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S. Toyooka



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    P2.07 - Poster Session 2 - Surgery (ID 190)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 2
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      P2.07-016 - Perioperative nutrition of induction chemoradiotherapy followed by surgery in locally advanced non-small lung cancer patients (ID 1411)

      09:30 - 09:30  |  Author(s): S. Toyooka

      • Abstract

      Background
      Induction chemoradiotherapy (CRT) followed by surgery (iCRT) is one of treatment strategies for locally advanced non-small cell lung cancers (NSCLCs). We have previously reported its feasibility and good clinical outcome with approximately 60% of 5-year overall survival rate. .Perioperative nutritional status,is considered as one of important factors for improved clinical outcome after surgery and other treatments. Here, we investigated the perioperative nutritional status in NSCLC patients treated by iCRT (CRT group) to evaluate the influence of nutritional variables on clinical outcome by comparing that in NSCLC patients with simple pulmonary resection without CRT (non-CRT group) .

      Methods
      Thirty-three consecutive patients with locally adcanced NSCLC who underwent iCRT from January 1, 2009, until December 31, 2011 at our institute were included in this study. The regimen of CRT was two cycles of docetaxel (40 mg/m[2]) plus cisplatin (40 mg/m[2]) with concurrent radiotherapy (46 gray) and the surgery was performed within 6 weeks of completing induction CRT. We compared nutrition-related factors and clinical outcome in 33 iCRT patients with those in 58 consecutive NSCLC patients who underwent lobectomy during January 1 to December 31, 2011 at out institute. .As for blood nutritional factors, total lymphocyte count (TLC), albumin (Alb), total cholesterol (T-cho), choline esterase (ChE), were examined. The prognostic nutritional index (PNI) was also calculated by Alb and TLC. Each nutrition-relatd factors were examined 1) before CRT, 2) before surgery and 3) one month after surgery.

      Results
      Median age of CRT group (61 years old) was significantly younger than that of non-CRT group (69 years old). Twenty-one males and 12 females and 44 males and 14 females were enrolled in CRT and non-CRT groups, respectively. Before any treatment, no significant difference was observed in body mass index and any blood nutritional factors in both groups. After induction CRT, TLC was significantly decreased, and additionally, Alb, T-cho, and ChE were significantly decreased after surgery comparing with those before surgery (after CRT). As for preoperative status in both groups, TLC, Alb and PNI were significantly lower in CRT group than in non-CRT group. Regard with surgery, extended surgery, operating time, and blood loss was significantly heavier in CRT group than in non-CRT group. Perioperative mortality rate was 0% in both groups and the frequency of post-operative complication was similar in both groups (51% and 41% in CRT and non-CRT groups, respectively). The length of hospital stay after surgery was significantly longer in CRT group (median 23 days) than in non-CRT group (median 14 days). Among CRT group, patients with loiw PNI index could not administrate adjuvant chemotherapy.

      Conclusion
      Perioperative nutritional status, especially TLC, is suppressed after CRT and moreover after surgery. Suppression of nutritional status continued one month after surgery with induction CRT and severe suppression of nutritional status disturbs further treatment such as adjuvant chemotherapy.

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      P2.07-023 - Extended sleeve lobectomy after induction chemoradiotherapy for locally advanced non-small cell lung cancer (ID 2013)

      09:30 - 09:30  |  Author(s): S. Toyooka

      • Abstract

      Background
      An extended sleeve lobectomy is a useful procedure so as to spare the lung parenchyma. However, the resection of the bronchus can cause an increment in the tension at the site of the anastomosis and mismatches in the size of the bronchial orifices. Induction chemoradiotherapy (CRT) followed by surgery is a therapeutic option for locally advanced non-small cell lung cancer (NSCLC). Induction CRT, especially radiotherapy, has a negative effect on bronchial healing in the bronchial stump or anastomosis in a pulmonary resection.

