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R. Flores
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MINI 20 - Surgery (ID 137)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 14
- Moderators:G. Veronesi, R. Flores
- Coordinates: 9/08/2015, 16:45 - 18:15, 201+203
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MINI20.01 - Do Secondary Lung Cancers Have the Same Disease-Specific Survival and Overall Survival as Primary Lung Cancers? (ID 2686)
16:45 - 16:50 | Author(s): C. Stock, J.M. Varlotto, S. Ali, J. Flickinger, M. Decamp, D. Maddox, K. Uy, J. Glanzman, J. Liebmann, S. Quadri, F. Gu, G. Graeber, V. Kasturi, W. Walsh, A. Yao
- Abstract
- Presentation
Background:
The risk of recurrent lung cancer decreases markedly after 4 years. It is unknown whether frequent surveillance after this time period would be beneficial in order to diagnose and treat secondary lung cancers. The purpose of investigation is to assess whether there is an increasing frequency of second lung cancers and whether the first primary reduces Overall Survival(OS)/Lung Cancer Specific Survival(LCSS) as compared to similar patients presenting with their first lung cancer (new primary, NP).
Methods:
The SEER databases were used to investigate incidence (1973-2010) and OS/LCSS (1998-2010) of secondary lung cancer. Incidence was examined by frequency and trend analyses. A SP population was chosen who was originally treated for Stage I-III NSCLC and developed a new primary at least four years after diagnosis of their original primary lung cancer (N=1,699). The OS/LCSS of their SP NSCLC were compared to patients presenting with a new primary (NP) NSCLC. OS/LCSS in NP and SP were analyzed by Kaplan-Meier estimation, multivariate proportional hazards modeling and log-rank tests in the overall group and in a favorable sub-group (stage I, < 4cm).
Results:
The annual incidence rates per 100,000 persons for SP NSCLC has increased almost 5 fold in last three decades (2.5 in 1973; 12 in 2010; p<0.001), more so in male patients. OS and LCSS in SP were higher than NP in the log rank tests (p<0.001). In the subgroup of NP and SP who had favorable tumor characteristics, OS/LCSS was significantly different between NP and SP (P=0.0032; P=0.0015), but did not remain so after accounting for treatment, tumor factors, and patient characteristics (HR=0.983, p=0.8493; HR=1.154, p=0.1770). Rates of OS and LCSS improved significantly with increasingly aggressive treatment in the SP group. Patient and tumor characteristics of the first primary NSCLC were not signantly linked to mortality.
Conclusion:
Patients presenting with a second primary lung cancer had a similar or better OS/LCSS as compared to patients presenting with a new primary lung cancer. The SP population also benefitted from increasingly aggressive treatment. Continued surveillance for new primary lung cancers after 4 years may be beneficial to lung cancer survivors.
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MINI20.02 - Risk-Adjusted Margin Positivity (RAMP) Rate as a Surgical Quality Metric for Non-Small-Cell Lung Cancer in the US National Cancer Data Base (NCDB) (ID 1247)
16:50 - 16:55 | Author(s): C.C. Lin, M.P. Smeltzer, X. Yu, R.U. Osarogiagbon, A. Jemal
- Abstract
- Presentation
Background:
Surgical resection is the most important curative treatment modality for early-stage non-small-cell lung cancer (NSCLC). However, incomplete (margin-positive) resection is associated with inferior survival. We sought to develop a valid facility-based quality metric to measure surgical quality, adjusting related patient demographic and clinical characteristics.
Methods:
We identified facilities that performed cancer-directed surgery for patients diagnosed with AJCC stage I-IIIA NSCLC in the NCDB between 2004 and 2011. We used a multivariate logistic regression model, adjusting for patient risk-mix in each facility, to predict the expected number of risk-adjusted margin positivity (RAMP) cases for each facility. We divided the number of observed margin positivity (OMP) cases by the expected number of RAMP cases to obtain an observed: expected (O/E) ratio for each facility. We categorized facility performance as low outlier (O/E ratio<1 and p<.05), high outlier (O/E ratio>1 and p<.05), or non-outlier. Facility characteristics across performance categories were compared by chi-square test. Five-year unadjusted overall survival (OS) rates were estimated by Kaplan-Meier analyses and compared across categories with the log-rank test.
Results:
A total of 96,596 NSCLC stage I-IIIA patients underwent surgery in 941 facilities. The overall OMP rate was 4.6%. We identified 73 facilities as low outliers (mean O/E ratio=0.41), 755 as non-outliers (mean O/E ratio=1.28) and 113 as high outliers (mean O/E ratio=2.78). Compared to patients treated at high-outlier facilities, patients treated at low-outliers were more likely to be privately insured (34.7%[Low] vs. 32.9%[High]), reside in high-income neighborhoods, have no comorbidity (51.7% [Low] vs. 41.9 [High], p<.001), have adenocarcinoma (62.4%[Low] vs. 58.1%[High], p<.001), stage IA disease (41.6%[Low] vs. 39.6%[High], p<.001) and receive sub-lobectomy (11.7%[Low] vs. 9.9%[High], p<.001). Low-outlier facilities were more likely to be teaching/research or NCI-designated programs (54.8% [Low] vs. 18.5% [High], p<.001) and in the highest quartile of total cancer surgical volume (90.4% [Low] vs. 34.5% [High], p<.001) and lung cancer surgery volume (42.5% [Low] vs. 29.2% [High], p<.001) (Table 1). They also had smaller proportions of uninsured/Medicaid patients (45.2% [Low] vs. 36.2% [High], p=.006). The 5-year unadjusted OS estimates were: 0.62 (low-outliers), 0.58 (non-outliers), 0.57 (high-outliers); log-rank p<.001. Table 1. Facility characteristics across performance categoriesHigh-Outlier(N=113) Non-Outlier(N=755) Low-Outlier(N=73) p-value N(%) Census_region Northeast 18(15.9) 154(20.4) 19(26.0) 0.03 Midwest 39(34.5) 223(29.5) 15(20.6) South 37(32.7) 257(34.0) 35(48.0) West 19(16.8) 121(16.0) 4(5.5) Facility_type Community_Cancer_Program 23(20.4) 164(21.7) 0(0.0) <0.001 Comprehensive_Community_Cancer_Program 62(54.9) 419(55.5) 28(38.4) Teaching/Research 17(15.0) 128(17.0) 28(38.4) NCI_program 4(3.5) 17(2.3) 12(16.4) Other 7(6.2) 27(3.6) 5(6.9) Proportion_of_Medicaid/uninsure_patients Q1(low) 25(22.1) 206(27.3) 13(17.8) 0.006 Q2 16(14.2) 204(27.0) 20(27.4) Q3 41(36.3) 174(23.1) 21(28.8) Q4(high) 31(27.4) 171(22.7) 19(26.0) Lung_cancer_surgery_as_a_proportion of_all_surgery Q1(low) 8(7.1) 73(9.7) 0(0.0) <0.001 Q2 37(32.7) 224(29.7) 9(12.3) Q3 35(31.0) 226(29.9) 33(45.2) Q4(high) 33(29.2) 232(30.7) 31(42.5) Total_cancer_surgery_volume Q1(low) 12(10.6) 98(13.0) 0(0.0) <0.001 Q2 32(28.3) 193(25.6) 0(0.0) Q3 30(26.6) 253(33.5) 7(9.6) Q4(high) 39(34.5) 211(28.0) 66(90.4)
Conclusion:
Facility performance in lung cancer surgery can be captured by using the RAMP rate. Low-outlier facilities delivered superior OS than high-outliers. RAMP metrics could allow facilities to understand their performance and serve as a quality improvement benchmark.
