Laser Assisted Pulmonary Metastasectomy (8 to 100 mets)
Posted: Tue Sep 24, 2013 10:24 am
I've put together some information these past days; thought about posting it here, in case it helps someone. If you have not time for more, you can watch at least this: http://www.youtube.com/watch?v=H3VH4fQ9Mks
LAPM stands for "Laser Assisted Pulmonary Metastasectomy", that is, surgery to reach the lung tissue and use of laser to remove the met.
Number of metastases is not a limitation -they say: "Usually 7-8 nodules are removed from each lung but even 100 can be removed in the same fashion. Very tiny nodules can be vaporised instead removed".
The conditions to qualify are:
-primary disease is completely under control.
-cancer spread is strictly restricted to lungs.
-the disease in lungs can be completely removed by surgery ((nodal metastases or unresectable hilar disease, in the lungs, would be exclusion criteria too. It has to be just mets, it doesn't matter the number)
-patient is physically fit to undergo the surgery.
*****************
Surgery description:
"Patient is put to sleep by general anaesthesia. Chest is entered through a small cut underneath the armpit. No muscle or rib is cut or removed. A spreader is inserted between the two ribs and ribs are spread apart. Surgeon carefully inspects and explores the entire lung with fingers. Thus he detects and notes the site and number of cancerous nodules.
One after the other, all nodules are removed along with a margin of 2-3 mm of healthy lung around them. Surgeon follows the contour of the nodule and goes all around in the healthy lung. One nodule usually takes 1-2 minutes. Though laser generates temperature of 700 degree Celsius, healthy lung is not damaged. Usually 7-8 nodules are removed from each lung but even 100 can be removed in the same fashion. Very tiny nodules can be vaporised instead removed.
Excised tumours can be subjected to pathological studies. Raw areas can be sutured back leaving lung nearly normal. Loss of lung tissue is hardly 10%. There is very little blood loss and hence, no blood transfusion is required. Total operating time varies between 1 and 2 hours. Complication rate is hardly 1 to 2 %. Mortality is rare. "
***************
GERMANY
The inventor of the technique and the machine (laser) used for this is a thoracic surgeon, Dr. Axel Rolle (Coswig, Dresden, Germany) http://www.ctsnet.org/home/arolle
He receive in 2004 an award for this; you can see him at the hospital and describing the technique in this video: http://www.youtube.com/watch?v=H3VH4fQ9Mks
Contact info easily available in his published papers/ google.
******************
UNITED KINGDOM
During some years, Dr. George Ladas (UK), other thoracic surgeon, trained with Dr. Rolle and in 2010 he started to use the technique at the Royal Brompton Hospital, London.
This is him: http://www.rbht.nhs.uk/healthprofession ... nts/ladas/
(contact info there)
Some newspaper/press articles about this is the UK:
http://www.dailymail.co.uk/sciencetech/ ... stamp.html
http://www.rbht.nhs.uk/media/press-rele ... ?locale=en
(Sending the written report of a chest CT scan to Dr Ladas' office got us an almost immediate reply about if a person is a candidate or not for this surgery).
*******************************
There is some place in India ("medical turism") where they perform LAPM, apparently.
Because of what I've reading, it's mainly patients with lung metastases from sarcoma who know better about Dr Rolle. You may find these discussions/ blog entries interesting:
http://sarcomatreatments.blogspot.com.a ... -lung.html
http://www.cureasps.org/forum/viewtopic ... fecaee6ebb (two pages long)
******************
Hope this helps someone.
Let's keep strong, all of us!
**
Edited to add:
Some abstracts from where to start to read, if interested:
Lasers Surg Med. 2006 Jan;38(1):26-32.
Laser resection technique and results of multiple lung metastasectomies using a new 1,318 nm Nd:YAG laser system.
Rolle A, Pereszlenyi A, Koch R, Bis B, Baier B.
Department of Thoracic and Vascular Surgery, Centre of Pneumology and Thoracic Surgery, Coswig Specialised Hospital, D-01640 Coswig/Dresden, Germany. dr.rolle@fachkrankenhaus-coswig.de
Abstract
BACKGROUND AND OBJECTIVES:
Advantages of a new 1,318 nm Nd:YAG laser based on multiple lung metastasectomies are shown.
