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A. Berry



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    MINI 20 - Surgery (ID 137)

    • Event: WCLC 2015
    • Type: Mini Oral
    • Track: Treatment of Locoregional Disease – NSCLC
    • Presentations: 1
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      MINI20.03 - The Survival Impact of Missed Lymph Node Metastasis in Surgically Resected Non-Small Cell Lung Cancer (NSCLC) (ID 2204)

      16:45 - 18:15  |  Author(s): A. Berry

      • Abstract
      • Presentation
      • Slides

      Background:
      Lymph node (LN) metastasis is an important prognostic factor for patients with surgically resected NSCLC. We have previously described the extent of missed N1 LN metastasis in a cohort of patients treated at metropolitan institutions. With long-term follow up, we now quantify the survival impact of missed LN metastasis.

      Methods:
      We conducted a prospective cohort study to retrieve intrapulmonary LNs from discarded NSCLC resection specimens after completion of routine pathology examination. Retrieved materials were histologically examined and classified as LNs with and without metastasis. Survival information was retrieved from institutional tumor registries. Survival distributions were plotted using the Kaplan-Meier method and evaluated with proportional hazards models controlling for gender, race, pathologic N-category, tumor size, margin status, and Charlson score.

      Results:
      We evaluated 111 patients who were 47% male with a median age of 66 years. Clinical characteristics are summarized in Table 1. Discarded LNs with metastasis were found after re-dissection in 25 (23%) patients. Patients with discarded LN metastasis had an increased risk of death (Figure 1) with an unadjusted hazard ratio (HR) of 2.0 (p-value=0.06) and an adjusted HR of 1.8 (p-value=0.23) compared to those with no discarded LNs with metastasis. When >2 discarded LNs with metastasis were found, patients had 4.8 (p-value=0.0002) times the hazard of death compared to those with no discarded LNs with metastasis (adjusted HR=4.4, p-value=0.0032).

      N(%) No LN Metastasis LN Metastasis Total
      Bi-lobectomy 8 2 10
      9% 8%
      Lobectomy 75 16 91
      87% 64%
      Pneumonectomy 3 7 10
      3% 28%
      N0 71 6 77
      83% 24%
      N1 6 12 18
      7% 48%
      N2 9 7 16
      10% 28%
      T1 45 3 48
      52% 12%
      T2 29 11 40
      34% 44%
      T3 10 8 18
      12% 32%
      T4 2 2 4
      2% 8%
      Margin Negative 83 22 105
      97% 88%
      Margin Positive 3 3 6
      3% 12%
      Mean(SD)
      Charlson Score 1.8 1.8 1.8
      1.6 1.7 1.6
      Tumor Size(cm) 3.2 5.0 3.6
      1.8 2.1 2.0
      Figure 1



      Conclusion:
      The presence of metastasis in inadvertently discarded LNs in NSCLC resection specimens has significant implications for patients’ post-operative clinical course. Additional LN metastasis found on re-dissection was associated with reduced survival. A more rigorous protocol for gross dissection of lung resection specimens is needed, and should prove beneficial to patients’ long-term survival.

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    P1.12 - Poster Session/ Community Practice (ID 232)

    • Event: WCLC 2015
    • Type: Poster
    • Track: Community Practice
    • Presentations: 1
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      P1.12-001 - Trends in Accuracy and Comprehensiveness of Pathology Reports of Resected Non-Small Cell Lung Cancer (NSCLC) in a High Mortality Area of the US (ID 1571)

      09:30 - 17:00  |  Author(s): A. Berry

      • Abstract
      • Slides

      Background:
      Pathologic examination of NSCLC resection specimens is vital to optimal treatment. In 2004, the College of American Pathologists (CAP) issued guidelines for NSCLC reporting, which were most recently updated in 2013. We evaluated the adoption of CAP reporting elements in a regional database.

      Methods:
      The Mid-South Quality of Surgical Resection (MS-QSR) database includes detailed information on 2,593 NSCLC resections in 11 institutions in 5 Dartmouth Hospital Referral Regions in Eastern Arkansas, North Mississippi and Western Tennessee from 2009-2014. In 2009, we started a multifaceted educational intervention: 1. Analyzed 2004-2008 pathology reports demonstrating the quality deficit in pathology reporting. 2. Recommended adoption of synoptic reporting of CAP checklist items. 3. Embedded a surgical intervention to improve mediastinal lymph node examination at some institutions. To allow for comparisons between eras and across the post-intervention era by intervention and type of hospital, we evaluated 4 groups: pre-intervention (pre-int), post-intervention participating hospital with surgical intervention (post-int/surg), post-intervention participating hospital without surgical intervention (post-int/non-surg), and non-participating non-surgical intervention hospital (post-int/non-part). We evaluated the inclusion of each CAP checklist item and the percent of cases with all items and 6 key items reported. We also evaluated the accuracy of T and N-stage categorization. Proportions reporting each item were compared between groups using Fisher’s Exact test.

      Results:
      Details of the completeness of pathology reporting are shown in Table 1 by group. The percent reporting the 6 key checklist items improved significantly from 63% pre-int to 76% post-int/non-part, 86% post-int/non-surg, and 95% post-int/surg (p-value<0.0001). A similar pattern of improvement was observed for N-stage (p-value<0.0001) and T-stage (p-value<0.0001) reporting. However, we observed significant decreases in the reporting of M-stage, and therefore all key items, post-intervention (p-value<0.0001). The accuracy of N-stage reporting improved significantly from 66% pre-int to 72% post-int/non-part, 86% post-int/non-surg, and 97% post-int/surg (p-value<0.0001). A similar trend was observed for T-stage accuracy (p-Value<0.0001).

      %Reporting Pre-Int (N=1390) Post-Int/ Non-Part (N=271) Post-Int/ No-Surg (N=645) Post-Int/ With-Surg (N=310) P-Value
      Specimen* 98.4 100 100 100 <0.0001
      TumorSize* 97.2 99.6 98.1 99.4 0.0094
      Histology* 99.8 99.6 99.5 99.7 0.59
      MarginStatus* 97.1 98.5 92.6 98.7 <0.0001
      T-Stage* 67.8 76.4 92.1 97.1 <0.0001
      N-Stage* 66.3 76.8 89.8 97.7 <0.0001
      *All Key-Items 62.7 75.7 85.7 94.8 <0.0001
      Laterality 99.8 100 99.5 100 0.56
      HistologicGrade 99.9 100 99.5 100 0.18
      M-Stage 75.8 31.4 25 21.6 <0.0001
      VascularInvasion 28.6 10.7 25 11.9 <0.0001
      All Items 10.7 4.1 6.2 3.2 <0.0001
      %Accurate
      N-Stage 66.2 71.6 86.2 96.8 <0.0001
      T-Stage 55.3 61.6 83 84.8 <0.0001


      Conclusion:
      There was significant improvement in reporting of CAP checklist items and the accuracy of pT- and pN-categorization. After the introduction of synoptic reporting, we observed a secular trend of improvement, shown by our post-int/non-part external control. Direct educational intervention in 2009-2010 further improved the completeness and accuracy of reports in participating hospitals. The surgical intervention provided additional benefit. Interventions to improve the quality of reporting for NSCLC are impactful on accuracy and thoroughness of reporting, thereby improving the quality of care.

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