DR. MARK DYLEWSKI: Good evening. My name is Dr. Mark Dylewski. I would like to welcome our distinguished speakers and all the attendees to the Miami Cancer Institute lung cancer conference. This is a collaborative effort between the Miami Cancer Institute and the Lynn Cancer Center.

This evening, we have a highly distinguished group of faculty speaking this evening. And for the sake of time, I'm going to limit the introductions to provide enough time for the speakers to cover their talks. So our first speaker this evening is Dr. John Roberts, who is the Chief of Thoracic Surgery at the Lynn Cancer Center.

And he will be speaking on minimally invasive surgery for the treatment of lung cancer. Welcome Dr. Roberts.

DR. JOHN ROBERTS: Thanks, Dr. Dylewski. I appreciate being here. I'm John Roberts. I'm the thoracic surgeon up at Boca Raton, which is the little brother North of the Cancer Institute. I'm delighted to be here. All right, so I want to talk about the minimally invasive surgery in the treatment of lung cancer.

Minimally invasive surgery first began some 25 years ago, and I've been doing thoracoscopic lung resections for 25 years and robotic surgery for approximately 10 years. During this talk, I wanted to try to describe what I think a good cancer operation means. I want to briefly cover staging criteria for lung cancer.

I want to discuss some of the limitations of radiologic staging for lung cancer. I'll discuss briefly some techniques for surgical staging, review the literature that compares SBRT and surgery, and then just briefly cover the incisions that we use.

All right, so why should we operate on someone for lung cancer when we've got safer options? You can see this is just a slide that briefly demonstrates the incidence of lung cancer worldwide. The US and Europe are amongst the highest, with some 30 to 40,000-- 40 cases per 1,000.

We've improved over time with the survival of non-small cell lung cancer. Five year survivals for the various classifications of stage one range from 68% to 92%. For stage two, 53 to 60%. And then stage threes begin to fall off. All of these numbers are about 20 percentage points better than we used to do 20 years or so ago.

All right, so there are several options for lung surgery. The standard is just a postal lateral thoracotomy. This was basically what I was trained primarily on. About 25 years ago, we began to use thoracoscopic surgery, which requires an access incision here and either two or three ports inferiorly.

And the latest and probably best iteration is robotic surgery. Again, requires an access incision here with somewhere between three and four additional ports for a total of five ports. A lot of studies have shown significant benefits as far as shorter recovery time after minimally invasive surgery.

And so if possible, thoracoscopic or robotic surgery should be the standard. We still occasionally have to make the larger incisions for larger tumors. All right, so-- to delve into why we consider surgery, certainly one of the techniques that's been a dramatic improvement in the treatment of lung cancer has been the development of SBRT.

There are few studies that show that SBRT in surgery might be equivalent. I'll lump these two together because they've actually been written together. There were two separate small prospective randomized trials, randomized patients between SBRT and surgery.

They were each supposed to get around 500 patients, but were closed early and together had a total of 60 patients. SBRT had about a 95% three year survival, and surgery a three year survival of 79%. Some of the problems with this was that it was a very small size study, obviously.

Did not reach the numbers that they wanted to get. And a lot of the operations were wedge resections, which we know is not an adequate operation in general.

In contrast, there's a large number of studies that show the superiority of surgery to SBRT with survival. None of these are randomized because there have been no other randomized trials done. But you can see that some of the numbers are very large. This particular study, this [INAUDIBLE] study, chose patients within the group that had been recommended to have resection and elected to have SBRT instead, and their survival was significantly less.

I won't spend all-- a lot of time on these numbers, other than just to point out that there are significant differences, and the average difference ranges between 15 to about a 30% improvement in survival with surgery. So that's why we still try to operate on patients if we can.

All right, so let's talk about staging. There's also some limitations with radiologic staging. And I just want to give as an example, a patient. This is-- VR is a 76-year-old female presented with a lung mass. Chest CT demonstrated Tucson meter mass in the left upper lobe.

She was referred to our multimodality clinic where the patient's surgeon, radiation oncologist, and medical oncologist and we obtained a PET scan. The PET scan was interpreted as showing a stage one cancer with no evidence of distant disease, period. She appeared to be healthy and we were inclined to surgery, but she was inclined to radiation.

We were able to convince her to do surgical staging, so she underwent end to endobronchial ultrasound. Which in addition to the known cancer here, demonstrated a lymph node involved here in the hilum. Other mediastinal nodes were sampled and were clear. So at this point now, we had her as a stage two cancer.

