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E. Vallieres



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    MO26 - Anatomical Pathology II (ID 129)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Pathology
    • Presentations: 1
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      MO26.01 - Comparison of outcomes for patients with “Bronchioloalveolar Carcinoma (BAC)” defined by the IASLC classification versus the AJCC staging system (ID 3414)

      10:30 - 12:00  |  Author(s): E. Vallieres

      • Abstract
      • Presentation
      • Slides

      Background
      Integration of the proposed IASLC classification of adenocarcinomas (ACA) into TNM staging has been challenging for pathologists. Until recently, at Swedish, we staged patients per the AJCC staging and separately described lesions with a BAC component placing them into 3 groups based on the percent of ACA invasion. But, we found this was not a good predictor of survival. We aimed to more clearly define this population by comparing patients reclassified according to the proposed IASLC classification and the AJCC 7[th] edition staging to determine if they could be integrated as a single staging system.

      Methods
      We retrospectively reviewed patients with BAC from 2000-2012 and classified them according to the IASLC classification as ACA in situ (AIS), minimally invasive ACA (MIA) or lepidic predominant ACA (LPA) and according to the AJCC 7[th] edition staging (stage I, II or III). We then reclassified these patients separating AIS and MIA as stage 0 in the AJCC 7[th] edition staging.

      Results
      We evaluated 145 consecutive patients with a median follow-up of 30 months. Using IASLC [AIS (N=23), MIA (N=18), LPA (N=104)]; local recurrence rates were: AIS (4%), MIA (11%) and LPA (2%). Regional (8%) and distant (10%) recurrences were only with LPA. Disease-free survival in patients with AIS (96%) and MIA (89%) was higher versus patients with LPA (80%). Five year cancer-specific survival was 100% for patients with AIS and MIA while it was 84% for LPA patients. Using AJCC 7[th] edition [I (N=125), II (N=12), III (N=8)]; recurrence rates were local: stage I (3%), stage III (13%). Regional: stage I (5%), stage II (8%), stage III (13%); and distant: stage I (6%), stage II (17%), stage III (13%). Stage I disease-free survival was 86%, stage II 75% and stage III 61%. Five year cancer-specific survival was stage I 90%, stage II 81% and stage III 60%. Separating AIS and MIA as stage 0 [0 (N=42), I (N=84), II (N=11), III (N=8)]; local recurrence rates were: stage 0 (7%), stage I (1%), stage III (13%). Regional: stage I (7%), stage II (9%), stage III (13%); and distant: stage I (10%), stage II (18%), stage III (13%). Disease-free survival was higher in stage 0 (93%) compared to stage I (82%), stage II (73%) and stage III (61%). Five year cancer-specific survival was 100% for stage 0, while it was lower for stage I 84%, stage II 80%, and stage III 60%, p<0.05.

      Conclusion
      The IASLC/ATS/ESR classification system appears to better discriminate patients with BAC compared to current AJCC staging. The results also suggest that patients with AIS and MIA may be classified as stage 0 in the AJCC staging system based on favorable outcomes and survival.

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    P1.07 - Poster Session 1 - Surgery (ID 184)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P1.07-041 - Characteristics of a North American Patient Population with the Diagnosis of "Bronchioloalveolar Carcinoma (BAC)" (ID 3001)

      09:30 - 16:30  |  Author(s): E. Vallieres

      • Abstract

      Background
      A body of literature exists describing the evolution of BAC from a subtype of adenocarcinoma of the lung to the currently proposed classification where it is further categorized as adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA) or lepidic predominant adenocarcinoma (LPA) based on the size of the invasive component of the lesion. The majority of these studies, however, were conducted with Asian populations and very few non-Asian studies on BAC have been published. Our aim was to describe the characteristics of North American patients with BAC, review the management and determine the influence of the epidemiologic difference.

      Methods
      We retrospectively reviewed all patients with a diagnosis of BAC or adenocarcinoma with BAC features on pathology from February 2000 to June 2012. Patients were categorized according to the IASLC/ATS/ESR classification into those with AIS, MIA or LPA based on the dominant lesion resected. Patients with mucinous BAC were excluded (n=7).

      Results
      One hundred and forty four patients were evaluated: AIS (23), MIA (18) and LPA (103). Patient demographics were similar between the groups with over 75% being of non-Asian ethnicity. More patients with AIS and MIA were clinical stage IA (table). Lobectomy was performed at comparable frequencies for AIS (48%) and MIA (53%), though it was the predominant resection approach for LPA (70%). The median size of the resected lesion in patients with AIS (1.5cm) and MIA (1.3cm) was significantly smaller than those with LPA (2.5cm), p<0.001. Patients with AIS and MIA had no clinical or pathological nodal involvement, whereas 12% of patients with LPA were found to have positive nodes (pN1: 6%, pN2: 6%). At a median follow-up of 30 months, recurrence rates were – local: AIS 4%, MIA 11% and LPA 2%; regional: LPA 8%; and distant: LPA 10%. Disease-free survival was significantly higher in the AIS (96%) and MIA (89%) groups versus the LPA group (80%). Five year cancer-specific survival was 100% for patients with AIS and MIA dropping to 84% for patients with LPA.

