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    MO02 - General Thoracic and Minimally Invasive Surgery (ID 99)

    • Event: WCLC 2013
    • Type: Mini Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      MO02.03 - Surgical intervention strategy for postoperative chylothorax after lung resection - clinical analysis of fifty patients who developed postoperative chylothorax (ID 3321)

      10:30 - 12:00  |  Author(s): S. Oh

      • Abstract
      • Presentation
      • Slides

      Background
      Chylothorax is a rare but well-known complication of general thoracic surgery. This study evaluated our treatment strategy for postoperative chylothorax and identified associated predictors.

      Methods
      We retrospectively reviewed 1235 patients who underwent lung resection and systematic mediastinal lymph node dissection for primary lung cancer at our department from January 2008 to September 2012. Postoperative chylothorax patients were analyzed. Chylothorax was diagnosed by the milky aspect of drainage fluid and confirmed by an elevated triglyceride level (>110 mg/dL) in the drainage fluid. We initially treated chylothorax patients conservatively with low fat diet (fat intake < 20 g/day). If this treatment was judged to be ineffective, we tried to do complete oral intake cessation or surgical intervention. Comparisons between conservative and surgical intervention groups were analyzed using Fisher’s exact test. Univariate and multivariate analysis of predictors for surgical intervention was performed using logistic regression analysis. Value of p<0.05 were considered statistically significant.

      Results
      Fifty patients (4.0%) developed postoperative chylothorax. There were 35 men and 15 women with a median age of 63 years (range 33 to 81 years). The operative procedures were pneumonectomy in 2 cases, bilobectomy in 5 cases, lobectomy in 32 cases, segmentectomy in 1 case, and sleeve lobectomy in 10 cases. Forty-one patients (82%) cured with conservative treatment. These patients continued a low fat diet for one month. The remaining 9 patients (8%) underwent surgical intervention at a median of 5.5 days after diagnosis (range 3 to 12 days). Postoperative chest tube drainage (ml/h) until first oral intake was significantly greater in the surgical intervention group than conservative group (37.4±15.7 ml/h vs. 24.7±9.7 ml/h; p=0.003). In multivariate analysis, postoperative chest tube drainage (ml/h) until first oral intake was significant predictor for the chylothorax patient required surgical intervention (p=0.012, Hazard Ratio 1.110, 95% Confidence Interval 1.024-1.205). Four patients (8%) had chest tube drainage exceeding 45 ml/h until first oral intake. Among them 3 patients (75%) required surgical intervention.

      Conclusion
      Postoperative chest tube drainage (ml/h) was independent predictor for surgical intervention in postoperative chylothorax patients. If postoperative chest tube drainage exceed 45 ml/h until first oral intake, we should suspect postoperative chylothorax and consider early surgical intervention.

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    O13 - Limited Resections (ID 101)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O13.02 - Is the Limited Surgical Resection Appropriate for Non-Small Cell Lung Cancers More than 2 cm in a Diameter? - Proposed Surgical Indication by the Presence of Ground-glass Opacity of The Tumor on Thin-section CT scan (ID 3266)

      10:30 - 12:00  |  Author(s): S. Oh

      • Abstract
      • Presentation
      • Slides

      Background
      The size of solid component is much more important for predicting survival than maximum tumor dimension on thin-section CT scan in lung cancer. Moreover, the presence of ground-glass nodule (GGN) is the other significant predictor of pathologic lymph node-positive status. Our previous study showed that tumors with the absence of GGN, i.e. pure-solid, have more pathologically invasive nature than tumors with the presence of GGN, i.e. part-solid, even if both tumors have the same size of solid component on thin section CT. Therefore, it could be estimated that part-solid tumors with the small size of solid component have less frequency of nodal involvement, regardless of the maximum tumor dimension for resectable lung cancer patients.

      Methods
      Between February 2008 and April 2013, 306 consecutive patients with part-solid tumors that measured less than 30 mm in diameter of solid component and had clinically negative nodal involvement (cN0) on thin-section CT underwent surgical resection at our hospital. The findings of preoperative thin-section CT scan were reviewed for all 306 patients and part-solid tumors were defined as a tumor containing both solid and GGN component. Consolidation tumor ration (CTR) of those tumors showed 0 < CTR <1.0 and both pure GGN and pure solid tumors were excluded from this study. Univariate and multivariate analyses were performed by the logistic regression procedure to determine the relationship between pathological lymph node positive status and clinical or radiological findings.

