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R. Shah
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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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MINI19.04 - Relationship Between Adequacy of Intra-Operative Lymph Node Sampling During Surgical Resection of NSCLC and Survival (ID 1239)
17:00 - 17:05 | Author(s): R. Shah
- Abstract
- Presentation
Background:
Intra-operative lymph node sampling during lung cancer resection is a key surgical performance measure. It informs prognosis, treatment selection for adjuvant chemotherapy and surveillance programs following treatment. This study aimed to analyse the relationship between adequacy of intra-operative lymph node sampling and survival at a large thoracic oncology centre in the United Kingdom.
Methods:
A retrospective review of pathological reports for all patients undergoing lung cancer resections at the University Hospital South Manchester from 01/01/2011 to 31/12/2013 was undertaken. Intra-operative lymph node sampling was assessed for adequacy against standards set out by the IASLC Staging Manual in Thoracic Oncology. Survival data was obtained through national death registry data and provided a minimum of twelve months follow-up for all patients at the time of analysis in January 2015.
Results:
A total of 987 patients underwent surgical resection for NSCLC in the study period. Overall, there was no significant difference in survival between patients with adequate intra-operative lymph nodal sampling and those with inadequate sampling (log rank p=0.66). Median survival times were not estimable for pN0 and pN1 patients as only a small proportion died. However there was a significant difference in the median survival time of pN2 patients according to whether the intra-operative lymph node sampling was adequate or inadequate (Figure 1). Figure 1Figure 2
Conclusion:
Few patients have died in the pN0 and pN1 categories limiting interpretation. As the data matures we expect to see a survival difference according to adequacy of intra-operative nodal sampling that is supported by the differential median survival data of pN2 patients according to nodal adequacy. The data supports that the survival difference is due to inaccurate staging, inadequate resection (R1) and inappropriate omission of adjuvant.
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MINI 20 - Surgery (ID 137)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 1
- Moderators:G. Veronesi, R. Flores
- Coordinates: 9/08/2015, 16:45 - 18:15, 201+203
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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): R. Shah
- 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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P1.02 - Poster Session/ Treatment of Localized Disease – NSCLC (ID 209)
- Event: WCLC 2015
- Type: Poster
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 2
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.02-015 - Pathological Variables in Resected NSCLC Tumours: Predictors of Survival? (ID 1249)
09:30 - 09:30 | Author(s): R. Shah
- Abstract
Background:
Lung cancer recurrence following treatment with radical intent remains a significant problem for thoracic oncology specialists. Identifying novel predictors of recurrence may inform future management strategies including indications for adjuvant chemotherapy and the intensity of surveillance programs. This study used survival analysis, as a surrogate marker of disease recurrence, to assess if pathological variables in resected NSCLC could predict survival.
Methods:
We retrospectively reviewed all pathological reports for patients undergoing surgical resection for NSCLC at the University Hospital South Manchester from 01/01/2011 to 31/12/2013. The following variables were analysed in univariate and multivariate (cox regression) analysis: extra-capsular nodal disease, lymphovascular invasion, pleural invasion (PL0-3), residual disease (R0 vs R1), grade of differentiation, pT-stage and pN-stage. Survival was provided by national death registry data.
Results:
Extra-capsular nodal disease (p=<0.001, Figure 1), Lymphovascular invasion (p=<0.001), pleural invasion (PL3, p=<0.001), residual disease (R1, p=<0.001), pT-stage (pT4, pT3, pT2b, p=<0.001) and pN-stage (pN2, p<0.001) were all associated with significantly lower survival on univariate analysis. A multivariate cox regrerssion model was run with all significant univariate variables. The least significant variable was removed and this was repeated until only those significant at the 0.05 level remained (Table 1). Figure 1 Table 1Variables Hazard ratio (95% CI) p-value Extracapsular spread Yes vs no 1.47 (1.00, 2.17) 0.049 Pleural invasion PL1 vs PL0 1.37 (0.97, 1.93) 0.002 PL2 vs PL0 1.08 (0.63, 1.85) PL3 vs PL0 2.42 (1.53, 3.83) T stage 1b vs 1a 1.04 (0.61, 1.79) 0.006 2a vs 1a 1.30 (0.81, 2.08) 2b vs 1a 1.63 (0.95, 2.81) 3 vs 1a 2.17 (1.28, 3.66) 4 vs 1a 2.99 (1.46, 6.11) N stage N1 vs N0 1.30 (0.91, 1.87) 0.005 N2 vs N0 1.80 (1.26, 2.58)
Conclusion:
Pathological T-stage and N-stage are well established predictors of prognosis and inform decisions around adjuvant chemotherapy. Extra-capsular nodal disease and pleural invasion (PL3) are additional independent predictors of survival. The presence of these pathological findings in resected NSCLC may help in the decision making around adjuvant therapy, the appropriate intensity of surveillance programs and the design or stratification of adjuvant therapy trials.
