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M. de Perrot
Moderator of
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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: 8
- Moderators:M. de Perrot, J. Mitchell
- Coordinates: 9/09/2015, 16:45 - 18:15, 601+603
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ORAL35.01 - Surgical Approach and Disease Recurrence in NSCLC Patients in the MAGRIT Study (ID 318)
16:45 - 16:56 | Author(s): E. Vallieres, M. Zielinski, E. Stoelben, Y. Wu, J. Fu, K. Costas, M. Takenoyama, S. Hazelrigg, J. Wang, C. Chen, M. Higashiyama, D. Harpole, R. Shen, D. Rice, R. Malthaner, W. Lai, G. Leschber, F. Tanaka, S. Yau, N. Mesaros, M. Debois, C. Debruyne, K. Langfeld, P. Therasse, T. Vanakesa
- Abstract
- Presentation
Background:
Surgical resection is the standard treatment for early stage Non-Small Cell Lung Cancer (NSCLC). Anatomical resection with lymphadenectomy is recommended in surgically treated patients with Stage I-IIIA NSCLC. Whether mediastinal lymph node dissection (MLND) or mediastinal lymph node sampling (MLNS) should be performed remains controversial, and there is currently no consensus within the literature. We describe surgical approaches and patterns of disease recurrence in patients enrolled in MAGRIT: a large global randomized study of the MAGE-A3 Cancer Immunotherapeutic versus placebo after complete tumor resection (Phase III trial, MAGRIT, NCT00480025).
Methods:
Study participants were aged ≥18 years, with histologically-proven, MAGE-A3-positive Stage IB, II or IIIA NSCLC (AJCC 6.0) who had undergone R0 anatomic resection of their tumor (lobectomy or pneumonectomy) with mediastinal lymphadenectomy. Patients were randomized to MAGE-A3 or placebo in a 2:1 ratio. A total of 2,272 patients were treated at 556 centers in 34 countries. Because MAGRIT did not demonstrate efficacy overall, and because the number of recurrences in the placebo arm was small (n=271), recurrence patterns by surgical technique are presented in the overall population. An analysis of the placebo population was also conducted as the overall population results are subject to potential bias (a limited treatment effect in small sub-groups cannot be excluded). Cox regression models were used to explore whether lymphadenectomy procedure could be prognostic for disease-free survival (DFS) or overall survival (OS).
Results:
In the total treated population, 76% were men, 52% had squamous cell carcinoma, and 52% received adjuvant chemotherapy. More than half (57%) of patients were enrolled in Europe, with 23% in East Asia, 16% in North America and 4% in other countries. 47% of patients had Stage IB, 6.5% IIA, 30% IIB, and 17% IIIA disease. Lobectomy (including bi- and sleeve-lobectomy) was performed in 85% of patients, and 14% required pneumonectomy. MLNS was performed in 53% and MLND in 47% of patients. MLNS and MLND patients had a similar disease stage distribution. By region, the percentage of patients who underwent MLNS was: 36% in Europe, 65% in East Asia, 94% in North America and 59% in other countries. Among patients who had undergone MLNS or MLND, 37% (n=447/1202) and 36% (379/1067) developed recurrent disease, respectively. Loco-regional recurrence was observed in 40% (177/447) of patients after MLNS and 31% (118/379) after MLND, with distant recurrence observed in 55% (244/447) and 64% (244/379), respectively. There was no difference in the pattern of distant metastases between patients who had MLNS or MLND. Cox modeling showed no impact of the extent of lymphadenectomy on either DFS or OS. A separate analysis of patients in the placebo arm demonstrated similar trends to those of the total study population.
Conclusion:
Lobectomy (including bi- and sleeve-lobectomy) was the most frequently used treatment for patients who participated in the MAGRIT study. Important regional differences in lymphadenectomy were observed. Although the patterns of recurrence varied to some extent with the type of lymphadenectomy, our study did not demonstrate any prognostic impact related to the type of lymphadenectomy performed.
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ORAL35.02 - Wedge Resection vs Segmentectomy for Patients with T1A N0 Non-Small Cell Lung Cancer (ID 3208)
16:56 - 17:07 | Author(s): C.J. Yang, D.Y. Chan, B.C. Gulack, P.J. Speicher, M.W. Onaitis, B.C. Tong, T.A. D'Amico, D. Harpole, M.F. Berry, M.G. Hartwig
- Abstract
- Presentation
Background:
A previous study of the Society of Thoracic Surgeons database showed that non-anatomic resection had lower perioperative morbidity than segmentectomy for non-small cell lung cancer (NSCLC); however the study lacked long term outcomes. We tested the hypothesis that segmentectomy for stage T1a N0 NSCLC had better long-term survival than wedge resection using the U.S. National Cancer Data Base (NCDB).