      Results
      Of the 306 patients, 14 (4.6%) had pathological lymph node metastasis. Nodal involvement was observed in 3(1.9%) out of 156 patients with the maximum tumor dimension less than 20mm, i.e. cT1a tumors, 5 (4.4%) out of 113 cT1b tumors and 6 (16.2%) out of 37 cT2a tumors. The size of solid component on thin-section CT scan and consolidation tumor ratio (CTR) were significant predictors of pathological nodal involvement in both univariate and multivariate analysis (p<0.05, respectively). Part-solid tumors with the size of solid component ≤ 17mm and CTR ≤ 0.7, which were obtained as cutoff values of predicting pathological lymph node metastasis based on the result of Receiver operating characteristics curves, 1(1.4%) in 73 patients with these criteria had pathological lymph node positive status even in the c-T1b and c-T2a part-solid tumors on thin-section CT scan.

      Conclusion
      Among part-solid tumors with cN0 status, even cT1b and cT2a tumors with small size of solid component on thin-section CT scan have less frequency of nodal involvement and less invasive nature on pathological examination. These tumors could be candidates for limited surgical resection such as segmentectomy with nodal dissection only when enough surgical margin is warranted.

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    P1.18 - Poster Session 1 - Pathology (ID 175)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pathology
    • Presentations: 1
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      P1.18-011 - Is Visceral Pleural Invasion Significant Prognostic Factor in Lung Cancer Patients with Ground Glass Opacity on Thin-Section CT Scan? (ID 1919)

      09:30 - 16:30  |  Author(s): S. Oh

      • Abstract

      Background
      Due to the recent amendment of lung cancer staging by the IASLC committee, pathological visceral pleural invasion (VPI) has been considered as a new prognostic factor and even pT1a-b lung cancers is included in pT2a, if the tumors have VPI. Basically, lung cancers with VPI are often revealed in patients with radiologically “pure-solid” appearance on thin-section CT scan. On the other hand, controversies still remain with regard to the prognostic significance of VPI in patients with radiologically early lung cancer with ground glass opacity (GGO) predominance.

      Methods
      Between 2004 and 2012, among 543 patients with surgically resected pN0 non-small cell lung cancer less than 30mm in diameter, 466 patients that revealed radiologically “part-solid” and “pure-solid” appearance on thin-section CT scan were retrospectively reviewed. Pure-solid tumors were defined as a tumor constructed only by consolidation without GGO, whereas part-solid tumors were defined as a focal nodular opacity that contained both consolidation and GGO on thin-section CT scan. Several clinicopathological factors were evaluated to elucidate the prognostic factors for each group using a multivariate analysis. Survivals for each group were calculated by Kaplan-Meier estimation.

      Results
      Among 466 eligible lung cancers, 209 (45%) were pure-solid and 237 (55%) were part-solid nodule on thin-section CT scan. In the group with pure-solid nodule, 128 patients were men and 81 were women with average age of 67 years. VPI was found in 79 (38%) patients. Based on a multivariate analysis, VPI, maximum tumor diameter and CEA level were significant prognostic factors in patients with pure-solid nodule (p=0.0071, 0.0278, 0.0314). The 5-year survival in patients with VPI (-) (81.3%) was significantly greater than that in VPI (+) (70.1%) (p=0.0051). While the group with part-solid nodule included 97 men and 140 women with average age of 66 years. VPI was found in 24 (10%) of the patients with part-solid nodule, however, it was not a significant prognostic factor in these lesions (p=0.4697). Furthermore, the 5-year survival in patients with VPI (-) was 94.9%, whereas that with VPI (+) was 85.6% (p=0.3798).

      Conclusion
      It is no doubt regarding the prognostic significance of visceral pleural invasion in patients with radiologically pure-solid lung cancer. On the other hand, even pleural invasion may not participate in the prognosis in patients with part-solid lung cancers. Thus, upgrading of TNM staging system and administration of postoperative chemotherapy due to pleural factor should be carefully considered in lung cancer patients with GGO predominance.

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    P1.20 - Poster Session 1 - Early Detection and Screening (ID 172)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Imaging, Staging & Screening
    • Presentations: 1
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      P1.20-011 - Retrospective Study of Lung Cancer Screening. (ID 3372)

      09:30 - 16:30  |  Author(s): S. Oh

      • Abstract

      Background
      The lung cancer screening in Japan is only chest radiography now. But in 2011, the national lung screening trial research team was reported reduced lung-cancer mortality with low-dose computed tomographic screening. We studied lung cancer patients about a difference of a screening type, for example radiography and computed tomography.

      Methods
      From January 2008 through May 2013, we performed the operation of 1344 lung cancer patients. In those patients, 1018 patients were proved the type of screening.