      Comparative characteristics between AIS, MIA and LPA
      AIS (N=23) MIA (N=18) LPA (N=103)
      Age (median) 68 68 69
      Female 19 (83%) 15 (83%) 77 (75%)
      Non-Asian 19 (83%) 14 (78%) 92 (89%)
      Smoker 16 (70%) 13 (72%) 81 (79%)
      # Comorbidities (median) 1 1 1
      FEV1% (median) 91 89 86
      DLCO/VA% (median) 94 [a] 104 [a] 82
      Clinical Stage
      IA 19 (83%) 16 (89%) 70 (68%)
      IB 4 (17%) 2 (11%) 29 (28%)
      IIA 0 0 3 (3%)
      IIB 0 0 1 (1%)
      Pathologic Stage
      IA 23 (100%) 18 (100%) 53 (51%)
      IB 0 0 31 (30%)
      IIA 0 0 7 (7%)
      IIB 0 0 4 (4%)
      IIIA 0 0 8 (8%)
      [a]p < 0.05 vs. LPA

      Conclusion
      Patients with AIS and MIA have favorable outcomes reflected by the absence of nodal metastases and a 100% 5 year cancer-specific survival compared to patients with LPA. The results of this North American population are consistent with those of published reports based on Asian populations.

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    P2.07 - Poster Session 2 - Surgery (ID 190)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P2.07-035 - Comparison of Cancer-Specific Outcomes between Open and Minimally Invasive Surgery (MIS) Lobectomy for Early Stage Non-Small-Cell Lung Cancer (NSCLC) (ID 2945)

      09:30 - 16:30  |  Author(s): E. Vallieres

      • Abstract

      Background
      The optimal surgical approach for early stage NSCLC continues to be debated. Nodal upstaging could be a surrogate measure for the quality of surgery and may help define superiority of a particular approach. However, nodal upstaging is only one measure of oncologic equivalence and may not translate into cancer recurrence or survival. Additionally, recent publications focusing on oncologic equivalence have compared approaches from different time periods. This study compares nodal upstaging, recurrence rates, disease-free and overall survival between matched groups of open and MIS (VATS/Robotic) lobectomy performed concurrently in a single time period.

      Methods
      We retrospectively compared patients undergoing lobectomy via thoracotomy to MIS for primary, clinical stage I/II NSCLC from 01/04-05/11. Patients were matched for age, gender, comorbidities, PFTs and clinical TNM status.

      Results
      Two hundred and fourteen patients were evaluated with 107 in each group. Preoperatively the MIS group had more T1a tumors (Table). The rate of nodal upstaging was significantly higher in the open group compared to the MIS group [N0 to N1: 12% (13) vs 4% (4), p=0.02; N0 to N2: 7% (7) vs 1% (1), p=0.03]. At median follow-up of 38 and 33 months respectively, recurrence rates for open vs MIS were similar: local 4% (4) vs 2% (2), regional 8% (9) vs 3% (3) and distant 13% (14) vs 12% (13), p=0.23. Disease-free survival was 74% (79) and 83% (88) for open and MIS groups respectively at 36 and 28 months, p=0.14. Overall 2 year survival was 89% (95) for the open group and 91% (97) for the MIS group, p=0.65.

      Characteristics of open versus MIS groups
      OPEN (N=107) MIS (N=107) p-Value
      Age (median) 69 68 0.574
      Female 63 (59%) 71 (66%) 0.260
      Smoker 82 (77%) 84 (79%) 0.340
      # Comorbidities (median) 1 1 0.589
      FEV1% (median) 83 85 0.835
      DLCO/VA% (median) 79 83 0.700
      Investigations
      PET Scan 93 (87%) 103 (96%) 0.264
      Mediastinoscopy 78 (73%) 85 (79%) 0.264
      Clinical Stage 0.150
      IA 73 (68%) 82 (77%)
      IB 33 (31%) 24 (22%)
      IIA 1 (1%) 1 (1%)
      Pathologic Stage <0.001
      IA 38 (36%) 68 (63%)
      IB 41 (38%) 32 (30%)
      IIA 16 (15%) 3 (3%)
      IIB 2 (2%) 1 (1%)
      IIIA 9 (8%) 3 (3%)
      IV 1 (1%) 0
      Pathologic T size (cm) (median) 2.8 2.1 0.003
      Pathologic N0 status 87 (81%) 102 (95%) 0.001

      Conclusion
      In the same time period, nodal upstaging after open lobectomy for early stage NSCLC was significantly higher compared to MIS. However, there were no differences in local, regional or distant recurrence rates. Disease-free and overall survival was equivalent at median follow up of 38 months despite the difference in upstaging rates.

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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 2
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      P3.07-018 - <strong>Assessing Survival and Grading the Severity of Complications in Octogenarians Undergoing Pulmonary Lobectomy</strong> (ID 1685)

      09:30 - 16:30  |  Author(s): E. Vallieres

      • Abstract

      Background
      Previous papers have demonstrated that pulmonary lobectomy on octogenarians is safe and feasible. However, there is little data characterizing the survival or the severity of complications in these frail patients after lobectomy. Therefore we reviewed our experience with patients aged eighty and above undergoing lobectomy.

