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T. Tanvetyanon



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    MO02 - General Thoracic and Minimally Invasive Surgery (ID 99)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      MO02.07 - Effect of Obesity on Peri-Operative Outcomes after Robotic-Assisted Pulmonary Lobectomy: Retrospecitve Analysis of 227 Consecutive Patients (ID 2440)

      11:00 - 11:05  |  Author(s): T. Tanvetyanon

      • Abstract
      • Presentation
      • Slides

      Background
      Attention has increased over the safety and efficacy of robotic-assisted surgeries in recent years. With rates of obesity on the rise, the impact of excessive body weight on surgical outcomes comprises an important concern for administering care. Our purpose was to determine the relationship between preoperative body mass index (BMI) on perioperative complications following robotic-assisted pulmonary lobectomy for at a high-volume tertiary-care referral cancer center.

      Methods
      We retrospectively studied 227 consecutive patients who underwent robotic-assisted pulmonary lobectomy for known or suspected lung cancer. BMI was calculated as being equal to weight in kilograms divided by height in meters squared. We stratified BMI into 4 groups as defined by the World Health Organization (WHO): Underweight (BMI <18 kg/m2), Normal Weight (BMI 18-25 kg/m2), Overweight (BMI 25.01-30 kg/m2), and Obese (BMI >30 kg/m2). Perioperative complications from surgery to discharge from the hospital were assessed and included respiratory failure, hemothorax, pleural effusion, prolonged air leak, subcutaneous emphysema, aspiration, pneumonia, and hypoxia. Hospital length of stay and in-hospital operative mortality were also assessed. Of 227 total patients studied, there were 6 Underweight patients, 87 Normal Weight patients, 71 Overweight patients, and 63 Obese patients. Initially, with the Underweight group omitted due to small sample size, comparison of the remaining three BMI groups revealed that there were no significant increases in peri-operative complication rates, hospital length of stay, or in-hospital operative mortality among the 3 groups, although there were clear trends toward increased morbidity and mortality when patients had higher BMI. Therefore, we compared the peri-operative complication rates, hospital length of stay, and in-hospital operative mortality between Obese and Non-Obese patients.

      Results
      The results are shown in the following table:

      Surgical Complication Non-Obese BMI ≤30 Obese BMI >30 P-value
      N=162, n (%) N=65, n (%)
      Hypoxia or Respiratory failure 6 (3.7) 7 (10.8) 0.04*
      Hemothorax 3 (1.9) 2 (3.1) 0.57
      Effusion or Empyema 2 (1.2) 2 (3.1) 0.34
      Prolonged air leak 30 (18.5) 5 (7.7) 0.04*
      Subcutaneous emphysema 6 (3.7) 2 (3.1) 0.82
      Aspiration 4 (2.5) 2 (3.1) 0.79
      Pneumonia 17 (10.5) 8 (12.3) 0.69
      In-Hospital Operative Mortality 2 (1.2) 2 (3.1) 0.34
      Median Length of Stay (days+SEM) 5 + 0.3 4 + 0.6 0.54
      *statistically significant, p<0.05

      Conclusion
      Our study shows that obesity increases the risk of peri-operative hypoxia or respiratory failure but results in a lower risk of prolonged air leak after robotic-assisted pulmonary lobectomy. However, we found no significant difference in hospital length of stay or in-hospital mortality between obese and non-obese patients. Thus, our study suggests that robotic-assisted pulmonary lobectomy is feasible and safe in obese patients.

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    P1.07 - Poster Session 1 - Surgery (ID 184)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P1.07-014 - Effect of Advanced Age on Peri-Operative Outcomes after Robotic-Assisted Pulmonary Lobectomy: Retrospective Analysis of 180 Consecutive Cases (ID 2992)

      09:30 - 09:30  |  Author(s): T. Tanvetyanon

      • Abstract

      Background
      Technological advances and increased life expectancies have resulted in increasingly complex procedures being performed more frequently on patients with advanced age. As surgeons gain competency in robotic-assisted surgery, surgeons are extending the benefits of these minimally-invasive procedures to geriatric patients. Thus, we investigated the complication rates after robotic-assisted pulmonary lobectomy in patients with advanced age.

      Methods
      We retrospectively analyzed 180 consecutive patients who underwent robotic-assisted lobectomy by one surgeon between September 2010 and February 2013. Patients were grouped by age >77 at the time of operation (Group A) versus age <77 (Group B). Clinically significant perioperative complications were noted, including minor complications, such as wound infection and anemia requiring transfusion, and more serious major complications, such as empyema and deep venous thrombosis/pulmonary embolus (DVT/PE). Rates of perioperative complications, conversion to open lobectomy, chest tube days, hospital length of stays (LOS), and in-hospital mortality were compared between the two groups, with p-value <0.05.

