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Paul Emile Van Schil
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MS 03 - Best Practice for Small-Sized Early Stage Lung Cancer: Standard Surgery, Limited Resection, SBRT (ID 525)
- Event: WCLC 2017
- Type: Mini Symposium
- Track: Early Stage NSCLC
- Presentations: 1
- Moderators:H.Y. Lee, Masami Sato
- Coordinates: 10/16/2017, 11:00 - 12:30, F203 + F204 (Annex Hall)
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MS 03.03 - Limited vs. Standard Surgical Resection: European Experience (ID 7650)
11:30 - 11:45 | Presenting Author(s): Paul Emile Van Schil
- Abstract
- Presentation
Abstract:
Until the beginning of the new century limited resection for pathologically proven, early-stage lung cancer was not frequently applied in Europe. The main reason for this practice were the results of the randomized phase III trial of the Lung Cancer Study Group published in 1995, showing that for peripheral, clinical T1N0 tumors, lobectomy yields better locoregional control with less recurrences compared to sublobar resection (1). This study was very influential in Europe. A majority of thoracic surgeons adopted the principle that lobectomy was the minimally acceptable lung volume to be resected for patients with an early-stage bronchogenic carcinoma and a low cardiopulmonary risk. Limited resection for lung cancer was only considered for elderly persons, patients with severe chronic obstructive pulmonary disease precluding lobectomy, patients with a high comorbidity score and limited life expectancy due to debilitating disease. Quite a substantial variation in practice is observed, not only within countries but also when comparing North America and Europe. In an interesting analysis of the thoracic surgical databases of the Society of Thoracic Surgeons (STS) and European Society of Thoracic Surgeons (ESTS), some important differences were discovered regarding the daily practice of lung resections performed during the period 2010-2013 (2). Patients in the STS database were more frequently operated by video-assisted thoracic surgery (VATS) compared to the ESTS dataset (63% versus 22%), and were more likely to undergo sublobar resection (43% versus 31%). However, most of the sublobar resections were wedge resections. Anatomical segmentectomies were more frequently performed in the ESTS database than in the STS dataset (7.4% versus 3.9%). For the ESTS patients 30-day mortality of wedge resections was lower compared to the STS data (0.1% versus 1.9%); however, mortality for lobectomy was higher (2.6% versus 1.4%) (2). With the start of European screening studies, although not at the scale of the National Lung Screening Trial, a new clinical problem arose for thoracic surgeons, namely how to deal with small pulmonary nodules and how to limit the false-positive rate? Thoracic surgical issues of screening were addressed in a recent paper by a task force of the ESTS (3). Recommendations were made for implementation of CT screening in Europe focussing on the training of thoracic surgeons, their clinical profile and the use of minimally invasive thoracic surgery. In general, it has been clearly demonstrated that the main goal of surgery for an invasive lung cancer is to obtain a complete resection which is a major prognostic factor. This mostly implies a lobectomy for tumors > 2cm, and at least a lobe-specific systematic nodal dissection as defined in 2005 by a working group of the International Association for the Study of Lung Cancer (IASLC) (4). Unfortunately, quite a lot of resections have to be considered uncertain due to the fact that the required number of lymph nodes, especially mediastinal, have not been removed for further pathological analysis (5). The new adenocarcinoma classification published in 2011 by a common task force of the IASLC , American Thoracic Society (ATS) and European Respiratory Society (ERS) and accumulating phase II data mainly coming from Japan, had important surgical implications (6). As new entities, adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) were introduced and the confusing term bronchioloalveolar cell carcinoma (BAC) is not used anymore. This clearly resulted in a paradigm shift and the concept of sublobar resection was reconsidered for smaller, early-stage lung cancers < 2cm. Anatomical segmentectomy is generally preferred to wide wedge resection because of concerns of local recurrence (7). Regarding the overall oncological results several meta-analyses have been performed. Their results are somewhat conflicting but overall, good long-term results are described for tumors until 2 cm treated by segmentectomy when no lymph node invasion is present. However, for small, early-stage lung cancer no high-level evidence is currently available and the reported evidence should be interpreted with caution. As most studies