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MINI20.03 - The Survival Impact of Missed Lymph Node Metastasis in Surgically Resected Non-Small Cell Lung Cancer (NSCLC) (ID 2204)
16:55 - 17:00 | Author(s): N. Faris, M.P. Smeltzer, C. Adair, A. Berry, X. Yu, L. McHugh, R.U. Osarogiagbon
- Abstract
- Presentation
Background:
Lymph node (LN) metastasis is an important prognostic factor for patients with surgically resected NSCLC. We have previously described the extent of missed N1 LN metastasis in a cohort of patients treated at metropolitan institutions. With long-term follow up, we now quantify the survival impact of missed LN metastasis.
Methods:
We conducted a prospective cohort study to retrieve intrapulmonary LNs from discarded NSCLC resection specimens after completion of routine pathology examination. Retrieved materials were histologically examined and classified as LNs with and without metastasis. Survival information was retrieved from institutional tumor registries. Survival distributions were plotted using the Kaplan-Meier method and evaluated with proportional hazards models controlling for gender, race, pathologic N-category, tumor size, margin status, and Charlson score.
Results:
We evaluated 111 patients who were 47% male with a median age of 66 years. Clinical characteristics are summarized in Table 1. Discarded LNs with metastasis were found after re-dissection in 25 (23%) patients. Patients with discarded LN metastasis had an increased risk of death (Figure 1) with an unadjusted hazard ratio (HR) of 2.0 (p-value=0.06) and an adjusted HR of 1.8 (p-value=0.23) compared to those with no discarded LNs with metastasis. When >2 discarded LNs with metastasis were found, patients had 4.8 (p-value=0.0002) times the hazard of death compared to those with no discarded LNs with metastasis (adjusted HR=4.4, p-value=0.0032).
Figure 1N(%) No LN Metastasis LN Metastasis Total Bi-lobectomy 8 2 10 9% 8% Lobectomy 75 16 91 87% 64% Pneumonectomy 3 7 10 3% 28% N0 71 6 77 83% 24% N1 6 12 18 7% 48% N2 9 7 16 10% 28% T1 45 3 48 52% 12% T2 29 11 40 34% 44% T3 10 8 18 12% 32% T4 2 2 4 2% 8% Margin Negative 83 22 105 97% 88% Margin Positive 3 3 6 3% 12% Mean(SD) Charlson Score 1.8 1.8 1.8 1.6 1.7 1.6 Tumor Size(cm) 3.2 5.0 3.6 1.8 2.1 2.0
Conclusion:
The presence of metastasis in inadvertently discarded LNs in NSCLC resection specimens has significant implications for patients’ post-operative clinical course. Additional LN metastasis found on re-dissection was associated with reduced survival. A more rigorous protocol for gross dissection of lung resection specimens is needed, and should prove beneficial to patients’ long-term survival.
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MINI20.04 - Right-Sided vs Left-Sided Pneumonectomy after Induction Therapy for Non-Small Cell Lung Cancer (ID 3064)
17:00 - 17:05 | Author(s): C.J. Yang, D.Y. Chan, B.C. Gulack, D.N. Ranney, B.C. Tong, M.W. Onaitis, D. Harpole, T.A. D'Amico, M.G. Hartwig, M.F. Berry
- Abstract
- Presentation
Background:
A right-sided pneumonectomy after induction therapy for non-small cell lung cancer (NSCLC) has been shown to be associated with significant perioperative risk. We examined the impact of laterality on long-term survival using the National Cancer Data Base (NCDB).
Methods:
Perioperative and long-term outcomes of patients who underwent pneumonectomy following induction chemotherapy ± radiation from 2003-2011 in the NCDB were evaluated using Kaplan-Meier method, multivariable logistic regression analysis and multivariable Cox proportional hazards modeling.
Results:
During the study period, 1,652 patients met inclusion criteria, of whom 740 (45%) underwent right-sided pneumonectomies. Right-sided patients were more likely to have adenocarcinomas, cN2 disease and lower co-morbidity scores (Table). The 30-day mortality rate was higher for right-sided procedures in univariable (11% [84/740] vs 4% [39/912], p<0.001) and multivariable (OR 9.1 [1.8-50.0], p<0.01) analysis. However, 5-year overall survival between right and left pneumonectomy were not significantly different (figure) after a median follow up of 30.2 months. Right-sided procedure also did not impact overall survival in multivariable analysis (hazard ratio (HR), 1.41 [95% CI: 0.87-2.27], p=0.16), while increasing age (HR, 1.02 [95% CI: 1.01-1.03]), Charlson co-morbidity Score of 2 (HR, 1.42 [95% CI: 1.04-1.93]), adenosquamous histology (HR, 1.72 [95% CI: 1.18-2.51]), cN1 status (HR, 1.27 [95% CI: 1.02-1.58]), cN2 status (HR, 1.38 [95% CI: 1.14-1.66]), cN3 status (HR, 1.84 [95% CI: 1.19-2.83]), cM1 status (HR, 2.04 [95% CI: 1.42-2.92]) and incomplete resection (HR, 1.45 [95% CI: 1.14-1.84]) all predicted worse survival. Figure 1Table: Baseline characteristics.
