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M. Hennon



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    O20 - Staging and Advanced Disease (ID 102)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O20.01 - Transcervical Extended Mediastinal Lymphadenectomy (TEMLA) is Superior to PET/CT for Restaging of the Mediastinum after Neoadjuvant Therapy for Non-Small Cell Lung Cancer (NSCLC) (ID 358)

      16:15 - 17:45  |  Author(s): M. Hennon

      • Abstract
      • Presentation
      • Slides

      Background
      Accurate staging of the mediastinum is critical in therapeutic decision making in NSCLC. PET/CT has emerged as an important modality for staging of treatment-naïve NSCLC, but like endobronchial ultrasound and conventional mediastinoscopy typically is inaccurate following neoadjuvant therapy. We sought to determine the accuracy of TEMLA in staging NSCLC after induction therapy.

      Methods
      A retrospective chart review looking at clinical stage assessed by PET -CT and TEMLA, pathologic stage, lymph node yield and clinical characteristics was performed. Accuracy of staging by TEMLA and PET-CT was compared.

      Results
      71 of 100 consecutive patients that underwent TEMLA had it for restaging after neoadjuvant therapy; 65 of these patients were also restaged by PET-CT. Clinical characteristics of these 65 patients are presented (Table 1). TEMLA was completed successfully on 63 (96.9%) patients and was associated with permanent recurrent laryngeal nerve injury in 2 (3%) patients. On average, 17 lymph nodes were obtained per TEMLA. Concomitant anatomic resections were completed in 58 (89.2%) of patients. 12 and 3 (18.5% and 4.6%) patients were classified as having N2 and N3 disease on final pathology. Compared to PET-CT, TEMLA more accurately classified these patients (95.4% vs. 80.0%; P<0.05). The sensitivity, specificity, positive predictive value and negative predictive value of PET/CT and TEMLA for detection of N2 disease are 50.0%, 86.8%, 46.1%, 88.5% and 75%, 100%, 100%, 94.6% respectively (Table 2). Of the 3 patients inaccurately classified by TEMLA, only 1 patient had N2 disease in TEMLA-accessible nodes. Figure 1

      Table 2: Patient numbers according to nodal status.
      Path + Path - PET + PET -
      TEMLA + 9 0 4 5
      TEMLA - 3 53 9 47
      PET + 6 7
      PET - 6 46

      Conclusion
      TEMLA is superior to PET/CT for restaging of the mediastinum after induction therapy. Since TEMLA showed little added morbidity despite central tumor and treatment effects, consideration should be given for its widespread adoption for mediastinal re-staging of NSCLC after neoadjuvant therapy.

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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P3.07-010 - Thoracoscopic Pneumonectomy - An 11 year experience (ID 931)

      09:30 - 16:30  |  Author(s): M. Hennon

      • Abstract

      Background
      While VATS lobectomy yields enhanced recovery and fewer complications than open approaches, outcomes for thoracoscopic pneumonectomy are understood less well.

      Methods
      107 consecutive pneumonectomy cases performed at a comprehensive cancer center from 1/2002 to 12/2012 were studied retrospectively. 40 cases were open, while 50 Successful and 17 VATS conversions were grouped together for an intent-to-treat analysis.

      Results
      Preoperative characteristics were similar except for greater age (64±10 vs. 60±10, p=0.07), female sex (57 vs. 30% p=0.007) and preoperative comorbidities in the VATS group (Table 1). Right side was similar (46% vs. 45% open, p=0.9) as was disease extent (Early Stage 1&2, 72 vs. 61% open, p = 0.24). Neoadjuvant chemotherapy use also was similar (34 vs. 40% open). All VATS pneumonectomy pulmonary arteries were controlled safely and there were no intraoperative deaths from bleeding or other technical mishaps. Pursuing a VATS approach yielded a similar number of complications (3.1±2.6 vs. 3.0±2.6, p=0.8). Completion pneumonectomy (13%VATS/8% open) patients stayed longer (median 7.5 vs. 5 days, p=0.05) but had better survival (median not reached vs 27 months, p=0.05) largely because of more favorable stage distribution. A learning curve was evident as the rate of successful VATS pneumonectomy rose from 26% to 63% by the second half of the series (p<0.001). VATS patients started adjuvant chemotherapy an average of 39 days earlier. Excluded from long-term analyses were 7 pneumonectomies (3% VATS/13% open) for emergent indications like hemoptysis that led to 3 deaths. Stage-matched pneumonectomy cases had similar survival curves between the two groups. Multivariate logistic regression analyses found only age and pathologic stage as independent predictors of overall and disease-free survival. While the subset of patients who required conversion from VATS stayed longer (7 vs. 6 days, p=0.07), their survival curves were superimposable on open operations for all stages. In fact, achieving a successful VATS pneumonectomy demonstrated a trend toward improved survival compared to open/converted cases for early stage patients (median survival 80 vs. 27 months, p=0.07).

      Procedure VATS n=67 Open n =40 p
      Predicted Post-resection Diffusing Capacity 38±10% 36±12% 0.6
      Comorbidities (number) 3.2±1.7 2.3±1.3 0.001
      Nodes retrieved 25±14 24±11 0.87
      OR time (min -median) 289 225 0.001
      EBL (ml -median) 400 325 0.84
      ICU (days -median) 3 2 0.24
      Hospital Stay (days -median) 5 6 0.2
      Non-Emergent Case Hospital Death 8% 6% 0.7
      Stage 1&2 Survival (mo -median) 26 26 0.74

      Conclusion
      Attempting VATS pneumonectomy appears to be a safe strategy that does not compromise short-term or long-term oncologic goals.