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Melanie Cole (Host):  The use of robotic assisted techniques is growing fast in several surgical disciplines, now including thoracic surgery. Today, we’re talking to Dr. Tiago Machuca. He’s a Thoracic Surgeon and Surgical Director of the Adult and Pediatric Lung Transplant Program at the University of Florida in the Division of Thoracic and Cardiovascular Surgery. Dr. Machuca practices at UF Health Shands Hospital in Gainesville. Today, we will aim to understand the current treatment algorithms for early stage lung cancer, identify the potential benefits from minimally invasive thoracic surgery to treat lung cancer and recognize expected quality metrics that lead to improved outcomes.

I’m so glad to have you join us today Dr. Machuca. Before we get going, let’s set the stage. What are you seeing as far as incidence and prevalence of lung cancer? Do you feel that there’s more awareness and are people getting the message?

Tiago Machuca, MD, PhD (Guest):  I think that there is an increasing awareness on the problem that lung cancer represents nowadays and not only that, but I think that the utilization of more consistent lung cancer screening programs and also the use or increased use of imaging techniques such as chest CT scans for unrelated reasons, I think we end up seeing an increasing number of early stage lung cancers. But certainly I think there’s a lot that needs to improve if you look back and just understanding that lung cancer continues to be the – amongst all cancers, one of the highest mortality, we still need to do a lot to get to a better spot.

Host:  Let’s talk a little bit about screening. So, the screening now, there are guidelines. Tell us a little bit about low dose CT screening for early stage lung cancer.

Dr. Machuca:  Yes, so CT screening now is validated after an extensive clinical trial that was run here in the United States and also counterparts in Europe. And that has shown that there is a significant benefit of implementing low dose CT screening to patients that are in the highest incidences of lung cancer. So, that is something that is validated but unfortunately, we still don’t see a widespread use of these protocols if you look at the general patient population.

Host:  Well then please help us to understand the current treatment algorithms for early stage lung cancer, whether you are starting at initial evaluation and clinical stage and pretreatment evaluation. Give us a little understanding of these algorithms.

Dr. Machuca:  Correct. So, I think that a lot of the treatment options and more importantly the prognosis of lung cancer is going to be dictated by the stage. Right, so what’s the stage of that lung cancer. Are we talking about stage one, two, three or four? And when we talk about screening for lung cancer, when we talk about using surgical therapies for curative intent in lung cancer; we are talking more about cancers in the stage one and two. So, these are small lesions for stage one up to three centimeters and for stage two up to five centimeters that do not have any spread to other areas such as mediastinal lymph nodes or metastasis to adrenal glands or liver or bones or the brain which are the most common sites of metastasis from lung cancer.

So, when you are talking about these types of lesions, they are usually smaller than five centimeters with no metastasis to mediastinal lymph nodes or to other organs; you are talking about curative intent, local therapy added or not by systemic therapy depending if there’s any regional spread to hilar lymph nodes or let’s say intrapulmonary lymph nodes.

When you start talking about let’s say more advanced stages such as stage three or four, when there is spread to those areas mentioned before, mediastinal lymph nodes or other organs; then the treatment focus starts to be more like systemic therapy with chemotherapy and now we have seen a boom in immunotherapy for lung cancer with improved outcomes. I think that that’s how you stratify what are your treatment options and algorithms to do further investigation on patients with lung cancer and also to come with a therapeutic plan.

Host:  Well thank you for that very comprehensive answer. So, as we are working on identifying the potential benefits for minimally invasive thoracic surgery to treat lung cancer; on the surgical side, Dr. Machuca, the field has moved, are there many more cases being managed through minimally invasive and newer kinds of techniques? Give us a little bit of an overview of some of the techniques and surgeries that you perform.

Dr. Machuca:  Yes. If you look back five, ten, fifteen years; a lot of the surgical therapy of lung cancer was centered on open surgery. So, let’s say conventional standard open thoracotomy to resect portions of the lung, most often a lobectomy. That’s how it was done and that’s how it’s still done in some circumstances. But the problem with that is that it involves a large incision and especially spreading the ribs. So, with spreading the ribs through an open large incision, later on patients will have increased pain, a longer postoperative recovery course and also that was all tied with increased rates of complications and that’s mainly respiratory complications.

So, even though we knew that surgical therapy for lung cancer involved removing a portion of it with the lymph nodes most often through a lobectomy; it was being done through open incisions and with that, I think that we were seeing an impact on the postoperative course of our patients. So, luckily, with the addition of new technologies, with the utilization of videoscopes and more recent with the addition of robotics; nowadays we have been able to perform these operations through small incisions usually three or four incisions about eight to twelve millimeters and more importantly, we do not spread any ribs. There’s no fracture on the ribs, there is no pressure on top of the intercostal nerves and with these newer techniques through small incisions; we are seeing that the surgical trauma on our patients is a lot improved.

So, with that, the patients tend to recover faster. They report less pain on the incisions and with less pain, they are able to take deeper breaths. They have a more effective cough. They avoid atelectasis or need for bronchoscopies for bronchial toilet or mucus plugging. So, with all of that what we see is that there is improved outcome in patients with lung cancer with the utilization of these newer techniques for treatment of lung cancer.

