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Y.M. Shim
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ES 05 - Surgical Skills (ID 514)
- Event: WCLC 2017
- Type: Educational Session
- Track: Surgery
- Presentations: 6
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ES 05.01 - Strategy for N2 NSCLC (ID 7599)
15:45 - 16:00 | Presenting Author(s): Joe B Putnam
- Abstract
- Presentation
Abstract:
The clinical stage is the clinician’s best and final estimate of the extent of the disease prior to the initiation of definitive therapy. As such, the clinical stage creates the foundation for all cancer treatment recommendations. Patients with lung cancer and metastasis to the ipsilateral mediastinal and/or subcarinal lymph node(s) (LN) have a nodal descriptor of N2. Such N2 metastasis reflects a biologically advanced disease with spread beyond the primary tumor in the lung itself. In the forthcoming eighth addition of the TNM classification for lung cancer, the current (7th edition) nodal descriptors and location for both clinical and pathological nodal status (N0 to N3) adequately predict prognosis. Although for lung cancer, nodal status is based on the anatomic location of the involved node, and not on the number of metastatic lymph nodes, future staging models could assess the number of involved nodes and location.(1) Determination of metastases to mediastinal lymph nodes constitutes a critical point in staging and treatment recommendations. Computed tomography and FDG-PET + CT scans are helpful to guide treatment decisions; invasive staging is still recommended to confirm mediastinal nodal involvement. (2) (3) (4) Invasive staging for diagnosis of N2 LN includes cervical mediastinoscopy (CME) or mediastinotomy (Chamberlain’s procedure), endoscopic bronchial ultrasound (EBUS), or esophageal ultrasound (EUS). The use of CME regardless of radiographic evidence of nodal involvement (“routine mediastinoscopy”) is not a cost effective approach, and adds little to the accuracy of staging in patients with an adequate noninvasive preoperative evaluation. (5) Endobronchial ultrasound combined with mediastinoscopy (2;4) can be effective. VATS techniques can evaluate enlarged level 5 or 6 lymph nodes, and as well, enlarged level 8 or 9 or low level 7 lymph nodes. Esophageal ultrasound (EUS) guided aspiration can be used for level 7 and AP window LN Patients with clinically early stage NSCLC (cStage I or II), who have complete resection (R0) and subsequently identified microscopic or occult N2 metastases, represent a biologically favorable subset with improved survival following adjuvant therapy. Surgery alone for cStage IIIA (N2) lung cancer is infrequently performed however, selected patients may benefit from a multidisciplinary approach to treatment which include local and systemic components. (6). Definitive concurrent chemoradiotherapy is commonly recommended for N2 disease given the identifiable locally advanced NSCLC and likely occult systemic metastases. . Induction chemoradiotherapy has been evaluated for treatment of clinical stage IIIA (N2) NSCLC. (7;8) In these two phase III trials, surgery did not provide an overall survival benefit; however, in an exploratory analysis, induction therapy followed by lobectomy had improved survival. Multidisciplinary team discussions for individual patients are essential to optimize benefits of treatment. In selected resectable IIIA NSCLC patients, induction chemoradiotherapy followed by resection is an alternative treatment to chemoradiotherapy alone. (6) The Society of Thoracic Surgery National General Thoracic Surgery Database evaluated identified only 3319 patient with cStage IIIA (N2) NSCLC who underwent resection between 2002 and 2012. (9) Patients were >65 years of age and only 46% were treated with induction therapy. 93% had FDG PET scans, and 51% were coded as having undergone invasive mediastinal staging. Nodal over-staging occurred in 43% of patients. Lobectomy was the most common procedure (69%). The unadjusted 5 year survival following induction therapy was 35%. Selection of patients for resection may depend on the number of ipsilateral LN stations involved, and the ability of induction therapy to create a clinical post-induction yN0 nodal status. Endobronchial ultrasound (EBUS) is used initially to diagnosis ipsilateral LN metastasis and exclude contralateral metastasis. Following induction therapy, repeat EBUS may confirm yN0 status of the previously involved LN, and be validated by cervical mediastinoscopy. The surgeon must answer this question for each patient with N2 disease: When does resection following induction therapy consistently provide better survival than definitive C+RT? Large pragmatic clinical trials may facilitate new knowledge in this area. Regardless of approach (open or minimally invasive techniques), a mediastinal lymph node dissection is recommended. A recent study utilizing the National Cancer Database from the American College of Surgeons Commission on Cancer, demonstrated that with Stage I NSCLC better survival was associated with resecting 10 or more lymph nodes to optimally confirm stage I status.(10) Although this is not a therapeutic intervention, it emphasizes the need for mediastinal lymph node dissection to ensure accuracy by decreasing variability in the mediastinal dissection, and optimizing the accuracy of the pathologic staging. Reference List (1) Asamura H, Chansky K, Crowley J, Goldstraw P, Rusch VW, Vansteenkiste JF, et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming 8th Edition of the TNM Classification for Lung Cancer. J Thorac Oncol 2015 Dec;10(12):1675-84. (2) Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013 May;143(5:Suppl):211S-50S. (3) Stamatis G. Staging of lung cancer: the role of noninvasive, minimally invasive and invasive techniques. European Respiratory Journal 2015 Aug;46(2):521-31. (4) Detterbeck FC, Postmus PE, Tanoue LT. The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013 May;143(5:Suppl):191S-210S. (5) Fernandez FG, Kozower BD, Crabtree TD, Force SD, Lau C, Pickens A, et al. Utility of mediastinoscopy in clinical stage I lung cancers at risk for occult mediastinal nodal metastases. J Thorac Cardiovasc Surg 2015;149(1):35-41. (6) Ramnath N, Dilling TJ, Harris LJ, Kim AW, Michaud GC, Balekian AA, et al. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013 May;143(5:Suppl):314S-40S. (7) Albain KS, Swann RS, Rusch VW, Turrisi AT, III, Shepherd FA, Smith C, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet 2009 Aug 1;374(9687):379-86. (8) van Meerbeeck JP, Kramer GW, Van Schil PE, Legrand C, Smit EF, Schramel F, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small-cell lung cancer. J Natl Cancer Inst 2007 Mar 21;99(6):442-50. (9) Boffa D, Fernandez FG, Kim S, Kosinski A, Onaitis MW, Cowper P, et al. Surgically Managed Clinical Stage IIIA-Clinical N2 Lung Cancer in The Society of Thoracic Surgeons Database. Ann Thorac Surg 2017 Aug;104(2):395-403. (10) Samayoa AX, Pezzi TA, Pezzi CM, Greer GE, Asai M, Kulkarni N, et al. Rationale for a Minimum Number of Lymph Nodes Removed with Non-Small Cell Lung Cancer Resection: Correlating the Number of Nodes Removed with Survival in 98,970 Patients. Annals of Surgical Oncology , 2016 23, Suppl 5:1005-1011.
