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T. Watanabe



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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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      MO02.04 - Safety and long term outcome of repeated lung resection for ipsilateral second primary lung cancer (ID 3048)

      10:45 - 10:50  |  Author(s): T. Watanabe

      • Abstract
      • Presentation
      • Slides

      Background
      Repeated lung resection for second primary lung cancer is indicated as an effective treatment in properly selected patients. Among repeated lung resections, surgery for ipsilateral lesion is a challenging modality for thoracic surgeons. We report our experience of repeated lung resection, especially focused on ipsilateral reoperation after anatomical major lung resection.

      Methods
      We retrospectively reviewed patients who had undergone a second lung resection for ipsilateral second primary lung cancer at the 3 institutions between 2000 and 2012. The diagnosis of the second primary lung cancer was based on the criteria from Martini. Variables analysis included clinical and pathologic data including age, sex, c-stage, surgical procedure, p-stage, histology, time interval between the two operations, operative findings, operative morbidity and mortality, as well as long term outcomes. Overall survival was calculated using the Kaplan-Meier method.

      Results
      There were 52 reoperations in 50 patients. Of the 50 patients, 35 were male and 15 were female. The median age at the time of a second operation was 69.9 years (range 51 to 85). The first lung resection was lobectomy in 48 patients and segmentectomy in 2 patients. According to the current TNM classification, p-stage of the first lung cancer was IA in 20, IB in 24, IIA in 3, IIB in 1, IIIA in 1, and IV in 1. The mean value of %vital capacity and forced expiratory capacity in one second /forced vital capacity obtained before the second surgery was 94.7% and 72.3% respectively. The second operation was wedge resection in 28, segmentectomy in 9, right middle lobectomy in 4, right upper lobectomy after lower lobectomy in one, and completion pneumonectomy in 7. The mean interval time between the two operations was 64 months (range, 15-156 months). During second surgery, vascular injury was occurred in 2 patients. Mean volume of blood loss during surgery was 354ml (range, 0 to 3440 ml), and blood transfusion was necessary in 6 patients. Intrapericaridial exposure of the main pulmonary artery was employed in 9 patients due to dense vascular adhesions. There was no operative death.　Complications occurred in 9 patients (prolonged air leakage in 5, empyema in 2, heart failure in 1, and delirium in 1). One patient died of pneumonia 5 months after the second operation. Therefore morbidity and hospital mortality was 18% and 2%, respectively. Pathological diagnosis of the second primary lung cancer was adenocarcinoma in 41, squamous cell carcinoma in 9, and sarcoma in 1. P-stage of the second lung cancer was IA in 37, IB in 8, IIA in 1, IIB in 2, IIIA in 1, and IV in 1. The 5-year overall survival after the second operation was 67 %, and more favorable 5-year survival of 77% was observed in p-stage IA.

      Conclusion
      Most second primary lung cancer in this retrospective study was treated in p-stage I. Reoperations for a second primary lung cancer on the same side of the first surgery shows an acceptable morbidity and mortality rate, and provides favorable survival in selected patients with adequate physiologic pulmonary reserve.

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    O13 - Limited Resections (ID 101)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O13.03 - Survival of 1963 lobectomy-tolerable patients who underwent limited resection for cStage I non-small cell lung cancer (ID 1030)

      10:50 - 11:00  |  Author(s): T. Watanabe

      • Abstract
      • Presentation
      • Slides

      Background
      Although the standard operation for lung cancer is lobectomy, precise preoperative diagnosis of the “very early” lung carcinomas may identify patients that can be treated by limited resection. Previous reports on limited resection included patients who were not candidates for lobectomy. The survival of non-small cell lung cancer (NSCLC) patients who were fit for lobectomy and underwent limited resection has not been studied in a large enough scale.

      Methods
      A nationwide multi-institutional project collected clinical data of patients who underwent limited resection (segmentectomy or partial resection) for clinical T1-2N0M0 non-small cell lung carcinoma, who were 75 years old or younger at the time of operation and were considered fit for lobectomy by the physician. Overall and disease free survival, freedom from recurrence were analyzed and factors affecting survival or recurrence were identified.

      Results
      The median age of 1963 patients was 63 years. The mean maximal diameter of the tumor was 1.4 ± 0.6 cm. The overall and recurrence free survival after limited lung resection was 93.7 % and 90.4 % at 5 years, respectively. The recurrence free proportion and local recurrence free proportion were 93.3 % and 98.4 % at 5 years, respectively. Prognostic factors in overall survival were pathologically proven lymph node metastasis, interstitial pneumonia, male gender, older age, complications (cardiac disease, diabetes etc.), radiological invasive cancer, and multiple lesions. The consolidation/tumor ratio on CT of ≤ 0.25 predicted good outcome especially in cT1aN0M0 disease. Prognosis and recurrence was not affected by the method of limited resection (segmentectomy (n=1225) or partial resection (n=738)).

      Conclusion
      If the patient was 75 years old or younger and was judged fit for lobectomy, the result of limited resection for cStage I NSCLC was excellent and was not inferior to the reported result of lobectomy for small sized NSCLC. The radiological noninvasive carcinomas rarely recur and are especially good candidates for limited resection.