Because of the demonstration of stage two cancer, she was referred back to our MMC and we were able to convince her that she should undergo surgery. She underwent a robotic left upper lobectomy, where we resected the entire upper lobe. We also harvested all these mediastinal nodes, including the AP window node which can't be biopsied from endobronchial ultrasound.

This node was also involved, so she ultimately proved to have a stage 3A non small cell lung cancer. You remember her PET scan staged her as a stage one. So we represent her tumor board, she tolerated her surgery well, and then underwent post-operative adjunct chemoradiotherapy.

There are a lot of studies that compared staging apparatus or modus. I'll just do one summary presentation. A publication in Chest in 2018 that basically showed that CT scan alone was about 60% accurate. PET scans and CT scans together, somewhere around 80% accurate.

You can get up to about 90% when you add endobronchial ultrasound. And then resection, of course, is the gold standard, or 100%. I think we've discussed now the benefits of surgery compared to SBRT, that surgical staging is often necessary to get a truly accurate stage.

I thought I'd talk further about what I consider to be a good cancer operation. The first is that the cancer has to survive surgery and recovery. The second affects, or concerns, how the surgery is done. Basically, there need to be complete surgical resection and signs that margins are negative, the nodes are all resected, and the patient should have a lobectomy, ideally, if their lung function allows.

All right, so how does minimally invasive surgery impact this definition? Well we know that minimally invasive surgery decreases perioperative risk, diminishes pain, and can probably broaden the application of surgery to frailer patients. However, the process of minimally invasive surgery, whether it's orthoscopic robotic, makes getting negative margins a bit more difficult, in some cases.

And so the good surgeon is choosing which approach, and is ready to change his approach in order to give a patient a good operation.

So I just want to briefly show two patients that were evaluated at other facilities and then got to us. This is a 77-year-old female with a significant smoking history, relatively borderline lung function with an FEV1 of 1.77 liters and diffusing capacity of 65%. She had these two lesions that were both biopsied and proven to be malignant.

She was evaluated by a non-Baptist surgeon in Miami and told that she shouldn't have surgery and no one else should. We evaluated her in her multimodality clinic, obtained quantitative perfusion studies as well as cardiopulmonary exercise testing, and got a PET scan which showed no activity elsewhere.

She underwent first endobronchial ultrasound, where all her notes are negative, and then underwent a thoracoscopic left upper lobectomy. The path showed two separate 3.5 and 3.8 centimeter cancers in the left upper lobe. They were both adenocarcinomas, nodes and margins were all clear.

She was in the hospital three days, and is alive at nine months with no evidence of disease. So I'd argue that in this particular case, the other surgeon didn't consider the benefits of minimally invasive surgery.

On the other side, though, it's possible to try to extend it too much. This is a 75-year-old male with a smoking history who was found to have a lung cancer. This was biopsied, it was an adenocarcinoma. You can just appreciate in the anterior mediastinum, he also had an anterior mediastinal mass that was biopsied and proved to be a thymic carcinoma.

We evaluated in multimodality conference, felt that the thymic cancer was large and that he should get neoadjuvant therapy prior to resection. However, he got a second opinion at another hospital, underwent a combined robotic thymectomy with robotic right upper lobectomy.

He had a completely resected lung cancer, but multiple positive margins in the thymus. He received an adjuvant radiotherapy, and then his PET scan at 12 months shows uptake in the left anterior mediastinum, as well as the hilum of the right lung. And he's undergone an endobronchial ultrasound, and these nodes are now involved with thymic carcinoma.

So a thorough operation in lung cancer is typically a lobectomy. And again, to go back to a crude drawing from the first patient, if this patient had had a wedge resection without appropriate staging, we would have missed that she had stage nodes in the hilar position, as well as nodes in the AP window, which made her a stage three cancer.

That's why a wedge resection is not a good operation, and it may also speak to why SBRT fails sometimes because there's so many cult stage twos and stage threes.

Multiple studies have shown that lobectomy gives a higher five-year survival over wedge resection, and we're-- remember, we're not talking just about control, but about pure. So in conclusions, radiologic staging, including PET and CT, is wrong in about 20% of patients.

The best surgery is lobectomy with mediastinal lymph node dissection. Lesser resection should be done in limited cases. A good surgeon chooses the appropriate approach, whether it's minimally invasive or open. The local control refers to the primary legion, not to the rest of the lung or distant recurrence.