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ES 05.02 - Superior Sulcus Tumor (ID 7600)
16:00 - 16:15 | Presenting Author(s): Valerie W Rusch
- Abstract
- Presentation
Abstract:
The unique location of Pancoast tumors makes complete resection challenging and usually includes the upper lobe, involved chest wall with or without the subclavian vessels, portions of the vertebral column and T1 nerve root, and dorsal sympathetic chain. Several approaches are used depending on tumor location. Posterior Approach The patient is positioned in the lateral decubitus position, rotated slightly anteriorly to expose the paravertebral region. The chest is explored via a posterolateral thoracotomy in the 5[th] intercostal space. If the tumor appears resectable, the incision is extended to the base of the neck posteriorly and around the anterior border of the scapula anteriorly. The scapula is elevated with an internal mammary retractor. The scalene muscles are detached from the first and second ribs. Involved ribs are divided anteriorly. Dissection is carried along the superior border of the first rib in the subperiosteal plane. The erector spinae muscles are retracted off the thoracic spine to expose the costovertebral gutter. The transverse processes and rib heads are resected en-bloc at the lateral border of the facet joint. The chest wall is retracted anteriorly, and the intercostal nerves ligated before division to prevent cerebrospinal fluid leak. Thoracic nerve roots below T1 are transected without neurologic sequelae. Since the T1 nerve root provides motor innervation to the hand, it is ligated only in cases of tumor invasion. Division of the C8 nerve root will result in permanent arm/hand paralysis. The detached chest wall is allowed to fall into the chest cavity and an upper lobectomy and lymph node dissection is completed. Reconstruction of the chest wall is necessary when the defect is larger than the first three ribs and can be performed with a 2 mm thick PTFE patch. Tumors Involving the Vertebral Bodies and Epidural Region Vertebral body invasion by Pancoast tumors no longer a contraindication to surgical resection because of contemporary spine instrumentation. With multimodality therapy, T4 lesions with vertebral body or epidural extension can be resected with curative intent. We use spine MRI to divide tumors into four classes, A-D, based on the degree of spinal column and neural tube involvement. Class A and B tumors are T3 lesions amenable to complete R0 resection. Class C and D tumors are T4 lesions not amenable to en-bloc resection but can still be completely resected. Class C tumors extend into the neural foramina with limited or no vertebral body involvement but have unilateral epidural compression. Class D tumors involve the vertebral column, either the vertebral body and/or lamina with or without epidural compression. Class A, B and some class C tumors are approached through a posterolateral thoracotomy. A high-speed drill is used to remove involved vertebral bodies. The posterior longitudinal ligament is removed and provides a margin on the anterior dura. The disc spaces adjacent to the tumor are exenterated in order to aid in spinal fixation. Anterior reconstruction alone is sufficient for resections of 1-2 vertebral bodies. Autologous bone from the iliac crest or non-diseased rib, allograft fibula, methymethacrylate with Steinman pins, or corpectomy cages can all be used for reconstruction. Patients requiring any degree of epidural decompression in the upper thoracic spine undergo combined posterior and anterior approach. Long segment posterolateral spinal instrumentation and fusion avoids the development of debilitating deformity. Class D tumors involving the posterior elements (spinous process, laminae, and pedicles) are also resected through a combined posterior/anterior approach. Patients are first positioned prone and a posterior midline incision made. The involved areas of the spinous process, laminae, and pedicles are resected. Epidural tumor is dissected off the dura and a multilevel resection of affected nerve roots done. Posterior fixation is accomplished in order to maintain coronal and sagittal stability. Muscle flap rotation by a plastic surgeon can be done to reduce the risk of skin breakdown and infection of the spine hardware. The incision is then closed, the patient turned to the lateral decubitus position, a posterolateral thoracotomy performed, and the lung and chest wall resection completed. Anterior Approaches Pancoast tumors involving the subclavian vessels are best approached anteriorly, using the anterior transcervical approach originally described by Dartevelle and modified by others. The patient is positioned supine with the neck hyperextended and the head turned to the opposite side of the lesion. An inverted L-shaped incision is carried down the anterior border of the sternocleidomastoid muscle and extended below the clavicle to the level of the second intercostal space, then turned horizontally following a parallel line below the clavicle to the deltopectoral groove. The sternal attachment of the sternocleidomastoid is divided along with the insertion of the pectoralis major. The scalene fat pad and lymph nodes are excised. If the tumor is resectable, the upper part of the manubrium is divided and the incision carried into the second intercostal space via an L-shaped incision. The involved section of the subclavian vein is resected but not reconstructed. The anterior scalene muscle is divided at its insertion onto the first rib. The phrenic nerve is preserved. The subclavian artery is resected and reconstructed with a 8 or 10 mm PTFE graft. The middle scalene muscle is detached from the first rib to expose the C8 and T1 nerve roots. The ipsilateral prevertebral muscles and paravertebral sympathetic chain and stellate ganglion are resected off the anterior aspect of the vertebral bodies of C7 and T1. TheT1 nerve root is commonly divided just lateral to the T1 intervertebral foramen. The anterolateral arch of the first rib is divided at the costochondral junction and the second rib is divided at its midpoint. The third rib is dissected on its superior border in a posterior direction toward the costovertebral angle and the first two through three ribs are disarticulated from the transverse processes. From this cavity, an upper lobectomy is completed. If exposure for the lobectomy and chest wall resection is inadequate, the anterior incision is closed, the patient turned into the lateral decubitus position and the rest of the resection performed via a posterolateral thoracotomy
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ES 05.03 - Management of Early Stage Lung Cancer (ID 7601)
16:15 - 16:30 | Presenting Author(s): Norihiko Ikeda | Author(s): T. Ohira, Naohiro Kajiwara
- Abstract
- Presentation
Abstract:
