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W.C. Hanna



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    MINI 32 - Topics in Localized Lung Cancer (ID 166)

    • Event: WCLC 2015
    • Type: Mini Oral
    • Track: Treatment of Localized Disease - NSCLC
    • Presentations: 1
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      MINI32.04 - Clinico-Pathological Correlations and the Role of Brain MRI in Combined Clinical Staging for Resectable Lung Cancer (ID 2441)

      18:30 - 20:00  |  Author(s): W.C. Hanna

      • Abstract
      • Slides

      Background:
      In our model of Combined Clinical Staging (CCS) for lung cancer, patients with a Computerized Tomography (CT) scan of the chest that does not show distant metastases will then routinely undergo whole body Positron Emission Tomography (PET/CT) and Magnetic Resonance Imaging (MRI) of the brain prior to any therapeutic decision. We aim to determine the accuracy of CCS and the value of brain MRI in this population.

      Methods:
      A prospective database was queried for all patients who underwent resection of lung cancer from 01/2012 to 06/2014. Demographics, wait times, clinical and pathological stage (7[th] edition AJCC/UICC), and costs of staging were collected. Krippendorff’s alpha was used to determine correlation between clinical and pathological stage.

      Results:
      Of 315 patients with primary lung cancer, 55.6% were female and the median age was 70 (27-87, Table 1). The mean time from initial CT scan to surgical treatment was 9.12 +/- 6.0 weeks. Krippendorff’s alpha between CCS and pathological stage was 0.193 (0.125 to 0.260, Table 2). When correlation was analyzed without consideration for sub-stages A and B, 49.8% (157/315) of patients were staged accurately, 39.7% (125/315) were over-staged, and 10.5% (33/315) were under-staged. Only 4.7% (15/315) of patients underwent surgery without appropriate neo-adjuvant systemic treatment. Preoperative brain MRI detected asymptomatic metastases in 4/315 patients (1.3%). At a median postoperative follow-up of 16 months (1-40), 7 additional patients developed symptomatic brain metastases, all of which had normal brain MRI preoperatively. The total cost of CCS was $416,924 over the study period, with $131,824 (31.6%) going towards brain MRI.

      Table 1: Baseline descriptive data, N=315
      Age Mean (SD) 69.80 (9.62) (Min: 27.34, Max: 86.61)
      Gender
      Female (%) 175 (55.6%)
      Male (%) 140 (44.4%)
      Weeks First Visit to Consent Mean (SD) 5.49 (8.15) (Min: 0, Max: 63)
      Weeks Consent to Surgery Mean (SD) 2.24 (2.07) (Min: 0, Max: 11)
      Weeks Initial CT to Surgery Mean (SD) 9.12 (6.01) (Min: 0, Max: 53)
      Weeks First Visit to Surgery Mean (SD) 8.00 (8.25) (Min: 0, Max: 64)
      Brain Metastases at Baseline (%) 4 (1.3%)
      Brain Metastases at Follow Up (%) 11 (3.5%)
      Table 2: Frequency and agreement of CCS and pathological stage
      Stage (N=315) Clinical Stage N (%) Pathological Stage N (%) Same Staging by Both (True Positives)
      0 1 (0.3%) - -
      Stage IA 89 (28.3%) 103 (32.7%) 55
      Stage IB 39 (12.4%) 82 (26.0) 19
      Stage IIA 42 (13.3%) 47 (14.9%) 7
      Stage IIB 32 (10.2%) 42 (13.3%) 12
      Stage IIIA 78 (24.8%) 39 (12.4%) 16
      Stage IIIB 21 (6.7%) 0 (0.0%) 0
      Stage IV 13 (4.1%) 2 (0.6%) 2
      Krippendorff's Alpha for level of agreement = 0.193 (0.125 to .260)


      Conclusion:
      CCS is effective for patients with resectable lung cancer, with less than 5% of patients being under-staged in a way that denied them appropriate systemic treatment before surgery. Brain MRI is a low yield and high cost intervention in this population, and its routine use should be questioned.

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    P2.02 - Poster Session/ Treatment of Localized Disease – NSCLC (ID 210)

    • Event: WCLC 2015
    • Type: Poster
    • Track: Treatment of Localized Disease - NSCLC
    • Presentations: 1
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      P2.02-021 - Robotic Pulmonary Resection for Lung Cancer: Analysis of the Learning Curve in a Novel Surgical Program (ID 1730)

      09:30 - 17:00  |  Author(s): W.C. Hanna

      • Abstract
      • Slides

      Background:
      We present the first Canadian series of robotic pulmonary resection for lung cancer, examining the effects of learning curves associated with new technology on perioperative outcomes.

      Methods:
      Prospective databases at two institutions were queried for patients who underwent robotic pulmonary resection for lung cancer between October 2011 and February 2015. Data was collected on demographics, comorbidities, perioperative variables and complications. Results are presented as median (range). The learning curve effect was evaluated in temporal tertiles, stratified by surgeon. Differences in perioperative outcomes were evaluated using the Mantel-Cox Log-Rank test.

      Results:
      Of 116 patients included, 48% were males and median age was 67 (28-88). The majority (88%, 102/116) underwent a robotic lobectomy, 9% (11/116) a segmentectomy, and 3% (3/116) a wedge resection. Five patients (4%) were converted to thoracotomy. Median operative time was 281 minutes (134-650) and length of stay was 4 days (1-19). Total operative time decreased significantly (p<0.01) over the learning curve; tertile 1 (326 min (290-362)), tertile 2 (275 min (261-289)) and tertile 3 (235 min (210-260)). Median time spent on the robotic console also decreased significantly (p<0.01) over tertiles- 195 (144-246), 148 (136-160), and 116 (100-132) minutes, respectively. Across tertiles, there were no differences in the median number of lymph node stations harvested (6, 5, 6; p=0.33), length of stay (4, 4, 4; p=0.25, or the rate of major complications (Clavien-Dindo Class >= III; 5, 1, 4, respectively; p=0.26). There were no mortalities.

      Conclusion:
      The early Canadian experience with robotic lung cancer resection demonstrates excellent results that are comparable to those of experienced centers in operative times, length of stay and conversion rates. Further improvement was demonstrated by the learning curve effect. A prospective study to examine the outcomes and cost of robotic pulmonary resection compared to video-assisted thoracoscopic surgery should be done in the context of the Canadian healthcare system.

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