There were no significant differences between the groups with regards to sex, race, facility type, and clinical T and M status.Variable Right-sided (n=740) Left-sided (n=912) p Induction chemoradiation 461 (62%) 584 (64%) 0.47 Age (median, IQR) 59 (52-66) 60 (52-67) 0.07 Charlson/Deyo Comorbidity Score 0.02 0 518 (70%) 610 (66%) 1 190 (26%) 243 (27%) 2 32 (4%) 68 (7%) Histology 0.02 Adenocarcinoma 227 (37%) 243 (32%) Squamous 310 (50%) 450 (59%) Large cell 28 (5%) 19 (2%) Adenosquamous 20 (3%) 21 (3%) Neuroendocrine/carcinoid 4 (1%) 7 (1%) BAC 28 (5%) 23 (3%) Clinical N < 0.01 0 190 (27%) 269 (31%) 1 134 (19%) 187 (21%) 2 368 (52%) 381 (44%) 3 16 (2%) 34 (4%)
Conclusion:
In this population analysis, right-sided pneumonectomy after induction therapy was associated with a significantly higher perioperative but not worse long-term mortality compared to a left-sided procedure. These findings can be used in the risk/benefit analysis when considering patients for pneumonectomy following induction therapy.
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MINI20.05 - Discussant for MINI20.01, MINI20.02, MINI20.03, MINI20.04 (ID 3420)
17:05 - 17:15 | Author(s): U. Pastorino
- Abstract
- Presentation
Abstract not provided
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- Abstract
- Presentation
Background:
Outcomes of pneumonectomy after neoadjuvant chemoradiastion therapy (CCRT) for patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) have been well-known as grave. Whenever possible, we have tried sleeve resection in patients to avoid pneumonectomy(PN). We evaluated whether the sleeve resection (SL) could have avoided the postoperative mortality/morbidity and achieved comparable long-term outcomes with pneumonectomy.
Methods:
We retrospectively reviewed medical records of 574 consecutive patients with clinical stage IIIA-N2 non-small cell lung cancer who underwent surgery after neoadjuvant CCRT from 1997 to 2013. Clinical outcomes were analyzed and compared in 98 consecutive patients who had either SL (n = 25) or PN (n = 73) after neoadjuvant CCRT in a single institution.
Results:
Thirty-day postoperative mortality were 0% (0/25) in SL group, and 5.5% (4/73) in PN group (p=0.120). Ninety-day postoperative mortality were 12.0% (3/25) in SL group, and 17.8% (13/73) in PN group (p=0.498). The most common cause of ninety-day mortality was acute respiratory distress syndrome (n=11). Morbidity rate was 48.0 % (12/25) in SL, and 49.3% (36/73) in PN. The 5-year survival was lower in the PN group (PN, 24.7 % versus SL, 45.1%, p=0.086). The recurrence pattern (locoregional versus distant) did not differ between two groups (p=0.726). When recurrences occurred (n = 50), the site of first recurrence was local (stump site) in 0 % (0/25) of patients with SL and in 4.1% (3/73) of patients with PN.
Conclusion:
Following neoadjuvant CCRT for patients with stage IIIA-N2 NSCLC, SL showed a comparable or even better early and long term clinical outcomes with PN. Therefore, SL should be considered, whenever possible.
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MINI20.07 - Extended Cervical Mediastinoscopy (ECM) for Biopsy of AortoPulmonary Window (APW) Lymph Nodes and an APW Index (APWI) Useful in Patient Selection (ID 565)
17:20 - 17:25 | Author(s): R.B. Cameron, S. Andaz, G. Hoal, L. Hua-Feng, M. Doyle, J. Benfield
- Abstract
Background:
Biopsy of APW (levels 5/6) lymph nodes can be important for lung cancer staging, but the APW is not accessible by routine mediastinoscopy or EBUS. Although some consider ECM potentially dangerous, we reviewed our ECM experience to determine safety and accuracy and to define/validate parameters for patient selection.
Methods:
With IRB approval we reviewed two institutions' databases for patients undergoing ECM between 3/1/97 and 12/31/11. Physical parameters (PP) that were thought to impact on the difficulty and safety of ECM, ie., clavicular head (CH), thoracic inlet (TI), and anterior mediastinal (AM) dimensions, were measured using 55 CT scans available from the first 100 pts.
Results:
Of 190 patients, 128 (67.3%) were male and ages ranged 28-91 yrs. Indication for surgery was either cancer (>95% with lung cancer >80%) or adenopathy (<5%). All procedures were performed by a single surgeon during routine mediastinoscopy. There were no intraoperative complications and blood loss was <25 cc in all cases. Morbidity occurred in 15 (7.9%) with 1 (0.55%) major complication and no mortality. A pathologic diagnosis was obtained in 189 (99.5%). Postop pain was easily controlled with bupivicaine. PP were compared to those in an additional 12 control patients with failed procedures (Table). Although each PP alone was not useful, the APWI (TI X AM product) did predict degree of difficulty (p=0.015) and divided patients into 3 groups predictive of the degree of difficulty: Straightforward (APWI>17), Intermediate (APWI=6-17), and Prohibitive (APWI<6) (Figure). The APWI was then prospectively validated with excellent accuracy in the next 90 patients. The APWI can be helpful in the selection of patients for thoracic surgeons, particularly those learning ECM. A short video demonstrating the technique of ECM will be presented.Table: Physical Parameter Measurements (values were obtained from CT scans available on 55/100 initial patients comparing with a separate group of 12 patients with unsuccessful ECM
Figure 1Parameter Successful ECM (cms) UnSuccessful ECM (cms) Clavicular Head (CH) 2.3+0.36 2.28+0.36 Thoracic Inlet (TI) 6.32+1.07 5.99+0.62 Anterior Mediastinum (AM) 2.53+0.82 1.89+0.82 APWI (TI X AM) 16.2+6.77 11.1+4.4* *p=0.015
Conclusion:
ECM is straightforward, safe, and accurate in mediastinal staging. Our novel APWI helps to safely select patients for any thoracic surgeon's skill and comfort level.
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MINI20.08 - Survival in Unexpected Multi-Station pN2 Following Surgical Resection of NSCLC (ID 1246)
17:25 - 17:30 | Author(s): M. Evison, S. Britton, H. Al-Najjar, R. Shah, P. Crosbie, R. Booton
- Abstract
- Presentation
Background:
In our cancer network, single station N2 NSCLC may be managed with surgical resection followed by adjuvant chemotherapy as meaningful survival has been shown in such circumstances. Multi-station N2 disease diagnosed pre-operatively is not considered a surgical entity. However, sometimes occult multi-station pN2 may only be identified during intra-operative nodal sampling. This study aimed to analyse the survival of such patients at a large thoracic surgical centre in the United Kingdom.