All art series that have compared SBRT in surgery and found large differences that favor surgery. And finally, complete resections can be done with all minimally invasive techniques for many patients. The best surgeon selects appropriate cases for each approach.

I think that's it. Those are the references I have if you want to chase any of those down. Thank you very much.

DR. MARK DYLEWSKI: Thank you very much, Dr. Roberts. Excellent talk. Our next speaker is Dr. DeRosimo, he's a thoracic surgeon at the Miami Cancer Institute. And he will be covering the ABCs of the state of the art of minimally invasive robotic surgery for lung cancer. Welcome Dr. DeRosimo.

DR. JOHN DEROSIMO: Good evening. Thank you, Dr. Dylewski. Thank you to the continuing education program at Baptist Health for inviting me to speak this evening on the ABCs of robotic assisted pulmonary resection. I'd also like to Thank Dr. Dylewski for assisting with some of the slides and videos that I will be showing this evening.

These are my disclosures.

Tonight, I'll review with you the basics of performing a robotic assisted lung resection. I want to emphasize that a robotic resection is different from a VATS approach in that it is complete port access surgery. There is no utility thoracotomy through which the surgeon operates.

Everything is done on screen through port access. We will review the equipment used, and how it is set up in the operating theater. We will review positioning of the patient. We'll review the different approaches for robotic lung surgery. We'll go over the position of the ports for access to the lung and hilum.

We'll review the main steps in surgery as the surgeon conducts the operation. I'll then review the handling of a technical problem, specifically a vascular injury.

These are the components of the robotic system used at Baptist Health of South Florida. We use the Da Vinci robotic system from Intuitive Surgical. The robot has three components. The surgeon sits at the surgeon console, seen here on the left of the screen. From that console, the surgeon directs the instruments.

The operating instruments are loaded on the patient cart, seen on the right of the picture. This cart is placed over the patient and the arms are inserted into the body cavity for surgery. The vision cart in the center of the photo contains an assistant screen, the camera interface, electrosurgical control units for monopolar and bipolar cautery, harmonic scalpel, and vessel sealer devices.

These three components make up the integrated system.

The operating theater is set up in this way for robotic pulmonary surgery. The personnel are in the pink circles. Once the robot is docked to the patient, the surgeon takes a seat at the surgeon console. The surgical assistant and scrub tech are on opposite sides of the patient field.

Each one will have access to the robot arms for changing instruments. We positioned the robotic patient cart to the patient's left side and the vision tower at the foot of the bed.

A few notes about the anesthesia management. We use double lumen endotracheal tubes for lung isolation and single lung ventilation during surgery. The experience level and comfort level of the anesthesiologist will usually determine whether a central venous catheter, arterial line, and Foley catheter are used during the operation.

We've tried to get away from the routine use of arterial lines and Foley catheters in lung surgery, with varying degrees of success depending on which hospital and which anesthesiologist is doing the case. In high volume centers for thoracic surgery, routine use of arterial lines and Foley catheters has been eliminated.

The positioning of the patient is similar to standard thoracotomy. We use a lateral decubitus position. The patient is secured into place by a bean bag. The table is flexed to open the rib spaces. We also use an inflatable pressure bag under the waist. This is inflated prior to activating the bean bag, and it gives us a little bit more elevation of the patient's waist.

This provides easier access for the assistant port instruments, especially in patients with wider hips.

The surgeon has a choice of docking three robot arms or four robot arms for the operation. A three-arm technique is easier to learn since there is no switching between arms at the surgeon console. Also, there may be more freedom of movement with the arms since the ports are slightly further apart.

With the three-arm technique, the surgical assistant provides retraction of tissue. During the four-arm technique, the surgeon uses the fourth arm to set the retraction.

The surgeon starts the operation by placing the ports and docking the robot arms to the ports. The anterior port is placed first. This is also the port that will be used for stapling later in the operation. I usually place the anterior port at the sixth interspace anteriorly, for both right and left sided operations.

The only difference is for a right middle lobectomy, where I like it better in the fifth interspace, which seems to give me a better approach to stapling the middle lobe artery, vein, and bronchus. The other arms are then visually guided depending on the position of the major fissure.

The ideal placement is one interspace below the fissure, which usually puts the arms in the seventh interspace. The assistant port is in the anterior axillary line at the ninth or 10th interspace. The 10th interspace has the advantage of having soft tissue that can stretch when the specimen bag is removed.

But I have had a couple of post-operative hernias at the 10th interspace when I use that spot.

