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L. Spaggiari



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    P1.03 - Poster Session with Presenters Present (ID 455)

    • Event: WCLC 2016
    • Type: Poster Presenters Present
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      P1.03-037 - Radio-Guided Localization and Resection of Small or Ill-Defined Pulmonary Lesions (ID 6224)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Screening programs increased identification of small or indistinct pulmonary lesions which are difficult to localize. We report our experience in their preoperative localization by radiotracer and resection.

      Methods:
      Patients with pulmonary nodule of subsolid morphology or smaller than 1 cm and/or deeper 1 cm below the visceral pleura underwent computer-tomography (CT)-guided injection of radiotracer technetium99m macroaggregates in vicinity of the lesion. During surgery, a handheld gamma probe was used to detect hot spot where radioactive was localized and this area was resected.

      Results:
      From November 2007 to December 2013, 112 patients (58 men; median age 62 years) underwent preoperative radiotracer injection with a successful marking in all patients. Complications included 33 pneumothoraces (29.4%) (one requiring chest tube placement), 23 (20.5%) parenchymal hemorrhage soffusions, and 1 (0.9%) allergic reaction to contrast medium. In all cases, except for 2, gamma probe revealed pulmonary lesion. Overall, 123 pulmonary nodules were localized and resected. Mean distance from the pleura was 12 mm (range, 0 to 39 mm). Pulmonary resection was performed by thoracoscopy in 70 (62.5%) cases, thoracotomy in 36 (32.1%), and converted thoracoscopy to thoracotomy in 6 (5.4%). Mean nodule size was 9 mm (range, 3-24 mm). Histology showed 14 (11.4%) benign lesions and 109 (88.6%) malignant lesions (85 primary lung cancers, and 24 metastases).

      Conclusion:
      Radiotracer localization of pulmonary lesions is a simple and feasible procedure with a high rate of success. Optimal candidates are patients with suspicious nodules detected by screening or incidental CT due to high rate of nonsolid morphology and small size.

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    P1.06 - Poster Session with Presenters Present (ID 458)

    • Event: WCLC 2016
    • Type: Poster Presenters Present
    • Track: Advanced NSCLC
    • Presentations: 1
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      P1.06-037 - Non-Small Cell Lung Cancer Invading the Diaphragm: Outcome and Prognostic Factors (ID 6240)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Diaphragmatic infiltration by non-small cell lung cancer (NSCLC) is a rare occurrence and surgical results are unclear. We assessed our experience with en bloc resection of lung cancer invading the diaphragm analyzing prognostic factors and long-term outcomes.

      Methods:
      We analyzed a prospective database of patients with NSCLC infiltrating the diaphragm who underwent en bloc resection. Univariate and multivariate analysis was performed to identify prognostic factors. Survival was calculated by the Kaplan-Meier method.

      Results:
      Nineteen patients (14 men, mean age 64 years) were identified. Surgery included nine pneumonectomies, eight lobectomies, and two segmentectomies. A partial diaphragmatic infiltration was observed in 10 patients (52.6%), and full-depth invasion in nine (47.4%). Diaphragmatic reconstruction was done primarily in 13 patients (68.4%), and by prosthetic material in six (31.6%). Pathological nodal status included nine N0, four N1, and six N2. Median hospital stay was seven days (range, 4-36 days). Postoperative mortality was 5.2% (1/19). Two patients (10.5%) had major complications (acute respiratory distress syndrome and bleeding), and 10 minor complications, arrhythmia in seven (36.8%), and pneumonia in three (15.8%). Five-year survival was 29.8%. Mean survival and disease-free survival were 30 months (range, 1-164 months) and 20 months (range, 1-83 months), respectively. Factors adversely affecting survival were diaphragmatic infiltration (50% superficial vs 0% full-depth infiltration; log-rank test, P=0.04), and nodal involvement (43% N0 vs 20% N1-2; log-rank test, P=0.03).

      Conclusion:
      Resection of NSCLC invading the diaphragm is technically feasible and could be a valid therapeutic option with acceptable morbidity and mortality and long-term survival in highly selected patients.

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    P1.08 - Poster Session with Presenters Present (ID 460)

    • Event: WCLC 2016
    • Type: Poster Presenters Present
    • Track: Surgery
    • Presentations: 6
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      P1.08-023 - Analysis of Prognostic Factors and Long-Term Results of Primary Pulmonary Pleomorphic Carcinoma (ID 6191)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Pulmonary pleomorphic carcinoma (PPC) is a rare neoplasm and factors affecting survival after pulmonary resection, as well as its clinical and pathologic characteristics, are still unknown. For a better understanding we reviewed our large experience with these patients.

