Virtual Library

 x 
My Library Virtual Library FAQ

Start Your Search

J. McLean



Author of

  • +

    MTE17 - Nursing Goes Global - Meeting the Challenges Posed by Mesothelioma (ID 61)

    • Event: WCLC 2013
    • Type: Meet the Expert (ticketed session)
    • Track: Mesothelioma
    • Presentations: 1
    • +

      MTE17.3 - Surgical Options and Global Differences (ID 613)

      07:35 - 07:50  |  Author(s): J. McLean

      • Abstract
      • Presentation
      • Slides

      Abstract
      Malignant Pleural Mesothelioma is a global challenge for heath professionals, and the role of surgery is key to that challenge. Surgery has a palliative function and a curative function. The palliative function is to drain the fluid, take a biopsy, optimise lung re-expansion, and prevent fluid recurrence by pleurodesis. Video assisted thoracoscopy (VAT) is the palliative operation of choice because it is less painful, has a reduced hospital stay, and the surgeon can assess the chest cavity for suitability for more aggressive treatment. An important predictor for a successful VAT pleurodesis is lung re-expansion after initial pleural drainage assessed by radiology and a patient response of “I can breath now.” If pleurodesis is ineffective and the fluid recurs, or if lung entrapment prevents lung re-expansion, then open surgery via thoracotomy with partial or subtotal pleurectomy / decortication should be considered, providing the patient is medically fit and has a reasonable life expectancy. Partial pleurectomy /decortication is more invasive, has an increased potential for prolonged air-leak, is more painful and has a longer recovery period, however the patient may benefit from an improved quality of life, living without symptoms related to lung entrapment. Brancatisano (1991) reported our experience of 50 patients having partial pleurectomy / decortication. The median survival was 16 months with a range of 3 to 54 months and 21% of patients survived more than two years. The curative role is less defined. Surgical resection is the curative treatment option for most solid malignant tumours and this ideal underpins the practice of surgeons treating MPM. Cytoreductive surgery, to reduce the burden of disease and prolong disease free living by complete macroscopic surgical resection is offered to patients with early disease in some centers. Here lies the key challenge. There are differing operative techniques aiming for the same outcome: extrapleural pneumonectomy, EPP, and lung sparing pleurectomy/decortication, EPD EPP, offered since the 1970s, involves complete resection en bloc of the lung, parietal pleura, ipsilateral pericardium, and ipsilateral hemi-diaphragm, along with complete excision of thoracic lymph nodes. Defects of the pericardium and hemi-diaphragm are repaired with Gortex mesh to prevent cardiac and visceral herniation. An early publication reported an unacceptable morbidity and mortality of 45% and 31%respecively (Butchart, 1976). David Sugarbaker, determined to improve patient survival, continued offering EPP but high recurrence rates proved surgery alone provided little benefit to survival. With persistence, his team offered EPP in combination with chemotherapy (prior to pemetrexed) and radiotherapy. In 1991 Sugarbaker reported survival rates of 70% at one year and 48% at two years. Morbidity and mortality rates were 19% and 6% respectively. This multimodality treatment required surgery to reduce tumour bulk, while chemotherapy and radiotherapy treated micro-metastatic disease. In 1996, Sugarbaker again reported similar results but added that epithelial cell types had better survival rates compared to sarcomatoid or mixed histology tumours. Other centres around the world reported individual surgical series each contributing to a collection of experiences. Weder (2007) reported on 45 EPP trimodality patients and found epithelial cell type had better survival. Cao (2010), attempted to evaluate the safety and efficacy of EPP found an overall survival of 13 – 23.9 months and concluded/confirmed that selected patients might benefit from EPP especially when combined with neoadjuvant chemo and adjuvant radiotherapy. Controversy about the ability of EPP to affect a cure or contribute to improved survival was to be sorted by the UK Mesothelioma and Radical Surgery feasibility study known as the MARS trial. This randomised control trial concluded that EPP offers no benefit and possibly harms patients. Surgeons, skilled at performing EPP and who had reported their results vehemently opposed this conclusion. The only centre in Australia offering trimodality therapy reported 70 patients having EPP between 1994 and 2008, having a median survival of 20 months, and morbidity and mortality of 37% and 5.7% respectively (Yan, 2009). Pleurectomy / decortication or P/D was the other preferred operation as some surgeons questioned the morbidity and mortality of EPP. Valarie Rusch (1993) pioneered P/D in order remove all visible and palpable tumours and achieve macroscopic complete resection. Other surgeons varied this procedure making comparing results difficult so specific terminology was used to describe 3 approaches. 1) Extended or radical pleurectomy/decortication (EPD); parietal and visceral pleura is resected along WITH diaphragm and pericardium. 2) Pleurectomy/decortication (PD); parietal and visceral pleura is resected WITHOUT diaphragm and pericardium. 3) Partial pleurectomy/visceral decortication as a palliative procedure. Individual cancer centers have reported case series. Flores (2008) compared EPP to pleurectomy / decortication. Nerangi-Miandoab (2008) reported epithelial cell type was a predictor of survival in patients having pleurectomy / decortication compared to no surgery. Nakas (2008) concluded patients not suitable for EPP should be offered radical P/D. Zahid (2011) found P/D may improve survival but at the expense of increased morbidity and is best offered to patients enrolled in prospective trials. Global differences related to the role of surgery in cytoreductive therapy relate to what radical surgical procedure provides the best chance of extended disease free survival. Is it EPP, lung sparing EPD, or P/D? What is certain is that EPP and EPD should be offered as part of trimodality therapy. Furthermore, the procedure must be performed by an experienced surgeon, and supported by a team with proven expertise and experience to care for these patients. Rusch (2012) reminds us that the role of surgery in the management of MPM remains controversial but it also remains a treatment option because of the limited benefits of radiotherapy and chemotherapy. Surgery is offered either as a palliative procedure or with curative intent. There is little need for debate about the palliative option but debate about curative intent continues. Finally, while global differences are important, what is learnt from collective experiences is more important. There is an urgent need to identify patients with favourable prognostic factors, suitable for cytoreductive therapy. We need to provide support, hopeful encouragement, and equitable access to multi modality treatment because there is a growing number of well living long-term survivors.

