ADVANCES IN PULMONOLOGY February 2013 Minimally Invasive Strategies To Evaluate and Treat SPECIAL EDITION Lung Lesions May Improve Cancer Outcomes t NewYork-Presbyterian Hospital, mini- A mally invasive methods to confirm and stage lung cancer are complementing broad efforts to improve outcomes in the most common cause of cancer death. Many suspicious pulmonary nodules discovered inadvertently or as part of ongoing computed tomography (CT) screening pro- grams once required open surgery for evaluation. Increasingly, minimally invasive strategies being pursued at the Hospital allow sufficient tissue to be acquired to confirm the diagnosis, provide SAVE THE DATE information about the cancer stage, and identify Brain Attack and molecular characteristics that may be relevant to Cerebrovascular Disease choice of treatment. NewYork-Presbyterian Hospital is implementing new mini- Update 2013 mally invasive techniques to reduce the need for invasive Minimally invasive strategies are complemen- procedures and surgery on patients without cancer. March 8, 2013 tary to CT screening programs that have been ini- New York Academy of Medicine tiated to identify lung cancers at an early stage “EBUS-TBNA is now being used widely for New York, NY in high-risk patients. Although studies suggest diagnosing and staging malignancy in pulmonary Brain Tumor Biotech lung cancer deaths can be reduced by at least nodules and thoracic lymph nodes, but the diag- Summit 2013 20% with screening, “the majority of nodules nostic yields vary,” Dr. Bulman said. “Developing June 7, 2013 found on CT scans are benign,” explained Nasser strategies to reduce the risk of false-negative results Weill Cornell Medical College Altorki, MB, BCh, Chief of Thoracic Surgery, is an area in which we have developed expertise. New York, NY NewYork-Presbyterian/Weill Cornell Medical Cen- We have addressed this in a very regimented way Advanced Endoscopic ter. Dr. Altorki added, “The trick is to avoid inva- and recently summarized our strategies in a review Skull Base and Pituitary sive procedures or surgery in patients who do not article,” noted Dr. Bulman, referring to an article Surgery, Hands-on have cancers. New minimally invasive techniques in the American Journal of Respiratory and Critical Symposium to obtain tissue samples significantly enhance our Care Medicine.1 June 14-15, 2013 ability to improve early diagnosis.” The goal is to obtain tissue samples that pro- Weill Cornell Medical College vide all of the information needed for management New York, NY EBUS-TBNA of a patient’s cancer. While confirming diagnosis of For more information and to The advances in minimally invasive strategies lung cancer is the critical first step, adequate tissue register, visit nyp.org/pro or for sampling potentially cancerous lung tis- samples are important for characterizing the can- e-mail [email protected] sue are largely derived from progress with imag- cer to provide prognostic information and guide ing to guide needle biopsy. These strategies therapy. depend highly on technique to reduce the risk “We have characterized strategies that increase for false-negative results, and investigators at the likelihood of obtaining evidence of malignancy NewYork-Presbyterian Hospital have been leaders to permit more consistent and reliable findings,” in identifying how to optimize diagnostic yield. Dr. Bulman explained. William Bulman, MD, Director of Bronchos- The importance of adequate tissue sampling copy at NewYork-Presbyterian/Columbia Univer- has further intensified now that it is clear that sity Medical Center, has been at the forefront of an the molecular profile of lung cancer is relevant to Top Ranked Hospital in New York. important effort to define optimal technique with the individualization of pharmacologic therapies. Twelve Years Running. endobronchial ultrasound real-time guided trans- Most importantly, novel small-molecule inhibitors bronchial needle aspiration (EBUS-TBNA). See Lung Cancer, page 3 ADVANCES IN PULMONOLOGY Robotic Applications and Operating Room Technology Are Transforming the Post-Op Surgical Experience uilding on the concept of mini- Services at NewYork-Presbyterian/ suggest that there are no outcome advan- B mally invasive procedures, robotic Columbia and a gynecologic surgeon. tages,” Dr. Evanko said. “In my opinion, surgical approaches performed at Dr. Evanko—whose expertise with the the jury is still out on whether these sur- NewYork-Presbyterian Hospital are da Vinci Surgical System includes a min- geries offer any significantly better clin- vastly improving the patient experi- imally invasive approach to treat uter- ical outcomes over conventional surgery, ence. Real-time imaging in the oper- ine fibroids, as well as other gynecologic but the