      Methods:
      Records of patients 134 patients (108 men, median age: 65 years) with diagnosis of PPC operated on between January 1999 and May 2015 were retrospectively analyzed from a prospective database; survival was calculated by using Kaplan-Meier method.

      Results:
      86 patients (64.1%) were smokers. Median tumor size was 4.8 cm (range, 0.6 to 23 cm). Initial histological diagnosis was NSCLC in 88 cases, adenocarcinoma in 21, pleomorphic tumor in 13, and no diagnosis in 12. 62 patients (46.0%) received a platinum based induction chemotherapy. Surgery included lobectomy in 87 patients (65%), pneumonectomy in 27 (20.1%), wedge resection in 12 (8.9%), and segmentectomy in 8 (6%). Four patients (3%) had an incomplete resection. Postoperative staging included 45 stage I (33.6%), 47 stage II (35.1%), and 42 stage III (31.3%). 64 patients (47.7%) received adjuvant treatment. Five-year overall survival and disease-free survival were 36.6% and 35.7%, respectively (median, 28 and 18 months, respectively). Recurrences occurred in 76 patients (56.7%) most of them at distant sites (47/76 [61.8%]). Factors associated with increased survival included no smoke habit (p=.02), no induction therapy (p=.04), right side disease (p=.01); pathological stage I (p=.001), no metastatic lymph nodes (p=.001), and adjuvant treatment (p=.003). At multivariate analysis, pN0, pstage I, and adjuvant treatment were independent prognostic factors (p=.002, 95%CI: 1.54-6.43; p=.003, 95%CI: 1.23-7.32, p=.001, 95%CI: 1.26-4.72, respectively).

      Conclusion:
      PPC are aggressive tumors usually presented as a large lesion in males. Preoperative diagnosis remains difficult. Prognosis is poor, and distant recurrence rate is high. Long-term survival can be achieved in early stage disease and by an appropriate adjuvant therapy.

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      P1.08-024 - Surgical Outcomes and Prognostic Factors in the Treatment of Adenosquamous Carcinoma of the Lung (ID 6200)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Adenosquamous carcinoma (ASC) of the lung is a rare pulmonary disease with poor prognosis. We evaluated the prognostic factors and outcome of this tumour.

      Methods:
      Records of patients undergoing pulmonary resection for ASC between 1998 through 2015 were reviewed using a prospective database. 124 patients (91 men, median age, 67 years) with ASC were operated on.

      Results:
      Surgical procedures included 3 exploratory thoracotomies, 6 bilobectomies, 76 lobectomies, 19 pneumonectomies, 12 wedges resections, and 8 segmentectomies. 38 patients (30.6%) received induction therapy (IT). 30-day mortality rate was 4.0% (n=5). Morbidity occurred in 29 (23.4%) patients; six patients (4.8%) had major complications: 2 bronchopleural fistulae, 3 haemothoraces, and 1 chylothorax. 23 patients (18.6%) had early minor complications: 14 (11.2%) atrial fibrillation, and 9 (7.2%) pulmonary (5 prolonged air leaks, 2 atelectasis and 2 subcutaneous emphysema). Overall 5-year survival rate and disease-free survival was 27.4% and 36.0%, respectively. 47 (37.9%) patients relapsed: 14 had brain metastases, 10 bone, 8 lung, and 15 at other sites. Patients <65 years (p=0.01), with early pathological stage (p=0.0001), without nodal involvement (p=0.001) had the best prognosis. At multivariate analysis, age <65 years (p=0.009 [95% CI 2.53-8.29]), early pathological stage (p=0.04 [95% CI 1.66-7.88]), and no nodal involvement (p=0.03 [95% CI 2.01-6.42]) influenced survival.

      Conclusion:
      ASCs are uncommon and extremely aggressive tumours. Young patients (<65 years) with early stage tumour and no nodal involvement have the best prognosis.

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      P1.08-031 - Non-Small Cell Lung Cancer in Patients Aged 40 Years or Younger: Clinical, Surgical, and Long-Term Outcomes (ID 6201)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Non-small cell lung cancer (NSCLC) in young patients is uncommon and has clinical characteristics different from that in older patients. We report the outcomes of a single institutional experience in the treatment of young patients with NSCLC.

      Methods:
      Records of patients with NSCLC operated on between 1998 and 2013 were retrospectively analyzed from a prospective database.We identify two groups: G1 with patients resected with intention-to-treat, and G2 who underwent only diagnostic surgical procedures due to advanced NSCLC. There were 47 patients (27 in G1, 13 men; and 20 in G2, 10 men) with a median age of 37 years in G1 (range, 16-40) and 38 years in G2 (range, 24-40).Survival was calculated by using Kaplan-Meier method.