Methods:
Perioperative outcomes and overall survival (OS) of patients with clinical T1a N0 NSCLC who underwent wedge resection or segmentectomy in the NCDB from 2003-2011 were assessed using propensity-score-matched analysis. Groups were matched for common prognostic covariates (year of diagnosis, race, sex, age, education, income, insurance status, facility type, distance from facility, Charlson/Deyo comorbidity score, tumor size and location). Additional propensity-matched analyses were performed on patients with tumors ≤ 1 cm, patients with no comorbidities, and patients with pathologic T1a pN0 disease.
Results:
Of 40,058 clinical stage T1a N0 NSCLC patients, wedge resection and segmentectomy were performed in 7,517 (19%) and 1,268 (3%) patients, respectively. After matching, all baseline covariates, including comorbidity scores, were balanced between the wedge (n=1,231) and segmentectomy (n=1,231) groups. There were no significant differences between wedge and segmentectomy regarding 30-day mortality (1.6% [n=20] vs 1.5% [n=18], p=0.94). However, wedge was associated with significantly lower long-term survival than segmentectomy (Figure 1); this finding remained consistent even in a propensity-matched analysis of patients with tumors ≤ 1 cm (5 year OS: 56.8% [wedge] vs 78.2% [segmentectomy], log-rank p<0.01). To minimize treatment selection bias due to comorbidities, a propensity-matched analysis was also performed between wedge (n=509) and segmentectomy (n=509) for patients without comorbidities; wedge resection was associated with worse survival when compared with segmentectomy (5 year OS: 65.5% vs 69.5%, log-rank p<0.01). An additional propensity-matched analyses demonstrated that wedge (n=1,099) was associated with worse survival when compared with segmentectomy (n=1,099) for patients with pathologic T1a pN0 disease (5 year OS: 56.8% vs 65.5%, log-rank p<0.01).Figure 1
Conclusion:
In an analysis of a population-based dataset, a large proportion of patients was found to have received wedge resection for stage T1a N0 NSCLC. Segmentectomy for T1a N0 NSCLC had similar 30-day mortality but improved long-term survival when compared to wedge resection, even for patients with very small tumors ≤ 1 cm, for patients with no comorbidities and for patients with pathologic T1a pN0 disease.
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ORAL35.03 - Salvage Surgery for Local Failures after Stereotactic Ablative Radiotherapy for Lung Malignancies (ID 626)
17:07 - 17:18 | Author(s): N. Verstegen, A. Maat, F. Lagerwaard, M. Paul, M. Versteegh, J. Joosten, W. Lastdrager, E. Smit, B. Slotman, J. Nuyttens, S. Senan
- Abstract
- Presentation
Background:
Stereotactic ablative radiotherapy (SABR) is a guideline-recommended therapy for unfit patients with early stage non-small cell lung cancer (NSCLC), and for pulmonary metastases. Experience with SABR for potentially operable patients is also increasing, and salvage surgery may have a role in patients who subsequently develop a local tumor recurrence. However, prior high-dose SABR could theoretically increase local adhesions and compromise wound healing. As the published literature is limited, we describe our experience with salvage surgery in 17 patients who developed a local recurrence after SABR.
Methods:
Patients who underwent surgical salvage for a local recurrence following SABR for pulmonary malignancies were identified from two Dutch institutional databases, as well as cases provided by other Dutch surgeons. Complications were scored using the Dindo-Clavien-classification.
Results:
Seventeen patients who underwent surgery for a local recurrence were identified. Patients were treated with SABR for either primary non-small cell lung cancers (N=9) or solitary metastasis (N=8). Four patients with solitary metastasis underwent surgery twice each for separate recurrences. Median time to local recurrence was 15.6 months. Recurrences were diagnosed with CT- and/or [18]FDG-PET-imaging, with 5 patients also having a pre-surgical pathological diagnosis. Extensive adhesions were observed during 5 resections, requiring conversion from a thoracoscopic procedure to thoracotomy in 3 procedures. Four patients experienced complications post-surgery; grade 2 (N=2) and grade 3a (N=2), respectively. All resected specimens confirmed the presence of viable tumor cells. Median length of hospital stay was 7 days (range 4-15 days) and 30-day mortality was 0%. Lymph node dissection revealed mediastinal metastases in 3 patients, all of whom received adjuvant therapy. Median follow-up after surgery was 41 months and median overall survival was 38 months.
