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L. Liu



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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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      MO02.11 - Video-Assisted Thoracic Surgery, Hybrid, versus Open Thoracotomy for Stage I Non-Small Cell Lung Cancer - A Propensity Score Analysis Based on a Multi-institutional Registry (ID 3034)

      10:30 - 12:00  |  Author(s): L. Liu

      • Abstract
      • Presentation
      • Slides

      Background
      We conducted a multi-institutional study comparing VATS lobectomy to Hybrid, and conventional open lobectomy for unmatched and propensity score-matched patients with stage I NSCLC in an attempt to stratify any potential differences in perioperative outcomes and long-term survival outcomes among the three procedures in patients with stage I NSCLC on a homogeneous well-balanced large population from multi-institutions.

      Methods
      Between January 2001 and December 2008 in eight institutions from the People’s Republic of China, a total of 2485 patients with stage I NSCLC who underwent lobectomy via c-VATS, Hybrid, or open thoracotomy were entered into the current multi-institutional registry. One thousand and fifty-six patients (42.5%) underwent c-VATS lobectomy, 273 patients (11.0%) underwent Hybrid lobectomy, and 1156 patients (46.5%) underwent open lobectomy. Of the patients who attempted to undergo c-VATS lobectomy, 65 were converted to assisted-VATS and 49 patients were converted to open lobectomy.

      Results
      After propensity-matching, c-VATS, Hybrid, and open lobectomy patients were similar in regards to age, gender, histological type and pathological TNM staging. Median operative time was 156.16±17.08 min in open lobectomy group, higher than in c-VATS lobectomy group (145.39±13.1 min) and Hybrid lobectomy group (148.86±11.62) before matching (P<0.001), after matching, it was 154.5±16.89 min, 145.41±12.17 min, and 148.81±11.63 min in open, c-VATS, and Hybrid lobectomy group, respectively (P<0.001). Transfusion occurred in 4 (12.9%) patients in c-VATS group and 6 (19.4%) patients in Hybrid group, both of them lower than in open lobectomy group of 21 (67.7%) patients (P=0.003). However, after matching, there was no statistical difference among three groups, 5 (41.7%) patients, 1 (8.3%) patients, and 6 (50.0%) patients in open, c-VATS, and Hybrid group, respectively (P=0.112). After selecting the propensity-matched patients, the 5-year survival of 78%, 74% and 76% in patients who underwent c-VATS, Hybrid, and open lobectomy, respectively. The perioperative mortality rate was 1.1% for the open group, 1.0% for the Hybrid group, and 0.8% for the VATS group. Two prognostic factors were independently associated with improved survival outcome in multivariate analysis: age < 60 (p = 0.01) and smoking history (p = 0.012). When comparing the three propensity-matched populations, patients who underwent c-VATS lobectomy had similar long-term survival outcomes to patients who underwent Hybrid or conventional thoracotomy (p = 0.770).

      Conclusion
      The present multi-institutional study represents the largest dataset evaluating surgical outcomes of patients who underwent c-VATS or Hybrid for NSCLC. VATS lobectomy for NSCLC was not associated with inferior long-term survival compared to Hybrid or conventional thoracotomy.

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    MS15 - Extending the Limits of Combined Modality Treatment for NSCLC (ID 32)

    • Event: WCLC 2013
    • Type: Mini Symposia
    • Track: Combined Modality
    • Presentations: 1
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      MS15.3 - Management of Patients with Oligometastatic/Resectable Stage IV NSCLC (ID 528)

