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E. Lim
Moderator of
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OA01 - Risk Assessment and Follow up in Surgical Patients (ID 371)
- Event: WCLC 2016
- Type: Oral Session
- Track: Surgery
- Presentations: 8
- Moderators:W. Zhong, E. Lim
- Coordinates: 12/05/2016, 11:00 - 12:30, Schubert 2
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OA01.01 - Institutional-Based Differences in the Quality and Outcomes of US Lung Cancer Resections (ID 6124)
11:00 - 11:10 | Author(s): R.U. Osarogiagbon, M.P. Smeltzer, C.C. Lin, A. Jemal
- Abstract
- Presentation
Background:
Institutional-level differences in NSCLC survival are associated with differences in the quality of oncologic care. We examined stage-stratified and overall survival of patients in different categories of US Commission-on-Cancer (CoC)-accredited institutions, to quantify inter-institutional differences in survival-impactful quality measures and estimate their relative survival impact, in order to identify the most impactful targets for improvement efforts.
Methods:
National Cancer Data Base (NCDB) institutions were grouped according to CoC category into: Community Cancer Program (CCP), Comprehensive Community Cancer Program (CCCP), Teaching Research Program (TRP), and NCI Program/Network (NCIP). Resections for stage I-IIIA NSCLC in the National Cancer Data Base from 2004-2013 performed within each category of institution were examined for specific quality parameters. Survival was estimated by the Kaplan-Meier method and compared with the log-rank test.
Results:
Of 125,408 NSCLC eligible patients, 8% received surgery at CCP, 52% at CCCP, 28% at TRP, and 12% at NCIP. The pNX rate was 8%, 5.7%, 5.5%, and 3.2% respectively (p<.0001); the median (IQR) nodal count for pN0/1 patients was 6 (7), 7 (7), 8 (9), and 10 (10) respectively, and the CoC quality criterion attainment rate (examination of >10 nodes for stage I/II patents) was 25.5%, 30.2%, 38.7%, and 51.4% (p<.0001). The nodal upstaging rate from clinical (c) N0 to pathologic N-positive was 10.4%, 10.8%, 10.7% and 13.1% (p<.0001); for cN1, nodal upstaging rate was 9.4%, 10.5%, 10.4% and 15.5% (p<.0001). There was no significant inter-institutional difference in 5-year OS for stage I/II patients with pNX resections: 0.47 v 0.50 v 0.51 v 0.54 (log-rank p=.27), whereas stage I/II patients with resections meeting or failing the CoC quality standard had persistent inter-institutional survival differences. For those with <10 nodes, 5-year survival was 0.59 v 0.63 v 0.65 v 0.69 (log-rank p<.0001) and for those with >10 nodes, it was 0.62 v 0.64 v 0.67 v 0.69 (log-rank p<.0001).
Conclusion:
Striking differences in the quality and accuracy of NSCLC pathologic nodal staging exist between the different categories of CoC-accredited facilities. Institutions with higher quality staging have significantly better stage-stratified OS. This inter-institutional survival difference disappears in the patients without examination of any lymph nodes, who arguably have similarly bad quality pathologic nodal staging. However, adjustment for other measures of pathologic nodal staging quality failed to eliminate the inter-institutional survival disparity. Further investigation of inter-institutional practice differences is needed to understand the institutional-level difference in survival after lung cancer surgery.
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OA01.02 - A Lung Cancer Surgical Mortality Risk-Prediction Algorithm to Inform Lung Cancer Screening Shared Decision-Making (ID 4601)
11:10 - 11:20 | Author(s): J.A. Roth, S.D. Ramsey
- Abstract
- Presentation
Background:
Low-dose computed tomography lung cancer screening has been demonstrated to increase detection of cases at an early-stage and reduce lung cancer mortality (vs. x-ray or no screening). However, screening benefits are greatly reduced in persons who are poor candidates for curative intent surgery in the event of screen-detected early-stage disease. To date, no practical tools have been developed to assess potential suitability for surgical treatment at the time of screening shared decision-making. The objective of this study was to use readily available socio-demographic and medical history variables to develop a prediction model that estimates the risk of 30-day mortality following surgical treatment for early-stage non-small cell lung cancer (NSCLC).