      Results
      A total of 180 patients were included (mean age 67yr). Group A had 31 patients with advanced age >77yrs (range 77-86yr; 16 men, 15 women); Group B had 149 patients (range of 29-76yr; 74 men, 75 women). Overall intraoperative complication rate was 17/180 (9%), overall postoperative complication rate was 87/180 (48%), and overall in-hospital mortality was 5/180 (3%). Group A had 7/31 (6%) intra-operative complications, compared to 10/149 (3%) for Group B (p=0.006). The most common intraoperative complication in both groups was bleeding from the pulmonary artery, with 3/31 (10%) in Group A and 3/149 (2%) in Group B. The overall rate of conversion to open lobectomy was 7/31(23%) in Group A versus 13/149 (2%) in Group B (p=0.026); although the rate of emergent conversion to open lobectomy was 3/31 (10%) in Group A compared to 3/149 (2%) in Group B. There were 19/31 (61%) patients in Group A with minor and/or major post-operative complications, compared to 68/149(46%) in Group B (p=0.11). The most common post-operative complications experienced by Group A were prolonged air leak 8/31 (26%), atrial fibrillation 6/31 (19%), pneumonia 4/31 (13%) and mucus plugs requiring intervention 4/31 (9%; p=0.24), while those for Group B were prolonged air leak 26/149 (17%; p=0.28), pneumonia 19/149 (13%; p=0.98), atrial fibrillation 16/149 (11%; p=0.23) and anemia 9/149 (6%). Group A had medians of 5+2.8 (S.E.M.) chest tube days and 7+1.3 (S.E.M.) hospital days, compared to 4+0.3 chest tube days and 5+0.4 hospital days for Group B (p=0.09 and p=0.004, respectively). Interestingly, Group A had 0/31 (0%) in-hospital mortality, compared to an in-hospital mortality rate of 5/149 (3%) for Group B (p=0.30).

      Conclusion
      Patients with advanced age >77 yr and who undergo robotic-assisted lobectomy have a higher risk of perioperative complications and conversion to open lobectomy. In addition, advanced age also resulted in longer hospital LOS. However, advanced age was not associated with increased in-hospital mortality and was actually associated with decreased mortality. Thus, our study suggests that robotic pulmonary lobectomy is feasible and safe in patients with advanced age.

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    P1.11 - Poster Session 1 - NSCLC Novel Therapies (ID 208)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P1.11-024 - A phase I/II randomized trial using GM-CSF-producing and CD40L-expressing bystander cell line (GM.CD40L) vaccine plus or minus CCL21 in stage IV lung adenocarcinoma: Updated results (ID 1878)

      09:30 - 09:30  |  Author(s): T. Tanvetyanon

      • Abstract

      Background
      Background: The GM.CD40L vaccine, an allogeneic tumor cell-based vaccine generated from a human bystander cell line which secretes GM-CSF and expresses CD40L on the surface (GM.CD40L), was developed by our team. It serves to recruit and activate dendritic cells. The mature dendritic cells in turn travel to regional lymph nodes and help to activate T cells which result in systemic tumor cell killing. CCL21 is a chemokine which serves to enhance recruitment of T cells and enrich T cell responses. In NSCLC mouse model, the vaccine combination of GM.CD40L plus CCL21 demonstrated additive effects.

      Methods
      Methods: We conducted a phase I/II randomized study to evaluate the GM.CD40L (Arm A) vs. GM.CD40L.CCL21 (Arm B) vaccine in patients with lung adenocarcinoma who had failed first-line therapy. Primary endpoints were safety and tolerability of Arm B in phase I and 6 month progression-free survival (PFS) in phase II; secondary endpoints included anti-tumor immune responses and T-cell responses by ELISpot assay on PBMC. Immune-related response criteria (irRC) determined discontinuation from study treatment at the discretion of the PI/treating physician. Intradermal vaccines were administered in the bilateral axilla and groin every 14 days for 3 doses and then monthly for 3 doses. A two-stage minimax design was used. Survival probabilities over time in each treatment group were estimated using the method of Kaplan and Meier.