STUDY DESIGN/MATERIALS AND METHODS:
Ninety-three percent of 328 patients with metastases (8/patient, range 1-124) had precision laser resections (lobectomy-rate reduced to 7%); this laser delivers 20 kW/cm(2) 1,318 nm power densities with 400 microm fibers, and a focussing handpiece. Absorption in water is tenfold higher.
RESULTS AND CONCLUSIONS:
Between 1/1996 and 12/2003 in 328 patients (164 males/females, 61 years) 3,267 nodules were removed. Pathologic examination revealed 2,546 metastases (range 3-80 mm) from kidney (n = 112), colorectal (n = 91), and breast cancers (n = 35). In 85% of patients where the complete resection was achieved the 5-year survival was 41%. For remaining 15% (incomplete resection) the 5-year survival was 7%. Five-year survival for patients with 10 (and more) metastases was 28%, for patients with 20 (and more) was 26%. No 30-day mortality was observed.
CONCLUSION:
This new laser system facilitates any kind of parenchymal lung resection in lobe-sparing manner and in case of complete resection improves significantly the survival.
**************
Bratisl Lek Listy. 2005;106(8-9):262-5.
Resection of multiple lung metastases--where are the limits?
Pereszlenyi A, Rolle A, Koch R, Schilling A, Baier B, Bis B.
Department of Thoracic and Vascular Surgery, Fachkrankenhaus Coswig, Centre for Pneumology, Thoracic and Vascular Surgery, Germany. Pereszlenyi@fachkrankenhaus-coswig.de
Abstract
Multiple lung metastases present a serious and challenging problem with increasing incidence for thoracic surgeons. In the lung metastasis management a significant role belongs to laser lung-parenchyma-saving resection. This parenchyma saving technique allows a removal of significant higher number of lung nodules in comparison to conventional techniques (stapler, clamp resection). Performing the lung metastasectomy by this manner, the only remaining question is the limitation of this technique. In this retrospective study, the results after Nd:YAG Laser (1318 nm, 40 Watt) interventions are being presented, the limitations of this technique are being discussed (Tab. 3, Fig. 4, Ref. 9).
***********
Ann Thorac Surg. 2002 Sep;74(3):865-9.
Lobe-sparing resection of multiple pulmonary metastases with a new 1318-nm Nd:YAG laser--first 100 patients.
Rolle A, Koch R, Alpard SK, Zwischenberger JB.
Department of Thoracic and Vascular Surgery, Fachkrankenhaus Coswig (Centre for Pneumology and Thoracic Surgery), Coswig/Dresden, Germany.
Abstract
BACKGROUND:
A new 1318-nm Nd:YAG laser has been developed to utilize the second wavelength (1318 nm; 40 watt) to more precisely cut, coagulate, and seal lung tissue adjacent to pulmonary nodules. This laser allows a precise intraparenchymal nodulectomy with a 5-mm rim of tissue destruction and subsequent lung parenchymal reapproximation to avoid lobar distortion. Resection of multiple, bilateral, and recurrent tumors in the lung is facilitated by this laser technique.
METHODS:
In 100 consecutive patients (53 men, mean age 60 years; 47 women, mean age 61 years) with various primaries (most commonly renal and colorectal), 155 laser resections were performed via anterolateral thoracotomy (staged 3 to 4 weeks, if bilateral) using a new 1318-nm Nd:YAG laser. All palpable and visible masses were removed with 2 to 3-mm visible tumor margins (plus a 5-mm rim of residual lung necrosis secondary to laser energy dispersal) if the tumor or residual lung ratio was judged favorable. No stapling devices or bioadhesives were used.
RESULTS:
Six hundred thirty-two metastases (6.3 per patient, range 1 to 124) were resected. Despite 41% centrally located metastases, tumor resections were possible in 95% of patients with only a 5% lobectomy rate. Of the 100 patients, 67 were considered "curative" with complete metastasectomy by inspection and palpation, and 23 were judged incomplete from too extensive tumor or residual lung, miliary lung spread, or pleural studding. There were no associated mortalities and two complications, including bleeding (1) and a prolonged airleak (1), both treated conservatively. Follow-up was complete in all patients for a median of 26.5 months with clinic visits and chest computed tomographic scan every 3 to 6 months. Nine recurrences were detected and underwent reoperation. Overall survival in the completely resected "curative" group was 85% at 1 year, 71% at 2 years, 69% at 3 years, 57% at 4 years, and 32% at 5 years; in the completely resected "palliative" group, they were 70% at 1 year, 36% at 2 years, 12% at 3 years, and 0 at 4 years; in the incomplete group, they were 56% at 1 year, 30% at 2 years, and 0 at 3 years.