In recent years, the number of early stage lung cancers has enormously increased mainly due to frequent use of chest CT in routine practice or screening purpose. Both curability and non-inavasiveness are required especially for such early disease. Increased number of VATS lobectomy and sublobar resection for selected patients is the international trend in such situation. Diagnosis: Retrospective data revealed that the sensitivity of conventional bronchoscopic examination for peripheral cancer < 2cm is only 34%. The combination of Virtual bronchoscopic navigation and EBUS guide-sheath has demonstrated the improved sensitivity, thus this new combination strategy should be necessary for differential diagnosis of small cancers detected by chest CT[1)]. Surgical procedure: A total of 38000 lung cancers were resected in Japan in 2013 and 70% of surgeries were video-assisted[2)]. Segmentectomy has been performed intentionally mainly for lung cancer 2cm or less in diameter. Several comparative studies between lobectomy and segmentectomy for tumors < 2cm showed no significant difference in survival[3)]. Recently, segmentectomy is selected based on the size and high resolution CT (HRCT) findings of the tumor. The proportion of consolidation diameter to tumor diameter correlates with biological malignancy and the establishment of robust image criteria predicting non-invasive cancer is desirable to find candidates for segmentectomy. The Japan Clinical Oncology Group (JCOG) conducted a prospective study to recognize the relationship between HRCT finding and pathological non-invasiveness in clicical stage IA cancer (JCOG0201)[4)]. This study revealed that adenocarcinoma <2.0 cm with <0.25 consolidation to the maximum tumor diameter showed pathological non-invasiveness in 98.7% and this criterion could be used to predict early lung cancer preoperatively[5)]. Based on the result of JCOG0201, two prospective studies were performed and finished recruitment, phase II trial of wide wedge resection for radiological non-invasive adenocarcinoma (tumor diameter 2cm or less and consolidationratio<0.25) (JCOG0804) and randomised phase III trial for radiological invasive adenocarcinoma (tumor diameter 2cm or less and consolidation ratio>0.25) to evaluate non-inferiority in OS of segmentectomy compared to lobectomy (JCOG0802)[6)]. The indication of segmentectomy will be demonstrated by the results of these studies. Clinical research: PET-CT has been routinely used for clinical staging and the standardized uptake value (SUV) of the main tumor is recognized to be as a predictor of the clinicopathological characteristics and prognosis. Analyses of 610 resected stage IA adecocarcinoma showed that maxSUV and GGO ratio cutoffs to predict recurrence were 2.9 and 25%, respectively. They were also related to nodal metastasis, histological tumor invasiveness and recurrence. The 5-year RFS of cases with maxSUV <2.9 (n=456) was 95%, while cases with maxSUV>2.9 (n=154), 72% (p<0.001)[7)]. Our result showed that maxSUV cutoff of possibility for recurrence was 2.6 in adenocarcinoma, which was also related to nodal metastasis and histological tumor invasiveness. The 3-year relapse-free survival was 99%/78% (maxSUV lower/higher than 2.6) and following multivariate analysis, pathological nodal status and SUVmax were found to be independent predictive factors for relapse-free survival. Surgical management of early stage lung cancer should be selected based on the tumor size and consolidation ratio on HRCT. The results of RCTs will demonstrate the indication of sublobar resection in near future. Further analysis is encouraged for the evaluation of biological aggressiveness in each case[8)]. References Asano F, Shinagawa N, Ishida T, et al. Virtual bronchoscopic navigation combined with ultrathin bronchoscopy. A randomized clinical trial. Am J Respir Crit Care Med 2013; 188:327-333 Committee for Scientific Affairs The Japanese Association for Thoracic Surgery, Thoracic and cardiovascular surgery in Japan during 2013 : Annual report by the Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg.2015;63:670-701. Okada M, Koike T, Higashiyama M, et al. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. J Thorac Cardiovasc Surg. 2006; 132: 769-775 Suzuki K, Koike T, Asakawa T, et al.: A prospective radiological study of thin-section computed tomography to predict pathological noninvasiveness in peripheral clinical IA lung cancer (Japan Clinical Oncology Group 0201). J Thorac Oncol 2011;6:751-756 Asamura H, Hishida T, Suzuki K, et al. Radiographically determined noninvasive adenocarcinoma of the lung: Survival outcomes of Japan Clinical Oncology Group 0201 J Thorac Cardiovasc Surg 2013;146:24-30 Nakamura K, Saji H, Nakajima R, et.al. A Phase III Randomized Trial of Lobectomy Versus Limited Resection for Small-sized Peripheral Non-small Cell Lung Cancer (JCOG0802/WJOG4607L) Jpn J Clin Oncol 2010;40:271–274 Uehara H, Tsutani Y, Okumura S, et al. Prognostic Role of Positron Emission Tomographyand High-Resolution Computed Tomography in Clinical Stage IA Lung Adenocarcinoma Ann Thorac Surg 2013;96:1958–1965 Tsutani Y, Miyata Y, Nakayama H,et al.. Sublobar resection for lung adenocarcinoma meeting node-negative criteria on preoperative imaging. The Annals of thoracic surgery. 2014;97:1701-1707
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ES 05.04 - Minimally Invasive Surgery for Lung Cancer, including Robotics (ID 7602)
16:30 - 16:45 | Presenting Author(s): Giulia Veronesi
- Abstract
- Presentation
Abstract:
During the last two-three decades the surgical approach for the treatment of lung cancer had significantly changed. Compared to the traditional posterolateral thoracothomy the introduction and diffusion of a more conservative muscle sparing lateral thoracothomy has shown a first change to lesser trauma for patients, but only with the advent of mininvasive surgery we have witnessed the real change in terms of improving the quality of life and reducing perioperative pain (1). According to some review articles (2) not only perioperative outcome was improved with MIS compared to thoracotomy but also advantages in terms of oncological outcome have been reported even if it is possible that some selection bias could have played a role in the review results. Many studies have confirmed the benefits for the patients treated with MIS compared to open including reduced pain, complications, blood trasfusions and postoperative stay, and improved quality of life, ahestetic and functional results (3). Different technique have been described with different number of small incisions but all have in common that no rib spreading is performed and the dissection is done looking at the monitor. The most common videothoracoscopic techniques are: a. the Cophenaghen approach with an anterior incision of 4-6 cm in the IV intercostal space and 2 more trocars is characterised by an anterior to posterior approach to the mediastinum. This technique has been described by Heine Hansen and by Mc Kenna (4); b. the posterior approach of the Edinburgh school has been described by William Walker and reproduces the posterior approach to the hylum similar to that of the posterolateral thoracothomy (5). In this technique the utility incision is posterior, in the auscultatory triangle and usually two or three additional ports are used; c. the single port described by Gaetano Rocco and Diego Gonzales Riva