Since adjusting my position-- my assistant port to the ninth interspace, I have not had any post-operative hernias at that site. Again, we see initial access via the anterior port site. Insufflation with carbon dioxide and then placement of the remaining ports using visual identification of the anatomy of the major fissure.

In the forearm technique, the anterior port is usually a little lower at the eighth interspace, with the remaining three arms along the seventh interspace. The assistant port at the bottom is shown in the 10th interspace at the insertion of the diaphragm to the chest wall.

It is important to keep in mind the objectives of a complete robotic port access lobectomy for maximum patient benefit. The operation is performed with trocar access only, and no utility thoracotomy. The robotic operation is performed the same way as an open lobectomy, and follows strict oncologic principles of anatomic dissection.

There is individual dissection and ligation of the vascular and bronchial structures. The surgeon performs a complete lymph node dissection and the specimen is removed without thoracotomy or rib spreading.

A note about stapling. The surgeon can use either a handheld stapler or the robotic stapler. The handheld stapler would be positioned and fired by your assistant standing at the field, while the robotic stapler comes in on a robot arm. The robotic stapler is guided by the surgeon at the console.

The robotic stapler is more steady and stable compared to a handheld stapler controlled by your assistant. I, as the surgeon, have less stress when I'm in control of the stapling instrument and it isn't bouncing around on the field on an 18 inch handle held by my assistant through a port site.

The operation is performed in a standard fashion. The operative field is exposed. A complete lymph node dissection is performed. The fissure or fissures are divided. The surgeon performs dissection with ligation of the vascular and bronchial structures for the particular lobe being removed.

We're now going to look at some videos showing parts of a right upper lobectomy from start to finish. Here on this video, we see the start of the operation and the division of the inferior pulmonary ligament. The level nine lymph nodes at the inferior pulmonary ligament are harvested at this time.

After this, I usually divide the anterior plural reflection at the hilum, harvesting any hilar lymph nodes in the area.

Now to the posterior aspect of the hilum. The subcarinal space is opened, and the level seven subcarinal lymph nodes are dissected out of the subcarinal space. You will see the esophagus posteriorally, the right main bronchus anteriorly, and the pericardium covering the left atrium deep to the lymph node packet.

Sometimes you will find large bronchial arteries in this area. They can be clipped for control. The lymph node packet is removed intact. For bulky specimens, the lymph node packet can be placed into the cut finger of a glove for intact removal.

We now move to the paratracheal lymph nodes at stations 2R and 4R, the upper and lower right paratracheal lymph nodes. The dissection starts with division of the pleural reflection of the superior aspect of the hilum, separating the lower paratracheal lymph nodes at the tracheal bronchial angle from the underside of the azygos vein and from the right main pulmonary artery and distal trachea.

This dissection is carried superiorly along the trachea and superior vena cava to the upper paratracheal area. You will notice the small, rolled gauzes in the field. These are three inch Raytec gauze made into rolls and tied with silk ties. These gauze are very useful for holding retraction and for mopping up the blood in the dissection field.

Again, the specimen is removed intact.

Dissection is then carried along the posterior and lateral aspect of the bronchus intermedius. This will allow us to take the interlobar lymph node, level 11, and to set up the division of the common bridge of tissue in the posterior major fissure.

Then dissecting along the interlobar pulmonary artery in the fissure, we identify in that same plane to the posterior hilum on the bronchus intermedius. You'll see that we use a modified Foley catheter as a guide for the stapler going through the tissue. The stapler then ligates and divides the common tissue in the posterior major fissure.

The posterior ascending branch of the pulmonary artery to the right upper lobe is then dissected. It is ligated and divided by a vascular stapler.

The right upper lobe bronchus is dissected next. We get around the bronchus and then ligate and divide the bronchus using a thick tissue stapler.

We then dissect along the pulmonary artery, elevating the lobar lymph nodes onto the specimen. This dissection is continued to the truncus anterior branch of the pulmonary artery. This arterial branch is isolated and the plane developed between the truncus vessel and upper edge of the superior pulmonary vein.

The arterial branch is ligated and divided with a vascular stapler. The minor fissure is then divided using a thick tissue stapler.

A heavy specimen bag is then rolled tightly and brought into through-- brought in through the assistant port. The bag is unrolled inside the patient and the specimen is placed into the bag. The bag is pulled closed. We then might use a commercially available pulmonary sealant along the fissure and dissected portions of the lung parenchyma.

