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G.M. Wright
Moderator of
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O13 - Limited Resections (ID 101)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Surgery
- Presentations: 8
- Moderators:G.M. Wright, K. Kernstine
- Coordinates: 10/29/2013, 10:30 - 12:00, Bayside 204 A+B, Level 2
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O13.01 - Limited Resection Trial for Pulmonary Ground-glass Opacity Nodules: Case Selection Based on High Resolution Computed Tomography: Interim Results (ID 1233)
10:30 - 10:40 | Author(s): J. Yoshida, G. Ishii, K. Nagai, T. Hishida, K. Aokage, H. Ito, T. Yokose, H. Nakayama, K. Yamada
- Abstract
- Presentation
Background
Japanese researchers have reported good correlation between radiologic and pathologic findings in early lung adenocarcinomas. For negative margin confirmation, we found a technique using lavage and cytological examination. The objective of this study is to confirm limited resection efficacy as radical surgery in patients with high-resolution (HR) computed tomography (CT) indicated minimally invasive lung cancer, and to confirm intraoperative cytology as a negative margin indicator and reliable margin non-recurrence predictor.Methods
Enrollment required patients with a tumor ≤ 2 cm in diameter, diagnosed or suspected as a clinical T1N0M0 carcinoma in the lung periphery based on a CT scan. They had to have a HRCT scan indicating a sub-solid nodule with tumor disappearance ratio; TDR ≥ 0.5. (TDR = 1- DM/DL; DM: maximum tumor diameter on mediastinal settings, DL: maximum tumor diameter on lung settings). Patients with a malignancy history within the past 5 years or those unfit for lobectomy and systematic lymph node dissection were excluded. We performed a wedge or segmental resection. The used stapling cartridges were washed with 50 ml saline. Washing saline was centrifuged and sediment stained using Papanicolaou’s method and examined for cancer cells. If cytology was cancer positive, additional margin was resected, and cytologic examination repeated. If the second exam was positive, a routine lobectomy and systematic lymph node dissection was performed. Patients are followed up every 6 months by chest CT for the first 3 years, and annually thereafter for at least 5 years. The initial endpoint was 5-year local recurrence free survival rate, but we are now looking at 10-year rate.Results
This prospective study started in November 2003, and 101 patients were enrolled as of November 2009. This was 4.5% of all resected lung cancer patients during this period, and 99 of them were eligible for analysis. There were 39 men and 60 women, aged 30-75, with an average 62 years. Tumor sizes ranged from 7 to 20 mm on high-resolution CT, averaging 15 mm. There were 11 Noguchi type A tumors, 54 type B tumors, 26 type C tumors, one type D tumor, one malignant lymphoma, one atypical adenomatous hyperplasia, one atypical cuboidal cell hyperplasia, one alveolar hyperplasia, and 3 inflammatory fibroses. All cancers showed no vessel invasion. Although no positive cytology results were obtained, pathologically positive margin was reported after surgery in one type C patient. He later underwent a routine lobectomy and systematic lymph node dissection. There was no clear correlation between tumor size, TDR, and Noguchi subtype. No mortality occurred, but one patient developed postoperative pneumothorax and pneumonia, and another hemorrhagic gastric ulcer. With a median follow-up period of 69 months, there have been no recurrences.Conclusion
So far, HRCT scans appear to predict non- or minimally invasive GGO lung cancers with high reliability, warranting limited resection as curative surgery in this cohort. Intraoperative cytology reliably indicated negative margins and seems to predict freedom from local recurrence.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O13.02 - Is the Limited Surgical Resection Appropriate for Non-Small Cell Lung Cancers More than 2 cm in a Diameter? - Proposed Surgical Indication by the Presence of Ground-glass Opacity of The Tumor on Thin-section CT scan (ID 3266)
10:40 - 10:50 | Author(s): T. Maeyashiki, T. Matsunaga, Y. Tsushima, K. Takamochi, S. Oh, K. Suzuki
- Abstract
- Presentation
Background
The size of solid component is much more important for predicting survival than maximum tumor dimension on thin-section CT scan in lung cancer. Moreover, the presence of ground-glass nodule (GGN) is the other significant predictor of pathologic lymph node-positive status. Our previous study showed that tumors with the absence of GGN, i.e. pure-solid, have more pathologically invasive nature than tumors with the presence of GGN, i.e. part-solid, even if both tumors have the same size of solid component on thin section CT. Therefore, it could be estimated that part-solid tumors with the small size of solid component have less frequency of nodal involvement, regardless of the maximum tumor dimension for resectable lung cancer patients.Methods