      Results

      symptom radiography CT
      pt 146 340 378
      age 64±1 64±0.7 67±0.5
      cStage IA 50 199 296
      IB 22 66 42
      IIA 18 25 6
      IIB 15 13 8
      IIIA 25 21 12
      IIIB 6 4 2
      IV 7 3 1
      pStage IA 35 155 259
      IB 18 57 53
      IIA 12 31 13
      IIB 16 23 11
      IIIA 41 50 30
      IIIB 6 4 1
      IV 12 7 4
      The number of patients by symptom, radiography and computed tomography are 146 (14%), 340 (33%) and 378 (37%), respectively. The rate of clinical stage I (789, 78%) are 72 (7%), 265 (26%), 338 (33%), respectively. The rate of pathological stage I (672, 66%) are 53 (5%), 212 (21%), 312 (31%), respectively. On the other hand, the rate of clinical III are 31 (3%), 25(2%), 14 (1%), respectively. The rate of pathological III are 47 (5%), 54 (5%), 31 (3%), respectively. The difference of between clinical stage I and screening type are 0.000, 0.813, and 0.000, respectively. The difference of between pathological stage I and screening are 0.000, 0.081, and 0.000, respectively.

      Conclusion
      In the group of symptom and radiography, there are a lot of advanced lung cancer patients, while in the group of computed tomography, we can detect a lot of early lung cancer patients. Computed tomography is better than the other screening about the detecting lung cancer. We should use a computed tomography in screening of lung cancer.

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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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      P2.07-050 - Short term preoperative efficacy of tiotropium for patients with resectable lung cancer and chronic obstractive pulmonary disease: Preliminary results of one arm prospective study (ID 3472)

      09:30 - 16:30  |  Author(s): S. Oh

      • Abstract

      Background
      It was reported that in chronic obstructive pulmonary disease (COPD) patients, tiotropium improves lung function. However diagnosis of COPD is often made during evaluation of patients with lung cancer for surgical intervention and the efficacy of tiotropium for these patients is unclear. Thus a prospective study is needed to investigate it.

      Methods
      A prospective study was conducted on patients undergoing pulmonary resection for lung cancer with COPD (ratio of forced expiratory volume in 1 second (FEV~1~)/ forced vital capacity (FVC) less than 70%) between July 2011 and January 2012. Patients with a known history of asthma, chronic respiratory disease other than COPD were excluded. Primary endpoint was evaluating the incidence of postoperative complication. Secondary endpoints were improvement of pulmonary function tests after more than 1-week treatment using tiotropium preoperatively.

      Results
      Of 168 lung cancer patients for six months, 21 (12.5%) patients with COPD were enrolled. Pulmonary complications (prolonged air leak; 4 (19.0%), sputum retention; 2 (9.5%), hypoxia needing transient home oxygen therapy; 2 (9.5%)) were observed in seven (33.3%), although there was no critical complication such as acute respiratory failure and no side-effect related tiotropium. Treatment of tiotropium resulted in a significant improvement of FVC (pre-FVC 2.96±0.70 vs post-FVC 3.18±0.58; p=0.005) and FEV1 (pre-FEV~1~ 1.78±0.44 vs post FEV~1~ 1.91±0.18; p=0.0003), but there was no significant difference between pre-RV (residual volume) / TLC (total lung capacity)% and post-RV/TLC% ( 108.8±20.1 vs 102.4±16.1; p=0.237).

      Conclusion
      In this prospective study, we were safely able to use tiotropium without critical complication and it improved FVC and FEV~1~ in patients with COPD. But it did not improve RV/TLC% statistically and there remains doubt about efficacy of titropium. We thought that there is a problem of compliance in inhalation drug and need to reveal the population in which tiotropium was effective, and then we should perform a prospective randomized control trial.

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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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      P3.07-031 - Surgical Outcome of Resected Lung Cancer Patients Complicated with Combined Pulmonary Fibrosis and Emphysema (ID 2348)

      09:30 - 16:30  |  Author(s): S. Oh

      • Abstract

      Background
      Combined pulmonary fibrosis and emphysema (CPFE) has been recently reported as a prognostic factor for patient with respiratory disorders. It might increase the risk of lung cancer. However controversisies remain as to surgical outcome in this population.

      Methods
      Retrospective study was performed on 981 patients who underwent surgical resection of lung cancer at our institute between 2008 and 2012. Findings on thin-section computed tomography which was available for all patients were reviewed. Based on the findings, patients complicated with CPFE were selected and clinicopathological features were investigated. Surgical outcome and prognosis following lung resection were also examined.