A chest tube is placed, the lung is re-expanded, and the robot is undocked from the patient. The assistant port site is enlarged slightly to accommodate the removal of the specimen in the bag. The specimen is removed and frozen section obtained on the bronchial margin.

The wounds are then closed in layers with absorbable suture.

I'll touch for a moment on how I handle a vascular injury, if it occurs. First, just hold pressure to control the bleeding. The rolled gauze is good for holding pressure. Or the lung tissue itself can be held over the injury to stop the bleeding. The pulmonary artery and veins are low pressure systems, so either of these maneuvers should provide control of the injury.

Suction brought in by your assistant will keep the field clean so that you can see. The injury can then be controlled with surgical clips, or repaired with a suture, depending on whether or not it's part of the specimen. I use a Pledgeted 4-0 Proline if it's an arterial injury in an area that is not part of the specimen.

If I need to open to control the injury, I'll place the anterior robot arm down, holding pressure, and remove the other robot arms so that I can perform a thoracotomy from behind the patient. Once I'm inside and I have a sponge stick ready to control the injury, I will remove the robot, undock, and then proceed.

Here's a video of a vascular injury.

The gauze is placed over the injury for control. Suction is brought in to keep the field clean. The injury is then controlled with surgical clips.

Here we have the closure and the incisions from a complete robotic port access lobectomy. Thank you very much.

DR. MARK DYLEWSKI: Thank you, Dr. DeRosimo. It was an excellent summary of a very complex technique. The next speaker is myself. I'll just let the video play, and it'll introduce me. And then we'll move on. Thank you very much.

Good evening. I'd like to thank the planning committee for the opportunity to speak to you all tonight at the MCI Baptist Health lung symposium. Tonight I'll be talking about robotic assisted pulmonary resection management of locally advanced and complex pulmonary malignancies using a surgical robotic technique.

I do have a few disclosures. I do serve as a clinical educator for a number of companies listed here.

Today, the treatment of lung cancer has been changing quite rapidly. And you can see a sort of a short timeline of how we've moved from an open approach to treating lung cancer to a more minimally invasive approach. And now we've moved into the digital age of what I call surgery.

Competing with technologies such as Cyberknife and transthoracic ablative technology and the advent of the robot and the adjunctive technologies that can be utilized along with the robot has really improved our abilities to manage patients using a minimally invasive technique.

And dealing with a very complex surgical disease that perhaps we were not able to manage using a minimally invasive technique. And I'd like to talk about some of those advantages and the reasons be-- the reasons why I believe there are advantages over the standard open technique and the traditional, what we call, minimally invasive technique.

Currently, the adoption of robotics is developing quite nicely. Today we are seeing about 25% of all lobectomies performed in the United States being performed robotically. This compares quite favorably to the open approach and the VATS approach.

The VATS approaches remain relatively stable, around 35% to 40% over the last decade or more. And what we're seeing now is more and more surgeons who used to do open surgery are adopting robotics because it tends to be a lot easier to integrate into your practice than traditional VATS or laparoscopic surgery.

So there's certainly an advantage to this patient population as more and more patients are being offered the minimally invasive approach. Whether that's done with traditional VATS or robotics. Now VATS, in my opinion, is a technology that has a limitation-- a significant limitation.

And [INAUDIBLE] in 1997 was-- published a paper looking at the adoption rates of traditional minimally invasive surgery for thoracic surgeons, both in the academic and the private practice setting. And it was a survey of over 300 practicing high volume surgeons as to-- the questions as to why VATS was not adopted in the majority of patients that they were operating on.

And the issues were multifactorial. Oncological control certainly was an outstanding question as to whether VATS was equivalent to open, limited instrumentation. Certainly there's been very little advancements in traditional VATS instrumentation for the past decade or so, making this surgery pretty much a counterintuitive type-- a very difficult, challenging technique to integrate into a practice without spending an exorbitant amount of time learning the technique.

Operative times tended to be quite long. And certainly, there's insufficient training once you've left your respective training program if you're out practicing as an independent surgeon. It's very difficult to train yourself in this technology. Later on, Dr. Demmy in 2008 recognized, in a retrospective analysis of online data, that traditional minimally invasive lobectomy demonstrated equivalence improving long term survival in early stage disease.

But he indicated in his conclusion that the technical inadequacies of minimally invasive lobectomy should be amplified for more advanced cancers. And I would like to talk in detail about that open question, as to whether traditional VATS is an oncological equivalent operation compared to open.

