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C. Cao



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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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      MO02.11 - Video-Assisted Thoracic Surgery, Hybrid, versus Open Thoracotomy for Stage I Non-Small Cell Lung Cancer - A Propensity Score Analysis Based on a Multi-institutional Registry (ID 3034)

      11:20 - 11:25  |  Author(s): C. Cao

      • Abstract
      • Presentation
      • Slides

      Background
      We conducted a multi-institutional study comparing VATS lobectomy to Hybrid, and conventional open lobectomy for unmatched and propensity score-matched patients with stage I NSCLC in an attempt to stratify any potential differences in perioperative outcomes and long-term survival outcomes among the three procedures in patients with stage I NSCLC on a homogeneous well-balanced large population from multi-institutions.

      Methods
      Between January 2001 and December 2008 in eight institutions from the People’s Republic of China, a total of 2485 patients with stage I NSCLC who underwent lobectomy via c-VATS, Hybrid, or open thoracotomy were entered into the current multi-institutional registry. One thousand and fifty-six patients (42.5%) underwent c-VATS lobectomy, 273 patients (11.0%) underwent Hybrid lobectomy, and 1156 patients (46.5%) underwent open lobectomy. Of the patients who attempted to undergo c-VATS lobectomy, 65 were converted to assisted-VATS and 49 patients were converted to open lobectomy.

      Results
      After propensity-matching, c-VATS, Hybrid, and open lobectomy patients were similar in regards to age, gender, histological type and pathological TNM staging. Median operative time was 156.16±17.08 min in open lobectomy group, higher than in c-VATS lobectomy group (145.39±13.1 min) and Hybrid lobectomy group (148.86±11.62) before matching (P<0.001), after matching, it was 154.5±16.89 min, 145.41±12.17 min, and 148.81±11.63 min in open, c-VATS, and Hybrid lobectomy group, respectively (P<0.001). Transfusion occurred in 4 (12.9%) patients in c-VATS group and 6 (19.4%) patients in Hybrid group, both of them lower than in open lobectomy group of 21 (67.7%) patients (P=0.003). However, after matching, there was no statistical difference among three groups, 5 (41.7%) patients, 1 (8.3%) patients, and 6 (50.0%) patients in open, c-VATS, and Hybrid group, respectively (P=0.112). After selecting the propensity-matched patients, the 5-year survival of 78%, 74% and 76% in patients who underwent c-VATS, Hybrid, and open lobectomy, respectively. The perioperative mortality rate was 1.1% for the open group, 1.0% for the Hybrid group, and 0.8% for the VATS group. Two prognostic factors were independently associated with improved survival outcome in multivariate analysis: age < 60 (p = 0.01) and smoking history (p = 0.012). When comparing the three propensity-matched populations, patients who underwent c-VATS lobectomy had similar long-term survival outcomes to patients who underwent Hybrid or conventional thoracotomy (p = 0.770).

      Conclusion
      The present multi-institutional study represents the largest dataset evaluating surgical outcomes of patients who underwent c-VATS or Hybrid for NSCLC. VATS lobectomy for NSCLC was not associated with inferior long-term survival compared to Hybrid or conventional thoracotomy.

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    MO14 - Mesothelioma II - Surgery and Multimodality (ID 121)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Mesothelioma
    • Presentations: 2
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      MO14.03 - Meta-analysis of extrapleural pneumonectomy versus radical pleurectomy for patients with resectable malignant pleural mesothelioma (ID 3467)

      10:40 - 10:45  |  Author(s): C. Cao

      • Abstract
      • Presentation
      • Slides

      Background
      Malignant pleural mesothelioma (MPM) is an aggressive disease of the pleural lining with a dismal prognosis of 6 – 12 months from the time of diagnosis. Surgical treatment of MPM includes extrapleural pneumonectomy and pleurectomy/decortication (P/D). Recently, IASLC has reclassified P/D according to therapeutic intent and surgical technique into partial P/D, P/D, and radical P/D. The present meta-analysis aimed to compare the perioperative and long-term outcomes of EPP and radical P/D for patients with resectable MPM.

      Methods
      A systematic review of the literature was performed on five electronic databases to identify all relevant data on comparative outcomes of radical P/D and EPP. Endpoints included perioperative mortality and overall morbidity, as well as long-term overall survival.

      Results
      Six relevant studies with comparative data of EPP (n= 601) versus radical P/D (n=493) were identified from the current literature. Comparison of these two groups demonstrated significantly lower perioperative mortality (3.0% vs 6.5%, p=0.04) and overall morbidity (30.4% vs 64.3%, p<0.0001) for patients who underwent radical P/D compared to EPP. Median overall survival ranged between 13 – 29 months for radical P/D and 12 – 22 months for EPP, with a strong trend favouring radical P/D. Figure 1Figure 2

      Conclusion
      Although it must be emphasized that patient selection and treatment strategies differ between EPP and radical P/D, a number of comparative studies have recently been conducted to compare these two surgical techniques for patients with resectable MPM. The present study indicated that appropriately selected patients who underwent radical P/D had lower perioperative morbidity and mortality with similar, if not superior, long-term survival compared to EPP.