CONCLUSIONS:
The new 1318-nm Nd:YAG laser is parenchyma-sparing, improves complete resection rates, and potentially improves survival with fewer required lobectomies.
************
AJR Am J Roentgenol. 2009 Mar;192(3):785-92. doi: 10.2214/AJR.08.1425.
Laser ablation of metastatic lesions of the lung: long-term outcome.
Rosenberg C, Puls R, Hegenscheid K, Kuehn J, Bollman T, Westerholt A, Weigel C, Hosten N.
Institute of Diagnostic Radiology and Neuroradiology, Ernst Moritz Arndt University, Ferdinand-Sauerbruch-Strasse, 17485 Greifswald, Germany. christian.rosenberg@uni-greifswald.de
Abstract
OBJECTIVE:
Pulmonary metastatic lesions are present in 20-54% of all patients who die of cancer. Surgical studies have shown that local management of distant tumor metastasis as part of multimodal cancer therapy improves survival. Minimally invasive procedures such as thermal ablation are still to prove their clinical relevance. The aim of this study was to monitor therapeutic outcome and long-term results after percutaneous laser-induced thermal ablation.
SUBJECTS AND METHODS:
Sixty-four patients with metastasis to the lung underwent laser-induced thermal ablation in an ongoing prospective study. A total of 129 percutaneous procedures were performed to manage a total of 108 lung lesions. The median tumor size was 2.0 cm (range, 0.4-8.5 cm). Adequate management of all known individual tumor correlates was critical for definitive patient therapy. The Kaplan-Meier method was used to calculate survival and recurrence rates.
RESULTS:
Definitive management of initial pulmonary disease was achieved in 31 of 64 patients. The 1-, 2-, 3-, 4-, and 5-year survival rates after ablative therapy were 81%, 59%, 44%, 44%, and 27%. The median progression-free interval was 7.4 months. There were no therapy-related deaths. Pneumothorax occurred in 38% of the patients, necessitating periprocedural drainage in 5% of all cases. Parenchymal bleeding (13% of cases) always was self-limited.
CONCLUSION:
Laser ablative therapy for pulmonary metastasis is a promising option in multimodal cancer therapy. The procedure is safe and effective. The initial clinical outcome data strongly suggest that this technique has the potential to improve survival among selected patients.
LAPM stands for "Laser Assisted Pulmonary Metastasectomy", that is, surgery to reach the lung tissue and use of laser to remove the met.
Number of metastases is not a limitation -they say: "Usually 7-8 nodules are removed from each lung but even 100 can be removed in the same fashion. Very tiny nodules can be vaporised instead removed".
The conditions to qualify are:
-primary disease is completely under control.
-cancer spread is strictly restricted to lungs.
-the disease in lungs can be completely removed by surgery ((nodal metastases or unresectable hilar disease, in the lungs, would be exclusion criteria too. It has to be just mets, it doesn't matter the number)
-patient is physically fit to undergo the surgery.
*****************
Surgery description:
"Patient is put to sleep by general anaesthesia. Chest is entered through a small cut underneath the armpit. No muscle or rib is cut or removed. A spreader is inserted between the two ribs and ribs are spread apart. Surgeon carefully inspects and explores the entire lung with fingers. Thus he detects and notes the site and number of cancerous nodules.
One after the other, all nodules are removed along with a margin of 2-3 mm of healthy lung around them. Surgeon follows the contour of the nodule and goes all around in the healthy lung. One nodule usually takes 1-2 minutes. Though laser generates temperature of 700 degree Celsius, healthy lung is not damaged. Usually 7-8 nodules are removed from each lung but even 100 can be removed in the same fashion. Very tiny nodules can be vaporised instead removed.
Excised tumours can be subjected to pathological studies. Raw areas can be sutured back leaving lung nearly normal. Loss of lung tissue is hardly 10%. There is very little blood loss and hence, no blood transfusion is required. Total operating time varies between 1 and 2 hours. Complication rate is hardly 1 to 2 %. Mortality is rare. "
***************
GERMANY
The inventor of the technique and the machine (laser) used for this is a thoracic surgeon, Dr. Axel Rolle (Coswig, Dresden, Germany) http://www.ctsnet.org/home/arolle
He receive in 2004 an award for this; you can see him at the hospital and describing the technique in this video: http://www.youtube.com/watch?v=H3VH4fQ9Mks
Contact info easily available in his published papers/ google.