      Results:
      Induction treatment (IT) was administered in 17 patients in G1; no patient in G2 received IT. In G1, surgery included 3 wedges, 1 segmentectomy, 18 lobectomies, 5 pneumonectomies; in G2, surgery included 3 explorative thoracotomies, 8 nodal biopsies, and 6 pleural biopsies. Histological diagnosis was adenocarcinoma in all the patients. Median tumor size was 22 mm (range, 5-125) in G1. Postoperative staging in G1 included 11 stage I, 4 stage II, and 12 stage III; all patients in G2 were stage IV and none was alive at 5-year. Five-year overall survival and disease-free survival in G1 were 55% and 51%, respectively (median, 30 and 16 months, respectively). In G1 recurrence occurred in 12 patients most of them at extra-thoracic sites (9/12 [75%]). Factors associated with increased survival in G1 included IT (p=.0002) and right side disease (p=.01). At multivariate analysis in G1, IT [p=.03 (95% CI: 0.67-0.89)] influenced long-term survival.

      Conclusion:
      In our experience, all young patients had adenocarcinoma with a predominance of women. Patients receiving pulmonary resection for curative intent had the best prognosis and among these, those receiving IT had the best long-term survival.

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      P1.08-080 - Bilobectomy for Lung Cancer: Analysis of Indications, Postoperative Results and Long-term Outcomes (ID 6220)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Bilobectomy for lung cancer is considered a high risk procedure for the increased postoperative complication rate and the negative impact on survival. We analyzed the safety and the oncologic results of this procedure.

      Methods:
      We retrospectively reviewed patients who underwent bilobectomy for lung cancer between October 1998 and December 2015. Age, gender, bilobectomy type and indication, complications, pathology, stage, and survival were analyzed.

      Results:
      Bilobectomy was performed on 166 patients (122 men; mean age, 62 years. There were 87 upper-middle and 79 middle-lower bilobectomies. Indications were tumor extending across the fissure in 37 (22.3%) patients, endobronchial tumor in 44 (26.5%), extrinsic tumor or nodal invasion of bronchus intermedius in 70 (42.2%), and vascular invasion in 15 (10%). An extended resection was performed in 25 patients (15.1%). Induction therapy was performed in 47 patients (28.3%). Thirty-day mortality was 1.2% (n=2). Overall morbidity was 43.4%. Mean chest tube persistence was 7 days (range, 6-46 days). Overall 5-year survival was 58%. Significance differences in survival were observed among different stages (stage I, 70%; stage II, 55%; stage III, 40%; p=.0003) and the N status (N0, 69%; N1, 56%; N2, 40%; p=.0005). Extended procedure (p=.0003) and superior bilobectomy (p=.0008) adversely influenced survival. Multivariate analysis demonstrated that an extended resection (p=.01), an advanced N disease (p=.02), and an upper-mild lobectomy (p=.02) adversely affected prognosis.

      Conclusion:
      Bilobectomy is associated with a low mortality and an increased morbidity. Survival relates to disease stage and N factor. Optimal prognosis is obtained in patients with lower-middle lobectomy without extension of the resection.

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      P1.08-081 - Resection of T4 Non-Small Cell Lung Cancer Invading the Spine (ID 6229)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Surgical treatment of non-small cell lung cancer (NSCLC) invading the spine is controversial. We evaluated surgical results and long-term outcome of patients with T4 NSCLC who underwent vertebral resection (VR) due to the infiltration by lung tumor.

      Methods:
      Retrospective analysis of 16 consecutive patients undergoing VR for NSCLC invading the spine between 1998 and 2015 was performed. Ten patients (62.5%) received induction therapy. Vertebral resection was divided into 5 types; type 1: only transverse process; type 2A: transverse process with a portion of the vertebral body; type 2B: a portion of vertebral body without transverse process; type 3, hemivertebrectomy; type 4: total vertebrectomy.

      Results:
      There were 15 men and one woman with a median age of 62 years (range, 41-80). Ten patients had induction therapy. Vertebral resection included 3 type 1 resection, 6 type 2A, 4 type 2B, 2 type 3, and 1 type 4. Pneumonectomy was performed in 3 patients, lobectomy in 7, segmentectomy in 3 and wedge in 3. Complete resection was achieved in 14 patients (87.5%). Surgical nodal status was N0 in 11 patients, N1 in 2, and N2 in 3, each. There were no postoperative mortality. Morbidity was observed in 7 patients (43.7%), including 1 (6.2%) neurologic complication, 3 (18.7%) ARDS, and 2 (12.5%) cardiac . Seven patients (43.7%) are alive without disease after e mean follow up of 44.4 months. The 1- and 5-year predicted survivals were 79% and 40.4%, respectively. Patients without nodal involvement had the best prognosis (56.3% vs 0%; p=0.0009). Induction therapy did not influence survival.