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      MO14.04 - Current evidence of pleurectomy in the treatment of malignant pleural mesothelioma (ID 2226)

      10:45 - 10:50  |  Author(s): C. Cao

      • Abstract
      • Slides

      Background
      Pleurectomy/decortication (P/D) in the treatment of malignant pleural mesothelioma includes a number of procedures with different clinical indications and therapeutic intents. To unify the nomenclature, IMIG and IASLC recently defined P/D-related procedures according to surgical technique, including ‘extended P/D’, ‘P/D’ and ‘partial pleurectomy’. The present systematic review aimed to assess the safety and efficacy of these techniques.

      Methods
      A systematic review of relevant studies was performed by electronic search of five online databases from 1985 to 2012 by two independent reviewers according to predefined selection criteria.

      Results
      Thirty-four studies involving 1916 patients who underwent pleurectomy were included for quantitative analysis. These included 12 studies on ‘extended P/D’, 8 studies on ‘P/D’ and 14 studies on ‘partial P/D’. Perioperative mortality ranged from 0% - 11% and perioperative morbidity ranged from 13% - 43%. Median overall survival ranged from 7.1 – 31.7 months and disease-free survival ranged from 6 – 16 months. One study reported on quality-of-life outcomes using a standardized questionnaire suggesting superior outcomes for ‘extended P/D’ compared to extrapleural pneumonectomy. Figure 1Figure 2

      Conclusion
      Results of the present systematic review suggested similar perioperative mortality outcomes between different P/D techniques but a trend towards higher morbidity and length of hospitalization for patients who underwent ‘extended P/D’. However, overall and disease-free survival appeared to favour ‘extended P/D’ compared to less aggressive techniques. Future studies on P/D should adhere to recent definitions to enable accurate analysis of similar procedures. Direct comparisons of pleurectomy to extrapleural pneumonectomy remain challenging, and should be restricted to ‘extended P/D’ procedures only.

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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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      P1.07-033 - Video-Assisted Thoracoscopic Surgery (VATS) Lobectomy: A Consensus Statement (ID 2246)

      09:30 - 09:30  |  Author(s): C. Cao

      • Abstract

      Background
      Video-assisted thoracoscopic surgery (VATS) lobectomy has been gradually accepted as an alternative surgical approach to open thoracotomy for selected patients with non-small cell lung cancer (NSCLC) over the past 20 years. The aim of this project was to standardize the perioperative management of VATS lobectomy patients through expert consensus and to provide insightful guidance to clinical practice.

      Methods
      A panel of 55 experts on VATS lobectomy was identified by the Scientific Secretariat and the International Scientific Committee of the ‘20[th] Anniversary of VATS Lobectomy Conference – The Consensus Meeting’. The Delphi methodology consisting of two rounds of voting was implemented to facilitate the development of consensus. Results from the second-round voting formed the basis of the current Consensus Statement. Consensus was defined a priori as more than 50% agreement amongst the panel of experts. Clinical practice was deemed ‘recommended’ if 50-74% of experts reached agreement and ‘highly recommended’ if 75% or more of experts reached agreement.

      Results
      Fifty VATS lobectomy experts (91%) from 16 countries completed both rounds of standardized questionnaires. No statistically significant differences in the responses between the two rounds of questioning were identified. Consensus was reached on 21 controversial points, outlining the current accepted definition of VATS lobectomy, its indications and contraindications, perioperative clinical management, as well as recommendations for training and future research directions. Figure 1 Figure 2

      Conclusion
      The present Consensus Statement represents a collective agreement amongst 50 international experts to establish a standardized practice of VATS lobectomy for the thoracic surgical community after 20 years of clinical experience.

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    P1.12 - Poster Session 1 - NSCLC Early Stage (ID 203)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P1.12-020 - Cross-sectional Survey on Lobectomy Approach (X-SOLA) (ID 2809)

      09:30 - 09:30  |  Author(s): C. Cao

      • Abstract

      Background
      To improve the understanding of current attitudes of the thoracic community to video-assisted thoracoscopic surgery (VATS) lobectomy, the Collaborative Research Group conducted the Cross-sectional Survey On Lobectomy Approach (X-SOLA) study. The aim was three-fold: to assess the practice of lobectomy in the current clinical setting, to identify potential reasons that may inhibit the popularization of the VATS lobectomy technique, and to hypothesize potential strategies that can advance this field in the future.

