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R. Calhoun
Moderator of
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E13 - High Risk Patients and Low Risk Surgeons (ID 13)
- Event: WCLC 2013
- Type: Educational Session
- Track: Surgery
- Presentations: 4
- Moderators:H. Date, R. Calhoun
- Coordinates: 10/30/2013, 14:00 - 15:30, Parkside Ballroom A, Level 1
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E13.1 - Salvage Surgery After Radiation: Residual Tumour and Complications (ID 432)
14:05 - 14:25 | Author(s): C. Dickhoff, M.A. Paul, J.J. Kloek
- Abstract
- Presentation
Abstract
Salvage surgery after Radiation: Residual Tumor and Complications Definitive chemoradiotherapy is increasingly used in the treatment of patients with stage III non-small-cell lung cancer. Historically, local control and overall survival rates have been poor. To improve local control higher doses of radiotherapy are being investigated, with or without new chemotherapeutic agents. Dose-escalation appears to provide a modest benefit in terms of preventing local failure and improving overall survival, but the benefit comes at a price: The risk of both early and late toxicity appears to increase as well. Despite improved treatment remnants of vital tumor often persist. In many patients this has no clinical significance because prognosis is determined by the occurrence of distant metastases. However, some tumors do not metastasize and local recurrence becomes a problem. These patients are then referred for possible surgical resection. Because of this possibility of isolated local recurrence, doctors Increasingly perform early re-staging procedures after definitive chemoradiotherapy. In case of persistent tumor patients are referred for resection as “late-induction cases”. Another category consists of patients presenting with complications caused by high-dose irradiation. These late sequalae of radiotherapy are: bronchial stenosis, fatal haemoptysis, esophageal stenosis, fistula’s, cardiac complications and the occurrence of 2nd primary tumors. They may occur as early as 3 months, but an interval of one or more years is not uncommon (1) Some of these complications, such as fistula’s or bronchial stenosis , require urgent surgical correction, due to their severe symptoms. Late surgical resection in irradiated patients has been described with good success (2). However, the impaired wound healing capacity of irradiated tissue makes surgery hazardous and the liberal use of non-irradiated tissue flaps is recommended. We describe our experience of surgical correction of late complications after concurrent chemoradiotherapy: Fistulae: A tracheo-esophageal fistula or broncho-esophageal fistula is best treated by esophageal resection and tube-stomach replacement, because the esophagus is often stenotic and mere interposition of a muscle flap between airway and esophagus will not suffice. Stenosis: Bronchial stenosis requires resection, but re-anastomosis carries a high risk of dehiscence. We have seen two cases of dehiscence after 6 and 8 weeks, after the sutures had been absorbed, in spite of wrapping the suture line with an intercostal muscle flap. Tracheomalacia requiring temporary stenting has also occurred following partial tracheal resection. Hemoptysis: Necrosis and cavitation of an irradiated area may be complicated by a fungal infection (aspergillus), causing haemoptysis. These patients, who are often weak and malnourished, are treated by a staged procedure: First thoracic wall fenestration for adequate drainage of the infectied area together with insertion of a gastrostomy or jejunostomy catheter for nutritional support. We try to avoid nasogastric tubes in these patients, to avoid aspiration. At a second stage the cavity is filled with a pedicled muscle flap. Depending on the size and location of the cavity, a partial thoracoplasty is also performed. The interval between the two operations should be limited if the cavity extends towards the hilum, because erosion of a vessel wall may cause fatal hemorrhage. New treatments for lung cancer create new situations for the thoracic surgeon. Good skill, knowledge of old techniques such as thoracoplasty and the use of muscle flaps, and emphasis on nutritional support are mandatory to solve these problems.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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E13.2 - Standards and Benchmarking of Surgery (ID 433)
14:25 - 14:45 | Author(s): A. Brunelli
- Abstract
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Abstract
Managed care system, public accountability, cost containment, pay-for-performance and ranking culture demand Quality of care to be monitored through appropriate instruments. Outcome endpoints (i.e. morbidity and mortality) are still the most widely used quality indicators in thoracic surgery. Outcomes however should be reported in the most correct way to prevent risk-averse behaviours and misleading information. They need risk-adjustment, as different case-mixes at different institutions may influence outcome and those units operating on older and sicker patients would be penalized without an appropriate risk-adjustment. Therefore, risk-modelling must become the logical and necessary approach for provider profiling and comparative audit. The most important tool of any quality assessment endeavour is a database that is made up of a representative sample of the study group of interest. The gold standard for data should be a specialty-specific, procedure-specific, prospectively maintained, periodically audited, electronic database that contain, at the minimum, a core set of variables that has been demonstrated to be associated with outcome. The practical steps that should be planned and possibly recorded to construct a solid clinical database are a clear definition of the data sources and the creation of a list of variables (and their definitions) that will constitute the database. These steps will permit that 1) the database can be used even by subjects that did not participate to its construction, 2) the database can be audited by external data managers to assess quality of data, 3) changes in data collection or variables recording may be adequately planned. The importance of the source and the quality of data cannot be overemphasized enough. Most of the data that are of clinical interest derive from clinical records or other attached documents, such as laboratory exams or PFTs. One of the most critical aspects of the database construction is the extraction of the data from the medical record to the database. Wherever possible, data should be entered in real time, at the point of capture; to this end a networked database should be accessible in the operating theatre, the ward, the clinic and the multidisciplinary team meeting room. When possible this data should be used to generate documents such as operation notes, MDT report, correspondence, so that data capture becomes integral to routine patient care. The person in charge of capturing or transferring data into a database should be properly qualified and adequately trained. A Clinical Audit Lead should be selected within each unit who will be responsible for the accuracy and quality of data collection. The data should be periodically checked for discrepancies, inconsistencies, missing values, in order to ensure a high quality database. In fact no model or predictive equation can