with a single incision of 4-8 cm usually in the V intercostal space through which the tools and the camera are inserted (6). More recently new approaches has been described including the microlobectomy and the subxhifoid approach. Both techniques are aimed to reduce the pain of the intercostal nerve injury by avoiding the utility incision in the intercostal space. Despite all these advantages for the patients the manual vats has been embraced by a minority of thoracic surgeons and the diffusion has been very slow mainly due to technical difficulties, like the limited visual information, limited freedom of movement, unstable camera platform and poor ergonomics, and doubts on oncological radicality. To overcome videothoracoscopic technical limitations, the micromechanic and robotic sophisticated technology has been introduced with the robotic surgical systems. Natural movements of the surgeon’s hands are translated into precise instrument movements inside the patient with tremor filtration. Three dimensional view offers a visual magnification that compensate the absence of haptic feedback. The robotic surgical system is the result of a long process of development aimed at producing a natural extension of the surgeon’s eyes and hands via the intermediation of a computer. In this way, the ease of movement obtained with open surgery is summated with the advantages of the minimally invasive technique. Since 2002, when the first robotic system for surgery was introduced, robot-assisted thoracic surgery (RATS) has been adopted by an increasing number of centres around the world, and today is used in ~10% of lobectomies in the US (7, 8). Two different techniques have been described in robotic thoracic surgery, the complete portal robotic lobectomy or segmentectomy (CPRL or CPRS) maynly used by surgeons of North American, characterised by 3-4 arms technique, CO2 insufflation, posterior to anterior hilar dissection and a specimen extraction incision at the end of the procedure (9); and the Robotic Assisted Thoracoscopic Surgery (RATS), characterized by a 4-arms approach, a utility incision since the beginning, no routine CO2 insufflation and anterior to posterior hilar dissection (10). To date, no randomized trials have reported comparative data on RATS vs. VATS or thoracotomy for lung cancer. Retrospective analysis comparing RATS vs. thoracotomy have revealed advantages for the RATS approach, especially shorter hospital stays and a lower complication rate but when compared to VATS, RATS produces similar or only slightly better results, the two being minimally invasive techniques with no need for rib separation. A few studies have reported RATS to be safer than VATS, with less conversions for bleeding, less complications and lengths of stay; in others, it was associated with lower postoperative consumption of pain killers and quicker return of patients to normal activity. In addition, lymph-node upstaging has been shown to be higher with RATS than with VATS, with a similar rate as thoracotomy. The main disadvantage of RATS is the higher costs of instrumentation and surgical kits. Nevertheless, the future will probably see reductions in the costs of robotics and improvements in the instrumentation, integration with 3D imaging to improve virtual reality, and more patients benefitting from minimally invasive procedures for lung malignancies. References 1. Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients a case-control study. Ann Thorac Surg 1999;68:194-200. 2. Whitson BA, et al. Thoracoscopic versus thoracotomy approaches to lobectomy: differential impairment of cellular immunity. Ann Thorac Surg 2008;86:1735-44. 3. Bendixen M, et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016;17:836-44. 4. Hansen HJ, et al. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach. Surg Endosc. 2011;25:1263-9. 5. Walker WS, et al. Thoracoscopic pulmonary lobectomy. Early operative experience and preliminary clinical results. J Thorac Cardiovasc Surg. 1993;106:1111-7. 6. Gonzalez-Rivas D, et al. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections†. Eur J Cardiothorac Surg 2016;49 Suppl 1:i6-16. 7. Park BJ, et al. Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results. J Thorac Cardiovasc Surg 2006;131:54-9. 8. Cerfolio RJ, et al. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011;142:740-6. 9. Dylewski MR, et al. Pulmonary resection using a total endoscopic robotic video-assisted approach. Semin Thorac Cardiovasc Surg 2011;23:36-42. 10. Veronesi G, et al. Four-arm robotic lobectomy for the treatment of early-stage lung cancer. J Thorac Cardiovasc Surg 2010;140:19-25.
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ES 05.05 - Lung Cancer Surgery for High Risk Patients (ID 7603)
16:45 - 17:00 | Presenting Author(s): Claudio Suarez Cruzat
- Abstract
- Presentation
Abstract:
High risk lung cancer patients represent a challenge in thoracic oncology, they are often related to heavy smoke habit with increased cardiovascular or respiratory diseases that prevents for getting optimal results in their lung cancer treatment. In the other hand it is widely accepted that lobectomy and lymphadenectomy is the standard treatment for younger patients with adequate cardiopulmonary function, specially in solid lung cancer patients (1). High risk patients with early stage lung cancer, often undergo sublobar resections, regardless of histology or tumor size, which increases the risk of local recurrence and may decrease long-term survival. However, a significant group of these patients have a good prognosis, either because their histology or tumor size are favorable, they present slow growing tumors or because they can undergo anatomical sublobar resections and a lymphadenectomy that provides an adequate disease control. In patients without respiratory or cardiovascular impairement it is accepted that sublobar resections have the same possibility of controlling the disease than lobectomy for ground glass opacity lesions, partially solid lesions (<50%) or with invasion area less than 5mm (2,3,4). The biggest problem appears in high-risk patients with solid lesions, in whom sublobar resections have not demonstrated the same oncological performance compared to lobectomy. This group will face the dilemma of decreasing operative morbimortality and the risk of postoperative respiratory disability versus decreased global and disease-free survival (5). Reports and our own expeience with the treatment of T1 and T2 patients with segmentectomies and wedge resections suggests that it is appropriate to try these patients with economical resections to improve the quality of life and survival in a group of patients whose survival curve does not depend only on cancer, but it is also important the competitive causes of mortality (ex. cardiovascular disease, pulmonary fibrosis, emphysema) (5). In our group, we evaluate cardiovascular risk with echocardiography and provocative test for myocardial ischemia, preferably exercise stress test. Respiratory risk is evaluated with spirometry, DLCO and cardiopulmonary exercise testing (peak VO2 and ventilatory equivalent VE/VCO2) (6,7). If ppoFEV1 <60%, ppoDLCO <60%, V02 <10-15ml/kg/min and/or CO2 equivalent >35, values that show that the patient is high-risk or inoperable, we incorporate the patient to an exercise training program. Our protocol considers 1-1.5 hours/day of training, with progressive load to improve muscular strength, cardiovascular and respiratory capacity, associated with full medical treatment (LABA/LAMA inhalers plus inhaled and eventually systemic corticosteroids). After completing the training period, the patient is reevaluated and the treatment plan is defined: 1.