******************
UNITED KINGDOM
During some years, Dr. George Ladas (UK), other thoracic surgeon, trained with Dr. Rolle and in 2010 he started to use the technique at the Royal Brompton Hospital, London.
This is him: http://www.rbht.nhs.uk/healthprofession ... nts/ladas/
(contact info there)
Some newspaper/press articles about this is the UK:
http://www.dailymail.co.uk/sciencetech/ ... stamp.html
http://www.rbht.nhs.uk/media/press-rele ... ?locale=en
(Sending the written report of a chest CT scan to Dr Ladas' office got us an almost immediate reply about if a person is a candidate or not for this surgery).
*******************************
There is some place in India ("medical turism") where they perform LAPM, apparently.
Because of what I've reading, it's mainly patients with lung metastases from sarcoma who know better about Dr Rolle. You may find these discussions/ blog entries interesting:
http://sarcomatreatments.blogspot.com.a ... -lung.html
http://www.cureasps.org/forum/viewtopic ... fecaee6ebb (two pages long)
******************
Hope this helps someone.
Let's keep strong, all of us!
**
Edited to add:
Some abstracts from where to start to read, if interested:
Lasers Surg Med. 2006 Jan;38(1):26-32.
Laser resection technique and results of multiple lung metastasectomies using a new 1,318 nm Nd:YAG laser system.
Rolle A, Pereszlenyi A, Koch R, Bis B, Baier B.
Department of Thoracic and Vascular Surgery, Centre of Pneumology and Thoracic Surgery, Coswig Specialised Hospital, D-01640 Coswig/Dresden, Germany. dr.rolle@fachkrankenhaus-coswig.de
Abstract
BACKGROUND AND OBJECTIVES:
Advantages of a new 1,318 nm Nd:YAG laser based on multiple lung metastasectomies are shown.
STUDY DESIGN/MATERIALS AND METHODS:
Ninety-three percent of 328 patients with metastases (8/patient, range 1-124) had precision laser resections (lobectomy-rate reduced to 7%); this laser delivers 20 kW/cm(2) 1,318 nm power densities with 400 microm fibers, and a focussing handpiece. Absorption in water is tenfold higher.
RESULTS AND CONCLUSIONS:
Between 1/1996 and 12/2003 in 328 patients (164 males/females, 61 years) 3,267 nodules were removed. Pathologic examination revealed 2,546 metastases (range 3-80 mm) from kidney (n = 112), colorectal (n = 91), and breast cancers (n = 35). In 85% of patients where the complete resection was achieved the 5-year survival was 41%. For remaining 15% (incomplete resection) the 5-year survival was 7%. Five-year survival for patients with 10 (and more) metastases was 28%, for patients with 20 (and more) was 26%. No 30-day mortality was observed.
CONCLUSION:
This new laser system facilitates any kind of parenchymal lung resection in lobe-sparing manner and in case of complete resection improves significantly the survival.
**************
Bratisl Lek Listy. 2005;106(8-9):262-5.
Resection of multiple lung metastases--where are the limits?
Pereszlenyi A, Rolle A, Koch R, Schilling A, Baier B, Bis B.
Department of Thoracic and Vascular Surgery, Fachkrankenhaus Coswig, Centre for Pneumology, Thoracic and Vascular Surgery, Germany. Pereszlenyi@fachkrankenhaus-coswig.de
Abstract
Multiple lung metastases present a serious and challenging problem with increasing incidence for thoracic surgeons. In the lung metastasis management a significant role belongs to laser lung-parenchyma-saving resection. This parenchyma saving technique allows a removal of significant higher number of lung nodules in comparison to conventional techniques (stapler, clamp resection). Performing the lung metastasectomy by this manner, the only remaining question is the limitation of this technique. In this retrospective study, the results after Nd:YAG Laser (1318 nm, 40 Watt) interventions are being presented, the limitations of this technique are being discussed (Tab. 3, Fig. 4, Ref. 9).
***********
Ann Thorac Surg. 2002 Sep;74(3):865-9.
Lobe-sparing resection of multiple pulmonary metastases with a new 1318-nm Nd:YAG laser--first 100 patients.
Rolle A, Koch R, Alpard SK, Zwischenberger JB.
Department of Thoracic and Vascular Surgery, Fachkrankenhaus Coswig (Centre for Pneumology and Thoracic Surgery), Coswig/Dresden, Germany.