And then we'll compare it to what we are seeing with the newer technology robotics.

If you look at Dr. Boffa's study, published in the Annals in 2012, he compared STS database of open surgeries to VATS surgeries. And you can see over time, videoscopic surgeons tended to be able to develop a better technique of nodal dissection compared to open, as their experience improved.

And the conclusion of the paper was quite interesting. He said during lobectomy or segmentectomy for clinical and zero lung cancer, mediastinal lymph node evaluation by VATS and thoracotomy results were equivalent in upstaging. In contrast, lower rates of N1 upstaging in the VATS group may be indicative of variability in the completeness of the peribronchial and hilar lymph node evaluation.

And this makes a lot of sense because it's much easier to use chopstick type instruments to dissect around the main bronchus or the large pulmonary arteries as compared to the central hilar structures, the pulmonary artery, because that's where the N1 lymph nodes lie.

And so using sort of traditional videoscopic surgery, it requires a higher level of skill and a more-- certainly a much more complex nerve-wracking procedure to dissect off N1 lymph nodes around the pulmonary arteries in the hilum as opposed to the N2 lymph nodes that are usually around the bronchus or the trachea.

So there may be a reason why we're seeing a lower rate of upstaging in N1 lymph nodes when VATS is used in this patient population.

If you look at another study by Merritt, he also compared VATS lobectomy to open lobectomy, and he showed that there is a significant percentage of upstaging from N0 to N2 or N2. Almost 25% in the open group versus the VATS group. So if you choose to use VATS, there's a potential that you'll be under staging 15% of your patient population by doing the surgery with traditional VATS as opposed to open.

And thus, those patients would not benefit from adjunctive therapy such as chemotherapy and radiation. So you really need to be cautious, in my opinion, in utilizing VATS for those patients that are truly clinical N0. Those patients that have a higher risk of having an occult metastases in the lymph nodes or more advanced cancers.

One should really ask whether traditional VATS is an appropriate operation for those patients who have more advanced disease or harboring a higher risk for occult metastases. And that's where robotics may play a significant role.

Now I'm going to talk a little bit about how the complexities of treating locally advanced disease. This is a challenging group of patients. It involves a heterogeneous population of patients with hilar and mediastinal involvement, central locating tumors. They may be very proximal to pulmonary vessels and the proximal bronchus and trachea.

And these patients often require induction therapy, which increases the risk of fibrosis and desmoplastic changes around these structures, making it sometimes very challenging to do these cases through a minimally invasive approach.

Now there has been some publications in the past, mainly out of the D'Amico group at Duke, and this is a small series of patients-- 97 consecutive patients with non-small cell carcinoma-- that received induction therapy and were approached videoscopically. 12 patients were successfully resected using traditional VATS approach.

67 of those patients received induction radiation therapy. And only one patient was converted. So in their conclusion of their paper, they found that utilizing minimally invasive surgery for patients who received induction therapy, who had locally advanced disease, was safe and had certain benefits with reduced length of stay of the hospital, overall complications in the patient population.

So they recognized that minimally invasive surgery was advantageous in this patient population. But it does not answer the question as to whether it's an equivalent oncological surgical procedure in patients with advanced disease compared to an open traditional approach.

Now if you look at the data using robotic lobectomy-- and I'll talk about some of the largest trials that have been run in the recent past few years. This is a trial that was recently published from the PORTaL Investigation Group. It was an analysis of over 6,300 cases from 21 high volume institutions.

And it was presented at the STS annual meeting in 2020. And you'll find when you compare traditional VATS to robotic lobectomy, there is a much higher conversion rate in the traditional VATS approach than the robotic approach, which may suggest that the traditional VATS approach may have challenges-- may not be able to perform to the level of resectability compared to an open approach or robotic approach.

And you can see here in this illustration that the stage two patients, which are the patients that have typically N1 lymph node involvement, may be a challenge addressing them with traditional VATS approach. Whereas robotic had a better-- lower conversion rate. And also the stage 3A patients had a much higher conversion rate, and those patients typically have more desmoplastic changes and fibrosis and invasion into more central structures.

Again, suggesting that the VATS approach may be inferior to robotics or open.

Now we also would like to spend some time talking about one of the largest long-term survival series, published by myself and Dr. [INAUDIBLE] in 2018. It incorporated almost 1,400 consecutive patients. And you can see that the outcomes were quite good. Operative times were quite respectable at 136 minutes.

