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W.J. Petty
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MINI 19 - Surgical Topics in Localized NSCLC (ID 138)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:D. Jablons, B. Stiles
- Coordinates: 9/08/2015, 16:45 - 18:15, 605+607
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MINI19.13 - Nodal Staging via Robotic-Assisted Thoracic Surgery for Clinical Stage I Non-Small Cell Lung Cancer (ID 1018)
16:45 - 18:15 | Author(s): W.J. Petty
- Abstract
- Presentation
Background:
One measure of the quality of thoracic surgery for non-small cell lung cancer (NSCLC) is the adequacy of nodal evaluation; the rate of pathological nodal upstaging can introduce bias in patient selection for surgical therapy. Robotic-assisted thoracic surgery (RATS) offers the ability to sample nodal stations not easily assessed with conventional open surgical methods. We sought to determine the rate of nodal upstaging as a function of the frequency of various lymph node stations sampled in clinical stage I NSCLC patients undergoing RATS.
Methods:
We retrospectively reviewed the charts of patients with right-sided clinical stage I NSCLC who underwent robotic-assisted pulmonary resection with mediastinal lymph node dissection at our institution from 2013 to 2015. CT or PET scan was used to determine clinical stage. The DiPasquale Quality Index (DQI) defines a complete lymph node dissection (LND) as sampling LN 4R, 7, and 9 for right-sided tumors. Our institutional policy for the initial two years of our RATS program was to limit such to right-sided tumors.
Results:
Robotic anatomic lung resection was performed in 70 patients with right-sided clinical stage I NSCLC. The majority were of the upper lobe (41; 58.6%). The most frequent lymph node stations sampled robotically were LN 4R, 7, 9, 10, and 11 (60.6%, 90.1%, 66.2%, 49.3%, and 64.8%, respectively). According to the DQI, 31 (44.3%) tumors underwent complete LND. Pathologic nodal upstaging occurred in 5 patients (7.1% [pN1 4, 5.7%; pN2 1, 1.4%]). Hilar (pN1) upstaging occurred in 2.8%, 0%, and 20.0%, respectively, for cT1a, cT1b, and cT2a tumors. Comparatively, historic hilar upstage rates of video-assisted thoracoscopic surgery (VATS) versus thoracotomy versus recent robotic data for cT1a, cT1b, and cT2a were 5.2%, 7.1%, and 5.7%, versus 7.4%, 8.8%, and 11.5%, versus 3.5%, 8.6%, and 10.8%, respectively. The 1-year overall survival was 97% and the disease-free survival was 98% at 1 year.
Conclusion:
When patients are appropriately selected and proper lymph node sampling is performed, the rate of upstaging with RATS is comparable to VATS and lower than thoracotomy. The rate of hilar upstaging with robotic resection, however, increases with increasing clinical T stage and appears superior to both VATS and thoracotomy for cT2a tumors. This also has implications for patients who may be considered for therapies like stereotactic radiation therapy. Larger studies comparing matched open, VATS, and robotic approaches are necessary to quantify long term survival and local failure rates.
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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
- Moderators:
- Coordinates: 9/08/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P2.02-023 - Robotic Thoracic Surgery for Elderly Patients with Non-Small Cell Lung Cancer (ID 1741)
09:30 - 17:00 | Author(s): W.J. Petty
- Abstract
Background:
The evidence supporting robotic pulmonary resection for the management of early stage NSCLC continues to grow. Limited data exist describing the results of elderly patients undergoing these procedures. We compared the outcomes of patients >70 years old versus patients <70 years old undergoing robotic-assisted thoracic surgery.
Methods:
We retrospectively reviewed the medical records of patients treated with robotic-assisted pulmonary resection with lymph node dissection for NSCLC at our institution from March 2013 to the present. Clinical, pathologic, and treatment-related factors were analyzed with regard to perioperative complication rates, hospitalization duration, and clinical outcomes in patients ≥70 versus <70 years old. Categorical and continuous data were compared between age groups using the Chi-square and t-test, respectively. Survival data were described using the Kaplan-Meier method and compared between age groups using the log-rank test.
