joshua sonett, md professor of surgery chief section of...
TRANSCRIPT
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Joshua Sonett, MD
Professor of Surgery
Chief Section of Thoracic Surgery
Columbia University
New-York Presbyterian Hospital
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Disclosure
Personal Bias
• Jaretzki Dictum: The less thymus left
behind the better…Tempered by potential
morbidity of Radicality
• Bilateral Thorascopic Thymectomy
• 90% Dissection via left thoracoscopy
• +/- Cervical
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MGFA Thymectomy Classification
T-1 Transcervical Thymectomy
a- Basic
b- Extended
c- Extended with Partial Sternal Split
d- Extended with Videoscopic Technology
T-2 Videoscopic Thymectomy
a- Classic VATS (unilateral)
b- VATET (bilateral with neck dissection)
c- Videoscopic with Robotic Technology (unilateral)
d- Videoscopic with Robotic Technology (bilateral)
T-3 Transsternal Thymectomy
a- Standard
b- Extended
T-4 Transcervical and Transsternal Thymectomy
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Operative Steps
Thoracoscopic
Thymectomy
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3 5mm ports
CO2 Insulflation to 8-10mmhg
Flex Head for Cervical dissection
Cervical Incision as needed ((<5%)
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Step
Pericardio-Dia.
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Step 2
Sternal release
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Step 3
Pericardial Dis.
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Step 4
Left Phrenic
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Step 5
I. Vein
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Step 6
Cervical Dis.
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Step 7
A-p window
Right Ph
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17% 16% 20%
12%
18%
43%
49%
65% 67%
71% 74%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Thymectomy: VATS (%) 2001 ~ 2011
Ann Thorac Surg 2012;94974-82
Columbia Experience
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Cervical (T-1a)
0
10
20
30
40
50
60
70
80
90
1 2 3 4 5 6 7 8 9 10
Rem
issi
on
s (%
)
Follow-up (years)
Cervical-Sternal (T-4)
VATET (T-2b)
Ext. Sternal (T-3b)
Ext. Cervical (T-1b)
Spontaneous (Children)
VATS (T-2a)
Thymectomy for M.G.- No Thymoma Remissions – Life Table Analysis
Seminars in Neurology 24:49-62, 2004
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Joshua Sonett, MD
Professor of Surgery
Chief Section of Thoracic Surgery
Columbia University
New-York Presbyterian Hospital
Thoracoscopic Thymectomy in Myathenias Gravis
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hopwood
Limits to the Radicality of Surgery
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Follow-up (months)
10 20 30 40 50 60 70 80 90 100 110 120
Cervical-Sternal (T-4)
100
90
80
70
60
50
40
30
20
10
0
Rem
iss
ion
s (
%)
Thymectomy for MG - No Thymoma Reality of Surgical wall
Trans-cervical (T-1a)
Neurology 48(Suppl 5):S52-63, 1997
? Immunologic Adjuvant tx
Rituximib/Alemtuzumab
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Thymectomy in Myathenias Gravis
• Extended Transsternal vs. Basic Transsternal
• Krakow , Poland, 1996-1999, 61 cons BTST/58 cons ExTST
• Zielinski et al. Ann Thorac Surg 2004:78:253-8.
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Thymectomy in Myathenias Gravis
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Estimated
Extent
of the
Thymic
Resections
Seminars in Neurology 24:49-62,
2004
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Posterior
Division
Mediastinal
Pleura
A - Vagus Nerve
B - Phrenic Nerve
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Open and Minimally Invasive
Thymectomy: Outcome Analysis of
263 Patients
Jeffrey Javidfar, J Jurrado, M Bacchetta, A Newmark, M LaVelle, F D'Ovidio, LA Gorenstein, ME Ginsburg, Joshua R. Sonett
Division of Cardiothoracic Surgery
Columbia University Medical Center, New York-Presbyterian Hospital
Disclosures: None
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Thymectomy and VATS
Is there optimal surgical approach to Thymectomy?
Should Thymomas be resected minimally invasively?