Abstract
BACKGROUND:
A new 1318-nm Nd:YAG laser has been developed to utilize the second wavelength (1318 nm; 40 watt) to more precisely cut, coagulate, and seal lung tissue adjacent to pulmonary nodules. This laser allows a precise intraparenchymal nodulectomy with a 5-mm rim of tissue destruction and subsequent lung parenchymal reapproximation to avoid lobar distortion. Resection of multiple, bilateral, and recurrent tumors in the lung is facilitated by this laser technique.
METHODS:
In 100 consecutive patients (53 men, mean age 60 years; 47 women, mean age 61 years) with various primaries (most commonly renal and colorectal), 155 laser resections were performed via anterolateral thoracotomy (staged 3 to 4 weeks, if bilateral) using a new 1318-nm Nd:YAG laser. All palpable and visible masses were removed with 2 to 3-mm visible tumor margins (plus a 5-mm rim of residual lung necrosis secondary to laser energy dispersal) if the tumor or residual lung ratio was judged favorable. No stapling devices or bioadhesives were used.
RESULTS:
Six hundred thirty-two metastases (6.3 per patient, range 1 to 124) were resected. Despite 41% centrally located metastases, tumor resections were possible in 95% of patients with only a 5% lobectomy rate. Of the 100 patients, 67 were considered "curative" with complete metastasectomy by inspection and palpation, and 23 were judged incomplete from too extensive tumor or residual lung, miliary lung spread, or pleural studding. There were no associated mortalities and two complications, including bleeding (1) and a prolonged airleak (1), both treated conservatively. Follow-up was complete in all patients for a median of 26.5 months with clinic visits and chest computed tomographic scan every 3 to 6 months. Nine recurrences were detected and underwent reoperation. Overall survival in the completely resected "curative" group was 85% at 1 year, 71% at 2 years, 69% at 3 years, 57% at 4 years, and 32% at 5 years; in the completely resected "palliative" group, they were 70% at 1 year, 36% at 2 years, 12% at 3 years, and 0 at 4 years; in the incomplete group, they were 56% at 1 year, 30% at 2 years, and 0 at 3 years.
CONCLUSIONS:
The new 1318-nm Nd:YAG laser is parenchyma-sparing, improves complete resection rates, and potentially improves survival with fewer required lobectomies.
************
AJR Am J Roentgenol. 2009 Mar;192(3):785-92. doi: 10.2214/AJR.08.1425.
Laser ablation of metastatic lesions of the lung: long-term outcome.
Rosenberg C, Puls R, Hegenscheid K, Kuehn J, Bollman T, Westerholt A, Weigel C, Hosten N.
Institute of Diagnostic Radiology and Neuroradiology, Ernst Moritz Arndt University, Ferdinand-Sauerbruch-Strasse, 17485 Greifswald, Germany. christian.rosenberg@uni-greifswald.de
Abstract
OBJECTIVE:
Pulmonary metastatic lesions are present in 20-54% of all patients who die of cancer. Surgical studies have shown that local management of distant tumor metastasis as part of multimodal cancer therapy improves survival. Minimally invasive procedures such as thermal ablation are still to prove their clinical relevance. The aim of this study was to monitor therapeutic outcome and long-term results after percutaneous laser-induced thermal ablation.
SUBJECTS AND METHODS:
Sixty-four patients with metastasis to the lung underwent laser-induced thermal ablation in an ongoing prospective study. A total of 129 percutaneous procedures were performed to manage a total of 108 lung lesions. The median tumor size was 2.0 cm (range, 0.4-8.5 cm). Adequate management of all known individual tumor correlates was critical for definitive patient therapy. The Kaplan-Meier method was used to calculate survival and recurrence rates.
RESULTS:
Definitive management of initial pulmonary disease was achieved in 31 of 64 patients. The 1-, 2-, 3-, 4-, and 5-year survival rates after ablative therapy were 81%, 59%, 44%, 44%, and 27%. The median progression-free interval was 7.4 months. There were no therapy-related deaths. Pneumothorax occurred in 38% of the patients, necessitating periprocedural drainage in 5% of all cases. Parenchymal bleeding (13% of cases) always was self-limited.
CONCLUSION:
Laser ablative therapy for pulmonary metastasis is a promising option in multimodal cancer therapy. The procedure is safe and effective. The initial clinical outcome data strongly suggest that this technique has the potential to improve survival among selected patients.