      Results
      Results: Between 4/2012 and 4/2013, phase 1 enrolled 3 patients on GM.GD40L.CCL21, while Arm A enrolled 17 and Arm B enrolled 14 patients. The baseline characteristics, including those in phase I are as follows: median age: 66/68 years, females: 50%/50%, PS1: 64.7%/76.5%, median prior regimens: 2.5/3 for Arm A vs. Arm B, respectively. No DLT’s were observed during phase 1. The most common toxicities for Arm A vs. Arm B were injection site reaction (70.6%/70.6%), fatigue (29.4%/41.2%), anorexia (23.5%/29.4%), and pain in extremity (5.9%/5.9%). Median PFS for Arm A vs. B was 1.9 vs. 4.4 months (p=0.10). All patients who remained on study per MD discretion/irRC, did ultimately demonstrate further progression on subsequent imaging. Treatment was discontinued in all of those patients. In Arm A versus Arm B, stable disease was 4/8 and progressive disease was 8/8, respectively. The disease control rate (DCR) for Arm B compared with Arm A was 50% versus 33%, respectively. ELISpot assay for immune responses and flow cytometry studies on PBMCs are underway.

      Conclusion
      Conclusion: GM.CD40L plus CCL21 chemokine is well tolerated. The phase II trial including further immune response assays collected pre and post vaccine are underway and updated results will be presented.

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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P2.07-043 - Effect of Female Gender on Peri-Operative Outcomes after Robotic-Assisted Pulmonary Lobectomy: Retrospective Analysis of 180 Consecutive Cases (ID 3174)

      09:30 - 09:30  |  Author(s): T. Tanvetyanon

      • Abstract

      Background
      Female gender has been associated with worse outcomes in cardiovascular surgery, including vein bypass for limb salvage and coronary artery bypass grafting. Women have also been found to prefer to suffer arthritis pain rather than risk orthopedic surgery and to delay surgery to await better technology and to avoid disrupting caregiving roles for spouses and other dependents. We investigated the effect of gender on perioperative outcomes after robotic-assisted lobectomy.

      Methods
      We retrospectively analyzed 180 consecutive patients who underwent robotic-assisted lobectomy by one surgeon between September 2010 and February 2013. Intraoperative estimated blood loss (EBL), operative times (skin incision to skin closure), conversion to open lobectomy, chest tube days, hospital length of stay (LOS), and in-hospital mortality were analyzed. All clinically significant perioperative complications were noted, including minor complications, such as wound infection and anemia, to more serious major complications, such as empyema and DVT/PE. Comparison of perioperative outcomes between men and women was significant at p-value <0.05.

      Results
      Of 180 total patients, there were 90 men (mean age 68yr; range 37-86yr) and 90 women (mean age 68yr; range 29-85yr; p=0.19). Skin-to-skin operative times were 191+12 min for men and 174+12 min for women. Men had median (+SEM) EBL of 235+60mL compared to 150+48mL for women (p=0.79). Intraoperative complication rates were 7/90 (8%) in men and 10/90 (11%) in women (p=0.45). The most common intraoperative complication in men was bleeding not requiring conversion in 2/90 (2%), compared to pulmonary artery (PA) bleeding in 5/90 (6%) of women. The overall conversion rate to open lobectomy was 14/90 (16%) in women versus 6/90 (7%) in men (p=0.06); although the emergent conversion rate was 5/90 (6%) in women versus 1/90 (1%) in men. The most common reasons for conversion to open lobectomy in women was PA bleeding in 5/90 (6%) and dense hilar pleural and/or tumor adhesions in 5/90 (6%); while the latter was the most common reason for conversion in men, occurring in 3/90 (3%). A minor and/or major postoperative complication occurred in 48/90 (53%) of men, compared to 39/90 (43%) in women (p=0.18). The most common postoperative complications in men were prolonged air leak 20/90 (22%), atrial fibrillation 14/90 (16%), pneumonia 11/90 (12%), and mucus plugs requiring intervention 7/90 (8%), while the most common in women were prolonged air leak 14/90 (16%; p=0.25), pneumonia 12/90 (13%; p=0.82), atrial fibrillation 8/90 (9%; p=0.12), and mucus plugs requiring intervention 7/90 (8%; p=1.00). Women had 4.0+0.5 chest tube days (median+SEM) and 5.0+0.5 hospital days, compared to 4.0+1.1 chest tube days and 5.5+0.6 hospital days for men (p=0.14 and p=0.44, respectively). In-hospital mortality was 4/90 (4%) in men compared to 1/90 (1%) in women (p=0.17).

      Conclusion
      While women had a slightly higher conversion rate to open lobectomy than men, female gender was not associated with increased intraoperative or postoperative complications nor with increased hospital LOS or in-hospital mortality. Our study suggests that robotic-assisted pulmonary lobectomy is feasible and safe in women.