Results:
This analysis included 101 consecutively treated patients, 40 of whom were over the age of 70 at diagnosis. The cohort was predominantly female (64%), clinical stage I (80%), with an ECOG performance status of 0-1 (97%). Lobectomy (92.5%), wedge resection (13%) and bilobectomy (3%) were performed involving the upper (48.5%), middle (16.8%) and lower (47.5%) lobes. The majority (80%) were right sided due to institutional policies. Open conversion was required in only 3 (3%) patients. The above data did not differ significantly between the two age cohorts. The median chest tube duration (4 days) and length of stay (5 days) were equal in both groups. The median length of epidural anesthesia was 3 days in patients <70 and 2 days in the patients ≥70 years of age. The most common complications for younger vs. older patients included persistent air leak (18% v. 12.5%), atrial fibrillation (8.2% v. 17.5%), urinary retention (3.3% v. 12.5%), and pneumonia (3.3% v. 10%); none of these differences reached statistical significance. Major perioperative complications included one non-fatal myocardial infarction and 2 inpatient deaths secondary to septic shock (one in each age group). The 1-month readmission rate was 4.9% vs. 2.5% for patients younger vs. older than 70 years (p=0.54). The 1-year overall survival was 90% and 89% for younger and older patients, respectively (p=0.35).
Conclusion:
Robotic-assisted thoracic surgery is an appropriate surgical approach for patients older than 70 years of age with early stage NSCLC. Although some complication rates were increased in older patients, these differences did not reach statistical significance and do not appear to be related to the particular surgical procedure performed. Elderly patients with good performance status tolerate minimally-invasive robotic pulmonary resection extremely well and should be considered candidates for this surgical procedure when clinically appropriate.
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P3.04 - Poster Session/ Biology, Pathology, and Molecular Testing (ID 235)
- Event: WCLC 2015
- Type: Poster
- Track: Biology, Pathology, and Molecular Testing
- Presentations: 1
- Moderators:
- Coordinates: 9/09/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P3.04-034 - Molecular Subtyping in Advanced Non-Small Cell Lung Cancer, a Minimally Invasive Strategy with Small Volume Fine Needle Aspirates (ID 550)
09:30 - 17:00 | Author(s): W.J. Petty
- Abstract
Background:
Lung cancer is the leading cause of cancer related deaths worldwide. Non-small cell lung cancer (NSCLC) accounts for the vast majority representing approximately 85-90% of cases. NSCLC is further divided into histological subtypes including adenocarcinoma (AC) and squamous cell (SCC). Significant treatment implications exist according to histological classification which can be difficult due to scarcity of tissue or poor cellular differentiation. Patients often present with advanced disease thus making small volume, minimally invasive biopsy techniques ideal. Small volume biopsies, however, present an inherent challenge in obtaining sufficient amounts of high quality cancer cell-specific genomic material for testing and diagnostics. Here we tested the RNA yields from several minimally invasive techniques. We utilized two separate platforms to test a previously determined adeno-squam signature. We hypothesized that RNA yields would be sufficient for molecular histologic classification from a single needle biopsy. We sought to compare the yields of small volume biopsy techniques to RNA extracted from larger volume fresh frozen surgical specimens.
Methods:
Forty-eight individuals with suspected lung cancer underwent diagnostic biopsy with the standard approaches utilizing trans-thoracic needle biopsy (n=22) and transbronchial needle aspiration (n=26). RNA was extracted from a single pass specimen after the diagnostic biopsies were obtained (multiple passes). The total mass (ug), RNA integrity number (RIN) and % mass equal to or above 300 base pairs were recorded for all specimens. Statistical t-test analysis was performed on subgroups with focus on yield and quality. RNA from both FNA specimens as well as fresh frozen surgical specimens (n=44) obtained from a tumor bank at our institution were analyzed using Nanostring technology with the previously identified specific gene panel (A/S signature) obtained on the Quantigene platform.
Results:
Histological classification of FNA samples included adenocarcinoma (n=24), squamous cell (n=16) and NSC-NOS (n=8). Mean values for all FNA specimens included total mass of 1.58 ug, RIN of 4.0, and 85.4% mass equal to or above 300 base pairs. Fresh frozen surgical specimens including adenocarcinoma (n=21) and squamous cell (n=23) underwent successful RNA isolation with mean total mass of 45.2 ug, RIN of 6.1, and 68.8% mass equal to or above 300 base pairs. Differential histological gene expression occurred for both FNA and fresh frozen surgical specimens on the Nanostring platform.
Conclusion:
RNA isolation from NSCLC related small volume tissue biopsies is possible among several minimally invasive FNA techniques. Small volume tissue biopsy RNA yields are a sufficient means for molecular analysis and histological subtyping. We have successfully validated differential histological expression on two separate platforms from both single pass FNA techniques and frozen tumor samples. Given the increasing prevalence of such techniques and evolution of molecular analysis this may prove to be a powerful research and diagnostic tool.