were not randomized, there was probably a clear selection bias regarding comorbidity, histology and tumor size. Recent guidelines and evidence from a randomized trial indicate that small nodules of ≤10 mm or ≤500 mm[3] that are clearly 100% pure ground-glass opacities (GGO) on chest CT may be considered as AIS or MIA, and hence may be suitable for close follow-up or sublobar resection rather than a formal lobectomy (8). Subcentimeter lung cancers, currently T1a disease, represent a specific subgroup as they comprise the smallest lesions. It should also be emphasized that for subsolid lesions the current tumor size is determined by the solid or invasive part only which represents a major change in the 8[th] TNM (tumor, node, metastasis) classification (9). For thoracic surgeons another important topic is the accuracy of intraoperative frozen section analysis to determine the intraoperative extent of resection. Recent studies show that a concordance rate of more than 80% can be reached between the frozen section and definitive pathological report (10) . However, AIS and MIA are more difficult to diagnose on frozen section and accuracy becomes less for lesions below 10 mm, which represent the main category to be considered for sublobar resection. This implies that a second intervention to perform a completion lobectomy may be indicated in patients with poor prognostic histological features who initially underwent a limited resection for a presumably low-malignant lesion. In conclusion, sublobar resection is currently more often applied in European countries but more high-level evidence on long-term oncological results is required to refine its indications and make this procedure a generally accepted intervention, not only by thoracic surgeons but also by thoracic oncologists and pulmonary physicians. References 1. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995; 60:615-22; discussion 22-3. 2. Seder CW, Salati M, Kozower BD, Wright CD, Falcoz PE, Brunelli A, et al. Variation in Pulmonary Resection Practices Between The Society of Thoracic Surgeons and the European Society of Thoracic Surgeons General Thoracic Surgery Databases. Ann Thorac Surg. 2016; 101:2077-84. 3. Pedersen JH, Rzyman W, Veronesi G, D'Amico TA, Van Schil P, Molins L, et al. Recommendations from the European Society of Thoracic Surgeons (ESTS) regarding computed tomography screening for lung cancer in Europe. Eur J Cardiothorac Surg. 2017; 51:411-20. 4. Rami-Porta R, Wittekind C, Goldstraw P, International Association for the Study of Lung Cancer Staging C. Complete resection in lung cancer surgery: proposed definition. Lung Cancer. 2005; 49:25-33. 5. Verhagen AF, Schoenmakers MC, Barendregt W, Smit H, van Boven WJ, Looijen M, et al. Completeness of lung cancer surgery: is mediastinal dissection common practice? Eur J Cardiothorac Surg. 2012; 41:834-8. 6. Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, et al. International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011; 6:244-85. 7. Sihoe AD, Van Schil P. Non-small cell lung cancer: when to offer sublobar resection. Lung Cancer. 2014; 86:115-20. 8. van Klaveren RJ, Oudkerk M, Prokop M, Scholten ET, Nackaerts K, Vernhout R, et al. Management of lung nodules detected by volume CT scanning. N Engl J Med. 2009; 361:2221-9. 9. Travis WD, Asamura H, Bankier AA, Beasley MB, Detterbeck F, Flieder DB, et al. The IASLC Lung Cancer Staging Project: Proposals for Coding T Categories for Subsolid Nodules and Assessment of Tumor Size in Part-Solid Tumors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol. 2016; 11:1204-23. 10. Yeh YC, Nitadori J, Kadota K, Yoshizawa A, Rekhtman N, Moreira AL, et al. Using frozen section to identify histological patterns in stage I lung adenocarcinoma of
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P3.13 - Radiology/Staging/Screening (ID 729)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.13-008 - Lung Cancer Associated with Cystic Airspaces: Clinical, Imaging, Histopathological and Molecular Correlation (ID 8202)
09:30 - 09:30 | Author(s): Paul Emile Van Schil
- Abstract
Background:
“Lung cancer associated with cystic airspaces” is a rare radiological entity that is becoming more frequently encountered on imaging studies and has been gaining more attention since the widespread use of CT for lung cancer screening. The goal of this retrospective study is to investigate and correlate clinical, imaging, histopathological and molecular findings in patients presenting with this type of lung cancer.
Method:
Between January 2014 and April 2017, 13 patients presented at the Multidisciplinary Thoracic Oncology Tumour Board with this rare entity. Clinical, histopathological and molecular data were collected and imaging studies were reviewed for the presence of emphysema, size, morphologic classification and findings on [18]F-FDG-PET.
