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.”
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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, this type of forward think- tems is attributed primarily to its role gery. “We’re routinely approaching these ing has allowed surgeons across special- in taking minimally invasive surgery to patients and doing complete staging ties to move quickly into robotic-assisted the next step. Although the laparoscope with robotic assistance,” Dr. Holcomb surgery where appropriate. One example brought momentum to minimally inva- said. “Obviously, performing primary is otolaryngology, where robotic-assisted sive surgery, modern imaging systems abdominal surgery in the instance of big, excision of oral pharyngeal cancer has allow visualization without a scope. It is bulky abdominal disease is problematic, been in place for almost 4 years. a new approach that demands ORs with but we are finding that there is a role “Robotic procedures are replacing different capabilities. for robotic-assisted surgery. There is the the major surgeries, which included “Imaging was once a preoperative patient who has an isolated recurrence mandibular resection in order to reach device to plan surgery,” Dr. Evanko after 3 years of being disease-free, for the back of the tonsil to remove these said. “Increasingly, imaging such as example, or the patient who has under- tumors,” said David I. Kutler, MD, CT [computed tomography] scan- gone chemotherapy and whose tumor Associate Professor of Otolaryngology at ning is an intraoperative tool to guide shrank appreciably—very often, I elect to NewYork-Presbyterian/Weill Cornell. the procedure. The modern OR has go back and handle these types of cases “With the robot, we can access these to be large enough to accommodate robotically. They’re not necessarily get- tumors through the mouth, without any the imaging systems, the displays, the ting a survival benefit from it, but there incisions made to the face, and still do robotic devices, as well as the monitor- is a huge benefit for quality of life.” an oncologic procedure to remove these ing equipment that would be found in cancers. The time in surgery has been a conventional OR. This requires plan- Otolaryngology reduced from upwards of 10 hours to ning and the infrastructure that allows It is this patient orientation that about 2 hours; hospitalization has been the OR to function efficiently.” Sim- has driven the interest of surgeons at reduced from 2 weeks to 4 days. Robotic ply running the wires to an increas- NewYork-Presbyterian Hospital since surgery also circumvents the need for ingly complex and sophisticated array of the early days of the movement toward chemotherapy and high-dose radiation devices limits the degree to which the minimally invasive resections. This has therapy.” OR can be retrofitted as needs evolve. produced a proactive approach to devel- “We have been deeply involved in oping ORs that can accommodate tech- Orthopedic, Gastrointestinal, attempting to anticipate these changes nological advances, such as real-time Neurologic and to approach the development of a imaging and high-definition moni- At NewYork-Presbyterian/Colum- modern OR with a prospective approach. tors that display laboratory results and bia, robotic-assisted surgery is now being This has allowed us to stay at the front of other information relevant to the case. employed for some common orthope- the curve in expanding robotic-assisted Some ORs incorporate teleconferenc- dic diseases, for resections of a vast array surgery where it has advantages for the ing that permits rapid communication of malignancies, and for gastrointestinal patient,” Dr. Evanko said. ■
continued from Lung Cancer, page 1 can now be selected to address activated New Technologies Guide Biopsy “Fine needle biopsy is one of sev- molecular pathways of proliferation. Dr. Altorki has led the effort at eral options for minimally invasive pro- “There is an evolving paradigm NewYork-Presbyterian/Weill Cornell cedures to access suspicious lesions. for lung cancer treatment. Therapy is to minimize false-negative results using Appropriate technique affects the accu- becoming increasingly personalized on CT-guided fine needle aspiration. The racy of all of them,” said Dr. Altorki, the basis of the molecular profile, and key strategies that he and his colleagues who described protocols to improve the the beauty of EBUS-TBNA is that it is identified to improve the accuracy of this diagnostic yield of fine needle biopsy a relatively safe and minimally invasive technique were recently published.2 The and ongoing efforts to employ fiber- approach for obtaining sufficient tissue work in CT-guided fine needle aspiration optic bronchoscopy more effectively. that may subsequently guide therapeu- is part of a larger effort to derive tissue While this tool has long been used tic strategies as well as diagnose the dis- from all pulmonary nodules with mini- to biopsy lung lesions that are visible ease,” Dr. Bulman explained. mally invasive strategies. See Lung Cancer, page 4
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continued from Lung Cancer, page 3 and accessible, the technology is being invasive access to pulmonary nodules is Association for Thoracic Surgery (AATS), stretched. One approach is navigational made on a case-by-case basis, according to have advocated lung cancer screening in bronchoscopy, which involves computer Dr. Altorki. high-risk patients, generally defined as processing of CT imaging data to guide “If all else fails, we can still consider a men or women older than age 55 years the bronchoscope to the target lesion. surgical biopsy, but this can almost always with a 30 pack-year history of smok- “The computer processes images of the be performed with minimally invasive ing. While the screening is a strategy for lung to identify the shortest possible route techniques. While the goal is to obtain catching cancers at a stage when they can when navigating the bronchoscope—it is a tissue sample with minimal risk to the still be cured, the efficacy of the screen- something like plotting a flight plan. This patient, it is also critical to select the tech- ing is highly influenced by the diagnostic is a very useful technique that not only nique with the lowest likelihood of a false- technique. improves efficiency during the procedure negative result,” Dr. Altorki said. “There is a broad array of variables that but increases the diagnostic yield, espe- In some cases, a combination of affect the diagnostic yield, including the cially when attempting to access distant approaches is employed. For an example, expertise of the pathologist reading the nodules,” Dr. Altorki said. Dr. Altorki described very small lesions tissue samples. Progress in this area may In some cases, the site of the lesion is that can be difficult to locate by a min- be less immediately dependent on develop- readily reached with a bronchoscope, but imally invasive technique. In this case, ing new tools for obtaining adequate tissue the lesion cannot be visualized because it image-guided bronchoscopy can be per- samples than in correctly using the tools is on the outside of the bronchial tube. formed to inject dye at the site of the that are currently available,” Dr. Bulman In this case, EBUS has been employed to lesion to ensure that the surgeon can see observed. position the scope to facilitate placement and access the affected tissue. These types of the needle into the target. The real-time of approaches have a large potential to References sonar images allow precision adjustments improve outcomes in lung cancer. Because 1. Bulman W, Saqi A, Powell CA. Acquisition of the needle and increase the likelihood of the fact that screening CT scans have and processing of endobronchial ultrasound- of obtaining evaluable cells for pathologic a high sensitivity but a low specificity guided transbronchial needle aspiration specimens in the era of targeted lung cancer evaluation. for lung cancer, minimally invasive strat- chemotherapy. Am J Respir Crit Care Med. egies are critical from a benefit-to-risk 2012;185:606-611. Bottom Line: Several Strategies Exist perspective. 2. Gelbman BD, Cham MD, Kim W, et al. Due to the strengths and weaknesses The value of effective but minimally Radiographic and clinical characterization of of available options for reaching suspi- invasive methods of sampling lung tis- false negative results from CT-guided nee- cious lesions in specific locations of the sue has only intensified now that several dle biopsies of lung nodules. J Thorac Oncol. lung, the choice of strategy for minimally organizations, including the American 2012;7:815-820.
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