Host:  Wow, it is amazing the technology. Dr. Machuca how are you recognizing the expected quality metrics that are leading to these improved outcomes and while you are telling us that, how have advances in radiologic imaging significantly augmented your diagnostic and therapeutic capabilities in surgery?

Dr. Machuca:  Yeah, I think it’s very important to look into quality metrics for lung cancer and I think that nowadays because of all the advantages that I just mentioned to you; one of the quality metrics is the utilization of minimally invasive techniques. So either with the use of a video thoracoscope or use of a robotic surgery; I think if you can increase the rate of lung resections being done with minimally invasive techniques you are certainly adding quality to your patients who are undergoing lung cancer surgery.

Other important quality metrics that we see nowadays that are recognized are obviously the negative margins on the pathology examination so that’s crucial to have a good quality lung cancer surgery. The resection of lymph nodes on the mediastinum stations and also in the hilar stations and specifically usually a number of more than eight to ten lymph nodes involving the mediastinal and hilar stations need to be present because that’s going to lead to improved staging of lung cancer and also the identification of patients that will benefit from adjuvant therapy.

And then on top of that, additional quality metrics that we have are the time for operations. So, by the time that the patient is diagnosed with lung cancer; usually there is has got to be a timeframe of four weeks for the patient to be undergoing surgery. So, these are metrics that you look at when you are thinking of early stage lung cancer treatment.

Host:  That’s absolutely fascinating and as you say, so important. As we wrap up, tell us about some of the latest advances in lung cancer treatment. What are some of the most exciting things that you are doing and that other oncologists should know that could be practice changing?

Dr. Machuca:  The way I see lung cancer treatment is that you need to provide let’s say excellent surgery to your patients with decreasing morbidity, decreasing mortality. What we are seeing with minimally invasive techniques is that we are opening a therapeutic window to patients that were not considered for surgery before. So, if you take other patients or patients that have limited lung function or more comorbidities, these were the patients that had the highest complication rates with open lung cancer surgery. So, I do think that there has been a complete shift in paradigm when you consider these patients nowadays for surgery, you really need to make your referring physicians, pulmonary physicians, medical oncologists aware that this new era of lung cancer surgery has completely changed.

So, nowadays with the use of these advanced techniques, we are able to offer surgery for patients that we would be very hesitant in the past because these patients would have a higher rate of respiratory complications, higher mortality. So with all of that, I think that we are seeing more and more patients that can be considered for therapeutic surgical treatment of lung cancer with improved outcomes. So, I think that this is a number one that we are certainly seeing this shift and then number two, I think that there has been also a higher consideration for lung sparing procedures. So, just think that patients that have limited lung function, if you can provide a oncologically sound resection but on the same time, preserve lung; I think that that patient is going to have a big benefit.

So, nowadays with the use of let’s say segmental resection, so anatomical segmentectomy that can be performed robotically or bronchoplastic procedures so let’s say instead of performing a pneumonectomy, removing the entire lung; you would perform a resection of a lobe of the lung and then reconstruct the airway performing a bronchial anastomosis. So, with these lung sparing procedures I think it illustrates very well in other let’s say window in lung cancer surgery that we can consider. So, patients that have borderline lung function that we can still offer the ideal oncological procedure, therapeutic procedure but on the other hand, we will also be able to preserve lung instead of removing the entire lung or the entire lobe; we can preserve lung so that the patient is going to have a lower impact on his postoperative lung function and tied to that, better quality of life.  

Host:  It is great information and Dr. Machuca, do you have any final thoughts? What would you like other providers to know about the importance of understanding and giving lung cancer patients better results with robotic surgeries and innovative techniques and when you feel it’s important that they refer to the specialists at UF Health Shands Hospital?

Dr. Machuca:  Yeah, so what I think is really important is consider a team approach. If you think of let’s say our internal lung cancer group here, but we also partner with outside medical oncologists, radiation oncologists to try to provide the best let’s say recommendations for the management of lung cancer of any given patient. So, whenever you have this team approach with unbiased views, and everyone is aligned to get the best outcome for the patient; I think that’s when you are truly impacting lung cancer care.

So, what I think is truly important is whenever you are seeing a patient with lung cancer, really seeing if there is any value in adding a thoracic surgeon in the decision making. So, let’s say denying an operation to a patient with a potential curable lung cancer based on previous assumptions or previous experiences I think that the patient will benefit a lot if you can change that view. So, if you can consider involving a surgeon and we always have a team approach and talk back to our referring physicians to come up with what’s the best plan for that patient.

So, I oftentimes receive patients that are borderline or considered high risk for resection and a lot of these patients we end up being able to take to the OR and do a curative intent lung cancer surgery and they do very well. But on the other hand, when I feel that a patient is not a good surgical candidate; we just circle back with the referring physician and come up with an alternative plan. So, I think that considering that team approach so you can come up with the best therapeutic plan for your patient is very important. And by team approach, oftentimes, considering involving a dedicated thoracic surgeon on that algorithm.

Host:  Thank you so much Dr. Machuca for coming on. It’s a fascinating topic and thank you so much for sharing your expertise with us today. And that concludes this episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit www.ufhealth.org/medmatters to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. For more health tips and updates on the latest medical advancements and breakthroughs please follow us on your social channels. I’m Melanie Cole.