Methods:
We used logistic regression to develop a risk-prediction model for 30-day mortality following surgical treatment for Stage I/II NSCLC in patients age 65 to 79 using SEER-Medicare linked databases (2007-2012). Additionally, all patients had at least 1 year of Medicare enrollment prior to NSCLC diagnosis and received initial surgical treatment within 6 months of diagnosis. We developed the model with a training sample of 1,571 surgical cases and conducted internal validation exercises with a sample 4,632 independent surgical cases. Models included age, sex, race, country of birth, urban-rural status, and comorbidities in the year prior to NSCLC diagnosis. The Hosmer-Lemeshow test (by decile) and area under the receiver-operating characteristic curve (AUC) were assessed as measures of model calibration and discrimination, respectively.
Results:
Within the full sample of 6,203 cases, 201 deaths were identified within 30 days of surgical treatment (3.2% of sample). In the training and internal validation sets, the AUC was 0.831 and 0.734, respectively. The observed risk of 30-day mortality was 9.3-fold greater in the highest decile of predicted risk (8.3%) vs. the lowest decile (0.7%), and the Hosmer-Lemeshow test indicated satisfactory model fit (p=0.92). The model had similar performance in women, men, whites, and non-whites; and also had similar calibration and discrimination for 60- and 90-day mortality.
Conclusion:
Our risk-prediction model has good ability to identify patients at increased risk of mortality following surgical treatment for early-stage NSCLC, and pending additional development and validation, can potentially be applied in clinic to inform lung cancer screening shared decision-making with minimal time or resource impacts.
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OA01.03 - Impact of Increasing Age on Cause-Specific Mortality and Morbidity in Stage I NSCLC Patients: A Competing Risk Analysis (ID 4952)
11:20 - 11:30 | Author(s): T. Eguchi, S. Bains, K.S. Tan, M.S. Bains, R.J. Downey, J. Huang, J.M. Isbell, B.J. Park, V. Rusch, D. Jones, P.S. Adusumilli
- Abstract
- Presentation
Background:
At the time of diagnosis, two-thirds of patients with lung cancer are ≥65 years of age with significant comorbidities. We sought to determine the short- and long-term cancer- and noncancer-specific mortality and morbidity in patients who underwent resection for stage I non-small cell lung cancer (NSCLC).
Methods:
Of 5371 consecutive patients who had undergone curative-intent resection of primary lung cancer (2000–2011), 2186 patients with pStage I NSCLC were included in the analysis. All preoperative clinical variables known to affect outcomes were considered, including, Charlson comorbidity index, predicted postoperative (ppo) diffusion capacity of the lung for carbon monoxide (DLCO), and ppo–forced expiratory volume in 1 second (FEV1). Association between factors and cause-specific mortality was performed using competing risks approach.
Results:
Of 2186 patients, 1532 patients (70.1%) were ≥65 years of age, including 638 patients (29.2%) ≥75 years of age. In patients ≥65 years of age, for up to 2.5 years after resection, noncancer-specific CID was higher than lung cancer–specific CID, the higher noncancer-specific early-phase mortality was enhanced in patients ≥75 years of age compared with 65-74 years of age (Figure 1a). Multivariable analyses adjusted by age, sex, smoking status, comorbidities, tumor size, and surgical procedures showed that low ppoDLCO was an independent predictor for severe morbidity (p<0.001), 1-year mortality (p<0.001), and noncancer-specific mortality (p<0.001), whereas low ppoFEV1 for lung cancer–specific mortality (p=0.002). PpoDLCO can be used for estimation of 5-year cumulative incidence of noncancer death (Figure 1b, right, red curve) because of its linear relation, whereas ppoFEV1 for lung cancer-specific death (Figure 1b, left, black curve).
Conclusion:
In patients undergoing curative-intent resection of stage I NSCLC, noncancer-specific mortality is a significant competing event, with increasing impact as patient age increases. Figure 1
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OA01.04 - Discussant for OA01.01, OA01.02, OA01.03 (ID 6961)
11:30 - 11:45 | Author(s): A. Brunelli
- Abstract
- Presentation
Abstract not provided
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OA01.05 - The Impact of Lung Age on Postoperative Complications in Patients with Lung Cancer Combined with Pulmonary Fibrosis and Emphysema (ID 4319)
11:45 - 11:55 | Author(s): M. Naito, Y. Kondo, H. Yamazaki, H. Nakashima, Y. Matsui, K. Shiomi, Y. Satoh
- Abstract
- Presentation
Background:
Postoperative complications after pulmonary resection may cause morbidities such as prolonged hospitalization. Recently, combined pulmonary fibrosis and emphysema (CPFE) have reportedly been linked to a high risk for postoperative complications following lung cancer surgery. Moreover, some studies have claimed that lung age (LA) is associated with postoperative complications. Here we clarify the relationship between LA and postoperative complications in lung cancer patients with CPFE.