      Results
      CPFE was observed in 97 (9.1%) patients with resected lung cancer.　Patients with pulmonary fibrosis alone were 43 patients (43.8%), patients with emphysema alone were 148 patients (15.1%) and patients without abnormal shadow were 649 patients. Lung function test were as follows (CPFE/ Fibrosis/ Emphysema): vital capacity (VC); 3.3L/ 2.9L/ 3.5L, forced expiratory volume in one second (FEV1); 71.5%/ 77.4%/ 67.9%, diffuse capacity (DLco); 44.6%/ 58.1%/ 58.6%. Ninety day-mortality(CPFE/ Fibrosis/ Emphysema) was 10.2%/ 2.3%/ 1.1%. Risk factor of ninety day mortality in patients with CPFE was operative blood loss. CPFE patients also have higher risk of major complication after surgery (CPFE 44.3%, non-CPFE 8.1%). The statistically significant difference in survival was found with the Kaplan-Meier method (p<0.001). Survival at 2 years(CPFE/ Fibrosis/ Emphysema/ Normal) was 74.6%/ 88.2%/ 91.4%/ 93.6% and survival at 5 years (CPFE/ Fibrosis/ Emphysema/ Normal) was 58.6% /61.8% /72.9%/ 81.5%. Within CPFE patients, multivariable analysis of hazard ratio for prognosis showed following significant factors; pO2<70 (HR 13.52, p=0.001), lymph node metastasis (HR 10.89, p=0.002).

      Conclusion
      Surgery for patients with CPFE is feasible. Postoperative complications were frequently and prognosis is poor compared with either emphysema or fibrosis. Not only the status of lung cancer but also respiratory status is a risk factor of prognosis after surgery for primary lung cancer with CPFE.

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      P3.07-043 - Pneumonectomy, bronchoplasty, pulmonary arterioplasty, and combined resections of the superior vena cava are feasible even in salvage surgery after treated lung cancer (ID 3084)

      09:30 - 16:30  |  Author(s): S. Oh

      • Abstract

      Background
      Salvage therapy could be indicated for residual tumor and local recurrence of treated lung cancer. However, there is no report of the meaning of making full use of bronchoplasty, pulmonary arterioplasty, and combined resections of superior vena cava (SVC) in salvage surgery for lung cancer. In this study, we investigated perioperative complications of the salvage surgery for lung cancer according to the mode of operations.

      Methods
      We retrospectively reviewed 1320 consecutive patients who underwent lung resection for lung cancer at our institution from January 2008 to May 2013 and surveyed 18 salvage surgery cases among them. The mode of operation, perioperative complication and long-term outcome were investigated in detail.

      Results
      Twelve salvage surgical therapies were indicated for residual tumor after 10 chemotherapy and two chemoradiotherapy cases, and another six salvage surgeries were indicated for local recurrence after chemoradiotherapy. Radiation dose was 45 – 66Gy in seven chemoradiotherapy cases and 140Gy of proton therapy in one case. The number of mode of operation was as follows; one pneumonectomy with carinal resection, three pneumonectomies, one lobectomy with bronchoplasty and pulmonary arterioplasty and combined resection of the SVC (triple plasty), one lobectomy with bronchoplasty and combined resection of the SVC (double plasty), one sleeve bilobectomy, two sleeve lobectomies, eight lobectomies and one wedge resection(Table 1). Median operation time was 178.5 minutes (range 80-395). Median intra-operative blood loss was 130ml (range 5-1720). Average duration of hospitalization days after salvage surgery was 10.5 days. Regarding to operation time, intra-operative blood loss, and hospitalization days after operation, there was no significant difference between salvage surgery and conventional lung resection at our institute. Post-operative complications were as follows; three empyemas, three pneumonias, two pleural fistulas, and one chylothorax. We had to make an open window for one empyema case, but another complications were recovered safely and there was no 30-day mortality. Median follow-up was 9.5 months. There was no local recurrence but there were three distant metastases cases after salvage surgery. The longest survivor without recurrence after salvage surgery survives for 31 months.Figure 1

      Conclusion
      There were no critical complications and mortality in salvage surgeries after chemotherapy and chemoradiotherapy for lung cancer. Pneumonectomy, bronchoplasty, pulmonary arterioplasty and combined resections of the SVC are feasible even in salvage surgery for treated lung cancer.