Result:
Median age at the time of diagnosis was 69 years (53-86 years) with a male/female ratio of 8:5. Ten out of 13 patients were smokers. Eleven patients (11/13) had no previous oncological history. Two patients with previous oncological history both had a history of head-and-neck and stage IA lung cancer. Imaging findings showed emphysema in 7 cases. Four patients had type I, 1 patient type II, 4 type III and 4 type IV morphology. Median diameter for the type I, II, III and IV lesions was 20 mm (17-43), 20 mm, 60 mm (25-67) and 46 mm (37-77) respectively. Lesions were more frequent in the right upper (4/13) and lower lobe (4/13). FDG-PET-scan was available in 11 patients and showed high uptake in all patients who presented with a solid aspect of the associated tumour. Four patients (4/13) presented with stage IV at diagnosis. Other stages varied: IA (4/10), IB (1/10), IIA (1/10), IIIA (2/10) and IIIB (1/10). Adenocarcinoma was found in 11 patients (11/13) and squamous cell carcinoma in 2 (2/13). Molecular genotyping for EGFR, ALK and ROS-1 was available in 10 patients (10/13). None of the patients showed positivity for ALK-immunohistochemistry. A single patient showed an exon-18 mutation in the EGFR gene. One patient showed a translocation at the 6q22 breakpoint of the ROS-1 gene. In one patient, a p.Gly469Ala B-RAF mutation was present. Two patients showed a mutation in the exon 2 of the KRAS gene (exon2 c/35G>C;p.Gly 12Ala and c/35G>T;p.Gly 12Val).
Conclusion:
In this series, 5 out of 10 patients with a “lung cancer associated with cystic airspaces” showed a molecular alteration. This suggests that targeted molecular profiling is mandatory in this subgroup. Larger series are needed to confirm these findings.
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PL 02 - Presidential Symposium including Top 3 Abstracts and James Cox Lectureship Award Presentation (ID 585)
- Event: WCLC 2017
- Type: Plenary Session
- Track: Early Stage NSCLC
- Presentations: 1
- Moderators:Hisao Asamura, Keunchil Park
- Coordinates: 10/17/2017, 08:15 - 09:45, Plenary Hall (Exhibit Hall D)
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PL 02.06 - The IASLC Lung Cancer Staging Project: Analysis of Resection Margin Status and Proposals for R Status Descriptors for Non-Small Cell Lung Cancer (ID 10325)
09:00 - 09:10 | Author(s): Paul Emile Van Schil
- Abstract
- Presentation
Background:
The residual tumor (R) classification describes the tumor status after treatment. It reflects the effectiveness of treatment, has prognostic impact and may affect further treatment. We analyzed existing and potential R status criteria, including the proposed IASLC definition for “uncertain” resection margin status (2005), from data collected for the IASLC Lung Cancer Staging Project.
Method:
This analysis is based on 14,712 patients undergoing NCSLC surgery, for whom full R status and survival data were available. R status criteria and the following data were evaluated: number of N2 stations explored; lobe-specific systematic lymph node dissection (SLND); extra-capsular extension (ECE); status of the highest station; bronchial carcinoma in situ (cis) at bronchial resection margin (BRM); pleural lavage cytology (PLC). Revised categories of R0, R(un), R1 and R2 were designated and tested for survival impact.
Result:
There were 14,293 R0, 263 R1 and 156 R2 cases, with median survival not reached, 33 and 29 months (p<0.0001). R status correlated with T and N stages (p<0.0001). Greater or equal to 3 N2 stations were explored for 9,290 cases (63%) and lobe-specific SLND in 6,619 (45%), with positive associations for increasing pN2 stage (p<0.0001). ECE was recorded in 61 (20%) of 304 N+ cases evaluated. The highest station was positive in 942 (6.4%) cases. PLC was positive in 59 (3.6%) of 1,646 cases and there was BRM cis in 13 cases. After reassignment according to the IASLC proposed definition, there were 6,103 R0 cases, 8,203 R(un), 250 R1 and 156 R2. Figure 1
Conclusion:
These data confirm the proposed criteria for Uncertain R status, R(un), with a prognosis stratifying between R0 and R1. Further detailed prospective data collection is required to characterize fully the prognostic impact of these criteria. Detailed evaluation of R status is of particular importance in the design and analyses of clinical trials of adjuvant therapies.
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