      14:00 - 15:30  |  Author(s): L. Liu

      • Abstract
      • Presentation
      • Slides

      Abstract
      For the past decade, the standard first-line therapy for stage IV non-small-cell lung cancer (NSCLC) patients with adequate ECOG performance status (<2) has been platinum-based doublet chemotherapy with a reported median overall survival (OS) of 8–10 months, which has slightly improved to 12 months with the addition of bevacizumab. More recently, tyrosine kinase inhibitors of epidermal growth factor receptor, gefitinib and erlotinib, and anaplastic lymphoma kinase, crizotinib, have been shown to provide longer progression-free survival (PFS) and fewer side effects as first-line therapy, compared with chemotherapy in patients with certain histological subtypes and activating mutations. However, despite therapeutic developments, palliative treatment is standard for many stage IV NSCLC patients and the prognosis remains poor, with relative 5-year survival rates ≤4%, compared with an average of approximately 17% for all patients with NSCLC. Oligometastatic NSCLC is a subgroup of stage IV NSCLC with a limited number/number of sites of metastatic disease, usually 1–5 metastatic lesions. While only a small subset of patients present with such limited metastases (brain metastasis <50%, adrenal gland metastasis ~7%), they may be suitable for, and achieve long-term survival following, eradication of both the primary and metastatic tumours. For example, reported 5-year survival rates for NSCLC patients with solitary brain or adrenal metastasis who underwent surgical removal of both primary lung and metastatic disease ranged from 7–24% and 25–34%, respectively, which is higher than the average of ≤4% for all stage IV NSCLC patients. In addition to having an adequate performance status, there are additional key prognostic factors for identifying oligometastatic NSCLC patients likely to benefit from aggressive therapy; staging of the metastatic lesions, lymph node involvement and status of the primary lung tumour. A lower number of metastatic sites is predictive of good clinical outcome, with >2 metastatic sites associated with shorter PFS. The organ involved in metastatic spread may also impact clinical outcome as, for instance, patients with brain and adrenal gland metastases are more suitable for surgical intervention compared with bone or liver. Given the importance of number and site of metastatic lesions, positron emission tomography and magnetic resonance imaging are vital for accurate staging of oligometastatic disease. An association between N0 disease and increased long-term survival compared with N1/N2 disease has been observed. For example, following surgical treatment of one cohort of patients with solitary NSCLC adrenal gland metastasis, those with N2 disease had 0% median 5-year survival rate, compared with 52% for N0/N1 patients (P=0.001). Pathologic staging of lymph nodes is therefore critical. The status of the primary lung tumour also impacts clinical outcome, as the primary tumour must itself be resectable. Stage III primary disease is associated with worse survival outcome than stage I or II in patients undergoing surgical excision of brain and adrenal gland metastases, with a reported 5-year survival rate of 0% for stage III, compared with 63% and 77% for stage I and II, respectively. Similarly, patients with oligometastatic disease and a controlled primary site, or ‘oligorecurrance’, have better prognosis than those with an uncontrolled primary tumour. Histological subtype of NSCLC may also impact prognosis in oligometastatic NSCLC, with adenocarcinoma associated with the most favourable outcomes. Although an optimal disease-free interval (DFI) to define synchronous and metachronous disease has not been agreed upon, synchronous oligometastasis is generally associated with poorer survival outcomes. Patients receiving adrenalectomy for oligometastatic NSCLC with DFI ≤6 months had median OS of 12 months versus 31 months for DFI >6 months. Similar results were reported for isolated brain metastasis. Oligometastatic NSCLC is a stage IV cancer and as a guiding principle therapy should be simple and minimally invasive. Furthermore, given the diffuse nature of this disease state, management should ideally involve a multidisciplinary team as the primary and metastatic cancer must be treated, requiring a wide range of expertise. Surgery and radiosurgery (stereotactic radiosurgery [SRS] in the brain and stereotactic body radiotherapy [SBRT] in extracranial sites) are the two most common methods of tumour ablation. In general, radiosurgery is less invasive than surgery and is therefore useful for patients ineligible for surgery. Additionally, evidence suggests SBRT may be more applicable to limited extracranial metastasis to multiple organs compared with surgery. The treatment of limited brain metastases has been evaluated through several randomised clinical trials. Surgical resection plus whole brain radiotherapy (WBRT) of oligometastasis in the brain led to significantly prolonged OS compared with WBRT alone – as high as 40 weeks in one trial, compared with 15 weeks for WBRT (P<0.01). Further, a study of SRS with WBRT in patients with 1–4 brain metastases showed improved survival outcomes for patients with solitary brain metastases and improved clinical outcomes for patients with >1 site of metastatic disease, compared with WBRT alone. Overall, SRS plus WBRT is considered an acceptable choice for those patients with limited brain metastasis who are not suitable for surgery. Adrenalectomy is the standard of care for adrenal gland metastases, with OS ranging from 11–31 months. There have been no randomised trials of the use of SBRT in the adrenal gland setting, although one retrospective study reported OS of 23 months for isolated adrenal metastases treated with SBRT. Further, a recent review article of extracranial oligometastatic disease from various primary cancers suggests that survival following SBRT compares favourably to surgery. One of the key challenges for the management of oligometastatic NSCLC is continuing to improve diagnosis and prognostic factors to more accurately identify those patients with oligometastatic NSCLC who are likely to benefit from ablative treatment, as well as distinguish truly isolated metastatic disease from early-stage metastasis that later develops into widely disseminated disease. Continuing advances in imaging technology will play a role in refining diagnosis and prognosis. From a treatment perspective, challenges include cognitive problems associated with WBRT and the current lack of randomised trial data comparing surgery, radiosurgery and standard of care. To this end, there are several ongoing clinical trials, such as the randomized SABR-COMET study, which compares palliative radiation with stereotactic ablative radiation for ≤3 metastatic tumours to any single organ.

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    P3.24 - Poster Session 3 - Supportive Care (ID 160)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P3.24-045 - A first attempt on video-assisted thoracic surgery bronchial sleeve lobectomy concomitant with pulmonary artery reconstruction (double sleeve) for non-small cell lung cancer (ID 2921)

      09:30 - 16:30  |  Author(s): L. Liu

      • Abstract

      Background
      Bronchial sleeve lobectomy concomitant with pulmonary artery reconstruction (double sleeve) is a reasonable alternative procedure for pneumonectomy in appropriately selected patients with non-small cell lung cancer. However, video-assisted thoracic surgery double sleeve lobectomy is technically more challenging than routine lobectomy, and has never been reported. We aimed to report the first attempt on video-assisted thoracic surgery double sleeve lobectomy for non-small cell lung cancer.

      Methods
      From May 2012 to February 2013, three patients with non-small cell lung cancer of the left hilum directly involving the pulmonary artery were selected for curative resection via the VATS approach. Surgical procedures were performed with four ports for the first patient and three ports for the next two patients. The bronchus and pulmonary artery were reconstructed by end-to-end anastomosis using running Prolene stitches. Low-molecular heparin was subcutaneously administered during the first week after surgery.

      Results
      Surgical duration ranged from 350 to 490 min with blood loss between 30 to 200 ml. The first two patients developed pneumonia after surgery with no mortalities. All the patients were discharged home within 9-14 days after surgery. A total of 17, 12 and 14 lymph nodes were removed, and pathological stage of these three patients were T~2b~N~1~M~0~, T~2a~N~0~M~0~ and T~2b~N~0~M~0~ respectively. The reconstructed bronchus and artery worked well during 3-12 months follow-up.

      Conclusion
      video-assisted thoracic surgery double sleeve lobectomy is technically difficult but feasible. The operation can be successfully finished by skilled thoracoscopic surgeons, but the surgical incisions, procedures, and specific instruments still require further improvement.