Hanhan Highlights How Robotic Techniques Have Shifted Surgical Care in Lung Cancer

Ziad Hanhan MD, MPH, FACS

Robotic surgery continues to push the envelope in lung cancer by providing increased visualization of the chest cavity, according to Ziad Hanhan, MD, MPH, who emphasized the importance of having a surgeon evaluate whether patients are eligible for this type of procedure.

“A few decades ago, we utilized open surgery across all disciplines. As we learned to put more cameras in body cavities, [these procedures] became more video assisted, which allowed us to remove the tumors with less trauma to the walls of the body,” explained Hanhan. “In the past 10 to 15 years, we have seen more widespread use of robotic techniques, which provide us with better visualization, more feedback on what’s going on with 3-D imaging, and more articulation of the instrumentation to do what we need to do in the chest cavity.” 

In an interview with OncLive^® during a 2020 Institutional Perspectives in Cancer webinar on lung cancer, Hanhan, a thoracic surgical oncologist at Hackensack Meridian Bayshore Medical Center and Riverview Medical Center, highlighted the evolution of surgery in the field of lung cancer, the advantages associated with robotic techniques, and the crucial role of the surgeon in determining eligibility for these approaches.

OncLive^®: What type of imaging technologies are currently being utilized in this space? 

Hanhan: Nationwide, we are really emphasizing the importance of screening for lung cancer in appropriate patients. In recent years, we have seen the widespread use of CT scans, which have led to [the identification of] more nodules that need to be worked up—whether that’s a biopsy, straight resection, or more imaging. Serial imaging can follow if there is any nodule growth. 

Fundamentally, thoracic surgeons will use CT scans and rely on those for information. Localization techniques also help if we have to go straight to resection. In other cases, we’re going after ground-glass opacities that we can’t palpate, so we use different techniques to localize them before resection.

What are some of the techniques you use to localize nodules in practice?

With the advent of robotics, because we’re doing very small incisions, a main disadvantage is that we’re not able to palpate the nodules. As you could imagine, to get a human hand in, you would need a pretty large incision in between the ribs to be able to palpate the nodules. The tradeoff is that we need to have better localization to palpate the nodules. 

However, you can’t palpate certain nodules, so you have to correlate with the anatomy and resect or localize. There’s navigational bronchoscopy, which utilizes a magnetic field, and a GPS-type technology to guide a catheter to the nodule. Then you can inject 2 different types of dye: methylene blue or indocyanine green. We are then able to localize and resect the nodules.

Could you expand on some of the benefits associated with these robotic approaches?

One advantage of robotics is that [it involves] less trauma to the chest wall. You don’t have to spread the ribs to get hands in there. The video-assisted technique typically involved the larger incisions, as well; we call this the utility incision. With robotics, increased visualization is key. [You get a] better sampling of lymph nodes, which allows you to stage the cancers more appropriately. You see better and, therefore, you can get a more thorough harvest of the lymph nodes from the mediastinal lymph node stations; that’s advantageous.

What does the future look like for surgery in lung cancer?

One can speculate that, as we conduct better studies in terms of tumor genetics, the future may actually be immunotherapy based, which could give surgery more of a salvage role. However, who knows? In 30 or 40 years, if we’re operating on these tumors, surgery could also be genetically based, in which patients receive an injection in the tumor or take a pill that blocks the tumor growth mechanism.

As a surgeon, what is your advice to medical doctors regarding selection for robotic surgery?

With robotic surgery, we’re pushing the envelope. At this point, [surgery is] still the standard of care for early-stage lung cancer. I’ve operated on patients who would not pass the “eyeball test.” For example, I’ve operated on a woman who was in great shape but was 91 years old. This patient was excited; she did her research and wanted robotic surgery, and she did very well.

I would tell the medical community, as a whole, that robotic surgery is very well tolerated. I would also emphasize the importance of allowing surgeons to evaluate these patients. I believe that many times, a medical doctor would see some of the patients who I have seen [and say that] they might not be [surgical] candidates, [but I found they] were able to get through an operation.

In addition, with surgery as opposed to nonsurgical treatments like targeted radiation or microwave ablation of tumors, there is a subset of patients that will be upstaged due to more accurate sampling of lymph nodes. Recently, I’ve had 2 patients where their PET scans did not show any nodal uptake of disease in the mediastinum. However, on pathological examination, after we examined the lymph nodes, we saw that they were positive. This means these patients went from stage I disease to stage III disease, and now they are going to receive chemotherapy. Had those patients just received noninvasive stereotactic body radiosurgery or microwave ablation, a treatment window may have been missed.