Conclusion:
Experience with 21 surgical procedures for local recurrences post-SABR revealed only two grade IIIa complications, and a 30-day mortality of 0%. Median overall survival after surgery was 38 months. These results suggest that salvage surgery may be safely performed in selected patients following SABR.
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ORAL35.04 - Discussant for ORAL35.01, ORAL35.02, ORAL35.03 (ID 3374)
17:18 - 17:28 | Author(s): D.R. Jones
- Abstract
- Presentation
Abstract not provided
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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, D. Nicastri, T. Bauer, R. Aye, S. Andaz, L. Kohman, B. Sheppard, W. Mayfield, R. Thurer, R. Korst, M. Straznicka, F. Grannis, H.I. Pass, C. Connery, R. Yip, J.P. Smith, D.F. Yankelevitz, C.I. Henschke, N. Altorki
- 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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ORAL35.06 - Limited Resection for Non-Small Cell Lung Cancer Referring to Pathology (ID 216)
17:39 - 17:50 | Author(s): M. Yano, J. Yoshida, Y. Fujii
- Abstract
- Presentation
Background:
Precise preoperative diagnosis of the in-situ or minimally invasive carcinomas may identify patients that can be treated by limited resection. Though some clinical trials of limited resection for lung cancer have started, it will take much time to get results. We have reported a large scale data of limited resection at the previous WCLC meeting. We report here the data of subclass analysis according to the differences of pathology.
Methods:
Data from multiple institutions was collected on 1,737 patients who had undergone limited resection (segmentectomy or wedge resection) for cT1N0M0 non-small cell carcinoma. As 11 patients without pathological diagnosis were excluded, 1726 patients were analyzed to determine the indication of limited resection in pathological differences. Disease free survival (DFS) and recurrence free proportion (RFP) were analyzed.
Results:
Median age was 63 years. Mean maximal diameter of the tumors was 1.4 ± 0.5 cm. DFS and RFP at 5 years were 91.0 % and 93.6 %, respectively. DFSs and RFPs at 5years in pathology were 92.2% and 94.7% in adenocarcinoma (n=1575), 76.3% and 82.4 % in squamous cell carcinoma (SqCC) (n=100), 100% and 100% in carcinoid (n=16), and 73.6% and 75.9 % in others (n=35). Adenocarcinomas were classified using 2 factors, the ratio of consolidation and tumor diameter (C/T) and tumor diameter into 4 groups, group A (C/T ≤ 0.25 and tumor diameter ≤ 2.0 cm), group B (C/T ≤ 0.25 and tumor diameter > 2.0 cm), group C (C/T > 0.25 and tumor diameter ≤ 2.0 cm), and group D (C/T > 0.25 and tumor diameter > 2.0 cm). DFSs and RFPs at 5 years were 96.7% and 98.8% in group A, 100% and 100% in group B, 89.2% and 92.3% in group C, and 76.7% and 77.8% in group D. In all groups of adenocarcinoma, the prognosis in patients who underwent segmentectomy was not superior to wedge resection.The prognosis in both groups A and B was good. These groups seemed to be good candidates of limited resection. The prognosis of group D were not good. Group D seemed not to be a good candidate of limited resection. Prognosis of group C was not bad, however, we could not conclude indication in group C because group C included both part solid tumors and solid tumors. In SqCC, tumor diameter was not prognostic factor and only segmentectomy was favorable prognostic factor (DFSs and RFPs in segmentectomy vs wedge resection: 78.2% and 85.5% vs 65.5% and 65.5%, respectively). In SqCC, there seemed to be indication of limited resection with segmentectomy. In carcinoid, all tumors except one were resected by segmentectomy. Segmentectomy for cT1 carcinoid seemed to be allowed. As prognosis in other pathologies was worse in limited resection, there seemed to be no indication of limited resection.
Conclusion:
Pathological diagnosis was important to determine the indication of limited resection. Measurement of tumor diameter and C/T was useful to determine the indication of limited resection for adenocarcinoma.
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- Abstract
- Presentation
Background:
General anesthesia with intubated ventilation is the standard in thoracic surgery. However, intubated anesthesia is often associated with postoperative discomfort and related complications. Recently, non-intubated anesthesia has emerged as a new option, but has only been assessed by several small-size reports. This study is to evaluate the feasibility and safety of non-incubated video-assissted thoracic surgery (VATS) for NSCLC under combined intravenous anesthesia (spontaneous respiratory status) and to compare it with the endotracheal intubated anesthesia.
