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G. Goma

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    ORAL 05 - Surgery (ID 97)

    • Event: WCLC 2015
    • Type: Oral Session
    • Track: Treatment of Locoregional Disease – NSCLC
    • Presentations: 1
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      ORAL05.02 - Quality of Resection in Pathological N2 NSCLC in the Phase 3 Lung Adjuvant Radiotherapy Trial (Lung ART): An Important Factor (ID 1001)

      10:45 - 12:15  |  Author(s): G. Goma

      • Abstract
      • Presentation
      • Slides

      The main objective of the ongoing phase III Lung Adjuvant Radiotherapy Trial (Lung ART) is to study the impact of post-operative conformal radiotherapy (PORT) on disease-free survival (DFS) in a population of patients with completely resected pathologically proven N2 non-small cell lung cancer (NSCLC), with or without induction or adjuvant chemotherapy. Quality of surgical resection and extent of lymph node dissection are critically important in the interpretation of results.

      A surgical advisory committee composed of 4 international expert thoracic surgeons meets regularly in order to establish the quality of resection, taking into consideration the International Association for the Study of Lung Cancer and European Society of Thoracic Surgeons published guidelines. The committee reviews anonymized surgical and pathological reports, and establishes whether tumor resection can be considered complete (no residual tumor and adequate lymph node assessment), uncertain (highest mediastinal nodal station involved, incomplete nodal exploration, involved N2 removed in fragments) or incomplete (presence of residual tumor). Nodal exploration is evaluated according to recommendations and classified as sampling, selective dissection or extensive dissection.

      As of April 15th 2015, 298 patients have been included in the Lung ART trial and 116 patients’ reports have been analyzed by the surgical advisory committee. The basic characteristics are specified in the following table:

      Total n=116
      Frequency Percent
      Induction chemotherapy
      no 89 77%
      yes 27 23%
      Type of surgery
      for right-side tumors 70 60%
      lobectomy 49 70%
      bilobectomy 9 13%
      pneumonectomy 5 7%
      other 7 10%
      for left-side tumors 46 40%
      lobectomy 34 74%
      pneumonectomy 10 22%
      other 2 4%
      Tumor Size (mm)
      Median size (range) 35 [0*-105]
      Number of mediastinal lymph nodes examined
      Median number (range) 10 [1-37]
      Number of mediastinal lymph nodes involved
      Median number (range) 1[0*-15]
      Number of mediastinal nodal stations involved
      0* 5 4%
      1 79 68%
      2 20 17%
      >2 12 11%
      * patients with downstaging after induction chemotherapy
      Nodal dissection was performed according to lobar location specific recommendations in most patients: for instance, station 7 was explored in 91% patients and right inferior paratracheal station 4R in 93% of right side tumours. Nodal dissection was performed according to recommendations in 71% pts; 16% patients had sampling, 22% a selective dissection and 62% a systematic dissection. Resection was considered complete (R0) in 43%, uncertain in 42%, microscopically incomplete (R1) in 14% and macroscopically incomplete (R2) in 1 patient. The most frequent reason for “uncertain resection” was involvement of the highest mediastinal lymph node.

      Most adjuvant trials have included completely resected patients, without monitoring of the quality of nodal exploration and resection. This analysis outlines the importance of an external committee evaluating the quality of resection in stage IIIA-N2 NSCLC, and the findings of this audit will be useful in the interpretation of the results of the trial.

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