      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.

      Only Active 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 or select "Add to Cart" and proceed to checkout.

  • +

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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
    • +

      P3.07-040 - Temporal trends in surgical outcomes for early stage non-small cell lung cancer (ID 2958)

      09:30 - 09:30  |  Author(s): J. McLean

      • Abstract

      Background
      There has been little investigation of temporal trends in outcomes following resection of early non-small cell lung cancer. Analyses are easily confounded by changes in patient characteristics and variations in background mortality when assessing all-cause survival. This study aimed to evaluate changes in patient characteristics, tumour factors and survival over time.There has been little investigation of temporal trends in outcomes following resection of early non-small cell lung cancer. Analyses are easily confounded by changes in patient characteristics and variations in background mortality when assessing all-cause survival. This study aimed to evaluate changes in patient characteristics, tumour factors and survival over time.

      Methods
      A retrospective analysis of 2816 consecutive pathological stage 1A to 3A patients, treated by surgical resection between 1984 and 2007 was performed. Patients were divided into four 6-year eras by date of surgery. Relative survival probabilities were estimated by era and TNM stage. Expected survival was calculated from national age, sex and period specific mortality rates. Multivariable regression using a generalised linear model with Poisson error was used to estimate the excess hazard of death in each era, using the 1984-1989 cohort as the baseline, controlling for age, sex, extent of resection, margin status, tumour stage and cell type.

      Results
      In later eras, patients were older, had a greater proportion of adenocarcinomas and stage 1A tumours. Relative 5-year survival rates for 1984-1989, 1990-1995, 1996-2001 and 2002-2007 were 45.4, 49.6, 48.5 and 57.9% respectively. There was a significant improvement in 5-year relative survival in the 2002-2007 cohort (Excess hazard ratio 0.62, p<0.001). Age ≥75, increasing TNM stage, positive margins and mixed cell type were also significant prognostic factors. The increased survival demonstrated in the most recent era can be attributed primarily to survival gains in stage IIa/b and stage 3a (Figure). Figure 1

      Conclusion
      Temporal trends in patient characteristics in this series mirror recent epidemiological data for non-small cell lung cancer. After controlling for known confounders and background mortality variation, improved survival was demonstrated for more recent patients. Advances in clinical staging and adjuvant therapy may explain these findings.

