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H. Asamura



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    G01 - Progress in Lung Cancer: Celebrating 40 Years of IASLC and Research Progress (ID 14)

    • Event: WCLC 2013
    • Type: Other Sessions
    • Track: Other Topics
    • Presentations: 1
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      G01.1 - Surgery and Staging (ID 436)

      H. Asamura

      • Abstract
      • Slides

      Abstract
      Staging is an objective measurement of the extent of cancer to allow logical grouping of patients with similar prognosis and pathobiological characteristics. Actually, the stage is expressed as combination of three factors: the size and invasion of the primary tumor (T), metastasis to the locoregional lymph nodes (N), and distant disease (M). Nowadays, any planning of the treatment is not possible without accurate staging. Moutain, who took the great leadership in the revision of TNM staging system, described staging as “assigning a simple coded designation to be a patient in accordance with an established set of rules”. Traditionally, UICC and AJCC have taken an initiative for the revision of the classification rules of TNM system. Since 7[th] edition which was published in 2009, IASLC was principally involved in the creation of proposals for revision to UICC and AJCC based upon the world-wide database. This process was known as “IASLC Lung Cancer Staging Project” lead by Goldstraw, and it is still underway for 8[th] edition. Although TNM staging system covers the malignant tumors of most organs, such aggressive intervention of international academic societies has been rarely seen except IASLC. The advent of mediastinoscopy, PET, and EBUS technique contrubuted to better staging. The IASLC Staging Project is now extended to cover not only lung cancer but also mesothelioma, thymic tumors, and esophageal cancer. As of 2013, surgery is still playing a principal role in the treatment of lung cancer especially for the relatively early stages of the disease with curative intent. Surgery is respected as the integration of two different parts: "art (surgical skill)" and "science". Therefore, we should realize that the evolution of lung cancer surgery has been achieved by the refinement of surgeons’ skills and advent of new technique (technology) as well as the accumulation of novel scientific evidence given by the well planned clinical trials. Surgery for lung cancer began as pneumonectomy as early as in 1930. However, the present-day gold standard surgery for lung cancer is defined as at least lobectomy and lymph node sampling/dissection. Series of clinical trials in 1980’s, mainly focusing upon the prognostic evaluation of adjuvant chemotherapy, were performed by Lung Cancer Study Group. The technically challenging surgery, such as those for superior sulcus tumor, has been also improved greatly. Even tumors located at the difficult potion of the thoracic inlet could be resected by refined method as shown by Grunenwald. How to manage the metastasis to the locoregional lymph nodes is also an important issue. Owing to the lymph node map originally drawn by Naruke and colleagues in 1970’s, the precise location of the metastatic nodes could be documented, and further analyses and comparison of the resected lung cancer with node metastasis became possible. The prognostic impact of the lymph node dissection was evaluated by the recent ACOSG study. In 1990’s, the minimally invasive technique (video-assisted thoracic surgery) was introduced in the surgery for lung cancer, and the comparison between open and VATS procedures were being performed. The trend toward the minimally invasive surgery is now generalized in the thoracic surgical community. The future directions in lung cancer surgery include the development of less invasive technique such as robotics, the improvement of the adjuvant treatment with new active drugs, the definition of the role of surgery in the multimodality treatment for advanced lung cancer, and the comparison between surgery and other local modalities (SBRT, ablation) as the treatment for pathologically early lung cancer. References 1970’s Pearson FG et al. The role of mediastinoscopy in the selection of treatment for bronchial carcinoma with involvement of superior mediastinal lymph nodes. J Thorac Cardiovasc Surg 1972;64:382-90. Naruke T et al. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;76:832-9. 1980’s Holmes EC, et al. THE LUNG CANCER STUDY GROUP. A randomized comparison of the effects of adjuvant therapy on resected stages II and III non-small cell carcinoma of the lung. Ann Surg 1985;202:335-41 Mountain CF. A new international staging system for lung cancer. Chest 1986;89:225S-33S 1990-1995 Valk PE, et al. Staging of non-small-cell lung cancer by whole-body positron emission tomographic imaging. Ann Thorac Surg 1995;60:1573-82. Lung Cancer Study Group. Randomized trial of lobectomy versus limited resection for T12 N0 non-small cell lung cancer. Ann Thorac Surg 1995;60:615-23. 1995-2000 TNM Classification of Malignant Tumours. 5[th] Ed. Lung. International Union Against Cancer. Wiley-Liss, New York, pp93-97, 1997. Grunenwald D et al. Transmanubrial osteomuscular sparing approach for apical chest tumors. Ann Thorac Surg 1997;63:563-6. 2001-2005 Goya T et al. Prognosis of 6,644 resected non-small cell lung cancers in Japan: a Japanese lung cancer registry study. Lung Cancer 2005;50:227-34. Mateu-Navarro M et al. Remediastinoscopy after induction chemotherapy in non-small cell lung cancer. Ann Thorac Surg 2000;70:391-395. Van Schil PE et al. Remediastinoscopy after neoadjuvant therapy for non-small cell lung cancer. Lung Cancer 2002;37:281-285. Stamatis G et al. Repeat mediastinoscopy as a restaging procedure. Pneumologie 2005;59:862-866. De Leyn P et al. Prospective comparative study of integrated PET-CT scan versus re-mediastinoscopy in the assessment of residual mediastinal lymph node disease after induction chemotherapy for mediastinoscopy proven IIIA-N2 non-small cell lung cancer. A Leuven Lung Cancer Group study. J Clin Oncol 2006;24:3333-9. 2005-2010 The IASLC Staging Manual in Thoracic Oncology, Editorial Rx, Florida, 2009. Falcoz et al. The Thoracic Surgery Scoring System (Thoracoscore): Risk model for in-hospital death in 15,183 patients requiring thoracic surgery., J Thorac Cardiovasc Surg 2007;133:325-32. 2010- Yasufuku K et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediatinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011;142:1393-400. Darling GE et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: Results of the American College of Surgery Oncology Group Z0030 Trial. J Thorac Cardiovasc Surg 2011;141:662-70. Swanson SJ et al. Video-Assisted Thoracoscopic Lobectomy Is Less Costly and Morbid Than Open Lobectomy: A Retrospective Multiinstitutional Database Analysis., Ann Thorac Surg 2012;93:1027-32