There was a 9% conversion rate for tumor-related reasons. Very small conversion rate for bleeding, about 2%. And the length of stay and the major morbidity and mortality was quite acceptable and comparable to either open approaches or VATS approaches. But what we were surprised to see was that the five-year stage specific survival for each stage tended to compare favorably to either anything previously published for the VATS patients or for open patients.

So this study certainly deserves more investigations and follow up, but it would suggest that perhaps robotics allows one to do a more thorough lymph node dissection, a thorough R0 resection, and may influence long-term survival.

So the study basically showed that the outstanding stage specific survival results are at least comparable, and maybe favorable. At this time, follow up data is superior to most other previous reported studies either using open or traditional VATS approach.

Our own data from our institution looked at 1250 cases produced between January 2007 and June of 2018. And in that category of patients, we collected about 214 patients with advanced stage disease. The outcomes in this group are quite favorable. All of this-- these patients received typically upfront adjuvant chemotherapy and radiation.

And the conversion rate in this patient population is quite respectable, similar to what we saw in the larger publication by Dr. [INAUDIBLE] at about 2.5%. And very few patients were converted for bleeding. They were mainly converted for two-- because of tumor reasons.

Either it was a very centrally located tumor and we had difficulty completing a sleeve lobectomy, or we were trying to spare a lobe that eventually needed a pneumonectomy. So this technique has been proven to be reliable, safe, and reproducible. You can see here in this 214 case series, there were 65 patients with stage 3A disease that received full dose radiation pre-operatively.

The median tumor range from 0.7 centimeters to 11 centimeters, so quite a challenging group of patients to treat. And what was surprising is that our overall morbidity and mortality was quite acceptable, with the overall morbidity being 26%. The major morbidity being 5%.

And you can see here in this illustration that the common morbidities included an air leak that lasted more than six days and an effusion requiring a thoracentesis typically after surgery. Arrhythmias, about 3%, and pneumonia rate about 5%. So these complications in this very challenging group of patients you can see is quite respectable.

If you recall how these patients responded to a previously open technique to treat locally advanced disease, these patients often had multiple complications postoperatively, spent a long time in the hospital recovering. Often repeat procedures such as bronchoscopies, readmissions to the hospital or to the ICU.

So robotics and minimally invasive surgery in general for this patient population has been a positive attribute, in my opinion.

This is just an example of a patient who had a very large, poorly differentiated neuroendocrine tumor in the left upper lobe. We treated her with preoperative chemotherapy and radiation. And you can see here that we're approaching her robotically. It's a very centrally located tumor.

We're certainly going to expect some significant desmoplastic changes around the central hilum. And you can see here as we're dissecting around the bronchus of the left upper lobe, we're unable to free up that large lymph node that was predominantly in the super hilar location.

And this just demonstrates the flexibility of robotics being able to perform very complex maneuvers, such as dividing the [INAUDIBLE] to be able to get better access to the main structures, namely the super hilar pulmonary artery structures, to safely divide them without getting into too much difficulty.

And without the availability of robotics, using traditional [INAUDIBLE] surgery, this type of surgery would be very difficult and challenging to do for most thoracic surgeons, even those of us that had experience with traditional VATS.

So in summary, conventional total endoscopic video-assisted anatomical resection remains technically demanding. I think advancements in robotic assisted platforms have made it possible and reliable to perform a complete port-based pulmonary resection, even for more advanced disease, not only just early stage disease.

Robotic assisted and topical lung resection is feasible and safe. It's been proven to be favorable to historical series published on conventional open technique or VATS technique. Robotic assisted lobectomy is associated with low morbidity, low mortality, and a short length of stay.

And robotic assisted pulmonary suction has a wider clinical utility. Those patients who have larger masses, more advanced disease, or lymph node involvement can be managed using a robotic minimally invasive technique. And one-- if one chooses to adopt this technology into their practice, if you're an open surgeon, certainly you're going to be able to manage a wider population of patients, those with more advanced disease, with a minimally invasive technique.

And I find that managing patients minimally invasive as much as you possibly can will improve the outcome, reduce the complications. And it has also been demonstrated that the utilization of minimally invasive surgery reduces the overall cost to the health care system.

So there's certainly an advantage to try to introduce minimally invasive techniques to as many patients with locally advanced disease or early stage disease for our lung cancer patients.

Thank you very much for the opportunity to speak this evening. Our next speaker is Dr. Rupesh Kotecha. He's the chief of radiosurgery in the field of thoracic oncology, and he'll be speaking about the treatment of early stage and advanced lung cancers, the role of ablative technology. Thank you, Dr. Kotecha.