Between February 2008 and April 2013, 306 consecutive patients with part-solid tumors that measured less than 30 mm in diameter of solid component and had clinically negative nodal involvement (cN0) on thin-section CT underwent surgical resection at our hospital. The findings of preoperative thin-section CT scan were reviewed for all 306 patients and part-solid tumors were defined as a tumor containing both solid and GGN component. Consolidation tumor ration (CTR) of those tumors showed 0 < CTR <1.0 and both pure GGN and pure solid tumors were excluded from this study. Univariate and multivariate analyses were performed by the logistic regression procedure to determine the relationship between pathological lymph node positive status and clinical or radiological findings.Results
Of the 306 patients, 14 (4.6%) had pathological lymph node metastasis. Nodal involvement was observed in 3(1.9%) out of 156 patients with the maximum tumor dimension less than 20mm, i.e. cT1a tumors, 5 (4.4%) out of 113 cT1b tumors and 6 (16.2%) out of 37 cT2a tumors. The size of solid component on thin-section CT scan and consolidation tumor ratio (CTR) were significant predictors of pathological nodal involvement in both univariate and multivariate analysis (p<0.05, respectively). Part-solid tumors with the size of solid component ≤ 17mm and CTR ≤ 0.7, which were obtained as cutoff values of predicting pathological lymph node metastasis based on the result of Receiver operating characteristics curves, 1(1.4%) in 73 patients with these criteria had pathological lymph node positive status even in the c-T1b and c-T2a part-solid tumors on thin-section CT scan.Conclusion
Among part-solid tumors with cN0 status, even cT1b and cT2a tumors with small size of solid component on thin-section CT scan have less frequency of nodal involvement and less invasive nature on pathological examination. These tumors could be candidates for limited surgical resection such as segmentectomy with nodal dissection only when enough surgical margin is warranted.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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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): M. Yano, J. Yoshida, T. Koike, K. Kameyama, A. Shimamoto, W. Nishio, K. Yoshimoto, T. Utsumi, T. Shiina, A. Watanabe, Y. Yamato, T. Watanabe, Y. Takahashi, M. Sonobe, H. Kuroda, M. Oda, M. Inoue, M. Tanahashi, H. Adachi, M. Saito, M. Hayashi, H. Otsuka, T. Mizobuchi, Y. Moriya, M. Takahashi, S. Nishikawa, Y. Matsumura, S. Moriyama, Y. Fujii
- Abstract
- Presentation
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.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O13.04 - DISCUSSANT (ID 3923)
11:00 - 11:15 | Author(s): H. Asamura
- Abstract
- Presentation
Abstract not provided
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- Abstract
- Presentation
Background
The patients for NSCLC with IPF are having at a high risk of pulmonary resection. The objective of this study was to compare the survival rate after sublobar resection and lobectomy or more resection for NSCLC among patients with IPF.Methods
The total 80 patients with IPF from 1995 to 2012 at Asan Medical Center had received pulmonary resection for NSCLC. Predictors of overall survival and disease-free survival were evaluated. Statistical analyses included Kaplan-Meier estimates of survival, log-rank tests of survival differences and multivariate Cox proportional hazards models.Results
Lobectomy or more resection (lobectomy group) was performed in 65 patients and sublobar resection (sublobar group) in 15 patients. The median age was 66 years (range, 42 to 86 years), The median follow-up was 17 months (range, 0.4 to 96.5 months). The postoperative early mortality rate was higher at lobectomy group than sublobar group (15.4% versus 6.7%, p<0.3), but there was no difference in postoperative late mortality between sublobar group and lobectomy group. (60.0% versus 56.9%, P<0.8) Lung cancer related death rate was higher at sublobar group than lobectomy group. (50.0% versus 23.4%, p=0.089), but the respiratory problem related death rate was higher at lobectomy group than sublobar group. (76.6% versus 50.0%, p=0.089) There was no difference in local recurrence between two groups (20.0% versus 7.7% P=0.15) Distant metastasis was higher at sublobar group than lobectomy group. (46.7% versus 10.9%, p<0.001) There was no difference in overall survival between two groups with a hazard ratio of 0.51 (95% confidence interval, 0.21 to 1.2). A disease-free survival of sublobar group was significantly lower than lobectomy group, with an increased hazard ratio of 4.7 (95% confidence interval, 1.1 to 20.2, p=0.03).Conclusion