Methods:
We retrospectively collected all NSCLC cases who underwent complete VATS lobectomy or segmental resection in our center under either non-intubated or intubated anesthesia. In this study, all non-intubated anesthesia cases were performed under combined intravenous anaesthetics plus analgesics while the intubated anesthesia cases were performed using double lumen endotracheal anesthesia. All procedures were conducted by the same group of surgeons and anesthesiologists from Dec 2011 to Dec 2014. Intra-operative and post-operative outcomes were compared between the two groups.
Results:
A total of 156 non-intubated and 188 intubated cases were included for analyses (Table 1). All non-intubated segment resections and the majority of non-intubated lobectomies were well exposed and were successfully completed; only 9 non-intubated cases planned for lobectomy (9/115, 7.2%) switched to intubated anesthesia. As shown in Table 2, both non-incubated lobectomy and segmentectomy had comparable outcomes with intubated anesthesia, regarding surgical duration, intraoperative blood loss, etc., as well as post-operative complications. Potential advantages were observed when comparing post-operative feeding time, volume of postoperative pleural drainage, and duration of post-operative hospital stay. Table1. Patient Demographics and Baseline Characteristics
Table2. Operative resultsSegmentectomy Lobectomy Intubated Non-intubated P- value Intubated Non-intubated P- value Age (years) 56.5±12.3 51.2±11.8 0.115 58.9±11.7 56.5±10.3 0.179 Sex(male,%) 11(44%) 12(35.3%) 0.087 97（58.4%） 64（55.2%） 0.215 Smoking 5(25) 7（20.6%） 0.161 21（12.7%） 15（13.0%） 0.679 BMI(kg/m2) 22.7±3.1 22.1±2.2 0.412 23.0±3.5 22.6±2.5 0.316 Tumor size 1.2±0.6 1.0±0.4 0.255 2.9±1.5 2.4±1.4 0.207 stage Ⅰ 25 32 108 87 Ⅱ 0 0 29 8 Ⅲ 0 0 26 20 Segmentectomy Lobectomy Intubated Non-intubated P- value Intubated Non-intubated P- value Surgical duration(min) 149.8±38.7 157.4±40.5 0.483 186.5±57.5 186.1±56.6 0.730 Intraoperative blood loss (mL) 83.6±64.1 73.9±56.5 0.076 154.7±258.3 130.8±185.7 0.165 Conversion to intubation 0 9 Postoperative feeding time (h) 13.9±4.6 7.6±3.2 <0.001 12.9±2.2 7.2±2.5 <0.001 Volume of pleural drainage (mL) 694.8±768.2 486.9±313.8 0.038 817.7±727.2 647.7±402.0 0.023 Chest-tube dwell time (days) 4.0±6.5 2.9±2.5 0.148 3.6±2.5 3.1±1.7 0.321 Duration of postoperative hospital stay (days) 9.5±7.4 7.1±3.5 0.041 8.8±4.1 7.6±2.4 0.044 Number of dissected lymph nodes 6.6±4.7 9.5±6.2 0.408 16.5±9.4 17.1±9.0 0.574 Stations of dissected lymph nodes 2.7±3.5 3.5±1.0 0.526 4.5±1.1 4.6±1.0 0.619
Conclusion:
This large comparative study demonstrated that complete VATS for resection of NSCLC under non-intubated anesthesia is feasible and safe. Non-intubated anesthesia is comparable to intubated approaches, and might have advanteages in terms of post-operative rehabilitation. However, the comparison regarding the long-term outcome is warranted.
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ORAL35.08 - Discussant for ORAL35.05, ORAL35.06, ORAL35.07 (ID 3375)
18:01 - 18:11 | Author(s): B. Passlick
- Abstract
- Presentation
Abstract not provided
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Author of
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ORAL 26 - Clinical Trials 2 (ID 127)
- Event: WCLC 2015
- Type: Oral Session
- Track: Thymoma, Mesothelioma and Other Thoracic Malignancies
- Presentations: 1
- Moderators:A. Scherpereel, C. Thomas
- Coordinates: 9/08/2015, 10:45 - 12:15, 702+704+706
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ORAL26.04 - Discussant for ORAL26.01, ORAL26.02, ORAL26.03 (ID 3362)
11:18 - 11:28 | Author(s): M. de Perrot
- Abstract
- Presentation
Abstract not provided
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