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A. Chang
Moderator of
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OA 04 - Surgery from Minimal to Radical (ID 661)
- Event: WCLC 2017
- Type: Oral
- Track: Surgery
- Presentations: 9
- Moderators:J. Lee, A. Chang
- Coordinates: 10/16/2017, 15:45 - 17:30, Room 311 + 312
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OA 04.01 - Randomised Trial of Systematic Lymph Node Dissection versus Bilateral Mediastinal Lymphadenectomy in Patients with Non-Small Cell Carcinoma (ID 7414)
15:45 - 15:55 | Presenting Author(s): Jaroslaw Kuzdzal | Author(s): Ł. Hauer, J. Hauer, J. Warmus, P. Kocon, Ł. Trybalski, Z. Grochowski, J. Włodarczyk, Tomasz Gil, T. Smęder
- Abstract
- Presentation
Background:
Experimental studies have shown different pathways of lymphatic drainage from particular pulmonary lobes. Especially important is lymphatic drainage from the left lower lobe to the contralateral mediastinal nodes. The aim of this study was to analyse the impact of bilateral mediastinal lymphadenectomy (BML) on survival in non small-cell lung cancer (NSCLC) patients.
Method:
Prospective, randomised trial including patients with proven or suspected NSCLC, stage cI-IIIA. Randomisation was performed in ratio 1:1. In the BML group, systematic lymph node dissection (SLND) was supplemented with contralateral mediastinal lymphadenectomy via additional cervical incision. In the SLND group, standard lung resection with SLND was performed.
Result:
102 patients were enrolled. 13 of them met the exclusion criteria, and data of 89 patients were analysed: 40 in the BML group and 49 in the SLND group. There were no significant differences between groups regarding age, sex, Thoracoscore, Revised Cardiac Risk Index, dyspnoea, lobar location of the tumour, histology and cTNM. Mean follow-up time was 66.5 months. In the whole group, the 4-year survival rate was significantly higher in the BML group than in the SLND group (72.5% vs 51%, p=0.039). Separate comparisons were performed for different lobar locations of the tumour. There was no significant difference in 4-year survival rates and mean survival time between both groups for tumours located in the right lung and those located in the left upper lobe. For the left lower lobe, the 4-year survival rate, and mean survival time was significantly higher in the BML group (90.9% vs 25%, p=0.003, and 1923 vs 1244 days, p=0.027, respectively). Also, analysis of the survival curves (Figure) has shown significant difference (p=0.018.).Figure 1
Conclusion:
For NSCLC located in the left lower lobe, removal of the contralateral mediastinal lymph nodes is associated with survival benefit. These results should be confirmed in larger studies.
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OA 04.02 - Feasibility of Pulmonary Resection Following Definitive Chemoradiotherapy for Primary Lung Carcinoma (ID 9633)
15:55 - 16:05 | Presenting Author(s): Yasuhiro Hida | Author(s): K. Kaga, Tatsuya Kato, M. Aragaki, R. Nakada-Kubota, Y. Yagi, R. Chiba, Y. Matsui
- Abstract
- Presentation
Background:
Induction chemoradiation (ICR) for advanced non-small cell lung caner is often limited to 50Gy or less to avoid perioperative complications. Pulmonary resection following definitive chemoradiotherapy (DCR) has been an alternative approach for locally advanced lung cancer.
Method:
In this study, we compared pulmonary resection following ICR and DCR. From 1997 to 2016, we had 31 pulmonary resections following CR. There were 13 ICR and 18 DCR. Intercostal muscle flaps were used in 7 ICR and 2 DCR. Omental flaps were used in 12 DCR. Pericardial fat pad was used in 1 DCR．There was no mortality in any groups.
Result:
In comparison with ICR and HCR, operation time (min, interquartile range) were 344 (283-513) and 418 (563-572) (p = 0.057), estimated blood loss (ml) were 440 (225-575) and 525 (323-1313) (p =0,262), morbidity (%), 69 and 28 (p = 0.021). Bronchopleural fistula developed in one case of DCR who used intercostal muscle flap. Post operation hospital stay (days) was 21 (13.5-26.5) in ICR, 14.5 (13-20) in DCR (P = 0.221). Although operation time was longer and there were more blood loss in DCR, there was no significant increase of peri- and post-operative complications. 2- and 5-year over all survival rates (%) were 50 and 42 in ICR, and 68 and 51 in DCR (p=0.73, log-rank test).