- If he leaves the high-risk group (VO2 >15ml/kg/min with VE/VCO2 <35), he will receive standard oncological surgery, according to tumor size and radiological/histological findings (TNM, GGO vs solid component, invasion). 2.- If the surgical contraindication persists (VO2 <10ml/kg/min with VE/VCO2 >35), we prefer non-surgical treatments (like SBRT). In our institution, less than 5% of patients that enter the training program remain inoperable. 3.- If the patient persists in the high or moderate-risk group (VO2 10-15ml/kg/min with VE/VCO2 <35), we prefer sublobar resections. In patients where the tumor is pure GGO or predominantly GGO (<50% solid) and measure less than 2 cms, we perform a VATS wide wedge resection plus hilar and mediastinal sampling. Frozen section must confirm that less than 50% is invasive or invasion area is smaller than 5mm. Margins should be larger than 1cm to persevere with wedge resection. If these requirements are not met: solid tumors larger than 10mm or mostly solid/GGO tumors, or GGO tumors greater than 2 cm with >25% solid, or has an invasive component larger than 5mm, we perform an anatomic segmental resection, by VATS or thoracotomy, associated with hilar and mediastinal lymphadenectomy (2,8,9,10). 4.- Even in larger tumors, we will attempt segmental resection in high-risk patients. We consider that although the risk of local recurrence is high, the lower morbidity and mortality rate of sublobar resections justifies this approach in high-risk patients. We believe that a sublobar resection with margins larger than 1 cm, grant better quality of life than a patient who becomes oxygen dependent, dies in the postoperative period or has not been resected due to the impossibility of lobectomy. In our institution, we have a prospective registry of morbidity that allows us to evaluate M&M rate and the relation with VO2 in patients with lobar and sublobar resections (5,9).(Fig1) Finally, in those patients with solid tumors and lymphovascular invasion, that are staged as clinically an pathological N0, the problem is that the intralobar lymph nodes are not completely accessible or evaluable. This implies that actually the N1 barrier is not adequately studied with sublobar resections, especially in those patients undergoing a training program and become candidates to wedge or even anatomical segmental resections as a treatment choise. This lack of information may be acceptable in AIS or MIA tumors, but constitute a greater risk in patients with solid or partially solid tumors, and even greater risk in those with lymphovascular invasion in the paraffin section. Should we consider these patients as potential N1 and add treatment to avoid the risk of relapse? There is no evidence to support this approach yet, but we feel it should be considered. References 1.- De Zoysa MK et al. Is limited pulmonary resection equivalent to lobectomy for surgical management of stage I non-small-cell lung cancer? Interactive CardioVascular and Thoracic Surgery 14(2012) 816-20 2.-Asamura H et al. Radiographically determined noninvasive adenocarcinoma of the lung: Survival outcomes of Japan Clinical Oncology Group 0201. J Thorac Cardiovasc Surg 2013;146:24-30 3.- Sakurai H, Asamura H. Sublobar resection for early stage lung cancer. Transl Lung Cancer Res 2014;3(3):164-172 4.- Suzuki K, Asamura H et al. “Early” peripheral lung cancer: prognostic significance of Ground Glass Opacity on thin-section computed tomographic scan. Ann thorac Surg 2002;74:1635-9 5.- Nakamura H et al. Comparison of the surgical outcomes of thoracoscopic lobectomy, segmentectomy, and wedge resection for clinical stage I non-small-cell lung cancer. 2011 Apr;59(3):137-41. 6.- Shafiek et al. Risk of postoperative complications in chronic obstructive lung disease patients considered fit for lung surgery: beyond oxygen consumption. Eur J Cardiothorac Surg 2016; doi:10/1093/ejcts/ezw104 7.- Salati M, Brunelli A. Risk stratification in lung resection. Curr Surg Rep. 2016; 4:37 8.- Hattori A et al. Prognostic impact of the findings on thin section computed tomography in patients with subcentimetric non small cell lung cancer. JTO 2017;12(6):954-962 9.- Valenzuela R et al. Long term survival of lung cancer in Chile. JTO2017;12(1):S745-S746 10.-Aokage K et al. Limited resection for early-stage non-small cell lung cancer as function-preserving radical surgery: a review. Jpn J Clin Oncol,2017,47(1):7-11 Figure 1 Fig 1: Survival in Resected NSCLC Lung Cancer by peak VO2, adjusted by TNM Patients with peak VO2 less than 15 ml/kg/min present a worse survival. Data obtained in a serie of 55 patients in the last preoperative evaluation, after training. Clinica Santa María, Santiago, Chile
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ES 05.06 - Salvage Surgery (ID 7604)
17:00 - 17:15 | Presenting Author(s): Hans Hoffmann
- Abstract
- Presentation
Abstract:
Salvage thoracic surgery has become an increasingly common indication in patients with lung cancer (1). In principle, three different indicative fields of salvage surgery in patients with lung cancer can be distinguished: a) the surgical resection of a persistent or recurring primary lung tumor after stereotactic radiotherapy, b) salvage lung resection after definitive chemoradiation therapy for Stage III non-small-cell lung cancer, or c) palliative surgery in cases with e. g. massive haemoptyses or bronchial obstruction with treatment-resistant retention pneumonia. Common to all indications is that they are always individual case decisions. The published series are all retrospective, comprise only a small number of patients and refer to a long period at a single institution. All studies show that these operations are often surgically challenging and demanding and require careful consideration of individual patient related factors. The presentation will provide an overview of the current literature, and will discuss own clinical experiences from selected cases. SBRT is an increasingly used modality in patients with stage I lung cancer. Whereas in the past SBRT was typically considered an alternative to surgery for patients unfit or at high risk for surgery, the modality is now being used more often also for healthier, potentially operable patients. In a recent study from MD Anderson Cancer Center, Antonoff and colleagues presented a retrospective analysis of the largest series of pulmonary resections after local SBRT failure reported to date, along with a cumulative review that incorporates all patients who have been previously reported. (2) They demonstrated that resection