Methods:
A retrospective review of all pathological reports from NSCLC resections at the University Hospital South Manchester from 01/01/2011 to 31/12/2013. Based on the histological results from intra-operative nodal sampling, patients were stratified into nodal categories pN0, pN1, pN2 single station and pN2 multi-station. Survival data was obtained through national death registry data allowing a minimum of twelve months follow-up for all patients at the time of analysis in January 2015.
Results:
987 surgical resections for NSCLC were performed during the study period 2011 to 2013 at UHSM. A total of 132 patients had pN2 disease; 85 with single station pN2 and 47 with multi-station N2. The median survival time for those patients with multi-station pN2 was 798 days (95% CI 405-1191 days) and 762 days (95% CI 616-908 days) for those with single station pN2. Median survival times were not estimable for patients with pN0 and pN1 as only a small proportion of patients died. For pairwise comparisons between N categories, a Bonferroni adjustment for multiple comparisons used a critical value of 0.008 for significance. Patients with single station pN2 and multi station pN2 had significantly lower survival times than patients with N0, but there was no statistically significant difference in survival between patients with pN1, single station pN2 and multi-station pN2 (Figure 1).Figure 1
Conclusion:
Interestingly, patients with multi-station pN2 had a similar survival to those with single station pN2. This cohort of multistation pN2 patients is likely to represent those with microscopic nodal metastases and does not represent all multistation N2 disease. Although the numbers are small it does raise interesting questions about the exclusion of patients with radiologically-occult multi-station N2 disease, detected during the pre-operative systematic sampling of small mediastinal nodes through endoscopic or surgical techniques, being excluded from surgery as part of their multi-modality treatment in our network.
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MINI20.09 - Discussant for MINI20.06, MINI20.07, MINI20.08 (ID 3549)
17:30 - 17:40 | Author(s): V. Rusch
- Abstract
- Presentation
Abstract not provided
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- Abstract
- Presentation
Background:
Current nodal staging for non-small cell lung cancer (NSCLC) only take into account the anatomic location of lymph node (LN). Although among patients with same pathologic N1 NSCLC, they are known to have heterogeneous prognosis and prognostic significance of extent of LN involvement is still uncertain. The objective of current study was to evaluate whether LN ratio (LNR) is a marker of prognostic factor for survival in patients with pathologic stage II/ N1 NSCLC after complete resection
Methods:
A total of 4,089 consecutive patients underwent curative surgical resection for NSCLC between 2004 and 2012. Of these, 413 patients who found to have pathologic stage II/N1 NSCLC after complete resection were retrospectively analyzed. For LNR, the optimal cutoff value was determined using chi square score, which were calculated using the Cox proportional hazards regression model. The prognostic value of the LNR was calculated by Cox regression hazard model analysis.
Results:
The study included 337 males and 76 females with a mean age of 62 years. The mean numbers of metastatic and dissected LN were 1.84 and 26 respectively and the mean LNR was 0.082. The number of the metastatic LN was significantly correlated to the LNR (r=721; p<0.0001). Based on the maximum chi square score and minimum p value approach, the optimal cutoff value of LNR was 0.1 and patients were classified into two groups according to LNR. Both 5-year overall survival rate and the lung cancer-specific survival rate in the high LNR group (LNR ≥0.1) were significantly lower than those in the low-LNR group (overall survival: 55.4.% vs 69.8%, p=0.003; lung cancer specific survival rate: 58.4% vs. 77.0%, p<0.0001) Also, disease free survival (DFS) rates according to LNR were 56.8% in low-LNR group (LNR<0.1) and 35.0% in high-LNR group (LNR≥0.1). DFS rate in the low-LNR group was significantly higher than that in the high-LNR group (p<0.001). LNR is an independently related prognostic factor with overall survival (OR=2.288; 95% CI=1.513~3.459; p<0.0001), lung cancer-specific survival (OR=2.740; 95% CI=1.709~4.395; p<0.0001) and DFS (OR=2.191; 95% CI=1.543~3.110; p<0.0001) after adjustments of clinical variables including sex, age, stage, surgical extent, histology and adjuvant treatment.
Conclusion:
LNR is an independent prognostic factor of survival in patients with pathologic N1 NSLC after complete surgical resection.
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MINI20.11 - Lymph Node Impact on Conversion of VATs Lobectomy to Open Thoractomy (ID 75)
17:45 - 17:50 | Author(s): Y. Li
- Abstract
Background:
Conversion to open thoracotomy occurs when thoracoscopic manipulation becomes difficult as a result of particular situations during complete thoracoscopic lobectomy after the surgeon starts to dissect blood vessels Based on special intra-operative situations, conversion to open thoracotomy can be divided into active and passive conversion. Active conversion to open thoracotomy implies that the surgeon gives up the thoracoscopic manipulation voluntarily and performs open surgery under direct vision as a result of the difficulty of thoracoscopic manipulation when encountering problems, such as adhesions of lymph nodes and difficulty of exposing huge tumors, which may result in massive bleeding, tumor rupture, and undue extension of the operative time. Passive conversion to open thoracotomy implies that the surgeon has to discontinue thoracoscopic manipulation and perform open surgery under direct vision because of urgent or serious intra-operative complications, including blood vessel breakage and bronchial membrane rupture, which are difficult to treat thoracoscopically. Lymph nodes are an important etiology affecting the conversion of complete thoracoscopic lobectomy to open thoracotomy.Five hundred consecutive patients with non-small cell lung cancer underwent complete thoracoscopic lobectomy at the Department of Thoracic Surgery of Peking University People’s Hospital, and the conversion to open thoracotomy was performed in 47 cases (9.4%). Lymph node interference means that a lymph node cannot be separated easily, and was the reason for conversion to open surgery in 31 cases (65.9% of 47 cases).The effect of lymph node interference on surgery has not been thoroughly addressed to date. We studied the data of patients who underwent complete thoracoscopic lobectomy in our hospital, and analyzed the effect of lymph nodes on the conversion to open thoracotomy and corresponding factors.