Conclusion:
As a conclusion, high dose ICR may contribute to better local control and longer survival. Pulmonary resection after DCR is as safe as that following ICR.
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- Abstract
- Presentation
Background:
To evaluate (1) the potential effect of primary tumor resection, an aggressive local consolidative therapy, for patients with oligometastatic NSCLC on 3 year overall survival; (2) the surgical outcomes in the treatment of patients with oligometastatic NSCLC; (3) the potential clinical factors predicting survival in order to better select patients for surgery.
Method:
According to the extent of pulmonary resection, the patients were divided into two subgroups. A. intent to cure (ITC: removal of total or primary pulmonary lesions); B. intent to biopsy (ITB: preservation of major lesions, only diagnostic biopsy via minimally invasive approach). M stage classified based on 8th UICC/AJCC TNM M categories.
Result:
From Jan 2002 through Dec 2015, a total of 115 consecutive metastatic NSCLC patients were enrolled from Peking University Cancer Hospital. The 3-year overall survival (OS) of ITC and ITB were 64.3% and 34.9% (log-rank p = 0.0009), respectively. Multivariate cox proportional regression analysis identified multiple station lymph nodes (LN) and bone involvement may be prognostic indicators. Figure 1Figure 2
Conclusion:
The current findings suggest that aggressive surgical therapy can extend the survival in selected stage IV NSCLC patients, and should be further explored in phase 3 trials as a standard treatment option in this clinical scenario.
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OA 04.04 - Discussant - OA 04.01, OA 04.02, OA 04.03 (ID 10850)
16:15 - 16:30 | Presenting Author(s): Hiroyasu Yokomise
- Abstract
- Presentation
Abstract not provided
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OA 04.05 - Intermediate Results of ICG Anatomical Segmentectomy Based on the Virtual Segmentectomy Simulation (ID 8050)
16:30 - 16:40 | Presenting Author(s): Yasuo Sekine | Author(s): D. Kaiho, T. Yun, E. Koh, T. Kamata, F. Ishibashi, T. Toyoda
- Abstract
- Presentation
Background:
The confirmation of an appropriate resection margin from the tumor is crucial for reducing the risk of local recurrence after lung segmentectomy for pulmonary malignancies. And the precise anatomical segmentectomy is also important for preserving pulmonary function. We evaluated intermediate results of tumor recurrence after anatomical ICG segmentectomy based on the virtual segmentectomy simulation.
Method:
From August 2014 to May 2017, forty-five patients underwent pulmonary segmentectomy under the guidance of ICG fluorescence. Before operation, several types of virtual segmentectomy were created by using Volume Analyzer Synapse VINCENT (Fujifilm co., Tokyo, Japan). We measured the shortest distance from the tumor to the resection margin in each simulated segmentectomy and selected the most appropriate area of sublobar resection based on the adequate resection margin of approximately 2 cm from the tumor. After this virtual segmentectomy, we performed segmentectomy by using an infrared thoracoscopy with transbronchial ICG instillation. Before operation, 10ml of 10-fold diluted ICG with autologous blood and 400ml of air were instilled into each associated subsegmental bronchus. Segmentectomy was performed under ICG visualization. We evaluated tumor recurrence and survival after the operation.
Result:
Thirty-seven patients were primary lung cancer and eight patients were metastatic lung tumor. Active limited resection was done in 28 patients, passive limited resection was in nine and metastatic lung tumor resection was in eight. Subsegmental resection was done in five, segmental resection in 22 and extended segmentectomy, which indicates resection of several segments with adjacent subsegment(s), was 18. The average shortest distance from the tumor to the resection margin in simulation and resected specimen were 22.5+/-11.7 mm and 24.1+/-7.3 mm, respectively (p=0.405). Postoperative complications were prolonged air leak longer than seven days in two cases and atrial fibrillation in one. In terms of the recurrence and survival after ICG segmentectomy, although the mean duration of follow-up was still short (530+/-349 days), no cancer recurrence in the ipsilateral lung was identified in lung cancer patients. In particular, no recurrence was found in the lung as well as lymph node in active segmentectomy patients.