Although sublobar group was associated with increased incidence of distant metastasis compared with lobectomy group but there is no difference in overall survival. Therefore, sublobar resection might be considered as one of the strategy for lung cancer with IPF.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O13.06 - Vio-soft-coagulation for repair of air leak from dissected intersegmental plane during thoracoscopic segmentectomy (ID 949)
11:25 - 11:35 | Author(s): A. Watanabe, T. Mishina, M. Miyajima, J. Nakazawa
- Abstract
- Presentation
Background
The VIO soft-coagulation system is a new device for tissue coagulation. This system regulates the temperature rise below boiling point without generating sparks, which is high enough to denature protein. The purposes of this study are to evaluate the effect of intersegmental air leak repair by the use of Vio-soft coagulation mode (ERBE Elektromedizin GmbH, Germany) during thoracoscopic segmentectomy and to show how to use the device.Methods
Between 2007 and 2013, we have performed 162 thoracoscopic segmentectomies for early stage primary lung cancer (In this period, 805 thoracoscopic lobectomies have been performed.). Among these patients, 36 underwent anatomical intersegmental plane dissection only using electrocautery without any staplers. Inclusion criteria for thoracoscopic segmentectomy are as follows: 1) c-stage IA peripheral non-small cell carcinoma, 2) No prior chemotherapy or radiation therapy, and 3) Confirmation of N0 status by intraoperative frozen examination. Furthermore, indication criteria for anatomical intersegmental plane dissection using electrocautery followed by any sealing to repair air leak from dissected intersegmental plane include the above-mentioned criteria and as follows: 1) Non-emphysematous lung, and 2) No pleural adhesion. In this series, we divided the intersegmental plane along the intersegmental vein and inflation-deflation demarcation line with an electrocautery (monopolar coagulation mode, 80W) and vessel sealing system. Soft coagulation was set at Effect 5 and 80W for divided intersegmental sealing. The massive air leak from the divided intersegmental plane was repaired with suture pneumorrhaphy or bronchiororraphy before the coagulation. These patients were assigned into two groups: group A consisted of 19 patients with air leak repair using Vio-soft coagulation system and group B consisted of 21 patients not subjected to the system.Results
There was no case of conversion to thoracotomy. The mean operative time was 229 + 73 vs 238 + 48 min (group A vs group B; P=0.69), and accordingly, the mean intraoperative blood loss was 104 + 112 vs 115 + 115 ml (P=0.77). Total number of endostapler cartridges was 1.3 vs 1.4 (P=0.99). Of course, the cartridge number used for intersegmental division was zero in both groups. Most importantly, the fibrin sealant was used in 5 patients (26.3%) vs13 patients (61.9%) to repair air leak from intersegmental division (P=0.031). There were no major postoperative complications in both groups. There were one cases of prolonged air leak in group A and one (requiring redo surgery) in group B (P>0.99). The median chest tube duration and postoperative stay were 2.0 + 1.7 (range 1-8 days) vs 2.4 + 0.8 days (range 2-5 days) (P=0.41) and 7.9 + 1.9 vs 7.9 + 2.3 days (P>0.99), respectively.Conclusion
The VIO soft-coagulation system is safe and feasible for repair of dissected intersegmental plane in patients during thoracoscopic segmentectomy. It enables reduction in the use of fibrin sealant and number of endostapler cartridges in this procedure without any postoperative increased air leak problem.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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- Abstract
- Presentation
Background
Lung cancer with small nodules(≤3cm) have less tendency of local regional lymph node metastasis. We investigate the value of preoperative clinicopathological characteristics in predict regional lymph node metastasis of cT1 lung cancer patients.Methods