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P1.02-020 - Physiological Assessment in Thoracic Surgery for High Risk Patients with Lung Cancer; How Do International Guidelines Compare? (ID 1461)
09:30 - 09:30 | Author(s): R. Shah
- Abstract
Background:
Surgical resection is the best curative option in patients with appropriately staged lung cancer. Physiological assessment is vital in selecting patients for surgical resection with particular attention to risk of mortality and morbidity with the planned surgery. This is most crucial in patients deemed high-risk. Physiological parameters employed include spirometry (FEV1%), diffusion (DLCO%), Shuttle walks, Cardiopulmonary Exercise Testing (VO2Max absolute value and %) as well as post-operative predicted values for all of these tests using segment counting to discriminate depending on the planned surgery. However, three major international guidelines exist which advocate different approaches to assessing this patient group (BTS, ERS, ACCP). We aim to assess how these guidelines compare to one another and our local practice in informing decision-making.
Methods:
Patients with operable thoracic malignancy who were candidates for surgery and had CPET were eligible for inclusion. We retrospectively analysed all patients who underwent CPET at the University Hospital of South Manchester, a tertiary Thoracic Oncology Centre, between 01/01/2013 and 31/12/2013. Physiology reports, clinical correspondence and survival databases were analysed.
Results:
96 patients fulfilled the inclusion criteria. 3 were excluded due to no available pulmonary function data. A further 17 were excluded as they were denied surgery for non-physiology reasons (patient declined surgery, metastatic disease discovered before, small cell histology, adequate resection margin impossible, severe comorbidities). The remaining 74 patients were included in the final analysis. 62/74(84%) underwent surgery (12 pneumonectomy, 3 bilobectomy, 33 lobectomy, 4 segmentectomy, 6 wedge resection, 4 futile thoracotomy due to finding unexpected advanced disease) The overall breakdown of risk classification of patients using the 3 guidelines was as follows. BTS: low-risk 27/74 (36%), medium-risk 31/74 (42%), high-risk 16/74 (22%). ACCP: low-risk 19/74 (26%), medium-risk 52/74 (70%), high-risk 3/74 (4%). ERS: low-risk 47/74 (63%), medium-risk 16/74 (22%), high-risk 11/74 (15%). Of the patients BTS guidelines classed high-risk, we operated on 8/16 (1 pneumonectomy, 3 lobectomy, 1 segmentectomy, 2 wedge resection, 1 futile thoracotomy) with 100% survival at 90 days. We did not operate on any of the 3 patients classed high-risk by ACCP guidelines. Of the patients ERS guidelines classed high-risk, we operated on 5/11 (1 pneumonectomy, 1 bilobectomy, 2 lobectomy, 1 segmentectomy) with 100% survival at 90 days. Of those classed high-risk by ACCP 2/3 would be high-risk by BTS guidelines and of those classed high risk by BTS 2/16 would be high-risk by ACCP guidelines. Of those classed high-risk by ERS 8/11 would be high-risk by BTS guidelines and of those classed high-risk by BTS 2/16 would be high-risk by ERS guidelines.
Conclusion:
From our results a lack of concordance between the three guidelines in classification of high-risk is evident. Also, with the exception of the ACCP guidelines, our local practice has shown that patients deemed high-risk for surgery were operated on (upto and including pneumonectomy) with no cases of 90-day mortality. With this in mind an appraisal of current guidelines is indicated as well as a more consistent approach worldwide to ensure that no potentially fit patients are excluded from surgical resection of lung cancer.
