz. “For some people, however, the thymus gland continues to grow and enlarge and can lead to myasthenia gravis, an autoimmune disease that allows small proteins to cling to muscle receptors and leads to a neuromuscular disorder.”
Myasthenia gravis can present through symptoms centering on fatigue, including drooping eyes, difficulty breathing, chewing and swallowing, and weakness in the arms and legs. As Dr. Andaz explains, removing the thymus gland in patients with the condition can provide significant relief for their symptoms.
For the robotic procedure, Dr. Andaz makes three 2-centimeter incisions at the side of the chest for lateral access. Seated at the da Vinci Surgical System console, Dr. Andaz manipulates the robotic arms to find the thymus gland behind the breastbone. He then completes the delicate separation of the gland from the adjacent fat, pericardium and the innominate vein.
After resecting the thymus gland, Dr. Andaz closes the incisions, and the anesthesiologist re-inflates the lung. Patients typically spend one to two days in the hospital and are back to work in one or two weeks.
Targeting the Right Site
For lung cancer patients whose poor lung reserves eliminate them from the surgical candidate pool, radiation has traditionally been the next treatment option. The choice is often made in an attempt to conserve what little function the lungs have. However, standard radiation often poses a significant threat not only to the tumor, but also to the surrounding healthy tissue.
“The problem with standard radiation is that the treatment can essentially cook the entire lung. The radiation can damage the surrounding lung tissue, which is difficult for someone who has poor lung reserve to begin with,” says Dr. Andaz. “The Novalis Tx radiosurgery technology uses advanced computerized techniques to focus an intense radiation beam on the tumor site only to preserve the rest of the lung.”
The radiosurgery platform offers a noninvasive, customizable treatment alternative to surgery. The system’s mechanical accuracy is within 0.5 millimeters of the tumor site during treatment, while the MV Portal Vision allows radiation oncologists to view the exact location of the tumor as the system targets it.
The Novalis Tx is also equipped with gating features to adapt the radiation to the patient’s natural respiration cycle. In addition, the system reduces the requisite number of treatments as compared to the standard radiation therapy. Patients undergo treatment once a week for only three to four weeks rather than six weeks.
The Communal Process
Every month, the specialists within the thoracic oncology program meet for a program-specific tumor board. The conference reviews patient cases one by one for insight from each physician, even those not directly involved in the treatment, which allows for a dynamic and multifaceted discourse. Medical oncologists, pathologists, pulmonologists, radiation oncologists, radiologists and surgeons are joined by primary care physicians to evaluate a patient from every possible perspective.
“These are very complicated decisions, and it requires lots of people to be involved in the decision-making process,” says Dr. Andaz. “I’m very open to the discussion of alternatives to the management of the case.”
In addition, staff with the thoracic oncology program participate in the weekly tumor board at South Nassau Communities Hospital and meet on a need-appropriate basis between the established conferences.
To learn more about thoracic oncology at South Nassau Communities Hospital, visit www.southnassau.org and click on “Surgical Services” and “da Vinci Robotic Surgery” under the “Services/Specialty Centers” tab.
A Measure of Change in Lung Cancer Detection
To maximize the rate of survival among women with breast cancer, the American Cancer Society recommends every woman receive a mammogram annually after age 40. To increase the survival rate among men and women diagnosed with colon cancer, the organization advises people older than 50 undergo a colonoscopy every 10 years. Now, lung cancer has a similar screening recommendation.
A 1991 initiative launched by a group of physicians from Cornell University Medical Center — investigating the impact of helical computed tomography (CT) imaging on the early detection of lung cancer — discovered that, when caught in Stage I, lung cancer isn’t as deadly.
“The traditional data has shown the overall survival rate is 15% at five years, meaning that 85% of patients will die,” says Shahriyour Andaz, M.D., FACS, FRCS, Director of Thoracic Oncology at South Nassau Communities Hospital and associate professor in the Department of Surgery at Hofstra University. “The participants in the Cornell study showed a survival rate far superior than any other data we have: 90% at 10 years. Even though lung cancer is three times as prevalent as breast cancer, there has been no test to detect early lung cancer — until this.”
In fact, the initiative has developed protocols to a) identify high-risk patients, b) distinguish between benign and malignant nodules detected by the CT scan, and c) determine when to biopsy or monitor the nodules, as well as timetables for when to follow up with patients. The International Early Lung Cancer Action Program (I-ELCAP) includes 48 institutions in nine countries, including South Nassau Communities Hospital, where Dr. Andaz pioneered the program.
Dr. Andaz recognized the significance of the I-ELCAP, and for the last three years, South Nassau Communities Hospital has contributed data to the program while offering free CT scans for high-risk patients in the community. The data is then sent to Mount Sinai Medical Center and incorporated into the I-ELCAP database. According to Dr. Andaz, of the 800 to 900 patients imaged at South Nassau Communities Hospital, 30 have been diagnosed with lung cancer, and 90% of the cases were detected within Stage I.