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O. Mercier



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

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Mesothelioma
    • Presentations: 1
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      MO14.09 - 5-year experience with accelerated induction hypofractionated hemithoracic intensity modulated radiation therapy (IMRT) followed by extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) (ID 2022)

      11:20 - 11:25  |  Author(s): O. Mercier

      • Abstract
      • Presentation
      • Slides

      Background
      Our experience in tri-modality therapy for MPM with induction chemotherapy followed by EPP and high dose hemithoracic radiation demonstrated that completion of EPP and radiation provided the best results. We therefore developed a new protocol of accelerated induction hypofractionated hemithoracic IMRT followed by EPP to deliver optimal radiation to the whole tumor bed in a short period of time. EPP is performed approximately one week after completion of radiation to limit the risk of pneumonitis. The results of Surgery for Mesothelioma After Radiation Therapy (SMART) was reviewed and compared to our previous cohort of patients undergoing induction chemotherapy followed by EPP and adjuvant hemithoracic radiation.

      Methods
      All patients undergoing EPP in our institution between 01/2001 and 06/2013 were reviewed. The SMART protocol (25 Gy in 5 daily fractions over 1 week delivered to the entire ipsilateral hemithorax by IMRT with concomitant boost of 5 Gy to volumes at high risk based on CT and PET scan findings) was started in 2008. EPP was performed 6±2 days after radiation therapy. The results of the SMART protocol were compared to the group of patients undergoing induction chemotherapy followed by EPP as part of a trimodality approach.

      Results
      A total of 111 patients underwent EPP between 01/2001 and 06/2013 with a hospital mortality of 4.5% (n=5). A total of 64 patients (81% men, 59±9 years old, 81% with epithelial histologic subtype) underwent induction chemotherapy, while 39 (82% men, 62±9 years old, 69% with epithelial histologic subtype) underwent SMART. Seven patients had no induction therapy and one had pre-operative chemo- and radiation therapy. Since 2008, the number of surgical patients undergoing SMART progressively increased from 14% in 2008 to 100% in 2013. None of the patients undergoing SMART died in hospital or within 30 days of surgery, while 4 of the 64 patients (6.4%) undergoing induction chemotherapy died in hospital after EPP (p=0.1). Patients undergoing SMART tended to have a greater proportion of ypN2 disease on final pathology than patients completing induction chemotherapy before EPP (58% vs 41%, respectively; p=0.09). After a median follow-up of 16 months after the start of therapy, the 3-year survival was significantly better in patients with epithelial disease undergoing SMART (n=27) compared to patients with epithelial disease undergoing induction chemotherapy and EPP (n=52) (79% 3-year survival vs 30% 3-year survival, respectively; p=0.04). In contrast, the 3-year survival of patients with biphasic disease was similar between patients undergoing SMART (n=12) or induction chemotherapy and EPP (n=12) (20% vs 8%, respectively; p=0.8). Multivariate survival analysis using Cox regression model demonstrated that epithelial histologic subtype (p=0.0003), the absence of ypN2 disease (p=0.007) and SMART (p=0.03) were predictors of better survival.

      Conclusion
      Over the past 5 years, accelerated hemithoracic IMRT followed by EPP has become our preferred approach for surgically resectable MPM. Surgery for mesothelioma after radiation therapy was feasible with no operative mortality in 39 patients. Although comparison with our historical cohort of patients has limitations, our current protocol provides very encouraging results in patients with epithelial disease with a 3 year survival of 79%.

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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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      P3.07-038 - Long-term outcome after resection of non-small cell lung cancer invading the thoracic inlet (ID 2929)

      09:30 - 09:30  |  Author(s): O. Mercier

      • Abstract

      Background
      Non-small cell lung cancer (NSCLC) of the thoracic inlet accounts for less than 5% of all lung cancers. Due to the lack of efficient treatment and the complexity of the anatomical structures commonly invaded, these tumors were deemed historically unresectable and fatal. In this study, we reviewed our surgical experience and long-term outcome after resection of NSCLC invading the thoracic inlet

      Methods
      All consecutive patients from a single center who underwent resection of NSCLC invading the thoracic inlet were reviewed with data retrieved retrospectively from the charts.

      Results
      A total of 65 consecutive patients with a median age of 61 years (range 32 to 76) underwent resection of NSCLC invading the thoracic inlet from 1991 to 2011. Tumors were located in the previously described (Reference) five zones of the thoracic inlet as follows: zone 1 or anterolateral (n=5, 8%), zone 2 or anterocentral (n=7, 11%), zone 3 or posterosuperior (n=12, 18%), zone 4 or posteroinferior (n=22, 34%) and zone 5 or inferolateral (n=7, 11%). Fifty-two (80%) patients had induction therapy, mostly two cycles of cisplatin-etoposide and 45 Gy of concurrent radiation. All patients underwent en bloc resection of the lung and chest wall. Lobectomy was performed in 60 patients (92%). A median of three ribs were resected (range 1 to 5) and included the first rib in all patients. Twenty-four patients (37%) had an additional vertebral resection of up to five levels (median 3). Considering the most extended vertebral resection, total vertebrectomy with anterior-posterior spinal stabilization was required in 6 patients (25%), hemi-vertebrectomy with posterior spinal stabilization in 15 (62%), and partial vertebrectomy without stabilization in 3 (13%). Arterial resections were performed in seven patients (11%) and included subclavian artery (n=5), vertebral artery (n=1) and combination of sublclavian and carotid arteries (n=1).The median postoperative length of stay was 11 days (range 4 to 173). Postoperative morbidity and mortality were 46% and 6%, respectively. Pathologic response to induction treatment was complete (n=19) or near complete (n=12) in 31 patients (49%). Pathologic stages were 0 in 19 patients (29%), IB in 1 (2%), IIB in 28 (43%), IIIA in 15 (23%) and IIIB in 2 (3%) patients. After a median follow-up of 20 months (range 0 to 193), 34 patients were alive without recurrence. The overall 3- and 5-year survivals reached 58% and 52%, respectively. Results of the Cox regression and log-rank/Breslow tests identified the site of tumor (zone 1/3 vs 2/4/5, p=0.050) and the response rate to induction treatment (complete/near complete vs partial, p=0.004) as significant predictors of survivals. A trend toward shorter survival was found in case of arterial resection (p=0.063).

      Conclusion
      Survival after resection of NSCLC invading the thoracic inlet in highly selected patients reached 52% after five years. Tumor location within the thoracic inlet and pathologic response to induction therapy were significant predictors of survivals. Reference: de Perrot M, Rampersaud R. Surgical approaches to apical thoracic malignancies. J Thorac Cardiovasc Surg. 2012 Jul;144(1):72-80.