Conclusion:
The combination of lung volume analyzer and ICG segmentectomy was an excellent tool for precise anatomical segmentectomy with an appropriate resection margin and excellent control of tumor recurrence.
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OA 04.06 - Surgeon Practices for Post Resection Lung Cancer Surveillance: Comparisons of STS and ESTS Members (ID 8689)
16:40 - 16:50 | Presenting Author(s): Leah Backhus | Author(s): P. Bhandari, Cecilia Pompili, A. Brunelli, N. Novoa, K. Naunheim, M. Edwards
- Abstract
- Presentation
Background:
A 1995 survey of Society of Thoracic Surgeons (STS) members revealed widespread variation in post resection lung cancer surveillance practices as well as pessimism regarding any survival benefit. We sought to compare contemporary practice patterns and attitudes toward post-resection surveillance among members of STS and of European Society of Thoracic Surgeons (ESTS).
Method:
A survey identical to one conducted in 1995 was administered via mail or electronically to surgeon members of the STS and ESTS requesting response from those treating NSCLC. Demographic information, type, frequency and duration of post-resection testing were collected. Goodness of fit tests were used to compare profiles of respondents and attitudes toward testing between groups. Analyses were performed using SAS 9.4 (SAS Institute, Cary, NC).
Result:
Between 8/2016-10/2016, 2978 STS members (response rate 7.8%, n=234) and 1450 ESTS members (response rate 8.4%, n=122) were surveyed. ESTS and STS respondents were similar in their frequent use of history and physical examination (75% vs 78%, p=0.26) and CT chest (71% vs 73%, p=0.61) although the timing of testing was widely variable. Compared to STS members, ESTS members reported more frequent use of testing not recommended by guidelines (for asymptomatic patients) including CXR (46% vs 34%, p=0.02) bronchoscopy (10% vs 1% p<0.01), bone scan (5% vs 0, p<0.01), brain CT (6% vs 0, p<0.01), and brain MRI (3% vs 0%, p=0.01). Compared to STS members, ESTS surgeons were more likely to “agree” or “strongly agree” that routine testing for NSCLC recurrence results in potentially curative treatment (86% vs 70%, p<0.01). Similarly, ESTS respondents were more likely to believe surveillance would identify a curable second primary NSCLC (94% vs 84%, p<0.01). More ESTS than STS respondents believed that current literature documents definitive survival benefits from routine follow-up testing (57% vs 30%, p<0.01), a misconception reported by only 26% STS respondents in the identical 1995 survey.
Conclusion:
Our survey suggests significant differences between ESTS and STS members regarding the method, frequency and attitudes regarding post-resection surveillance for NSCLC. European surgeons report a more optimistic belief in significant survival benefit from early detection of both recurrent and second primary NSCLC thus adopting more aggressive surveillance practices. This is in spite of a lack of definitive evidence-based literature underscoring the need for both better prospective studies and joint recommendations to standardize practice.
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OA 04.07 - Initial Results of Tubeless Single-Port Thoracoscopic Surgery for Pulmonary Tumor (ID 8924)
16:50 - 17:00 | Presenting Author(s): Chao-Yu Liu | Author(s): P. Hsu, H. Chien, C. Hsieh
- Abstract
- Presentation
Background:
Tubeless technique, defined as non-intubated anesthesia and omitting chest tube after lung resection surgery, is a new concept to further minimize surgical trauma of thoracoscopic surgery. However, the feasibility and safety have been less investigated. Here we set up a protocol to prevent postoperative pneumothorax after tubeless single-port thoracoscopic surgery with the aid of digital chest drainage system (DCS).