after local failure of SBRT in highly select individuals is feasible and safe, and has an overall acceptable morbidity and mortality, albeit higher than what is typically observed in nonirradiated patients. It is of note that in their series the majority (73%) of patients underwent lobectomy, and only 24% of patients underwent sublobar resections. In considering salvage resection, the authors recommend careful consideration of the patient’s performance status and the likely extent of required resection, to be discussed thoughtfully both with the patient and in a multidisciplinary tumor board setting. Local recurrence is observed in 20% - 35% of patients after definitive chemoradiation therapy for Stage III non-small-cell lung cancer. In selected cases salvage surgery may be considered. A recent study from Italy identified 35 cases that underwent salvage surgery after definitive chemoradiation therapy for locally advanced non–small cell lung cancer over a period of 10 years, representing 1.2% of all lung resections for lung cancer performed at their institution. (3) The authors showed acceptable postoperative survival (2- and 3-year OS was 39% and 33%, respectively) and complication rates (25.7% of both minor and major complications). Another recent study from the Netherlands reported on 15 patients that underwent salvage surgery for locoregional recurrence or persistent tumor after high dose chemoradiation therapy for locally advanced non-small cell lung cancer. The authors concluded that selected patients with locoregional recurrence or persistent tumor after high dose chemoradiation therapy, can undergo salvage surgery with acceptable morbidity and mortality, even when a pneumonectomy is required (4). Factors that might have contributed to their favourable results included adequate pre-operative staging, ability to obtain an R0 resection and a good performance status. Based on the favourable results, the authors emphasised that medically operable patients presenting with locoregional recurrence or persistent tumor after definitive chemoradiation therapy for NSCLC, should have all treatment options reviewed in an experienced multidisciplinary tumor board. In conclusion, salvage surgery after stereotactic radiotherapy or after definitive chemoradiation therapy for Stage III non-small-cell lung cancer has become a new challenge for thoracic surgeons. References: 1. Van Schil PE. Salvage surgery after stereotactic radiotherapy: a new challenge for thoracic surgeons. J Thorac Oncol; 2010. p. 1881-2. 2. Antonoff MB, Correa AM, Sepesi B, Nguyen QN, Walsh GL, Swisher SG, Vaporciyan AA, Mehran RJ, Hofstetter WL, and Rice DC. Salvage pulmonary resection after stereotactic body radiotherapy: A feasible and safe option for local failure in selected patients. J Thorac Cardiovasc Surg; 2017;154(2):689-699. 3. Casiraghi M, Maisonneuve P, Piperno G, Bellini R, Brambilla D, Petrella F, Marinis FD, and Spaggiari L. Salvage Surgery After Definitive Chemoradiotherapy for Non–small Cell Lung Cancer. Seminars in Thoracic and Cardiovascular Surgery. Elsevier BV; 2017;. 4. Dickhoff C, Dahele M, Paul MA, van de Ven PM, de Langen AJ, Senan S, Smit EF, and Hartemink KJ. Salvage surgery for locoregional recurrence or persistent tumor after high dose chemoradiotherapy for locally advanced non-small cell lung cancer. Lung Cancer; 2016;94:108-13.
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Author of
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P1.08 - Locally Advanced NSCLC (ID 694)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Locally Advanced NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 10/16/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P1.08-004 - Adjuvant Chemoradiotherapy vs. Chemotherapy for Completely Resected Unsuspected N2-Positive Non-Small Cell Lung Cancer (ID 8238)
09:30 - 09:30 | Author(s): Y.M. Shim
- Abstract
Background:
We investigated whether concurrent chemoradiotherapy (CCRT) would increase survival in patients with completely resected unsuspected N2-positive non-small cell lung cancer (NSCLC), compared with adjuvant chemotherapy alone.
Method:
Eligible patients were randomly assigned (1:1 ratio) to either the CCRT arm or the chemotherapy arm. In the CCRT arm, patients received concurrent thoracic radiotherapy (50 Gy in 25 fractions) with five cycles of weekly paclitaxel (50 mg/m[2]) and cisplatin (25 mg/m[2]), followed by two additional cycles of paclitaxel (175 mg/m[2]) plus cisplatin (80 mg/m[2]) at three-week intervals. In the chemotherapy arm, patients received four cycles of adjuvant paclitaxel (175 mg/m[2]) and carboplatin (AUC 5.5) every three weeks. The primary endpoint was disease-free survival.
Result:
We enrolled and analyzed 101 patients. The median disease-free survival of the CCRT arm was 24.7 months, which was not significantly different from that of the chemotherapy arm (21.9 months; hazard ratio [HR] 0.94, 95% CI: 0.58–1.52, P = 0.40). There was no difference in overall survival (CCRT: 74.3 months, chemotherapy: 83.5 months, HR: 1.33, 95% CI: 0.71–2.49). Subgroup analysis showed chemotherapy alone increased overall survival in never-smokers and multi-station N2-positive patients. The pattern of disease recurrence was similar between the two arms.
Conclusion:
There was no survival benefit from adjuvant CCRT compared with platinum-based chemotherapy alone for completely resected unsuspected N2-positive NSCLC.
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P2.02 - Biology/Pathology (ID 616)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Biology/Pathology
- Presentations: 1
- Moderators:
- Coordinates: 10/17/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P2.02-001 - Detection of Gene Fusions in NSCLC Using NGS Fusion Assay (ID 10033)
09:30 - 09:30 | Author(s): Y.M. Shim
- Abstract
Background:
ALK/RET/ROS and MET exon 14 skipping detection are important to guide of treatment in non-small cell lung cancer (NSCLC) patients. Next generation sequencing (NGS) platform has been implemented in the daily practice for the diagnosis. However, the validation of the NGS-based panel is still complicated and difficult.
Method:
We developed NGS-based fusion assay panel to detect 183 total fusion variants including ALK/RET/ROS as well as MET exon 14 skipping. The fusion call agreement between OCP-50 NGS assay and Nanostring was performed. The result was compared with the FISH and IHC results. This study describes the validation of the assay to define assay parameters, performance characteristics and reproducibility across laboratories.
Result:
For the 55 samples analyzed, the results are as follows;ALK Fusion ROS1 Fusion RET Fusion METD14 NGS(+) NGS(-) Total NGS(+) NGS(-) Total NGS(+) NGS(-) Total NGS(+) NGS(-) Total NS (+) 20 0 20 6 0 6 5 0 5 0 0 0 NS (-) 1 33 34 1 47 48 0 49 49 2 52 54 Total 21 33 54 7 47 54 5 49 54 2 52 54
Conclusion:
The results of our study will be of help in learning the process of establishing, validating and applying the fusion gene detection method in NSCLCs. Furthermore, NGS based OCP-50 assay for fusion detection is more accurate and reliable method for the diagnosis.