      Conclusion:
      Resection of NSCLC with vertebrectomy is technically demanding and is associated with acceptable morbidity. However, an encouraging long-term survival observed in this series suggest that resection could be a valid option in selected patients with vertebral invasion by NSCLC.

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      P1.08-082 - Surgical Techniques and Long-Term Results of the Pulmonary Artery Reconstruction in Patients with Lung Cancer (ID 6216)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Pulmonary artery (PA) reconstruction for lung cancer is technically feasible with low morbidity and mortality. We assessed our experience with partial or circumferential resection of PA during lung resection.

      Methods:
      Between 1998 and 2015, we performed PA angioplasty in 150 patients with lung cancer. Seventy-five patients received induction chemotherapy (IC). Partial PA resection was performed in 146 cases. PA reconstruction was performed by running suture in 113 and using a pericardial patch in 33. A circumferential PA resection was performed in 4 patients and reconstruction was made in PTFE and by a custom-made bovine pericardial conduit each. Bronchial sleeve resection was associated in 56 cases. Thirty-two patients had stage I disease, 43 stage II, 51 IIIA, and 17 IIIB. Seven patients had a complete response after IC.

      Results:
      Thirty-day mortality was 3.3% (n=5); two of these patients had a massive hemoptysis leading to death; 33 patients had pulmonary complications, 28 cardiac, 17 air leaks. Overall 5- and 10-year survival was 50% and 39%, respectively. Five- and 10-year survival for stages I and II versus stage III was, respectively, 66% versus 32% and 56% versus 20% (p<.0001). Five-year survival was 61% for N0 and N1 nodal involvement versus 28% for N2, respectively; 10-year survival was 45% versus 28% (p=.001). IC did not influence survival. Multivariate analysis yielded advanced stage, N2 status, and squamous cell carcinoma as negative prognostic factors.

      Conclusion:
      PA reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option to pneumonectomy for patients with lung cancer.

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    P3.03 - Poster Session with Presenters Present (ID 473)

    • Event: WCLC 2016
    • Type: Poster Presenters Present
    • Track: Mesothelioma/Thymic Malignancies/Esophageal Cancer/Other Thoracic Malignancies
    • Presentations: 1
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      P3.03-059 - Diaphragmatic and Pericardial Reconstruction by Heterologous Pericardial Patch after Extrapleural Pneumonectomy for Mesothelioma (ID 6208)

      14:30 - 14:30  |  Author(s): L. Spaggiari

      • Abstract

      Background:
      Extrapleural pneumonectomy (EPP) with resection of pericardium and diaphragm offers acceptable therapeutic results in patients with mesothelioma. We analyzed efficacy of biological bovine pericardial patch (BPP) versus artificial materials (Marlex/Goretex, Vicryl) for diaphragmatic and pericardial reconstruction after EPP.

      Methods:
      We reviewed 61 patients operated on for EPP after induction chemotherapy (01/2013-05/2015). We distinguished two groups: Group 1, in which BPP 12x25 cm patch was used, and Group 2, in which artificial materials were used. Technically, diaphragmatic patch was sewn circumferentially to diaphragmatic remnant posteriorly, chest wall anteriorly, and hiatal musculature medially by separated stitches. Pericardial patch was sewn circumferentially to pericardial remnant by separated stitches.

      Results:
      Group 1, 27 patients (44.3%), right side in 14 (51.8%) and left in 13 (48.2%): BPP was used for pericardium and diaphragm in 21, only pericardium in 4, and only diaphragm in 2. Group 2, 34 patients (53.7%), right in 15 (44.1%) and left in 19 (55.9%): Marlex/Goretex for diaphragm and Vicryl for pericardium in 28, Goretex for diaphragm and Vicryl for pericardium in 2, only Goretex or Vicryl for both in 1 and 3 patients, respectively. In Group 1, a single BPP was used for pericardial and double patch for diaphragm. Two patients (7.4%) in Group 1 and 2 (5.9%) in Group 2 (p=0.56), all on the left side, had early dehiscence of diaphragmatic prosthesis requiring re-intervention. No early complication for pericardial patch. At follow-up (Group 1: median 14.7 mo., range 0-72; Group 2, median 14.2 mo., range 0-76), no late complications were observed for pericardial/diaphragmatic prostheses.

      Conclusion:
      Reconstruction of pericardium and diaphragm using BPP, is safe, easy, and may be considered a viable alternative to synthetic materials. Attention should be used in fixing the BPP on the left side (costo-phrenic angle) to avoid BPP dehiscence and visceral herniation.