Methods:
Between September 2006 to April 2013, 1006 patients （545 men, 461women, median age 60 years, range from 13 to 86 years)received completly thoracoscopic lobectomy, including segmectomy(n=13), simple lobectomy(n=846), compound lobectomy(n=131), pneumonectomy (n=8), sleeve lobectomy(n=8). The main procedure was completely video-assisted anatomical lobectomy with mediastinal lymphadenectomy as we have reported.
Results:
All procedures were carried out smoothly without serious complication. 83 cases converted to thoracotomy(8.2%), including 70 cases of initiative conversion and 13 cases of passive conversion in which 59 cases was interference by doornail lymph nodes. Pathological result show 821 cases of malignant disease and 185 cases of benign disease. All patients recovered well.the average operative time in the conversion thoracotomy group was significantly longer (272.7 ± 67.2min versus186.9 ± 58.1min, P = 0.001)compared with completely endoscopic surgery group, the average blood loss was significantly increased(564.2 ± 507.7ml versus 158.0 ± 121.0ml, P = 0.001), the drainage time was significantly longer(8.9 ± 5.0d versus 6.6 ± 3.5d, P = 0.001) and the postoperative hospital stay was significantly longer(12.5 ± 7.7d versus 9.2 ± 5.8d, P = 0.001).
Conclusion:
Interference of lymph doeds was the main reason for conversion to thoracotomy on VATs lobectomy. It may prolonged the operative time, increase the blood loss in operation and delay the postoperative recovery of the patients. Select the proper indication of conversion thoracotomy may reduce the negative effects of conversion thoracotomy.
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MINI20.12 - Advancements in Bronchoplasty as Treatments for Lung Cancer: Single Institutional Review of 213 Patients (ID 1331)
17:50 - 17:55 | Author(s): T. Nagayasu, N. Yamasaki, T. Tsuchiya, K. Matsumoto, T. Miyazaki
- Abstract
- Presentation
Background:
Bronchoplasty has become widely accepted as a reliable and safe lung-saving procedure for lung cancer. The purpose of this study was to evaluate the factors contributing to the outcomes of bronchoplasty for lung cancer by analyzing a single institution’s data for a 30-year period.
Methods:
In the 2416 patients who underwent lung resections for lung cancer at Nagasaki University Hospital from 1980 to 2010, there were 222 bronchoplastic procedures. After excluding patients who underwent carinoplasty, 213 patients (161 bronchoplasty and 52 broncho-angioplasty) were included. The patients were divided into two groups by the date of surgery: the 1[st] period was 1980 to 1995, and the 2[nd] period was 1996 to 2010.
Results:
Bronchoplasty and broncho-angioplasty were performed in 100 (75.8%) and 32 (24.2%) patients, respectively, in the first period and 61 (75.3%) and 20 (24.7%) patients, respectively, in the second period. Overall 90-day operative morbidity and mortality rates were 25.8 and 9.8%, respectively, in the first period and 45.7 and 2.5%, respectively, in the second period. Thirty-day mortality rates were 6.8% in the first period and 0% in the second period. Five-year survival was 41.1% (n = 132) in the first period and 61.5% (n = 81) in the second period (P = 0.0003). Comparing bronchoplasty and broncho-angioplasty, the 5-year survival was 45.6 and 26.5%, respectively, in the first period (P = 0.0048) and 60.9 and 62.1%, respectively, in the second period (P = 0. 8131). Using multivariate analysis to identify potential prognostic factors, the type of operation (broncho-angioplasty), postoperative complications and histology (non-squamous cell carcinoma) were significant factors affecting survival in the first period, but none of the factors significantly affected survival in the second period. When the rates of pN2 or N3 histological type disease were compared in each period, the rate of pN2 or N3 disease in non-squamous cell carcinoma was 51.4% in the first period and 45.5% in the second period; both were significantly higher than in squamous cell carcinoma (31.6 and 16.9%, respectively; P = 0. 0365 and 0.0073). Figure 1
Conclusion:
The present study suggests that progress in the preoperative staging system and perioperative medical management, as well as surgery, has contributed to current improvements in patients undergoing bronchoplasty and broncho-angioplasty. However, since nodal status in non-squamous cell carcinoma is not precisely evaluated before the operation, the indication for bronchoplasty should be considered carefully.
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MINI20.13 - A Prospective Comparison of FDG-PET & EBUS for Determining the Extent of Mediastinal Lymph Node Involvement in NSCLC (ID 2323)
17:55 - 18:00 | Author(s): D.P. Steinfort, S. Siva, T. Leong, M. Rose, D. Gunawardana, P. Antippa, D. Ball, L.B. Irving
- Abstract
- Presentation
Background:
Non-small cell lung cancer (NSCLC) may be treated with curative intent using radiotherapy, either as single modality or in combination with systemic chemotherapy. Most commonly, radiation treatment is planned based on findings at 18-Fluorodeoxyglucose Positron Emission Tomography (PET), following pathologic confirmation of involvement at a single mediastinal site. We hypothesized that systematic mediastinal evaluation with EBUS-TBNA in NSCLC patients considered for radical radiation therapy may identify disease extent discrepant with that indicated by PET-CT.
Methods:
This prospective ethics board-approved multi-centre cohort study in three Austrailan tertiary centres consented patients prior to mediastinal evaluation with Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) for NSCLC,where non-invasive imaging indicated the likely treatment modality would include radical radiotherapy. EBUS evaluation was performed systematically with sampling of any lymph node (LN) exceeding 6mm diameter.
Results:
Thirty eligible patients with NSCLC form the basis of this report. No procedural complications occurred during performance of EBUS-TBNA. LN sampling was performed from a mean 2.5 lymph node stations per patient (median 3,range 1–5). Adequate samples were obtained from all sites examined by EBUS-TBNA. Mean long-axis size of sampled LN was 16+7.8mm (median 13mm,range 5–36mm). 24% of sampled LN were 10mm or less. Discordant findings were observed in 10 of 30 patients (33%) (Figure 1) EBUS-TBNA identified a greater extent of mediastinal involvement than PET in four patients, with invasive sampling resulting in upstaging in three patients. In one further patient, extent of disease was greater than noted on PET due to more proximal involvement of LN disease not resulting in stage advancement. Median size of LN upstaged by EBUS was 7.5mm (range 7–9). In eleven mediastinal LN in six patients, EBUS identified a lesser extent of mediastinal disease than PET, including two patients down-staged from N3 à N2. Median size of LN down-staged by EBUS was 12mm (range 6–21). FIGURE 1. Flowchart of patients Figure 1
Conclusion:
Our findings demonstrate clinically significant discrepancy between two modalities frequently used to stage mediastinal disease extent in NSCLC patients being considered for radiotherapy. PET-based radiotherapy planning alone may not be appropriate given the risk of excessively large, or insufficiently large, radiation fields where planning is not based on invasive LN sampling. These results suggest minimally invasive comprehensive/systematic mediastinal staging should be considered for all patients prior to radiotherapy to accurately assess pathologic stage and extent of disease, and to ensure treatment fields most accurately encompass all sites of disease.