be better than the data upon which it is based. If any underperformance in data collection would be detected this should be reported to all persons involved in the process of data recording with the final objective of continuously improving the quality of the database. The European Society of Thoracic Surgeons (ESTS) appointed a Database Committee responsible to develop and maintain an online clinical Database with the aim to collect clinical data from thoracic surgery units across Europe. The ESTS Database is an online database, which is free to members and directly accessible from the link on the ESTS homepage. The main purpose of the ESTS database is for quality monitoring and improving activities. Several outcome and process indicators are included in the dataset. These indicators have been used to construct a Composite Performance Score, which is used as one of the parameters necessary for the European Institutional Accreditation System (EIAS). The EIAS is a process aimed at standardization of thoracic surgery practice across European units. It is currently based on the information submitted to the ESTS Database and focused on major lung resections for lung cancer, the prevalent activity in our specialty. In the construction of the CPS, indicators covering all three temporal domains of our practice (preoperative, intraoperative and postoperative) were selected. These indicators included risk-adjusted hospital mortality and morbidity (outcomes) and 3 process measures derived from published guidelines: the proportion of lung resection candidates with measured DLCO, the proportion of candidates to lung resection for NSCLC with clinically suspicious nodal disease submitted to preoperative invasive mediastinal staging and the proportion of patients with a intraoperative mediastinal staging according to the ESTS published guidelines. The final composite score combined 3 processes and 2 outcomes indicators into a single comprehensive quality score which was able to discriminate between the units entering in the comparison process. Units eligible for the accreditation process are then inspected by a team of auditors appointed by the ESTS to verify a sample of data submitted to the ESTS database and the structural, procedural and qualification characteristics of the unit and surgeons working in that unit. Most recently the ESTS Executive Committee revised the structural characteristics of general thoracic surgery unit in Europe with the aim to provide a comprehensive document in line with the quality initiatives of the Society and serving as a guide for harmonizing the general thoracic surgical practice in Europe. That document will be used as a reference for future quality initiatives and educational activities of the societyOnly 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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E13.3 - Micrometastases: Magic or Mainstream? (ID 434)
14:45 - 15:05 | Author(s): Y. Wu
- Abstract
- Presentation
Abstract not provided
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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E13.4 - Decision-Making and the New IASLC Staging System (ID 435)
15:05 - 15:25 | Author(s): P. Goldstraw
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Abstract
The 7th edition of TNM for Lung Cancer, introduced in January 2010, was based entirely upon recommendations from the IASLC Staging and Prognostic Factors Committee. The enormous size of the data base, its international accrual of cases diagnosed over a relatively short time period and its inclusion of cases treated by all modalities of care, coupled with detailed analysis and intensive validation ensured that this version aligned stage with prognosis more accurately than ever before. This was achieved by introducing new size cut-points for tumour size, re-assigning some T and M descriptors and moving some T, N, and M combinations to new stage groupings. Inevitably there are questions as to whether there should be consequent changes to established treatment algorithms. These discussions will focus upon the following scenarios: a) Larger node negative tumours, > 5cms, are now included in stage II. In the past 10 years we have seen data showing that stage II cases benefit from adjuvant chemotherapy after complete resection. Do these "new" stage II cases benefit from adjuvant therapy? b) Cases in which there are additional tumour nodules in the tumour-bearing lobe and other ipsilateral lobes have with certain combinations of N category, been down-staged to IIIA. Selected cases of stage IIIA disease have benefitted from resection, usually in a multi-modality setting. Should these cases, now included in stage IIIA be treated with regimens including surgery? c) Tumours invading certain mediastinal structures that were classified as T4 in previous editions of TNM have not been re-assigned but when associated with N0 or N1 disease these cases have been down-staged to stage IIIA. Should they also be considered for surgery in a multi-modality setting? Whilst it is impossible to give dogmatic and unequivocal advice on the right answer to these questions the speaker hopes to give some insights into the factors which might influence the decisions made by the Multi-Disciplinary Team in such situations. Other issues raised by the 7th edition include: a) The distinction between pulmonary metastases and synchronous primary tumours has been clarified and the opinion of the pathologist has been emphasised in this distinction. Thus in cases in which there is more than one malignant nodule biopsy of additional lesions may be required if such a distinction would alter the treatment advised in any case. b) The IASLC nodal map and definitions of nodal stations and zones are now the recommended means of describing regional lymph node involvement in lung cancer. All members of the MDT should be familiar with this nomenclature. c) The definition of an R0 resection now requires that a defined minimum of lymph nodes/stations be removed by the surgeon and examined by the pathologist. Surgeons and pathologists need to comply with this requirement and other members of the MDT need to understand this expanded definition. d) The 7th edition of TNM and the new IASLC/ATS/ERS classification of Adenocarcinomas may influence the management of screen-detected lesions. The new T category of T1a tumours no larger than 2cms and the fall in prognosis seen in lesions above this threshold may influence the choice of approach to lesions around this watershed, one's policy of structured surveillance and the extent of surgical resection for lesions confirmed to be malignant. As LDCT screening becomes more widely available the MDT managing these cases will need to consider these matters when developing their investigative algorithms.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.
Author of
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GR01 - Surgery and the New Stage IIIA (ID 16)
- Event: WCLC 2013
- Type: Grand Round Session
- Track: Surgery
- Presentations: 1
- Moderators:F. Detterbeck, J. Mitchell
- Coordinates: 10/29/2013, 14:00 - 15:30, Parkside Ballroom A, Level 1
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GR01.4 - Multiple Primaries, Satellites or Intrapulmonary Metastases? (ID 449)
15:05 - 15:25 | Author(s): R. Calhoun
- Abstract
- Presentation
Abstract not provided
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.