DR. RUPESH KOTECHA: I want to thank the organizers for having me here today. My name is Rupesh Kotecha, and I'm a radiation oncologist in the Department of Radiation Oncology at MCI. Today I will be speaking on treatment of early stage and advanced lung cancer: the role of ablative technology.

These are both my personal disclosures, as well as my institutional research funding. As well as from a conference perspective, I'm going to discuss some of the equipment or brand names in our department, but this is all an educational effort to explain how patients are triaged across the different technologies at our institution.

These highlight examples that we have made for patients that we have treated in the clinic, but do not represent the only acceptable option for any particular patient.

So this is our beautiful Cancer Center here in Miami. And what's really remarkable and unique is that on this first floor, we essentially have one of every single radiation machine there is, so we can personalize the radiation therapy treatment options for every patient that we see in the clinic.

Really, all of this technology is here to employ the optimal modality for any patient, given any diagnosis. Today, we will actually discuss in detail how we use these advanced technologies for patients with early stage and locally advanced lung cancer. Now under the hood of each of these machines, just like under the car hood, there are differences in what are called the inter-fraction, intra-fraction.

Those are imaging that is occurring before and during each radiation treatment. There's differences in the radiation type that each machine has. And this basically leads to ideal clinical indications for each of the technologies that we have at our center. This is actually complicated enough that we have an established workflow in place, in which a patient is seen in consultation.

We would create a directive as to how we want to simulate and treat a patient. This undergoes a multidisciplinary prospective peer review, which is actually very unique to our institution. The only one in, really the entire world, that does this. Then the patient undergoes simulation.

We delineate the target volumes and the organs that are at risk close to that target. We also review that contour set. We then do treatment planning. And then that is approved by an individual physician and then peer reviewed with another physician team. This undergoes quality assurance, typically by our physicist.

And then the patient actually delivers this radiation therapy treatment. This is an established workflow that we have, and our processes have been published in the peer reviewed literature.

Now for a patient with early stage lung cancer being evaluated at our center, I can think about five different radiation therapy machines that we could potentially treat that patient with. And as we are seeing the patient in clinic, as we're gathering the information from the shared medical record for that patient, as we are seeing them and doing a physical examination or looking at the imaging studies, we're processing all of this information for each patient.

They then be able to triage them appropriately to the machine of choice, which would be best to treat their cancer. In some circumstances, there is more than one machine that could be potentially used for each individual patient. If this circumstance or scenario arises, then we can do what's called a comparative treatment plan, and we can generate different treatment plans across the different platforms and do comparisons between them.

And essentially, at the end of the day, we want to treat the patient with the best quality plan.

Now for the purposes of the discussion today, for early stage lung cancer, I'm going to review one of the newest machines that we've added to our portfolio, which is an MR linear accelerator. This was the second machine in the country, the third in the world to be installed at any facility.

Essentially, the workflow for this, or as a patient comes into the clinic, they undergo an MRI scan in our department. That's very unique. Then they undergo a CT scan. That's what we use to calculate radiation dosimetry. We also do what's called a four-dimensional CAT scan.

That means that we watch the tumor as a patient breathes. The physician then does the target volume delineation. We want to delineate that target, as well as the nearby organs at risk. That undergoes planning and QA. And then when the patient's actually receiving their treatment, they undergo an MRI at the time of treatment in which we can visualize that tumor. And then the patient is actually treated with radiation.

Again, this is all non-invasive. The patient does not see anything, they do not hear anything, the machine does not touch them at any point. In fact, this allows us to see a tumor, track a tumor, and treat a tumor. And we can actually do this in just even one single fraction or a single treatment.

And we triage patients specifically to this platform, for this particular purpose. We can visualize the entire treatment and the patient themselves can actually visualize this as well.

This is a study that we published in the peer reviewed literature showing our single fraction radiation therapy workflow for patients with early stage non-small cell lung cancer and how we do this safely and effectively.

Now there is an established workflow for how this entire process arises. First, at the time of the treatment, I need to identify a target for anatomical tracking. That could be a region of interest to be treated, which is typically what we use for lung cancer patients, but could also be a critical structure that one wants to avoid treating.

For example, the spinal cord. We then create a boundary to identify a tracking region, and then we are able to visualize the tracking algorithm as it deforms the anatomical target and each subsequent frame. In the next slides, I'll actually show you visually of what this looks like.