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MINI20.14 - Discussant for MINI20.10, MINI20.11, MINI20.12, MINI20.13 (ID 3479)
18:00 - 18:10 | Author(s): G. Darling
- Abstract
- Presentation
Abstract not provided
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Author of
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MINI 19 - Surgical Topics in Localized NSCLC (ID 138)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:D. Jablons, B. Stiles
- Coordinates: 9/08/2015, 16:45 - 18:15, 605+607
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MINI19.14 - Survival After Sub-Lobar Resection for Early Stage Lung Cancer: Methodological Obstacles in Comparing the Efficacy to Lobectomy (ID 1583)
18:00 - 18:05 | Author(s): R. Flores
- Abstract
- Presentation
Background:
Surgery is the treatment of choice for early stage lung cancer (LC). While lobectomy (L) is the historic standard, whether long term outcomes of sub-lobar resection (SL) are comparable is still under debate. The only randomized trial was conducted 20 years ago; 5 subsequent meta-analyses showed inconclusive or conflicting results. We present a comprehensive review of the literature on 5 year-survival after SL compared to L for early stage LC.
Methods:
A priori inclusion criteria were: 1) observational studies, 2) L compared to SL for early stage LC, 3) at least CT staging, 4) 5-year survival reported. A Medline search through January 2015 resulted in 32 studies, representing 24 distinct datasets. The absolute difference in 5-year survival was calculated and plotted for each study.
Results:
There were 4,702 cases treated with L, 2,323 treated with SL. Of 20 studies reporting the reason for SL, 11 indicated that SL was performed because of comorbidities, or impaired cardiopulmonary function. Among all 24 studies, 4 showed no difference in 5-year survival, 13 favored L, and 7 favored SL (Figure 1). Of the two studies using propensity scores, one favored L and the other SL. No meta-estimate could be calculated due to high statistical heterogeneity. Of 21 studies reporting recurrence rate (Figure 2), 11 favored L and 10 favored SL. Figure 1
Conclusion:
Studies comparing 5-year survival rates of SL to L are heterogeneous, and traditional meta-analytic summary estimates of survival and recurrence could not be calculated. SL survival is often similar to L survival, despite the fact that SL is performed in patients with comorbidities or impaired cardiopulmonary function. New approaches to comparing L to SL survival are needed.
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MINI 36 - Imaging and Diagnostic Workup (ID 163)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Screening and Early Detection
- Presentations: 1
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MINI36.11 - Pre-Operative Fine Needle Aspiration (FNA) for Diagnosis of Suspected Early Stage Lung Cancer Reduces Non-Malignant Resection Rate (ID 2124)
19:30 - 19:35 | Author(s): R. Flores
- Abstract
- Presentation
Background:
Rates of resection of non-malignant lung nodules suspected pre-operatively to be lung cancer vary widely and are reported to be as high as 40%. Commonly used modalities in the pre-operative workup of new lung nodules suspicious for lung cancer include positron emission tomography (PET), bronchoscopy, and computed tomography (CT)-guided fine needle aspiration (FNA). We evaluated the non-malignant resection rate (NMRR) and the frequency of benign resections among patients with pre-operative FNA in our lung cancer center.
Methods:
The study population was identified using databases of the Mount Sinai Departments of Thoracic Surgery and Radiology. Eligible patients included those with a CT-guided FNA and/or surgical resection performed during the 12-month period between July 2013 – July 2014 for known or suspected first primary early stage lung cancer presenting with a lung nodule or mass. Cases were included if patients were >18 years of age with no history of cancer treated within 5 years. Patient data were abstracted from the electronic medical records.
Results:
A total of 283 nodules from 264 patients met inclusion criteria. Of these, FNA was performed in 217 (77%) of the 264 patients, with 131 results (60%) categorized as malignant. Similarly, 228 nodules (81%) were PET imaged, and 141 (62%) of these were positive (Standard Uptake Value >2). Sensitivity and specificity of FNA and PET for diagnosis are reported in Table 1. Post-FNA pneumothorax requiring a chest tube occurred in 11/193 FNAs performed at Mount Sinai (6%). Of 208 surgically resected nodules, 27 cases (13.0%) had a non-malignant diagnosis on pathologic examination. The non-malignant resection rate (NMRR) ranged from 0% to 39% by different surgeons and did not correlate with surgical case volume. Among the 142 resections preceded by FNA, 11 (7.7%) were found to have non-malignant pathology. In contrast, among the remaining 66 resections without a pre-operative FNA, 16 (24.2%) were benign (OR 3.81, 95%CI 1.52-9.69; p = 0.001). Figure 1
Conclusion:
In this single center retrospective analysis, the overall NMRR was lower than in previously published reports. Furthermore, the NMRR was significantly lower in thoracic operations preceded by a CT-guided FNA compared with those without a pre-operative FNA. Diagnostic accuracy of FNA in this cohort of patients at moderate to high risk for lung cancer is higher than that of PET, with an acceptably low complication rate. These findings suggest that pre-operative diagnostic confirmation by FNA results in a low rate of non-malignant resection.
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MINI 38 - Biology and Prognosis (ID 167)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Thymoma, Mesothelioma and Other Thoracic Malignancies
- Presentations: 1
- Moderators:R. Tsuchiya, M. Wynes
- Coordinates: 9/09/2015, 18:30 - 20:00, 702+704+706
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MINI38.14 - Surgery and Not Radiation Improves Survival in Malignant Pleural Mesothelioma (ID 3168)
19:45 - 19:50 | Author(s): R. Flores
- Abstract
- Presentation
Background:
Surgery has a controversial role in the treatment of malignant pleural mesothelioma (MPM) as no trial has demonstrated independent survival benefit of surgery. Likewise, there is lack of consensus regarding the role of radiation in MPM. We evaluated whether cancer-directed surgery and/or radiation independently influenced MPM survival in a large population-based dataset.
