Transcription:
Segmentectomy: How Research Changed the way Surgeons Treat Lung Cancer

Joey Wahler: New research is changing the way surgeons treat lung cancer, so we're discussing a resulting procedure called a segment resection or a segmentectomy. Our guest, Dr. Peter Ellman, a cardiovascular and thoracic surgeon.

This is FirstHealth and Wellness Podcast from FirstHealth of the Carolinas. Thanks for listening. I'm Joey Wahler. Hi, Dr. Ellman. Thanks for joining us.

Dr. Peter Ellman: Hi there. How are you doing?

Joey Wahler: Doing great. So, first, simply put, what patients are candidates for a segmentectomy and what exactly is done?

Dr. Peter Ellman: So first of all, we're talking about patients who have lung cancer and an early lung cancer. That would be a small cancer, usually in the one to two centimeter range caught early, usually incidentally or found on a screening CT scan of the chest that is done for people who have a history of smoking and, oddly, there's a very small percentage of people who are actually getting those scans done. So, the one thing I'd really want to talk about, at least briefly here, is just if you're listening to this podcast and you have a history of smoking, you should talk to your primary care doctor about getting a screening CAT scan. It's low dose, it's no contrast. And what it'll do is see if there's potentially a small cancer there that needs to be dealt with. And, you know, once somebody becomes symptomatic with lung cancer, not to be too graphic here, but if you say you're having shortness of breath or even coughing up a little bit of blood, that's often one of the late stages of cancer where you can't have surgery. Or somebody like me is kind of out of the game and you're dealing more with radiation or oncologists. But if we can catch these things early, in many cases, we can actually do a resection and minimally invasively with small incisions and you go home the next day.

And so, we're really trying to push for this screening CAT scan program that's been demonstrated from a research study that was done about 10 years ago, printed in the New England Journal of Medicine that shows these screening CAT scans can really save lives. So if we can catch one of these things early and it's about the size of a pea, we start talking about surgery. So, we get the CAT scan. We would probably do some kind of a biopsy. Usually, here, Dr. Michael Pritchett, who's a world expert in navigational bronchoscopy, can go in and biopsy very, very small tumors and prove that you have a cancer. And then, we would do staging studies, PET scan, brain MRI, and probably a bronchoscopy maybe at the same time when the biopsy was done to make sure that it hasn't spread to the lymph nodes that are running along your trachea or spread elsewhere. And if we feel that the cancer is limited to that one small area of your lung, and you have lung function that would tolerate a resection, then we would want to take it out because that's your best chance at a cure.

Now, a segmentectomy, the recent data has shown that this can be as good as a lobectomy. The classic operation for lung cancer is a lobectomy, which there's basically five lobes of your lungs. On the right side, there's three lobes. On the left side, there's two. And so, you can imagine if the lung on the left side, say, is divided into two lobes and you take out one of the lobes for a lung cancer, that's great from the standpoint of the cancer operation, because these cancers can spread in the lung itself, but you've now taken out half of that person's lung on that side, which depending on their lung function, and a lot of people who've smoked don't have totally normal lung function, you may leave them slightly short of breath afterwards. Though we really try to make sure, based on the preoperative lung function studies, that they're not going to feel short of breath afterwards, and they have the lung capacity to stand the resection.

Now, if you're on the borderline and, you know, depending on where the tumor is, there's some areas that are more amenable to a segmentectomy than others. And so, a segmentectomy is just taking part of that lobe out. And, if you have that small tumor in one of the segments that's more amenable to it than others, that would make you a candidate for the segmentectomy, either because your lung function would do better without the whole lobectomy or if it's just in the right segment to do it.

Joey Wahler: Gotcha. And great advice by the way, that you mentioned at the outset. So, let me ask you this. What can you tell us in a nutshell about that aforementioned research leading to this becoming the standard of care for these patients.

Dr. Peter Ellman: I think it is a beneficial option in certain cases. I mean, the bottom line is if you can do an equal cancer resection and spare some lung tissue, you'd want to do that. So, particularly on the superior segments of the lower lobes, those lend themselves to the segmentectomy. The lingula of the left upper lobe is also one of the areas, one of the segments that lends itself, you know, anatomically. All of every segmentectomy and every lobectomy is like a different operation unto itself. In every anatomic lung resection, either a lobectomy or a segmentectomy, you've got to divide in at least one artery and one vein and then an airway, the bronchus.

The research shows that that the segmentectomies can be as good a cancer operation. There's also research that shows that even a good wedge resection, which is a non anatomical, and that's even more of the data that's come out recently, that as long as you can get a good margin, a couple centimeters, let's say you just wedge out that part of the lung that has the cancer, that's also a good option. All of these things, the main point is to try and get the tumor out with a good amount of lung tissue, so you feel your margins are good. The segmentectomy, particularly against both the superior segments and the lingula on the left side, those are the places where even if you have normal lung function, it makes sense to do that because why not spare a huge portion of those lobes. If the tumor is in other parts of the lung, it doesn't make quite as much sense to do it. And you might be looking at a lobectomy, which isn't the end of the world. It's still a great cancer operation. It's still done thousands of times every day, all over the world. But the segmentectomy, most of the research for that has also come looking at something called ground-glass opacities, which is a kind of a lung cancer, not sometimes as aggressive. And some of that research is out of Japan. But we're pretty proud of the fact that we've been moving in the direction of sticking with the things that are being done that are cutting edge and our gold standard all over the world.