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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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      P2.07-012 - Long-term results of limited resection for small adenocarcinoma showing ground-glass opacity (ID 1269)

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

      • Abstract

      Background
      In 2005, we reported the study of intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration. At that time, only 14 patients with a small adenocarcinoma showing ground-glass opacity (GGO) had undergone limited resection. After that, we have continued limited resection and follow-up. The median follow-up time from the operation has reached 80 months, so we analyze the long-term results of this procedure.

      Methods
      Between 1996 and 2013, we enrolled 56 patients in this study. Entry criteria were: 1) cT1aN0M0 peripheral adenocarcinoma, 2) High resolution computed tomography (HRCT) findings suspected of having a Noguchi type A or B adenocarcinoma, and 3) pulmonary function adequate to permit lobectomy. When the tumor consisted of GGO only or GGO with a solid component that accounted for less than 50% of the surface area on HRCT, the tumor was suspected to be Noguchi type A or B adenocarcinoma. Wedge resection or segmentectomy was performed, and was followed by an intraoperative pathologic exploration. After confirming the diagnosis of Noguchi type A or B by intraoperative pathologic exploration, operation was completed. No systematic lymph node dissection or sampling was performed. If the lesion was not Noguchi type A or B, extended segmentectomy or lobectomy with systematic lymph node dissection was performed instead.

      Results
      Between 1996 and 2013, we enrolled 56 patients in this study. Limited resection was performed in all patients, wedge resection in 52, and segmentectomy in 4. Intraoperative pathologic exploration revealed that the lesion was not Noguchi type A or B in 11 patients. In these 11patients, we underwent extended segmentectomy in 2 and lobectomy in 9 with systematic lymph node dissection. Intentional limited resection was completed in 45 patients. Of these, 7 had Noguchi type A tumors, and 38 had Noguchi Type B tumors based on intraoperative pathologic exploration. Postoperative pathologic examination revealed 10 patients with Noguchi type A, 31 patients with Noguchi type B, and 4 patients with Noguchi type C. We recommended reoperation to 4 patients with Noguchi type C, but all refused reoperation and has been carefully followed at 3-month intervals. There was no postoperative and 30-day mortality or in-hospital mortality. There were no morbidities. All patients but one are alive without recurrence of lung cancer at the time of writing. Only one patient died of malignant lymphoma without recurrence. The follow-up periods have ranged from 6 to 195 months, and median follow-up period is 80 months. The overall 5- and 10-year survival rates were 96% and 96%, respectively. The 5- and 10-year recurrence –free proportions were 100% and 100%, respectively.

      Conclusion
      When patients are carefully selected by preoperative HRCT and intraoperative pathologic exploration, limited resection can be an acceptable option for the treatment of T1aN0M0 adenocarcinoma showing GGO lesion.

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      P2.07-019 - Postoperative Outcome of Patients with Pulmonary Large-cell Neuroendocrine Carcinoma (ID 1725)

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

      • Abstract

      Background
      Although large-cell neuroendocrine carcinoma (LCNEC) was categorized as a variant of large cell carcinoma on the WHO histologic classification of lung carcinomas, the clinical and biological features of LCNEC resemble those of small cell lung carcinoma. Therefore, there is no consensus on the treatment strategy for LCNEC, and an indication of surgical treatment for LCNEC is still controversial. Even though preoperative accurate diagnosis of LCNEC is difficult, the aim of this study was investigating patients with pulmonary LCNEC in whom better postoperative outcome is expected.

      Methods
      We retrospectively reviewed patients with pulmonary LCNEC on permanent pathologic diagnosis who underwent pulmonary resection at the 3 institutions between 1999 and 2011. We reviewed the medical records of each patient for demographic, clinical, and pathologic data including age, sex, smoking status, preoperative serum CEA, radiologic tumor size, c-stage, surgical procedure, extent of lymphadenectomy, p-stage, lymph node metastasis, visceral pleural invasion, lymphatic permeation, vascular invasion, and adjuvant chemotherapy. Disease-free survival (DFS) was calculated using the Kaplan-Meier method, and factors associated with DFS were analyzed with the log-rank test.

      Results
      Of the 18 patients eligible for this study, 14 were male and 4 were female. The median age was 74 years (range, 53 to 85). According to the current TNM classification, 12 patients had c-stage I disease, 4 had c-stage II disease, and 2 had c-stage IIIA disease. The majority of patients (13 patients, 72%) underwent lobectomy, 1 underwent pneumonectomy, 1 underwent bilobectomy, and 3 underwent wedge resection. On pathologic diagnosis, 8 patients had p-stage I disease, 5 had p-stage II disease, and 5 had p-stage IIIA disease. Following surgical treatment, cisplatin-based adjuvant chemotherapy was applied for 3 patients. The 1-year and 2-year DFS were 39% and 39%, respectively, with the median follow-up period of 9 months (range, 2 to 80). During the follow-up period, 10 patients (56%) developed recurrence, and the recurrence was identified within the first year post-resection in all the 10 patients. By the log-rank test, smoking status (non- or former, vs. current) and surgical procedure (lobectomy or greater, vs. limited resection) were identified as significant factors associated with DFS.Figure 1

      Conclusion
      Of patients with pulmonary LCNEC undergoing surgical treatment, a long-term prognosis might be expected if no recurrence is identified within the first year post-resection. If diagnosis of LCNEC is preoperatively obtained, surgical treatment is recommended for patients without current smoking status, and lobectomy or greater resection should be the surgical procedure of first choice.