A retrospective review of database identified 384 patients with cT1N0M0 lung cancer, diagnosed by CT/PET-CT/MRI and pathologically confirmed as primary lung cancer. All the patients underwent surgery (include sublobar resection, lobectomy and pnemonectomy) and systemic mediastinal lymphadenctomy, and receive no preoperative chemotherapy or radiotherapy. The correlation between clinicopathological factors and the nodal status was analyzed by logistic regression model.Results
The prevalence of lymph node metastasis is 69/384 (18.0%) . Univariate analysis identified tumour size, elevated CEA level and Standar uptake value(SUV)≥2.5 affect nodal status. Shown in Table1. In multivariate analysis, only tumour size (≤1cm vs >1-≤2cm vs >2-≤3cm，P=0.000) was found to be independent predictors of nodal metastasis. Shown in Table 2.Figure 1Figure 2Conclusion
Tumour size is the only predictive factor of nodal metastasis for patients with cT1 lung cancer. Futher invastigation is recommend in omission of mediastinal lymphadenctomy in cT1 patients with tumour size of <2cm and SUVmax<2.5.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O13.08 - DISCUSSANT (ID 3924)
11:45 - 12:00 | Author(s): N. Alam
- Abstract
- Presentation
Abstract not provided
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Author of
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MS06 - Surgeons as Drivers of NSCLC Research (ID 23)
- Event: WCLC 2013
- Type: Mini Symposia
- Track: Surgery
- Presentations: 1
- Moderators:N. Alam, Y.T. Kim
- Coordinates: 10/28/2013, 14:00 - 15:30, Bayside 105, Level 1
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MS06.4 - Into the Lab: The Surgeon as Translational Researcher (ID 484)
15:05 - 15:25 | Author(s): G.M. Wright
- Abstract
- Presentation
Abstract
Introduction Building translational research capacity is a daunting task if a thoracic surgeon has not inherited a fully set up laboratory. It is possible, however, for a thoracic surgeon to be involved in and even drive translational research. Given that surgeons are the major procurers of tissue and data in lung cancer, it should actually be more commonplace. It requires passion, organization, the understanding and assistance of colleagues, and the ability to seize what opportunities exist and create new ones with strategic collaboration. Creating this capacity also involves modifying surgical practice to facilitate research then building the relationships, funding and infrastructure. In this article, these building blocks are explored. A translational research project is presented as a successful application of this formula. Building Blocks As a principle, the pillars research capacity-building are: ~ Research-Based Surgical Practice ~ Relationships ~ Infrastructure ~ Funding Sources For individual surgeons and circumstances, these may differ. Some components may already exist and some may seem unattainable. It is often overlooked that simple changes to standard practice can make research a natural activity. For example, focusing audits on the procedures that are the subject of potential research, aligning timing of routine follow-up so that outcome assessment becomes automatic, or a policy that all tissue excess to diagnostic needs is routinely stored in a tissue bank. A research coordinator, at least part-time, is essential for any sustainable research activity. Beyond that, key relationships may differ. For me, the most important initial relationship is an anatomical pathologist with a keen interest in lung. Without such a person to review and precisely classify tumors, the power and applicability of any study is seriously diminished. However, a relationship with a laboratory-based clinician or scientist is necessary in order to have access, training and conduct of the benchtop component of research. The surgeon should be active in these endeavours (at least initially) to promote goodwill and a free-flowing exchange of ideas. Other clinicians or specialist scientists may then need to be involved depending on the scope of the potential research projects. Whatever infrastructure is available for research will often need to be augmented. Many useful research tests are already available in a diagnostic pathology laboratory (e.g. advanced immunohistochemistry, mutation screening, PCR). Some facilities may be shared with researchers in other specialties, resulting in synergies for both groups. This may be the way to acquire part time bench space, for example. After determining what capabilities are required to conduct the projected range of research, funding will be the next concern. It is not usually possible to get large project and infrastructure support without a track record and without the funds it is difficult to get a good track record. Therefore preliminary work needs to be funded from a range of more modest resources to pay for direct