      Methods
      We performed a retrospective review of consecutive patients aged 80 or above that underwent lobectomy between 2004 and 2012. Chart reviews were performed evaluating comorbidities, clinical stage, perioperative and postoperative course, time to recurrence, and date and cause of death. All complications were graded per the Seely Thoracic Surgery morbidity and mortality classification schema.

      Results
      45 patients (mean 82.2 years) underwent lobectomy. PFTs averaged 86% predicted for FEV1. Pathologic stage IA comprised 26% (10 of 39) of our patients; IB 33%(13), IIA 8% (3), IIB 8% (3), IIIA 18% (7), IIIB 3% (1), and IV 5% (2). Of the 45 patients, 28 had complications (60%), but only 18% (8 of 45) were significantly morbid to the patient (grade IIIB or above). Perioperative mortality was 2% (1 of 45). The most common complication was arrhythmia. Median LOS was 6 days for thoracotomy patients, 5.5 days for VATS patients, and 4.5 days for robot. 78% were discharged home, and 16% were readmitted to hospital within thirty days. Six patients had recurrent disease that occurred at an average of 768 days. 50% of our patients are still alive. Only three of the seven known causes of death were from metastatic disease. Five year actuarial survival was 52.3%. Mean survival was 53 months, and median survival was 72 months.

      Complications Separated by Grade
      Grade Definition Example Incidence
      Grade I Clinically Insignificant Asymptomatic vocal cord paralysis, urinary retention 4% (2 of 45)
      Grade II Medical Therapy Only AFib, esophagitis, new home O2 26.7% (12 of 45)
      Grade IIIA Interventions not requiring anesthesia Percutaneous pleural catheters 13.3% (6 of 45)
      Grade IIIB Interventions requiring anesthesia Return to OR 8.8% (4 of 45)
      Grade IV Critical illness, reintubation, organ failure MI, PNA, chyle leak 6.7% (3 of 45)
      Grade V Death 2.2% (1 of 45)

      Conclusion
      Lobectomy on carefully selected octogenarians can be done safely regardless of approach with a low mortality. 60% experienced a complication but when graded in a validated system only 18% were considered significant.

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      P3.07-047 - Developing thoracic surgery quality across a broad region of western United States: Thoracic Surgery Initiative (TSI) (ID 3336)

      09:30 - 16:30  |  Author(s): E. Vallieres

      • Abstract

      Background
      Objective: In the United States, thoracic surgery quality, as measured in mortality, morbidity or processes (eg lymphadenectomy after lung cancer resection), is very heterogeneous between institutions and surgeons. Despite barriers involving surgeon specialties, payors and administrative systems, health care quality is measurable & implementable. We describe the Thoracic Surgery Initiative (TSI), a grass roots quality improvement effort within Providence Health & Services (PHS), which consists of 34 facilities providing healthcare over a large Western region (Alaska, California, Montana, Oregon & Washington).

      Methods
      Methods: The TSI was conceived and driven by a thoracic surgeon. A core team (surgeons, administrators, data manager) was formed, thoracic surgery (TS) service line specifics defined & identified (of 34 facilities, 14 perform TS), stakeholders identified & surveyed regarding interest & resources. A series of meetings, agreements and collaborations were formed to define and implement quality care with the following goals: decrease mortality & morbidity, clinical standardization & cost savings.

      Results
      Results: 2011- Feb 2012: (1) intra-mural grant for TSI development obtained, (2) development activities described above, (3) organizing meeting of stakeholders (40 attendees-12 hospitals) accomplished: (a) persuasion of site-specific & system leaders/physicians/administrators, (b) executive committee (EC), (c) operational calendar (bimonthly phone conferences). Surgeon-leader spent 265 hrs on project Aug 2011-Mar 2012. 2012 EC accomplishments: (1) formulated charter & mission statement, (2) agreed upon & defined TS clinical data elements, (3) determined system/site-specific data system costs, (4) endorsed electronic health record (EHR) as platform for standardization, (5) endorsed development of TS best practice. Dec 2012 meeting (42 attendees; 12 hospitals): (1) established data system requirements, (2) began system wide TS practice standardization using EHR (TS consult, op note, daily rounding note, discharge summary, clinic note, multidisciplinary thoracic oncology conference note), (3) consensus regarding required components of lung cancer screening program. 2013: Executive committee established best practice component candidates (performance status, clinical staging, lymphadenectomy, etc). Surgeons surveyed for importance of possible components. 38 components chosen for incorporation into EHR templates. Data system and EHR templates developed. Quarterly newsletter informs all TSI stakeholders.

      Conclusion
      Conclusion: Health care quality can be defined & implemented across a broad geographic area but requires dedicated physician leadership & support. The TSI serves as a model for other regions and systems to define & implement high quality thoracic surgery. Clinical data is required to monitor success.