Method:
From Nov. 2016 to Jun. 2017, 34 consecutive non-intubated single-port thoracoscopic surgery were performed in patients with pulmonary nodules. After excluding patients with nodule≧2 cm, intrapleural adhesion, and FEV1< 1.5 L/sec., 21 patients were selected to enter the tubeless protocol. At the end of the procedure, a single 16-Fr. catheter was placed into the pleural cavity and connected to a DCS which pressure was set at −15 cmH2O. Then the single incision was closed continuously. If the air flow reached zero after completion of wound closure, the catheter will be removed immediately; otherwise the catheter will be kept for drainage. The clinical characteristics and perioperative outcomes of patients were presented. Figure 1
Result:
Among tubeless protocol cases, 3 patients were detected to have minor air leak by DCS and were converted to have intrapleural drainage remained after closure of surgical wound. Among the remaining 18 patients, in whom the DCS showed no air leak, the intrapleural drainage catheter was not placed. Immediate postoperative chest roentgenogram showed full expansion in all protocol patients without pneumothorax. Only 5 (23.8%) patients developed minor subclinical pneumothorax on the first postoperative day. All patients were discharged uneventful without the need of intervention.
Conclusion:
Our tubeless protocol utilizes DCS to select patients for omitting intrapleural drainage after non-intubated single-port thoracoscopic surgery. With objective parameters by DCS, we believe that this is an effective way to reduce the rate of pneumothorax after tubeless single-port thoracoscopic surgery in selected patients after lung resection.
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OA 04.08 - Is Lobe-Specific Lymph Node Dissection in Clinical N0-1 Non-Small Cell Lung Cancer Adequate for Pathological Nodal Staging (ID 9714)
17:00 - 17:10 | Presenting Author(s): Apichat Tantraworasin | Author(s): S. Siwachat, N. Lertprasertsuke, S. Kongkarnka, J. Euathrongchit, Y. Wannasopha, N. Tanatip, E. Taioli, S. Saeteng
- Abstract
- Presentation
Background:
Lobe-specific lymph node dissection (L-SND) was proposed for clinical T1a-2b N0-1 non-small cell lung cancer (NSCLC), however, the benefit of this approach is still uncertain, especially for pathological nodal staging. In this study, we evaluated the percent detection of pN2 disease in L-SND and in systematic lymph node dissection (SLND).
Method:
From 2010 to 2016, 166 patients with cT1a-T2b N0-1 NSCLC underwent a lobectomy with SLND at Chiang Mai University Hospital. The pathologic results of the lymph nodes dissected in each station were extracted form medical records. Patients who underwent a SLND when then reclassified as L-SLN according to the site of the primary tumor; right upper lobe (station 2R-4R), left upper lobe (station 4L-6), and both lower lobes (station 7-9). Percent detection of pN2 disease was compared between L-SLN and SLND.
Result:
The rate of detection of pN2 in the SLND was higher than in the L-SLD, but the difference was not statistically significant (27.0 %versus 23.6%, p=0.474). The overall percent of cases upstaged to pN2 was only 4.4% after SLND; it was 4.4% in right upper lobe, 3.4 % in left lower lobe, 3.2 % in right lower lobe, and 1.9 % in left upper lobe (p=0.904). The pN2 disease detection agreement between L-SND and SLND was high (kappa=0.911 (95% CI; 0.784 - 0.957). Table 1 pathological N2 status in lobe-specific dissection and systematic lymph node dissectionLocation of primary tumor Clinical N0-1 status Pathologic N2 status (lobe-specific dissection) Pathologic N2 status (Systematic dissection) % upstaged to N2 disease Negative Positive Negative Positive Negative Positive RUL (n=67) 57 (85.1) 10 (14.9) 52 (77.6) 15 (22.4) 49 (73.1) 18 (26.9) 4.5 RLL (n=31) 29 (93.65) 2 (6.5) 24 (77.4) 7 (22.6) 23 (74.2) 8 (25.8) 3.2 LUL (n=51) 43(84.3) 8 (15.7) 37 (72.5) 14 (27.5) 36 (70.6) 15 (29.4) 1.9 LLL (n=29) 24 (82.8) 5 (17.2) 23 (79.3) 6 (20.7) 22 (75.9) 7 (24.1) 3.4
Conclusion:
These results suggest that lobe-specific lymph node dissection is as adequate as SLND for pathological N2 staging in clinically early stage NSCLC surgery. However, systematic lymph node dissection achieved a higher detection of pN2 disease. Further studies with a larger sample size are warranted to confirm these results.
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OA 04.09 - Discussant - OA 04.05, OA 04.06, OA 04.07, OA 04.08 (ID 10851)
17:10 - 17:25 | Presenting Author(s): Anthony Kim
- Abstract
- Presentation
Abstract not provided
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