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    MS23 - Treatment of the Small Malignant Nodule (ID 40)

    • Event: WCLC 2013
    • Type: Mini Symposia
    • Track: Pulmonology + Endoscopy/Pulmonary
    • Presentations: 1
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      MS23.4 - Surgery for Early Stage Lung Cancer and Oligometastases (ID 570)

      H. Asamura

      • Abstract
      • Presentation
      • Slides

      Abstract
      Very recently, the revised international multidisciplinary classification of lung adenocarcinoma was published by the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society, and European Respiratory Society.[1,2] This new classification is characterized by the creation/abandonment of some terminology for early and advanced adenocarcinomas and by a multidisciplinary approach for the application of the new classification in a clinical setting. In particular, the term "bronchioloalveolar carcinoma (BAC)" is no longer used and, instead, new concepts are introduced, such as “adenocarcinoma in situ (AIS)” and “minimally invasive adenocarcinoma (MIA)”. Invasive adenocarcinomas are classified according to the predominant pattern after comprehensive histologic subtyping with lepidic, acinar, papillary, micropapillary, and solid patterns. The term of mixed subtype adenocarcinoma is no longer used. The gold standard surgery for documented lung cancer has been lobectomy with lymph node sampling/dissection. The randomized, prospective study was performed between lobectomy and sublobar, limited resection in 1980’s by North American Lung Cancer Study Group (LCSG) and the results of this study justified the lobectomy as the standard surgical mode.[ 3] However, looking back this study from the present view point, it is obvious that the earlier forms of lung cancer, as mentioned above as adenocarcinomas of AIS or MIA, were not involved in the LCSG study, and its conclusion could not be applied for these tumors. The present-day issue of lung cancer surgery is to define the role of lobectomy or limited, sublobar resection in relation to newly defined pathological entities. The Japan Clinical Oncology Group (JCOG) has been focusing upon defining the most appropriate surgical approach for tumors of relatively early stages in recent series of clinical trials. JCOG 0201 was intended to define the radiological non-invasive lung cancer on the high-resolution CT image, and it has shown that a consolidation/tumor ratio (C/T ratio) on thin-section computed tomography (TSCT) ≤0.25 in cT1a (≤2.0 cm) could be used as a radiological criterion for a noninvasive pathology.[4] Further prognostic analyses have also indicated that according to this radiological definition of non-invasive lung cancer the 5-year overall survival rate at 97.1% could be achieved.[5] JCOG 0804 is a prospective phase II trial, targeting the radiological non-invasive lung cancers of a diameter of 2.0 cm.[6] Again, the radiological criteria of non-invasive lung cancer were defined as those with a consolidation/tumor ratio (C/T ratio) on thin-section computed tomography (TSCT) ≤0.25. For these tumors, the wide wedge resection or segmentectomy was performed. Targeted number of accrual is 340 patients, and accrual has been already over, awaiting the data maturation. JCOG 0802 is a prospective, randomized phase III trial between lobectomy and segmentectomy for peripheral lung cancers with a diameter of 2 cm or less in a non-inferiority setting.[6] The endpoints are overall survival (primary) and postoperative pulmonary function (secondary), and the targeted accrual is 1,100 patients. As of June, 2013, more than 800 patients were registered. In case that the prognosis of patients undergoing segmentectomy was not significantly inferior to that of those undergoing lobectomy and that the postoperative pulmonary function is significantly better for those undergoing segmentectomy, it can be definitively concluded that standard surgical mode for these early tumors are segmentectomy. The similar randomized trial is also underway in US (CALGB), and the sooner launch of these data is expected to change the daily practice of lung cancer surgery. Oligometastases are the state in which the patients show distant relapse in only a limited number of organs/sites. These distant, metastatic lesions are found both before and immediately after surgery, and obviously these indicate the systemic spread of the cancer cells as stage IV disease. The gold standard treatment for systemic disease has been systemic therapy (chemotherapy). However, it has been anecdotally reported that local treatment modality such as surgery for both primary and metastatic sites cure the patients. The present-day issue for patients with oligometastatic disease is the proper selection of surgical candidate who might benefit from such aggressive treatment in lung cancer. REFERENCES 1. Travis WD, Brambilla E, Noguchi M, 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;6:144-85. 2.Van Schil P, Asamura H, Rusch VW, et al. Surgical implications of the new IASLC/ATS/ERS adenocarcinoma classification. Eur Respir J 2012;39:478-86. 3. 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. 4. 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;6:751-6. 5. Asamura H, Hishida T, Suzuki K, Japan Clinical Oncology Group Lung Cancer Surgical Study Group. Radiographically determined noninvasive adenocarcinoma of the lung: Survival outcomes of Japan Clinical Oncology Group 0201. J Thorac Cardiovasc Surg. 2013 [Epub ahead of print]. 6. Nakamura K, Saji H, Nakajima R, Okada M, Asamura H, Shibata T, 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;40:271-4. 7. Niibe Y, Hayakawa K. Oligometastases and oligorecurrence: the new era of cancer therapy. Jpn J Clin Oncol 2010;40:107-11.