  • +

    P3.14 - Poster Session 3 - Mesothelioma (ID 197)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Mesothelioma
    • Presentations: 2
    • +

      P3.14-005 - Integrating a well living programme into a support group for EPP survivors and carers (ID 1493)

      09:30 - 09:30  |  Author(s): J. McLean

      • Abstract

      Background
      A brief review of the quality of life of one group of survivors and carers identified that after EPP the most common symptoms affecting quality of life were fatigue, dyspnoea, insomnia and pain. Survivors struggled to return to normal levels of social and role functioning. Interviews also identified the need to share stories with others survivors. In response to this information a well living programme was integrated into an EPP survivor support group. The aim being: to provide information and develop skills to empower survivors and carers to react and improve their quality of life; to optimize the physical, emotional, and social functioning of survivors; and, to assist carers to perform their role while remaining mindful of their own care need.

      Methods
      Four 1 day support / well living meetings were held during 2012. Each involved invited speakers, fitness assessments (6-minute walk test), and time allocated for networking over food and beverages. Topics included: optimizing living with one lung, physical and respiratory assessments, exploring survivor and carer experiences, mindfulness healing, exploring survivor and carer resilience, creating opportunities for self-attention and nurturing, relating science to the living experience, pain management, writing and music for healing, eating for wellbeing and a goal for 2013. Physiotherapy staff contributed regularly to the meetings.

      Results
      The average meeting attendance was 20 participants consisting, of 50% survivors and 50% carers. Patients responded positively to the physical challenges and set their 2013 goal as participation in a community 7 Km fun walk – The Sydney Bay Walk in August. In 2013, an exercise physiologist has worked individually with some group members, either face-to-face or via telephone. This encouraged increased aerobic and resistance training. A number of survivors report improvements in overall fitness, enjoyment of daily living and satisfaction with life.

      Conclusion
      There appears to be consistent changes in participant confidence, and attitude toward physical fitness leading to improved enjoyment of life. The support group is an important link between long term survivors, those currently being treated and a valuable resource for new patients deciding about EPP.

    • +

      P3.14-013 - Longitudinal Observation of Health Related Quality of Life following Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma (ID 3159)

      09:30 - 09:30  |  Author(s): J. McLean

      • Abstract

      Background
      The aim of this study was to describe the longitudinal picture of Health Related Quality of Life (HQOL) in people with Malignant Pleural Mesothelioma (MPM) post Extrapleural Pneumonectomy (EPP).

      Methods
      Participants receiving EPP from 2011- 2013 were assessed pre-operatively, pre and post adjuvant radiotherapy (Rt), and at 8, 12 and 24 months following surgery. Here we report Global HQOL and HQOL Domain Scores of the EORTC QLQ-C30, and Fatigue Scores from FACT-F. Least squares means were obtained from a mixed models analysis with time as a fixed effect, the pre-op assessment as a covariate and a random subject effect.

      Results
      Twelve men with a mean age of 65 years (range 48-78) completed pre-op and at least one post op assessment. Table 1 and Figure 1 report the mean HQOL domain scores, global HQOL and fatigue at baseline as well as the least squares mean and 95% confidence intervals at each follow up assessment. Table 1. Health related quality of life over time Figure 1 Figure 2 Figure 1: Health related quality of life over time These results suggest that people who elect to have EPP have baseline levels of HQOL comparable to the general population. As expected, HQOL declines after surgery and during adjuvant radiotherapy. Emotional functioning changes least, while physical and social functioning closely mirror each other. Role functioning is the domain most affected and remains low out to 24 months. Global HQOL is relatively stable over time, with an apparent increase at 24 months. Fatigue is worst at the conclusion of radiotherapy and gradually improves.

      Conclusion
      People electing to have EPP report a sudden decline in HQOL, with the nadir around the end of adjuvant radiotherapy. This gradually improves over time, returning to slightly below baseline in many domains.