research costs and services outside any collaborative effort. Local organizations such as Rotary, Apex etc. are often keen to donate to research with a potential impact on their community. This could, for example, fund the construction of tissue microarrays or purchase of essential equipment. Anything that a name can be attached to is usually fair game for such donors. Hospital research foundations are the easiest target for competitive grants. Specialist societies commonly have foundations for distributing grants-in-aid. Participation in capitation-funded clinical trials may provide the salary for a research coordinator, allowing their spare time to be dedicated to translational projects. An Example of Surgeon Driven Translational Research After several years of building relationships, collaborations, infrastructure and funding, our group was able to assess our core research advantages. Figure 1 plots the gradual ascent to critical mass for research funding in our thoracic unit.Figure 1 Our example project investigated the genomic/transcriptomic landscape of the recently classified subtypes of lung adenocarcinoma.[1] Other than one gene expression study[2] using outdated array-based platforms and subtype classifications, no molecular signature has been reported to correlate to the morphology seen by the pathologist under the microscope. It is debated whether these subtypes are genetically different or just a spectrum of the same tumour. Inter-observer differences in classifying these subtypes are particularly problematic for the new micropapillary subtype; therefore a molecular marker is an important goal. To investigate these new subtypes (table 1), we carefully selected tumors with classical morphological regions of the differing subtypes. From this group, 29 tumours were selected with known mutations in one or more of EGFR, KRAS, BRAF and TP53. These would be the most likely cases to prove our hypothesis that there are differential genomic aberrations within subtypes of the same tumor.Table 1. Subtypes of lung adenocarcinoma investigated, as classified in the 2011 IASLC/ATS/ERS pathological classification of lung adenocarcinoma.
After marking the subtypes in areas of tumor purity > 50%, punches of formalin-fixed paraffin embedded tumor were deparaffinized and DNA was extracted. High resolution melting was then used to screen for mutations in all selected subtypes of each tumor. In 3 out of 11 KRAS mutant tumors and 2 out of 4 BRAF mutant tumors, heterogeneity was found in mutation status between subtypes of lesser and higher metastatic potential. No differences were seen between subtypes for EGFR mutant tumors, however we did find a single case of very high copy number of the EGFR mutant allele mapping only to the micropapillary subtype in the tumor. The significance of this finding is far-reaching. It provides a genetic basis to support the new pathological classification and may inform its next revision. It also brings into question the accuracy of small biopsies in detecting mutations other than EGFR. It has the potential to unravel the biological evolution of lung adenocarcinoma, with EGFR apparently an early event, whereas KRAS and BRAF may be acquired later and result in a transition to a more malignant subtype phenotype within a given tumor. Conclusion This example demonstrates that surgeons can drive important translational research as well as advancing other researchers’ goals. Although it takes years to develop such programs, once critical mass is achieved the results create further opportunities to sustain future research and incorporate advances in sequencing platforms and knowledge in lung cancer biology.Subtype Description Lepidic Minimal metastatic potential. Malignant cells growing along but not invading airway walls Acinar Moderate metastatic potential. Glandular structures in invasive stroma Papillary Moderate metastatic potential. Branching structures with fibrovascular stromal cores covered by malignant cells. Solid with/without mucin High metastatic potential. Sheets or nests of malignant cells with or without intracellular mucin. Micropapillary High metastatic potential. Papillary tufts of tumor cells without fibrovascular cores either lying apparently free in alveolar spaces or surrounded by thin fibrous septa, often at a tumor’s edge. References
1 Travis, W. D. et al. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol 6, 244–285 (2011). 2 Bryant, C. M. et al. Clinically relevant characterization of lung adenocarcinoma subtypes based on cellular pathways: an international validation study. PLoS One 5, e11712 (2010). Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