Methods:
Among a total of 1166 consecutive patients who underwent curative resection for lung cancer from January 2004 to April 2016 at the Kitasato University Hospital, Japan, a dataset of 36 patients with CPFE was retrospectively analyzed. Lungs with CPFE were defined based on preoperative chest computed tomography (CT) findings. LA was determined using the methods advocated by the Japanese Respiratory Society. The difference between “real age” (RA) and LA was calculated as “RA−LA,” and patients were classified into three groups: group A, RA−LA > 0 (n = 10); group B, −15 ≤ RA−LA ≤ 0 (n = 13); group C, RA−LA < −15 (n = 13).
Results:
The average age was 70 (males, 69.1; females, 73.2) years. Thirty two patients were male and four were female. Almost all patients were ex- or current smokers. The average postoperative hospital stay was 16 (range, 7–56) days. There were no significant differences in age, gender, smoking history, and postoperative hospital stay among the three groups. The surgical procedures were lobectomy (n = 29), segmentectomy (n = 2), and wedge resection (n = 5). Histologically, the tumors were squamous cell carcinoma (n = 22), adenocarcinoma (n = 9), and other types (n = 4). Postoperative complications were arrhythmia (4 cases), hypertension (4 cases), air leakage (3 cases), pneumonia (5 cases), hypoxemia (3 cases), and others (5 cases). There were no significant differences in postoperative complications among the groups (p = 0.69). However, cardiovascular complications in group C were significantly higher than those in the other groups (p = 0.008). There were 26 patients with postoperative acute exacerbation, but there were no significant differences among the groups.
Conclusion:
LA accurately predicted postoperative cardiovascular complications in lung cancer patients with CPFE.
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OA01.06 - Early Post-Operative Ambulation after Thoracic Surgery - The WAVE Experience (ID 5194)
11:55 - 12:05 | Author(s): S.J. Khandhar, C.M. Powers, C. Schatz, C. Rosner, A. Mahajan, P. Kiernan
- Abstract
- Presentation
Background:
The occurrence of minimally invasive thoracic surgery interventions has grown steadily since the early 1990s, yet practice patterns for peri-operative management of these patients has lagged behind technical progress. Our thoracic program has created WAVE (Walking After VATS Experiment) which focuses on a multidisciplinary approach to early ambulation after thoracic surgery. A report from our first 3 years of data (July 2010 - July 2013) was presented at the 2013 IASLC meeting in Sydney, Australia. In response to the positive comments, we have continued our endeavor and in addition, investigated 30 day outcomes and length of stay for the homogeneous subset of anatomic lobectomy.
Methods:
Data was collected from a single surgeon at a single center and includes all consecutive thoracic surgical patients recovered through the WAVE program from July 2010 - July 2016. We excluded patients undergoing tracheostomy, endoscopic only procedures, and mediastinoscopy. Data was collected prospectively and analyzed retrospectively.
Results:
From July 2010 - July 2016, 1152 patients were included for analysis. Within the 6 year period, 798/1152 patients (69%) walked any distance within one hour of extubation, 945/1152 patients (82%) walked 250 feet at any time while in the PACU, 721/1152 patients (63%) successfully walked the targeted distance of 250 feet within one hour of extubation and only 37/1152 patients (3%) were unable to ambulate at all in the PACU. There were no adverse events. The subset of anatomic lobectomies included 290 patients of which 197/290 patients (68%) walked any distance within one hour of extubation, 239/290 patients (82%) successfully walked 250 feet at any time while in the PACU, 175/290 patients (60%) achieved the target distance of 250 feet within one hour of extubation and only 5/290 patients (1.7%) were unable to ambulate at all in the PACU. The rate of 30 day post-operative complications compares favorably with the literature and are as follows: 4.1% atrial arrhythmia, 1.0% pneumonia, 6.6% air leak > 5 days, 0.7% DVT, 0.3% acute renal failure, 0.3% pulmonary embolism, 0% stroke, 0% myocardial infarction, 4.8% readmission and 0% mortality. Mean length of hospital stay was 1.6 days with a median of 1 day.
Conclusion:
Our “WAVE” experience reveals that aggressive early ambulation is effective in reducing post-operative complications and shortening length of stay. The platform is simple, reproducible and feasible for any thoracic surgical program. Key features for successful implementation include patient and family engagement, a multi-disciplinary team and administrative support.