      Methods
      The medical records were reviewed for nine NSCLC patients who underwent extended sleeve lobectomy after CRT between December 2007 and January 2013. Disease stage was evaluated with imaging analyses, including enhanced chest computed tomography (CT) scan, brain magnetic resonance imaging, positron emission tomography-CT scan and bronchoscopy. Induction CRT was performed for eight cases using cisplatin and docetaxel with concurrent thoracic radiation. For one patient who had synchronous laryngeal cancer, 5-fluorouracil and nedaplatin were used as chemotherapy. The radiation dose was 46 or 40 Gy using a conventional fractionation (2 Gy/day). Patients without progressive disease or good general condition underwent surgery. The bronchial anastomosis was basically wrapped with an omental pedicled flap or pericardial fat pad with prophylactic intent. The pre- and postoperative first-second forced expiratory volume was measured. The overall survival (OS) and the disease-free survival (DFS) were calculated from the date of initialing induction CRT until the date of death or the last follow-up for OS and until confirmed death of any cause or recurrence at local or distant site for DFS. The survival curve was calculated by the Kaplan-Meier method.

      Results
      The median patient age was 60 years (range, 50 to 73 years). There were seven men and two women. The histological subtype was squamous cell carcinoma in six patients and adenocarcinoma in three patients. Five patients had clinical stage (c-stage) IIIA, two patients had c-stage IIIB, and two patients had c-stage IIB. The radiation dose was 46 Gy in seven patients and 40 Gy in two patients. An extended sleeve lobectomy was performed for the left lingular division and the lower lobe in four patients, the right upper lobe and trachea in one patient, the right upper lobe, carina and trachea in one patient, the right middle and lower lobe in one patient, the right upper and middle lobe and the carina in one patient, and the right upper lobe and superior segment of the lower lobe in one patient. While no postoperative 90-day deaths occurred in this series, one case developed a bronchopleural fistula on postoperative day (POD) 25 and one case developed a bronchovascular fistula on POD 163. No cases of local recurrence occurred. The first-second forced expiratory volume before surgery was 2.52 ± 0.58 L (mean ± standard deviation), while that after surgery was 1.80 ± 0.66 L. The 2-year overall survival and disease-free survival rates were 63.5% and 47.6%, respectively.

      Conclusion
      Our experience suggests that an extended sleeve lobectomy after induction CRT is feasible, but careful patient selection and perioperative management is mandatory.

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    P2.09 - Poster Session 2 - Combined Modality (ID 213)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Combined Modality
    • Presentations: 1
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      P2.09-011 - Tumor arising from lower lobes is a poor prognostic factor in non-small cell lung cancer patients with N2 disease treated with induction chemoradiotherapy (ID 2239)

      09:30 - 09:30  |  Author(s): S. Toyooka

      • Abstract

      Background
      Trimodality therapy consisting of induction chemoradiotherapy (CRT) followed by surgery can be one of the treatment options for locally advanced non-small cell lung cancer (NSCLC). While recent randomized phase III trials failed to demonstrate a benefit from the addition of surgery in the entire population, the subset analysis of the intergroup trial 0139 indicates that trimodality therapy is beneficial for population who did not undergo pneumonectomy. This result strongly suggests that the status of disease may influence the prognosis even in same stage population. Thus, identifying prognostic factors and their inclusion in stratification are critical for the appropriate randomized study. In this study, we retrospectively examined the prognostic impact of tumor location in NSCLC patients with clinical (c-) N2 disease who underwent trimodality therapy in our institute.

      Methods
      Among patients who underwent induction CRT followed by surgery between 1999 and 2011 at our institution, a total of 76 NSCLC patients with c- N2/3 stage III were enrolled for this retrospective study. Induction CRT basically consisted of docetaxel and cisplatin with concurrent radiation at a dose of 40 - 60 Gray.

      Results
      A total of 76 patients consisted of 53 male and 23 female, 43 adenocarcinomas and 33 non-adenocarcinomas, and 44 c-Stage IIIA and 32 c-Stage IIIB. Primary tumors were located in right upper lobe for 33 patients, right middle lobe for 5, right lower lobe for 11, left upper lobe for 20, and left lower lobe for 7. For all population, lower lobe tumors showed significantly shorter overall survival (OS) and disease-free survival (DFS) times compared to non-lower lobe tumors (OS, p = 0.022; DFS, p = 0.0007). In a multivariate analysis, tumor location was independent prognostic factor for poor prognosis. Limited to pathologically proven N2/3 disease before induction CRT (n = 36), location of lower lobe tend to be poor prognosis compared to other location (OS, p = 0.068; DFS, p = 0.0075).

      Conclusion
      We showed that tumor arising from lower lobes is a poor prognostic factor in NSCLC patients with N2 disease treated with induction CRT. The status of tumor location should be considered in stratification in randomized trails that estimate the impact of the trimodality therapy.