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P3.01 - Advanced NSCLC (ID 621)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Advanced NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.01-082 - Surgical Rebiopsy in Advanced Non-Small Cell Lung Cancer Resistant to Previous Chemotherapy (ID 10505)
09:30 - 09:30 | Author(s): Y.M. Shim
- Abstract
Background:
To optimize the personalized medicine for advanced non-small cell lung cancer (NSCLC), sufficient tumor tissue is mandatory to analyze molecular and genetic profile. The demand for repeat biopsy in NSCLC is increasing, it is more difficult to obtain specimen after initial treatment. The aim of this study was to evaluate the impact of surgical rebiopsy in advanced NSCLC.
Method:
From Jan 2014 to Mar 2017, 146 consecutive patients underwent surgical rebiopsy for NSCLC which was resistant to prior chemotherapy. Their medical record were reviewed retrospectively.
Result:
There were 60 male and 86 female patients with mean age of 57 years (range 30-83). Adenocarcinoma was most common histologic type (n=142, 93%). Among them, 107 patients represent EGFR mutation before chemotherapy, deletion in exon 19 (n=73) was most frequently observed. Before surgical rebiopsy, 121 patients (83%) were treated with EGFR-TKIs. The mean number of change in chemotherapy regimen was 2 (range 1-6) and 24% of patients underwent more than 3 different chemotherapy before rebiopsy. The median time between initial treatment and rebiopsy was 17.4 months (IQR 9-25). Surgical rebiopsy was possible in all cases. One hundred and seven patients (73%) underwent pleura biopsy, 22 underwent lung resection and 12 patients underwent both pleural and lung resection. Most procedure underwent video-assisted thoracic surgery (n=136, 93%), 10 patients required mini-thoracotomy. Median postoperative hospital stay was 4 days (IQR, 3-6) and the 30-day mortality was 2.7%. All specimens were confirmed as NSCLC and adequate for mutational and genetic analysis except 2 patients. One patient was failed to mutational analysis, other patients was failed to genetic sequencing due to low tumor volume. After surgery, 129 patients can resume chemotherapy. Of those, 85 patients were enrolled clinical trial or treated with new target agent. Thirty nine patients were treated with cytotoxic chemotherapy and 5 patients continued with prior target agent.
Conclusion:
Surgical rebiopsy can detect changes in cancer characteristics and may be used in therapeutic decision making in advanced NSCLC resistant to previous treatment.
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P3.02 - Biology/Pathology (ID 620)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Biology/Pathology
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.02-011 - A Prospective Study of Serial Circulating Tumor DNA Assessment in Detecting Recurrence of Resected Early-stage Lung Cancer (ID 10062)
09:30 - 09:30 | Author(s): Y.M. Shim
- Abstract
Background:
In advanced non-small cell lung cancer (NSCLC), circulating tumor DNA (ctDNA) can be used to identify clinically actionable mutations when tissue is insufficient or unobtainable for genotyping. In early-stage NSCLC, the persistence of ctDNA after complete resection may suggest the presence of minimal residual disease and predict an increased risk of recurrence; however, data on the longitudinal use of ctDNA is very limited. The aim of this study is to assess the clinical feasibility of ctDNA assessment for the prediction of lung cancer recurrence following surgical resection.
Method:
Patients undergoing curative-intent surgery for NSCLC were prospectively enrolled. Peripheral blood samples were collected at pre-specified time points immediately prior to surgery and 2-3 weeks after surgery. Plasma cell-free DNA samples were analyzed with a novel 21-gene Digital Sequencing NGS panel (Guardant Health, Inc.) with a theoretical genomic sensitivity of > 90% for NSCLC. For each patient, the identities and quantities of somatic alterations identified in ctDNA were correlated to clinical outcomes.
Result:
Of the 55 pair-matched patients, 33 were evaluable at the time of abstract submission. The median age was 61 (18 men). The histologic type was adenocarcinoma in 19 (58%), squamous cell carcinoma in 14 (42%), and small cell lung cancer in 2 (6%). The pathologic stage was I in 20 (61%), II in 3 (9%), and IIIA in 10 (30%). Median clinical follow up was 13 months. Of the 4 patients with detectable post-operative ctDNA, 3 recurred within the follow-up period. Of the 8 total recurrences observed, the most common site was the brain (4) and lung (3). One of 4 adenocarcinoma recurrences, 1 of 2 squamous cell carcinoma recurrences, and 1 of 2 small cell recurrences were associated with detectable post-operative ctDNA. By stage, post-operative ctDNA was detected in 1 of 1 stage II and 3 of 7 stage IIIA patients. Recurrences not associated with detectable post-operative ctDNA were enriched in oligometastatic recurrence (4 of 5 unpredicted recurrences were in isolated lymph nodes or the brain).
Conclusion:
In this small pilot cohort, ctDNA detected at 2 weeks post resection was associated with recurrence (RR 9.38, p=0.038), while the absence of detectable ctDNA was not significantly associated with lack of recurrence (RR 0.65, p=0.12). Oligometastatic disease, especially in the brain, was a primary risk factor for ctDNA-negative recurrence. These findings establish proof of concept for the use of ctDNA diagnostics as a risk stratification tool in resected lung cancer.
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P3.04 - Clinical Design, Statistics and Clinical Trials (ID 720)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Clinical Design, Statistics and Clinical Trials
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.04-011 - A Prospective Study to Optimize the Extent of Pulmonary Resection According to Decision-Making Algorithm in cStage IA NSCLC (ID 10047)
09:30 - 09:30 | Author(s): Y.M. Shim
- Abstract
Background:
Recent advances in imaging technology and the widespread use of low-dose computed tomography screening have greatly increased the chance of detecting small-sized non-small cell lung cancer (NSCLC) with indolent features (radiologically ground-glass opacity and histopathologically lepidic pattern adenocarcinoma). This change in the disease pattern of NSCLC has led to a resurgence of interest in sublobar resection. The purpose of this study is to determine the outcome of patients with clinical stage IA NSCLC treated by 3 types of surgical resection (wide wedge resection, segmentectomy, or lobectomy) according to the institutional decision-making algorithm.