Joey Wahler: So in terms of recovery, both timetable and otherwise, what's that like and what is the main benefit that patients are experiencing after having this done?

Dr. Peter Ellman: The main thing is whether or not this operation is done minimally invasively or open. For years, to have a lung operation done, you would need to have a big incision about 10 centimeters long, made in the side of your body, kind of continuing up underneath your scapula, and then you basically have to spread the ribs apart and sometimes cut part of the ribs to do a traditional thoracotomy incision to do a lung resection. Back in 2015, 2016, I started the robotic program here at this hospital as a means to bring minimally invasive lung resection to our lung cancer program here, because that really is the gold standard now for these early lung cancers.

So, there's two different ways to do a minimally invasive resection for lung cancer, video-assisted thoracoscopy, VATS, which is small incisions, but you're standing at the bedside and you're holding the instruments that you're operating with. The other option is robotic video-assisted thoracoscopy. And so with that, you actually have a robot, a da Vinci robot, which has forearms at the bedside. Those instruments then are placed by the surgeon through trocars that have been placed in the body, which are like little tubes. And then, the surgeon sits in the corner of the room and controls the robot using both his feet and his hands and has stereoscopic vision. That allows you to do that operation that traditionally was done through a very large incision, that would mean you're in the hospital for three or four days and there's more significant pain, longer recovery, through small incisions that many times now I'm sending patients home the next day because we're not making that big incision and we're not spreading the ribs apart.

So, the robotic lobectomy and the robotic segmentectomy, the real benefit in terms of the short-term recovery in your hospital stay is that you haven't gotten that thoracotomy. From the standpoint of the actual recovery afterwards, it's not significantly different, say, the difference between a segmentectomy and a lobectomy just immediately after you get out of the hospital. But probably long-term, sparing, you know, that extra part of the lung, I think certainly in certain people who have already had a little bit of limited lung function because of smoking, they would notice a difference compared to how they would've felt with the full lobectomy, because I think they'd have a little bit more wind and a little bit more stamina. But the main thing is whether or not you can do these operations minimally invasively and without having to convert to an open procedure and getting people home the first day or two after surgery.

Joey Wahler: I think we can agree that most of us, if not all of us, can use some more wind and stamina, right?

Dr. Peter Ellman: There you go. Who wouldn't? That's right.

Joey Wahler: Absolutely. Finally, let me ask you this, just generally speaking, going forward in the near future, any other technological advance coming down the pike that'll change the way lung cancer patients are being treated.

Dr. Peter Ellman: The things that we're doing here, particularly combined procedures that I've been doing with Dr. Pritchett and, you know, Dr. Pritchett really is leading the way here in terms of lung cancer. He's a real innovator and has brought some great technology here on the pulmonology side in terms of the bronchoscopic techniques, some of the imaging techniques. And part of the thing that we've been able to do together is he can go in in a tumor that really just recently at one of the academic hospitals north of us, they didn't really have the capabilities to do it, but we could do it here, was that we can mark a subcentimeter tumor, a tumor you can't even feel with your fingers if you had your hand inside the chest and had that thoracotomy. It's a tumor that's small, and mark it with a little gold marker that then I can the same day take the patient to the operating room and with video-assisted thoracoscopy, again, small incisions and a fluoroscopy machine, which is like an x-ray machine that has movie capabilities, bring that machine in and I can find where that marker is., And I can wedge out that cancer before it's even grown to the size of a pea. And that kind of combined marking and then dealing with the tumor the same day, I think that that's where things are going. With the robot, we're also getting some different capabilities in terms of marking the tumors that way, so we can wedge the tumor out using the robot, where we also have the Firefly technology. The robot has the ability to change the camera to this kind of green camera that only shows this molecule, this ICG molecule that you inject, so it shows where tissue is still perfusing, still has blood flow or if you mark it where the tumor is.

So, there's all sorts of exciting stuff that's going on. I think that from a pulmonology standpoint, Dr. Pritchett's group and his colleagues all over the world are looking at ablation strategies so that people like me might not be involved at all, which is you have a tumor and they can go in with the bronchoscope and then they can ablate the tumor there before it ever gets big. So, that probably is really where some of the future's going. And that future would not include a surgeon, but that's the honest answer to some of that stuff.

Joey Wahler: Well, folks, we trust you're now more familiar with a segmentectomy. Dr. Peter Ellman, thanks so much again.

Dr. Peter Ellman: Thank you. I really appreciate it.

Joey Wahler: Same here. And for more information, please do visit firsthealth.org/chestcenter. Again, firsthealth.org/chestcenter. If you found this podcast helpful, please do share it on your social media. And thanks again for listening to FirstHealth and Wellness Podcast from FirstHealth of the Carolinas. Hoping your health is good health, I'm Joey Wahler.