      Methods
      Participants included thoracic surgeons identified through an index search from the Web of Science and the cardiothoracic surgery network. A confidential questionnaire was emailed in June, 2012. Non-responders were given two reminder emails at monthly intervals.

      Results
      838 thoracic surgeons completed the questionnaire within a three-month period, including 416 surgeons who only performed lobectomy through open thoracotomy and 422 surgeons who performed VATS or robotic-VATS. Two sets of standardized questionnaires were completed by these two groups. Ninety-five percent of VATS surgeons agreed with the definition of ‘true’ VATS lobectomy according to the CALGB trial. Ninety-two percent of surgeons who did not perform VATS lobectomy were prepared to learn this technique, but were hindered by limited resources, exposure and mentoring. Both groups believed VATS lobectomy should be incorporated into thoracic surgical training and for more standardized workshops to be made available. Figure 1 Figure 1. Survey responses for surgeons who performed video-assisted thoracoscopic surgery lobectomy (n=422) Figure 2

      Conclusion
      The X-SOLA study represents the largest cross-sectional report within the thoracic community to date, demonstrating the current status of clinical practice of lobectomy approach for NSCLC worldwide and identifying areas in need of further development.

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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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      P2.07-032 - Video-Assisted Thoracic Surgery versus Open Thoracotomy for Non-Small Cell Lung Cancer - A Meta-analysis of Propensity Score Matched Patients (ID 2816)

      09:30 - 09:30  |  Author(s): C. Cao

      • Abstract

      Background
      This meta-analysis aims to compare the perioperative outcomes of video-assisted thoracic surgery (VATS) versus open thoracotomy for propensity score-matched patients with early-stage non-small cell lung cancer (NSCLC).

      Methods
      Four relevant studies with propensity score-matched patients were identified from six electronic databases. Endpoints included perioperative mortality and morbidity, individual postoperative complications and duration of hospitalization.

      Results
      Results indicate that all-cause perioperative mortality was similar between VATS and open thoracotomy. However, patients who underwent VATS were found to have significantly fewer overall complications, and significantly lower rates of prolonged air leak, pneumonia, atrial arrhythmias and renal failure. In addition, patients who underwent VATS had a significantly shorter length of hospitalization compared to patients who underwent open thoracotomy. Figure 1 Figure 2

      Conclusion
      In view of a paucity of high level clinical evidence in the form of large, well-designed randomized controlled trials, propensity score matching may provide the highest level of evidence to compare VATS with open thoracotomy for patients with NSCLC. The present meta-analysis demonstrated superior perioperative outcomes for patients who underwent VATS, including overall complication rates and duration of hospitalization.

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    P3.07 - Poster Session 3 - Surgery (ID 193)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P3.07-037 - A Systematic Review and Meta-analysis on Pulmonary Resections by Robotic Video-Assisted Thoracic Surgery (ID 2822)

      09:30 - 09:30  |  Author(s): C. Cao

      • Abstract

      Background
      Pulmonary resection by robotic-video assisted thoracic surgery (RVATS) has been performed for selected patients in specialized centers over the past decade. Despite encouraging results from case-series reports, there remains a lack of robust clinical evidence for this relatively novel surgical technique. The present systematic review aimed to assess the short- and long-term safety and efficacy of RVATS.

      Methods
      Nine relevant and updated studies were identified from 12 institutions using five electronic databases. Endpoints included perioperative morbidity and mortality, conversion rate, operative time, length of hospitalization, intraoperative blood loss, duration of chest drainage, recurrence rate and long-term survival. In addition, cost analyses and quality of life assessments were also systematically evaluated. Comparative outcomes were meta-analyzed when data were available.

      Results
      All institutions used the same master-slave robotic system (da Vinci, Intuitive Surgical, Sunnyvale, California) and most patients underwent lobectomies for early-stage non-small cell lung cancers. Perioperative mortality rates for patients who underwent pulmonary resection by RVATS ranged from 0 – 3.8%, whilst overall morbidity rates ranged from 10 – 39%. Two propensity-score analyses compared patients with malignant disease who underwent pulmonary resection by RVATS or thoracotomy, and a meta-analysis was performed to identify a trend towards fewer complications after RVATS. In addition, one cost analysis and one quality of life study reported improved outcomes for RVATS when compared to open thoracotomy. Figure 1 Figure 2

      Conclusion
      Results of the present systematic review suggest that RVATS is feasible and can be performed safely for selected patients in specialized centers. Perioperative outcomes including postoperative complications were similar to historical accounts of conventional VATS. A steep learning curve for RVATS was identified in a number of institutional reports, which was most evident in the first 20 cases. Future studies should aim to present data with longer follow-up, clearly defined surgical outcomes, and through an intention-to-treat analysis.