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    P3.12 - Poster Session 3 - NSCLC Early Stage (ID 206)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 1
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      P3.12-020 - Derailed analysis of lung cancer with scattered consolidation (ID 3236)

      09:30 - 16:30  |  Author(s): S. Oh

      • Abstract

      Background
      Background: We have reported that the definition of lung cancer with scattered consolidation (LCSC) was difficult to measure the size of ground glass opacity (GGO) on thin section computed tomography (Matsunaga T, Suzuki K, et al. Interact Cardiovasc Thorac Surg. 2013).To add to clinicopathological features, We investigate in LCSC in detail.

      Methods
      Methods: Between Jan.2009 and Oct.2012, 590 consecutive patients underwent pulmonary resection for lung cancer with clinical stage IA and are performed on thin section computed tomography for preoperative evaluation. Among them, 79 patients (13.4%) who had lung cancers in which it was difficult to measure the size of consolidation tumor ratio (CTR) were investigated in this study. LCSC was divided into three categories: tumor with discontinuous consolidation like islands (small islands type); tumors with reticulate consolidation (reticulation type); tumors with denser GGO (denser type). The medical record of each patient was examined for the frequency of pathological nodal status, lymphatic invasion, vascular invasion, and adenocarcinoma in situ (AIS).

      Results
      Results: All of LCSC patients are adenocarcinoma. No nodal involvement was observed in all cohort. Pathological lymphatic invasion were found in 5 (17.2%) out of 29 pts with island type, 2 (7.4%) out of 27 patients with reticular type, 1 (4.3%) out of 23 patients with denser type.. Vascular invasion was found in 3 (11.5%), 2 (7.4%), and 0 (0%), respectively. AIS were included in 3 (11.5%), 5 (13.5%), and 2 (8.6%), respectively. There were no statistically significant differences.

      Conclusion
      Conclusions: There were no significant differences in the three categories as to pathological invasive factors among LCSC. Vascular and lymphatic invasions were frequently seen in island or reticular type compared with denser type. On the other hand, AIS was frequently seen in denser type.

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    P3.18 - Poster Session 3 - Pathology (ID 177)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pathology
    • Presentations: 1
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      P3.18-009 - Clinicopathological characteristics of primary lung mucinous adenocarcinoma in surgically resected cases (ID 1850)

      09:30 - 16:30  |  Author(s): S. Oh

      • Abstract

      Background
      Primary mucinous adenocarcinomas (MA) are relatively rare, and the clinicopathological characterisics have remained unclear. The aim of this study was to clarify the clinicopathological characteristics of MA.

      Methods
      We selected MA from 1450 cases of surgically resected primary lungWe selected MA from 1450 cases of surgically resected primary lung adenocarcinoma. The clinicopathological characteristics of MA (30 cases) were analyzed.

      Results
      MA showed a high rate (22/30, 73%) of tumor location in the lower lobe. Vascular invasion was observed in 6 cases (20%). Pulmonary metastasis was observed in 5 cases (17%). Lymphatic permeation was present in 1 case (3%). Pleural invasion was observed in no cases. Lymph node metastasis was present in 1 case (tumor size: 75mm, 3%). MA showed a significantly higher rate of cases aged 65 and over, tumor location in the lower lobe and pathological N0 stage cases, when compared with the other of adenocarcinoma. Furthemore, MA displayed a lower frequency of plural invasion, lymphatic permeation, and vascular invasion, and a high frequency of pulmonary metastasis. We compared the frequency of invasive cases in the two groups with respect to their size (tumor size; TS). In MA, the frequency of invasive cases in TS ≦ 3cm, 3cm < TS ≦ 5cm and TS > 5cm was 11% (2/18), 50% (2/4), 62% (5/8), respectively. In the other types of adenocarcinoma, the frequency of invasive cases in TS ≦ 3cm, 3cm < TS ≦ 5cm and TS > 5cm was 89% (918/1027), 98% (274/281), 100% (112/112), respectively. Therefore, even as TS became bigger, MA displayed lower invasive capacity. We compared the frequency of recurrence cases in the two groups.MA showed local recurrence in 3 of 30 cases (10%), no incidents of distant metastasis. The tumor size of all 3 cases showed more than 5 cm. Pulmonary metastasis showed 1 case (3%) in same side, 2 cases (7%) in the both side. MA showed a significantly lower rate of pulmonary metastasis and distant metastasis (P < 0.05), when compared with the other of adenocarcinoma.

      Conclusion
      The pathogenesis of MA might differ from that of lung adenocarcinoma without MA based on higher rate of tumor location in the lower lobe and recurrence of pulmonary metastasis. MA less than 5cm may be treated as a local disease and could omit mediastinum lymph node dissection.