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OA01.07 - Alternative Follow-Up Methods Based on Recurrence Patterns after Surgery for Non-Small Cell Lung Cancer (ID 4323)
12:05 - 12:15 | Author(s): K. Watanabe, K. Sakamaki, T. Nishii, A. Gorai, T. Yamamoto, T. Nagashima, K. Ando, Y. Ishikawa, T. Woo, H. Adachi, Y. Kumakiri, T. Maehara, H. Nakayama, M. Masuda
- Abstract
- Presentation
Background:
There is no consensus for the appropriate follow-up of patients after complete resection of non-small cell lung cancer (NSCLC). Our study was designed to visually represent postoperative recurrence patterns for NSCLC with the use of event dynamics and to optimize postoperative follow-up schedule based on risk factors for recurrence.
Methods:
A total of 829 patients with NSCLC who underwent complete pulmonary resection were studied. There were 538 men and 291 women with a mean age of 69.2 at the time of operation. The majority of the patients had adenocarcinoma (62.5%), underwent lobectomy (85.9%) and pathological stage IA (47.3%). Event dynamics, based on the hazard rate, were evaluated and only first events (distant metastases or local recurrence) were considered. The effects of sex, histological type and pathological stage were studied.
Results:
On non-parametric kernel smoothing, the resulting hazard rate curves indicated that the recurrence risk pattern was definitely correlated to sex, with a sharp peak in the first year for men and broad peak during the 2 to 3 years for women. This finding was also confirmed by the analysis of histological type. Although pathological stage IA patients lacked such a large peak in both sexes during the follow-up period, gender difference was shown in pathological stage IB and stage IIA to IIIB patients. Figure 1
Conclusion:
The use of recurrence dynamics allows the times of peak recurrence to be visualized. The hazard rate and the peak times of recurrence differed considerably between genders in pathological stage IB or higher. Postoperative follow-up methods should be based on currently recommended follow-up guidelines, give adequate consideration to the recurrence patterns, and be modified individually.
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OA01.08 - Discussant for OA01.05, OA01.06, OA01.07 (ID 7007)
12:15 - 12:30 | Author(s): T. Klikovits
- Abstract
- Presentation
Abstract not provided
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Author of
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P2.04 - Poster Session with Presenters Present (ID 466)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Mesothelioma/Thymic Malignancies/Esophageal Cancer/Other Thoracic Malignancies
- Presentations: 1
- Moderators:
- Coordinates: 12/06/2016, 14:30 - 15:45, Hall B (Poster Area)
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P2.04-008 - Diagnostic Performance of PET-CT for Anterior Mediastinal Lesions - The DECiMaL Study (ID 5709)
14:30 - 14:30 | Author(s): E. Lim
- Abstract
Background:
The diagnostic performance of 18-FDG positron emission tomography (PET) on the ability to differentiate malignant from benign lesions in the anterior mediastinum is not defined and therefore the clinical utility is unknown. The aim of this study is to collate multi-institutional data to determine the value by defining diagnostic performance of FDG PET/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass.
Methods:
DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK sites. We included all patients undergoing surgery (diagnostic or therapeutic) who presented with an anterior mediastinal mass and underwent PET/CT as part of their diagnostic work-up. PET/CT was considered positive for any reported PET avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria. Diagnostic test performance was expressed as sensitivity, specificity, positive and negative predicted values with corresponding 95% confidence intervals.
Results:
Between January 2002 and June 2015 a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. All patients had pre-operative PET CT and the histology was thymic hyperplasia in 10 patients (8%), thymic cyst in 8 (6%) and no malignancy in 15 (11%) and these were classified as “benign”. Histology was thymoma in 55 patients (41%), other malignancies in 38 (28%) and thymic carcinoma in 8 (6%), and these were classified as “malignant”. The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (37 to 78). The positive and negative predictive values were 90% (83 to 95) and 42% (26 to 61%).
Conclusion:
The results of our study suggests reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign disease of the anterior mediastinum.
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PC01 - Pro Con Session: Invasive Mediastinal Staging for N2 Disease (ID 323)
- Event: WCLC 2016
- Type: Pro Con
- Track: Radiology/Staging/Screening
- Presentations: 1
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PC01.03 - No Invasive Staging Nor Restaging (ID 6595)
15:00 - 15:20 | Author(s): E. Lim
- Abstract
- Presentation
Abstract not provided
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