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    O13 - Limited Resections (ID 101)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O13.04 - DISCUSSANT (ID 3923)

      H. Asamura

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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    P3.07 - Poster Session 3 - Surgery (ID 193)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P3.07-029 - Clinicopathological Features of Resected Subcentimeter Lung Cancer (ID 2253)

      H. Asamura

      • Abstract

      Background
      Background. Subcentimeter lung cancers are still rare and their pathobiological behavior and management have not yet been fully clarified. In this retrospective study, we investigated the clinicopathological characteristics of patients with subcentimeter lung cancers.

      Methods
      Methods. From among 7,463 patients with primary lung cancers that were surgically resected at the National Cancer Center Hospital, Tokyo, from 1993 through 2011, 291 (4%) patients with peripheral lung cancers of 1.0 cm or less in diameter were studied retrospectively with regard to their clinicopathological characteristics including prognosis. Of these 291 patients, 141 (48%) were male and 150 (52%) were female, and they had a mean age of 62.0 years. According to the proportion of consolidation component within the tumor in preoperative imaging on high-resolution computed tomography (HRCT), the tumors were classified into 4 types; Type 1 (n = 50): non-solid ground-glass opacity (GGO) lesion, Type 2 (n = 89): part-solid GGO lesion including 50% or more GGO within the lesion, Type 3 (n = 62): part-solid GGO lesion including less than 50% GGO within the lesion, and Type 4 (n = 90): solid lesion with no GGO component.

      Results
      Results. Patients with Type 4 included significantly greater percentages of males and smokers than those with the other types. Pleural invasion and vascular/lymphatic permeation were significantly more frequent in Type 4 than in the other types. While none of the patients with Type 1 to 3 had lymph node metastases, these were found in 10% of the patients with Type 4. Overall, recurrence was observed in 13 patients (4.5%). Almost all of these patients with recurrence had Type 4 tumors. The lone exception was a Type 3 patient in whom local recurrence developed adjacent to a surgical staple line. The 5-year overall survival rates were 100% in Type 1 and Type 2, 98% in Type 3, and 88% in Type 4. Patients with Type 4 had a significantly worse prognosis than those with other types.

      Conclusion
      Conclusions. Subcentimeter lung cancers with a GGO component on preoperative HRCT (Type 1 to 3) can be considered “early” lung cancers. Thus, in these cases, limited resection may be warranted to achieve a cure because patients with Type 1 to 3 did not have lymph node metastasis. On the other hand, lobectomy should still be considered the standard operation of choice for Type 4 tumors.