Methods:
The Surveillance, Epidemiology, and End Results database was explored from 1973 to 2009 to identify all cases of pathologically-proven MPM. Age, sex, race, diagnosis year, stage, cancer-directed surgery, radiation, and vital status were analyzed (chemotherapy data not available). The association between prognostic factors and survival was estimated using a Cox proportional hazards model.
Results:
There were 14,228 patients with pathologic diagnosis of MPM. On multivariable analysis, female gender, younger age, localized stage, and cancer-directed surgery were independently associated with longer survival (Table). Survival was longer for patients who underwent surgery or surgery and radiation but not for those who underwent radiation only (Figure).
Figure 1Table. Association between Patient and Disease Characteristics and Survival Variable Category Adjusted HR (95% CI) * Sex Male 1 (Ref) Female 0.78 ( 0.75-0.82) Race White 1 (ref) Black 1.07 (0.98-1.16) Other 0.99 (0.89-1.09) Age (years) continuous 1.24 (1.22-1.26) Stage Localized 1 (ref) Regional 1.30 (1.21-1.40) Distant 1.34 (1.26-1.42) Diagnosis year 1973-1989 1 (ref) 1990-1994 0.91 (0.85-0.97) 1995-1999 0.86 (0.81-0.92) 2000-2004 0.86 (0.81-0.91) 2005-2009 0.80 (0.75-0.84) Therapy No radiation or surgery 1 (ref) Radiation only 1.17 (1.10-1.25) Surgery only 0.65 (0.62-0.68) Radiation and surgery 0.69 (0.63-0.75)
Conclusion:
In this study of 14,228 patients over 36 years, cancer-directed surgery was associated with better survival in MPM, independent of other forms of therapy, including radiation. These data support the role of surgery-based therapy as the cornerstone for treatment in this challenging disease.
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MS 01 - How to Treat Multiple GGO's (ID 19)
- Event: WCLC 2015
- Type: Mini Symposium
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:J. Donington, M. Tsuboi
- Coordinates: 9/07/2015, 14:15 - 15:45, 102+104+106
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MS01.02 - What Is the Role of Surgical Resection in the Setting of Multiple GGO's? (ID 1849)
14:40 - 15:00 | Author(s): R. Flores
- Abstract
- Presentation
Abstract:
Main point: Given the nonspecific nature of a GGO or multiple GGOs, a conservative approach to GGOs without a solid component is suggested. Ground glass opacity is a localized nodular lesion which appears as an undetermined finding ‘of hazy lung opacification, without obscuration of the underlying vascular markings’ on a CT scan. Any condition that decreases the air content of the lungs without totally obliterating the alveoli can produce ground glass opacity. GGOs, also known as nonsolid nodules, have been known to decrease or increase in size and/or disappear. There are benign and malignant causes of GGOs. A GGO can be indicative of inflammation, infection and fibrosis that are usually not fatal: pulmonary edema, alveolar proteinosis, many causes of alveolitis or interstitial pneumonitis, including idiopathic pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis, early radiation pneumonitis, aspergillus infection, pneumonia, and bronchiectasis. GGOs can also be an early finding of neoplasms such as bronchioalveolar carcinoma (BAC). A recent study has shown that lung cancers appearing as nonsolid nodules were Stage I adenocarcinomas. Analysis of 57,496 participants in the International Early Lung Cancer Action program has shown a 100% survival rate regardless of the time from diagnosis to treatment and tumor size. There are methods to indicate malignancy without surgery: marginal characteristics, the size and development of the solid component or the attenuation on the CT scan, patient’s medical history of cancer, and fine needle aspiration. These are not without some controversy. A solid component is concerning because they are areas of collapsed alveoli or fibroplastic proliferation which signifies more invasive lesions. However, nonsolid nodules can be followed safely by CT screening annually to see if they transition to a part-solid component. Lung cancers diagnosed among nonsolid nodules tend to be slow growing and indolent in nature. The recent I-ELCAP study shows that until the identification of molecular markers, CT imaging can differentiate among different levels of lung cancer sufficiently early so delay in treatment did not change prognosis. A surgeon has to weigh the risks inherent to surgery while leaving the patient with as much lung as possible. Note that a patient’s desire to have the nodule removed may factor in. If feasible, follow the patient and if the GGO’s morphologic characteristics begin to change dramatically, proceed with surgical intervention, preferably VATS. In most cases, with a conservative approach, the patient has enough pulmonary reserve for aggressive action if required. Location of the lesions may make surgical resection challenging. The decision to perform a lobar versus sublobar resection is based on multiple factors and varies from patient to patient. REFERENCES Cho J, Ko SJ, Kim SJ, Lee YJ, Park JS, Cho YJ, Yoon HI, Cho S, Kim K, Jheon S, Lee JH, Lee CT1. Surgical resection of nodular ground-glass opacities without percutaneous needle aspiration or biopsy. BMC Cancer. 2014 Nov 18;14:838. Cho JH, Choi YS, Kim J, Kim HK, Zo JI, Shim YM. Long-term outcomes of wedge resection for pulmonary ground-glass opacity nodules. Ann Thorac Surg. 2015 Jan;99(1):218-22. Engeler CE, Tashjian JH, Trenkner SW, Walsh JW. Ground-glass opacity of the lung parenchyma: a guide to analysis with high-resolution CT. AJR Am J Roentgenol. 1993 Feb;160(2):249-51. Kim HK, Choi YS, Kim J, Shim YM, Lee KS, Kim K. Management of multiple pure ground-glass opacity lesions in patients with bronchioloalveolar carcinoma. J Thorac Oncol. 2010 Feb;5(2):206-10. Miettinen OS, Henschke CI, Smith JP, Yankelevitz DF. Is ground glass descriptive of a type of pulmonary nodule? Radiology. 2014 Jan;270(1):311-2. Mirtcheva RM, Vazquez M, Yankelevitz DF, Henschke CI. Bronchioloalveolar carcinoma and adenocarcinoma with bronchioloalveolar features presenting as ground-glass opacities on CT. Clin Imaging. 2002 Mar-Apr;26(2):95-100. Yankelevitz DF, Yip R, Smith JP, Liang M, Liu Y, Xu DM, Salvatore MM, Wolf AS, Flores RM, Henschke CI; As the Writing Committee for The International Early Lung Cancer Action Program Investigators Group. CT Screening for Lung Cancer: Nonsolid Nodules in Baseline and Annual Repeat Rounds. Radiology. 2015 Jun 23:142554. [Epub ahead of print]
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ORAL 35 - Surgical Approaches in Localized Lung Cancer (ID 155)
- Event: WCLC 2015
- Type: Oral Session
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:M. de Perrot, J. Mitchell
- Coordinates: 9/09/2015, 16:45 - 18:15, 601+603
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ORAL35.05 - The Role of Surgical Mediastinal Resection in CT Screen-Detected Lung Cancer Patients (ID 960)
17:28 - 17:39 | Author(s): R. Flores
- Abstract
- Presentation
Background:
Comparison of long-term survival of patients with clinical Stage I non-small-cell lung cancer (NSCLC) with and without mediastinal lymph node resection (MLNR) in the International Early Lung Cancer Action Program, a large prospective cohort in a low-dose CT screening program.