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Mediastinal Thymic Disbursement
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Operative Approach for Minimally Invasive
Thymectomy • Bilateral VATS
• Identify and visualize entire phrenic nerve
– Facilitates more complete resection
• “Jeretzki” Thymectomy:
– Resect all thymic tissue and mediastinal fat
– Complete, radical excision with negative margins
– Take pericardium and/or phrenic nerve if needed
• “Touch-Free” policy: care is take to not violate thymoma capsule – Any violation would degrade curative
intent
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Study Design
• Single-center, retrospective study
• 263 patients over 11 years
– 77 Minimally invasive thymectomy
– 186 Open thymectomy
• Three approaches
– Transsternal (N=186)
– Video Assisted Thoracoscopic Surgery (N=75)
– Robotic (N=2)
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14%
31% 55%
Pre-Operative Minimally Invasive Diagnosis (n=77)
2%
47% 51%
Pre-Operative Open Diagnosis (n=186)
HYPERPARATHYROIDISM
MEDIASTINAL MASS
MYASTHENIA GRAVIS
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Baseline Characteristics
Thymectomy
Minimally Invasive* Open* p-value
Sample Size (n=263) 77 186 0.36
Sex (Male) 24 69 0.89
(Female) 53 117
Age, years 46 (36-54) 52 (38-61) 0.02
BMI, kilogram/meter2 26.9 (23-29) 25.7 (23-30) 0.77
Comorbid Condition
Hypertension 20 53 0.68
Coronary Artery Disease 4 14 0.50
Diabetes 1 16 0.03
Hyperlipidemia 6 33 0.04
Atrial Fibrillation 1 6 0.38
COPD 0 8 0.07
Asthma 7 16 0.90
Autoimmune Disease 4 16 0.34
*Median Values with Interquartile Range Where Appropriate
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Myasthenia Gravis
Characteristics
Myasthenia Gravis Foundation of America Preoperative Staging Thymectomy
Grade Frequency Percent Minimally Invasive Open p-value
p= 0.71
1 27 19.42 5 22
2a 49 35.25 14 35
2b 33 23.74 11 22
3a 6 4.32 2 4
3b 11 7.91 2 9
4 4 2.88 0 4
4b 1 0.72 1 0
5 8 5.76 2 6
MIT: Minimally Invasive Thymectomy; OT: Open Thymectomy
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Temporal Distribution of
Surgical Technique
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Results: All Patients
Thymectomy
Minimally Invasive Open p-value
ICU LOS, days 0 (0-1) 1 (0-2) <0.01
Hospital LOS, days 3 (3-4) 5 (4-7) <0.01
Estimated blood loss 20 mL (0-25) 100 mL (20-200) <0.01
Duration of Surgery 2 hrs 47 min (1:17-3:33) 2 hrs 24 min (1:44-3:09) 0.88
Complications 0.60
Vocal Cord Paralysis 1 0
Cardiac 2 11
Respiratory 3 9
Other 1 5
None 70 161
LOS: Length of Stay; ICU: Intensive Care Unit; mL: milliliters; hrs: hours
*Median Values with Interquartile Range Where Appropriate
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Myasthenia Gravis Results
• Remission* from symptoms
– Incomplete data, representative sample
– Equal remission rate between MIT and OT: 64% (p=0.59)
• * Did not require any medications to treat Myasthenia Gravis symptoms
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Suspicious Mediastinal Mass Pathology
Pathology Frequency Percent Thymectomy
Minimally Invasive Open
Dermoid Cyst 1 0.93 1 0
Ectopic tissue 4 3.70 3 1
Liposarcoma 1 0.93 0 1
Lymphoma 2 1.85 0 2
Metastatic 3 2.78 1 2
Teratoma 1 0.93 1 0
Pseudotumor 1 0.93 0 1
Thymic Remnant 2 1.85 1 1
Thymic Cyst 16 14.81 4 12
Thymic Carcinoma 6 5.56 1 5
Thymoma 71 65.74 9 62
Positive Margin 5 7.00# 0 5
Extended resection 39 55.00# 6 33
*Final Pathology # Percentage of thymoma subgroup
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Ruckert J, Swierzy M, Ismail M
Comparison of robotic and nonrobotic thoracoscopic
thymectomy: A cohort study
JTCVS volume 141, Issue 3 2011 673-677
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Thymectomy for Thymoma
Minimally Invasive * Open * p-value
Sample size (n=71) 9 62 0.5
Sex Male 3 28 0.64
Female 6 34
Age, years 47 (40-48) 58 (46-65) 0.10
BMI, kilograms/meter2 25.9 (24.9-26.9) 26 (23.5-30.1) 0.82