Method:
In this study, we are planning to prospectively enroll 1,000 patients with clinical stage IA NSCLC undergoing curative-intent surgical resection. Our decision-making algorithm regarding the optimal extent of pulmonary resection has been developed based on our institutional consensus building meetings. We are planning to prospectively measure radiologic features such as tumor diameter and consolidation/tumor (CT) ratio. For ≤ 2cm tumors with CT ratio of ≤ 0.25, wide wedge resection needs to be performed. For ≤ 2cm tumors with CT ratio of 0.25 to 0.5 or 2-3cm tumors with CT ratio of ≤ 0.5, segmentectomy should be chosen. When CT ratio is larger than 0.5, lobectomy is required regardless of tumor size. When either parenchymal or bronchial resection margin is found to be insufficient during surgery, segmentectomy or lobectomy should be done even when a lesser resection was planned. Resection margins greater than the maximal tumor diameter (lesions less than 2cm) or at least 2cm gross margins (lesions larger than 2cm) should be achieved. Hilar and mediastinal lymph node dissection or at least systematic lymph node sampling is strongly recommended for any kind of pulmonary resection.
Result:
The primary objective is to determine disease-free survival following sublobar resection and lobectomy. The secondary objectives are (1) to determine overall survival following surgery, (2) to determine rates of loco-regional and systemic recurrence following surgery, (3) to compare postoperative pulmonary function between 3 different resection types, (4) to explore the relationship between radiologic parameters and pathologic subtypes, and (5) to determine the predictors of unexpected nodal involvement.
Conclusion:
This study is registered with ClinicalTrials.gov, number NCT03066297 (“OREX-IA” study) and we started recruiting patients in February, 2017 and will also be planning to follow up patients for at least 5 years to analyze their survival and recurrences.
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P3.05 - Early Stage NSCLC (ID 721)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Early Stage NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.05-012 - Clinicopathological Determinants of Circulating Tumor DNA Detection in Early-Stage Non-Small Cell Lung Cancer (ID 10329)
09:30 - 09:30 | Author(s): Y.M. Shim
- Abstract
Background:
Circulating tumor DNA (ctDNA)-based liquid biopsies have recently demonstrated substantial promise in the diagnosis and monitoring of advanced non-small cell lung cancer (NSCLC); however, data regarding utility in early-stage (operable) disease are very limited. The aim of this study is to define the clinical feasibility of ctDNA assessment in operable NSCLC.
Method:
We prospectively recruited 80 patients with clinical stage I-IIIa NSCLC undergoing cruative intent tumor resection. Pre-surgical plasma cell-free DNA (cfDNA) and matched tumor genomic DNA were collected and analyzed with a novel 21-gene Digital Sequencing NGS panel (Guardant Health, Inc.) with a theoretical genomic sensitivity of > 90% for NSCLC. Genomic results, including cfDNA yields, technical sequencing information, and identity and quantity of somatic variants, were correlated with various clinicopathological characteristics, including age, sex, smoking history, clinical and pathologic stage, histological tumor type, and preoperative treatment status.
Result:
[Cohort enrollment and sample collection is complete. Sequencing and analysis have been completed for the first 20 patients. The remaining patients will be completed within 1-2 months. Results from the complete cohort will be updated as directed by the Core Program Committee and will include the data elements described in the methods above. A preliminary review of the data is included below.] Of the 18 patients with somatic variants detected in tumor tissue (18/20, 90%), pre-operative ctDNA was detected in 12 (67%). Pre-operative ctDNA detection was high in squamous cell carcinoma (8/8), small cell lung cancer (1/1) and mixed histology (1/1) relative to adenocarcinoma (2/10, 20%). Clinical stage did not influence detection of small cell or squamous cell carcinoma; however, no ctDNA was detected in stage I or II adenocarcinoma samples (0/5). Detailed data from the complete cohort will be submitted as a late-breaking abstract.
Conclusion:
[Conclusion to be updated pending full cohort data.] ctDNA demonstrates sufficient pre-operative clinical sensitivity to be a feasible recurrence monitoring tool but appears to be influenced by tumor type.
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P3.08 - Locally Advanced Nsclc (ID 724)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Locally Advanced NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.08-006 - Treatment Response and Survival Outcomes Are Associated with Histologic Type in Non-Small Cell Lung Cancer Treated with Trimodal Treatment (ID 9972)
09:30 - 09:30 | Author(s): Y.M. Shim
- Abstract
Background:
Trimodal treatment incorporating neoadjuvant concurrent chemoradiotherapy (CCRT) and surgical resection is one of the treatment strategies for non-small cell lung cancer (NSCLC) patients with N2 disease. Although pathologic phenotypes as well as biological features might be different between adenocarcinoma (ADC) and squamous cell carcinoma (SqCC), histologic type has been rarely considered when selecting treatment strategy in patients with N2 disease. The aim of this study is to investigate if histologic type is associated with treatment response and survival outcomes in patients undergoing trimodal treatment for N2 disease.
Method:
A retrospective review of patients with N2 disease who underwent neoadjuvant CCRT followed by surgery at our institution was performed. Clinicopathologic features, response to CCRT, and survival outcomes were compared between ADC and SqCC.
Result:
From 2003 to 2013, 374 patients underwent curative-intent surgery after neoadjuvant CCRT for either ADC (n=233, 62.3%) or SqCC (n=141, 37.7%) with pathologically proven N2 disease. Sixty-nine patients (18.5%) had bulky and/or multi-stationed N2 diseases on pre-CCRT imaging tests. There were more male, more smokers, more advanced clinical T and N stages, and more bulky and/or multi-stationed N2 diseases in the SqCC group than in the ADC group. Conversely, the SqCC group had more radiologic responders, earlier pathologic T and N stages, more pathologic complete responders, and more frequent mediastinal downstaging than the ADC group. With a mean follow-up of 50.1 months, patients with SqCC showed significantly better 5-year recurrence-free survival than those with ADC (ADC, 22.8% vs. SqCC, 43%; p=0.001). However, there was no significant difference in the 5-year overall survival between the two groups (ADC, 57.5% vs. SqCC, 52.3%; p=0.366). This may be related to significantly better (p<0.001) post-recurrence survival in the ADC group (mean, 28 months) than in the SqCC group (mean, 14.5 months). In the ADC group, 164 patients developed recurrences and of those, 68 (41.5%) received targeted therapy. Patients who received targeted therapy for recurrences showed significant better 5-year overall survival than those who did not receive (61% vs. 45.6%, p=0.025).
Conclusion:
In this study, SqCC was associated with better treatment response and more favorable recurrence-free survival than ADC. Despite poor recurrence-free survival in ADC, its overall survival was improved by prolonged post-recurrence survival, which might be related to the use of targeted therapy for recurrence. Since treatment response and survival outcomes are different according to histologic type, individualized treatment strategy could be considered to improve outcomes of N2 disease.