Methods:
All instances of thoracic surgery for first solitary primary non-small-cell lung cancer prompted by low-dose CT screening, performed under an IRB approved common protocol at each of the participating institutions since 1992 to 2014, are included. Follow-up time was calculated from diagnosis to death from lung cancer, last contact, or December 31, 2014, whichever came first. Univariate logistic regression analysis of the demographic, CT, and surgical findings for those with and without MLNR was performed. Kaplan-Meier (K-M) survival rates and Cox regression analysis was performed using all significant univariate variables.
Results:
The 10-year Kaplan-Meier (K-M) NSCLC-specific survival rate for the 225 patients manifesting as a subsolid nodule was 100%, regardless of whether they had MLNR (N = 169) or not (N = 56). For the 373 NSCLC patients manifesting as a solid nodule, for those who had MLNR (N = 285) and those who did not (N = 88), the K-M NSCLC-survival rate was not significantly different (86 % vs. 93%, P = 0.23). The rate was 95% vs. 96% (P = 0.86) for those whose pathologic tumor diameter was <= 10 mm; 83% vs. 94% (P = 0.19) for 11-20 mm, and 79% vs. 86% (P = 0.67) for 21-20 mm. Cox regression analysis comparing MLNR with no MLNR showed that survival rates were not significantly different (P = 0.33), but significantly survival decreased when the tumor diameter was above 20 mm (HR= 5.1, 95% CI: 1.6-15.7).
Conclusion:
Lymph node evaluation is not necessary for resection of subsolid nodules in patients with screen-detected lung cancer.
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P2.08 - Poster Session/ Thymoma, Mesothelioma and Other Thoracic Malignancies (ID 225)
- Event: WCLC 2015
- Type: Poster
- Track: Thymoma, Mesothelioma and Other Thoracic Malignancies
- Presentations: 1
- Moderators:
- Coordinates: 9/08/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P2.08-017 - Chest Wall Soft Tissue Sarcomas: Impact of Adjuvant Radiation Therapy Following Surgical Resection (ID 1587)
09:30 - 09:30 | Author(s): R. Flores
- Abstract
Background:
Primary chest wall soft tissue sarcomas are rare tumors of the thoracic wall. The objective of this study is to evaluate the impact of adjuvant radiation therapy on survival following surgical resection using the Surveillance, Epidemiology, and End Results (SEER) database.
Methods:
We queried the SEER database for all surgically resected histologically proven primary chest wall soft tissue sarcomas between 1998 and 2010. Exclusion criteria included pediatric sarcomas, multiple malignancies and unknown grade, stage or radiation therapy status. Chi-square tests were performed to identify covariates associated with receiving adjuvant radiation therapy. Coarsened-exact matching was used to generate a matched cohort of patients who received adjuvant radiation following surgery and patients who underwent surgery alone. Cox regression and Kaplan-Meier analyses were performed to determine covariates associated with overall survival.
Results:
A total of 570 patients were included in the cohort prior to matching based on the selection criteria. Histological type (p = 0.003) and tumor grade (p < 0.001) were independently associated with receiving radiation therapy. Cox-regression did not demonstrate reduced hazards of death for adjuvant RT. After coarsened-exact matching, Kaplan-Meier survival analysis of matched groups (105 surgery alone and 104 surgery + RT) showed significant 1-, 3- and 5-year overall survival difference (p = 0.034) in surgery + RT compared to surgery alone.
Conclusion:
In a matched large population cohort, adjuvant radiation therapy appears to improve overall survival following surgical resection of chest wall soft tissue sarcomas. Further trials are required to determine the efficacy of adjuvant radiation therapy in this population.Figure 1
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P3.02 - Poster Session/ Treatment of Localized Disease – NSCLC (ID 211)
- Event: WCLC 2015
- Type: Poster
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 9/09/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P3.02-005 - Third Primary Lung Cancers: Incidence and Benefits of Surgical Therapy (ID 1688)
09:30 - 09:30 | Author(s): R. Flores
- Abstract
Background:
Continued surveillance of lung cancer patients after curative surgery allows for the diagnosis of new disease. However, there is a relative paucity of data in regards to the development of third primary lung cancers. The goals of this study were to examine the incidence of third primary cancers and the results of surgical therapy.
Methods:
Surgically resected Stage 1 second primary lung cancers with complete data were identified in The Survival Epidemiology and End Results (SEER) database between 2004 and 2010. Among these 238 cases, those which developed a third primary lung cancer 6 or more months after the diagnosis of the second primary were analyzed. Statistical methods were performed using Kaplan-Meier and multivariate analysis. A p value < 0.05 was considered statistically considered significant.
Results:
Twenty-four patients (10.1%) experienced a third primary lung cancer; sixteen cases (66.7%) were diagnosed in stage I. Twelve patients (50% of cases) underwent cancer surgery. Nine patients (37.5%) were treated with beam radiation – alone (8 cases, 89%) or in combination with surgery (1 case, 11%). Surgery was performed more frequently in early stages (75% of surgical cases were stage I versus 58% of non-surgical cases). There was no difference in age between patients who underwent any treatment and those who did not. Length of follow-up in third primary cancers was 18 months if surgically treated and 8 months if not surgically treated (p < 0.02). At multivariate analysis, the only independent predictor of improved survival was treatment (Hazard ratio (HR) 0.21, 95% CI: 0.07-0.66; p=0.007). Both surgery (HR=0.02; 95% CI: 0.002-0.29) and radiation (HR= 0.04; 95% CI: 0.002-0.54) significantly improved survival. Figure 1
Conclusion:
The overall incidence of third primary lung cancers after a second primary is 10.1%. Surveillance and intervention at early stage results in improved survival.