extent to which this approach ating suite combined with continually surgeries—reported that real-time imag- advances a minimally invasive approach advancing robotic systems offer the ing has been fundamental to creating the and allows patients to recover more potential for greater precision with less modern OR, which is capable of offering quickly is perceived by patients as a very trauma, less scarring, less blood loss, minimally invasive endovascular proce- important advantage.” and quicker healing. Surgeons are driv- dures, as well as radiologic-guided inter- Kevin Holcomb, MD, who is Direc- ing the advances, and there are pro- ventional, cardiothoracic hybrid, and tor of Minimally Invasive Surgery of the grams at both NewYork-Presbyterian/ robotic procedures. Department of Obstetrics and Gyne- Columbia University Medical Center “ORs for minimally invasive endo- cology, NewYork-Presbyterian/Weill and NewYork-Presbyterian/Weill Cor- vascular procedures provided a head Cornell, noted that the benefit of offer- nell Medical Center that create an envi- start because they were set up for real- ing advanced robotics technology is to ronment that encourages their rapid time imaging and had the structure improve patient quality of life while pro- implementation. and size to accommodate the equip- viding similar survival outcomes. Dr. “Our surgeons are the ones driving ment and connectivity that we need Holcomb is also Associate Attending in robotic applications. My goal is simply for robotic procedures,” explained Dr. Obstetrics and Gynecology at Weill Cor- to ensure we are setting up our operating Evanko, who works to assist OR innova- nell Cancer Center, and Associate Profes- rooms [ORs] to facilitate these innova- tion at NewYork-Presbyterian/Columbia. sor of Clinical Obstetrics and Gynecology tions,” said John C. Evanko, MD, MBA, “Minimally invasive surgery overall and at Weill Cornell Medical College. who is Medical Director of Perioperative robotics in particular are now being used effectively across specialties, including Oncology gynecology, urology, otolaryngology, and “A major focus for us at Weill Cornell thoracic and general surgery.” Cancer Center is working to improve the quality of our patients’ lives, leaving them Gynecology with less morbidity from our treatments For most of the diseases and condi- so they go on to live fruitful lives without tions in which robotic surgery is now any long-standing detriment. I think in an alternative to an open approach, it is that regard, robotics plays a major role,” not yet clear whether robotic-assisted Dr. Holcomb said. He added that his surgery necessarily yields better out- team is studying robotic-assisted surgery, comes. This is difficult to prove because which involves the use of the da Vinci of the challenges of performing random- Surgical System, in gynecologic cancers ized trials with appropriate controls, other than those for which it has already but Dr. Evanko said that there are clear demonstrated benefit, such as in endo- advantages for the patient in regard to metrial cancer. “We’ve been performing recovery when robotic-assisted surgery many robotic surgeries for recurrent ovar- reduces the size of incisions. In gynecol- ian cancer, and really pioneering this,” ogy, the da Vinci Surgical System has said Dr. Holcomb, who instructs other been part of a movement to achieve min- surgeons on the technology. “Recently I imal scarring and speedier return to nor- was able to debulk a patient’s ovarian can- mal activities after common procedures, cer robotically. She was rendered in com- such as hysterectomy and myomectomy. plete clinical remission with a surgery “The published data that claim bet- that lasted about 2 hours and she didn’t NewYork-Presbyterian Hospital is improving their ter outcomes with robotic-assisted sur- have to stay in the hospital overnight. I patient care by implementing new, advanced robotic systems that help to improve the patient gery are largely anecdotal and not any think that is a huge benefit and it isn’t experience. more compelling than the data which being offered in many places.” 2 www.nyp.org NEWYORK-PRESBYTERIAN HOSPITAL Additionally, patients contraindi- with pathologists or other specialists who diseases, including resections of the cated for a minimally invasive surgi- might influence decision-making during bowel. The precision of robotic-assisted cal approach, such as the morbidly obese the course of the surgery. surgery has long made it attractive for and patients with severe comorbidi- At both NewYork-Presbyterian/ neurologic applications, but the expan- ties, also have shown positive outcomes Columbia and NewYork-Presbyterian/ sion to such a broad array of organ sys- when robotics were employed for sur- Weill Cornell,