ICU LOS, days 0 (0-0) 1 (0-2) <0.01
Hospital LOS, days 4 (3-4) 5 (4-7) <0.01
Estimated blood loss 7.5 mL (0-17.5) 200 mL (20-250) <0.01
Duration of Surgery 3 hrs 46 min (3:33-4:53) 2 hrs 10 min (1:44-3:13) 0.03
Total mortality 0 9 0.59
Masaoka Stage 0.50
I 4 16
II 5 41
III 0 5
BMI: Body Mass Index; LOS: Length of Stay; ICU: Intensive Care Unit; mL: milliliters; hrs: hours; min: minutes
*Median Values with Interquartile Range Where Appropriate # Patients with a pathological diagnosis of thymoma
Results
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14%
31% 55%
Pre-Operative Minimally Invasive Diagnosis (n=77)
2%
47% 51%
Pre-Operative Open Diagnosis (n=186)
HYPERPARATHYROIDISM
MEDIASTINAL MASS
MYASTHENIA GRAVIS
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Thymoma Pathology and Margins
Thymectomy for Thymoma
Minimally Invasive * Open * p-value
Sample size (n=71) 9 62 0.5
Specimen Size 4.45 cm (3-6) 6.5 cm (4.3-8.5) 0.09
Involved Surgical Margins 0 5
Extended Resection (n=38) 0.11
Lung (n=8) 0 8
Pericardium (n=12) 4 8
Lung & pericardium (n=13) 3 10
Pleura (n=3) 0 3
Innominate Vein/ SVC (n=2) 0 2
Masaoka Stage 0.50
I 4 16
II 5 41
III 0 5
*Median Values with Interquartile Range Where Appropriate # Patients with a pathological diagnosis of thymoma
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Conclusion
• Minimally Invasive Thymectomy
– Can be safely performed
– May have clinical advantages
• Equivalent Surgical Tenets
• Can be used in all indications, including thymoma
– Selective cases
– Long-term follow up necessary
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New York-Presbyterian Hospital
Columbia Universtiy
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Sharp Dissection
on Pericardium
Note Relation of
Nerves to Thymus
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The Real Issues
• Is Complete Total thymectomy important?
– Does a more extensive resection improve
results?
• Are all Thymectomy approaches equal?
– Extent vs. Morbidity
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Thymectomy in Myathenias Gravis
Prospective study of the role of
thymectomy in Myathenias Gravis
• Multi-Center, International, Single–Blind,
Randomized Study comparing thymectomy to no
hymectomy in Non-thymomatous MG patients
receiving prednisone.
• Accrual goal: 200. MGFA class II-IV, Ab +
• NIH supported
• John Newsome-Davis, MD Study chair Clinical
Coordinator.
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Thymecotmy in Myathenias Gravis
• Gronseth et al., evidenced base review, 1953-1998
• 310 articles, 28 articles with 8490 patietns consistent with class II evidence
• Broadly favorable effect of surgery vs. no surgery, with remission rate of 2.1,
• Benefis ascribed to thymectomy blurred due to multiple confounding variables
“The benefits of thymectomy in MG remain unproven”
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Right
Phrenic
nerve
release
Right Mammary
vein release
Release from
Left
Brachiocephalic
vein
Cervical neck
dissection
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Anterior
Division
Mediastinal
Pleura
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Surgical resection of persistent thymic Tissue
after intial Thymectomy
Author/series
Patients Original
Procedure
Pathologic
Thymus Found at
Resection
Myasthenia
Improvement
Henze A et al.
Masaoka A et al.
Miller RG et al.
Rosenberg M et al.
20
6
6
13
Transcervical
Transcervical
Tanscervical
3
Basic
Transternal
3
Transcervical
20/20
6/6
5/6
11/13
19/20
3/6
5/6
6/13
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Extent of Thymic Tissue Recoverd
in Peri-thymic mediastinal fat tissue
Author/Series. Surgical
Approach
Extracapsular
Thymic tissue
Jaretzki et al.
Masaoka et al.
Zielinski et al.
Ashour
Scelsci et al.
Mineo et al.
Maximal
Extended
Extended
Extended
VATET
VATS
50 pts 98%
18 pts 72%
58 pts 56.0%
38 pts 39.5%
27 pts 37%
31 pts 32%
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