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Wentao Fang

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    MS 06 - Combined Modality Treatment for Thymic and Pleural Malignancy (ID 528)

    • Event: WCLC 2017
    • Type: Mini Symposium
    • Track: Thymic Malignancies/Esophageal Cancer/Other Thoracic Malignancies
    • Presentations: 1
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      MS 06.02 - Is There a Role for Minimally Invasive Surgery in Locally Advanced Thymic Tumors? (ID 7664)

      15:45 - 17:30  |  Presenting Author(s): Wentao Fang

      • Abstract
      • Presentation
      • Slides

      Background: Thymectomy via median sternotomy has been the standard surgical approach for patients with thymic malignancies. However, the last decade has seen an increasing interest in minimally invasive thymectomy for early stage tumors. By avoiding sternal split, video-assisted thoracoscopic surgery (VATS) has been reported to be associated with similar operating time but less blood loss during operation, shorter length of intensive care unit and hospital stays, diminished postoperative pain, and improved postoperative pulmonary function. A recent propensity-score matched study by the Chinese Alliance of Research for Thymomas (ChART) reported 100% complete resection rate in both VATS and open thymectomies for UICC stage I (T1N0M0). Both overall and disease-free survivals, as well as cumulative incidence of recurrence were similar between the matched groups. The role of minimally invasive surgery has thus been well established in early stage thymic tumors. Using the International Thymic Malignancy Interest Group (ITMIG) global database, a recent propensity-score matched study found that complete resection rate was comparable between minimally invasive and open approaches (96% vs. 96%, P=0.7), including 33 and 10 patients with Masaoka stage III and IV diseases. And surgical approach was not a predictor of R0 resection in that study. The results suggested that minimally invasive surgery may also have a role in some patients with locally invasive tumors. To prove this, it is necessary to show that VATS is associated with improved peri-operative results, while maintaining similar resection rate and oncologic outcomes as open surgery. We therefore carried out a propensity-score matched study comparing the results of VATS and median sternotmy in UICC T2-3 thymic tumors to see whether minimally invasive surgery might be an acceptable approach. Patients and Methods: Surgical patients with UICC stage pT2-3 thymic tumors were retrospectively retrieved from a prospectively maintained database at the Shanghai Chest Hospital. Those who undergone VATS resection were compared with patients receiving median sternotomy (Open). A propensity-score matched study was then carried out to compare resection rate, peri-operative outcomes, and follow-up results between the two matched groups. Results: During 2007-2017, 115 patients who undergone surgical resection of thymic malignancies turned out to have UICC pT2-3 tumors upon histological examination. In 29 patients, video-assisted thoracoscopic surgery (VATS) was attempted and completed in 26 cases. In 89 patients (including the 3 conversion cases due to extensive tumor invasion) the lesion was resected via Open median sternotomy. Comparing with the VATS group, the Open group has larger tumor size, higher T stage, and received more induction therapies. A propensity-score match was carried out according to concomitant autoimmune disease, co-morbidity, induction therapy, tumor size, and UICC pTNM stage in 1:2 ratio. This leaves 26 patients in the VATS group and 52 patients in the Open group (Table 1). Induction therapies were given in 7.7% and 9.6% patients in the two groups (p=0.779). The two groups were comparable in patients’ age, gender, tumor histology, as well as all the matching factors. Complete resection (R0) rate was comparable (76.9% in both groups), with higher primary tumor resection rate in the VATS group (96.2% vs. 86.7%, p=0.151). Because of local tumor invasion, pericardium, lung (wedge resection), phrenic nerve, and left innominate vein were resected together with the tumor in 21, 17, 3, and 3 patients, respectively. Postoperative morbidity rate was also similar between the two groups (15.4% vs. 17.3%, p=0.830). Comparing to the Open group, VATS patients had less intraopertaive blood loss (127 ml vs. 219 ml, p=0.005), shorter duration of chest drainage (3±1.2 day vs. 5±4.7 day, p=o.oo5) and length of hospital stay (5.9±3.1 vs. 9.6±5.1, p<0.001). During a median follow-up of 35 months, overall survival was 100% in the VATS group and 95.2% in the Open group (Figure 1, p=0.664), and 3-year recurrence rates were 0.052 and 0.167, respectively (Figure 2, p=0.554). Conclusions: In addition to UICC stage I thymic malignancy, VATS may also be an acceptable approach for locally advanced thymic tumors. Complete resection rate and follow-up results are comparable to open surgery in well selected cases. And better peri-operative results can be expected via VATS approach as compared to median sternotomy. Based on these results, VATS should be attempted in those patients with potentially resectable thymic tumors. And long-term follow-up is still necessary to confirm its oncological effectiveness. Table 1. Comparison of patient demographics, tumor characteristics, and peri-operative results between the VATS and Open groups.

      VATS N=26 Open N=52 P Value
      Gender male 17 (65.4) 34 (65.4) 1.0
      Age year 58.5±13.0 57.7±10.1 0.781
      Autoimmune diseases yes 5 (19.2) 8 (15.4) 0.667
      Co-morbidity yes 8 (30.8) 14 (26.9) 0.722
      Tumor size cm 5.7±2.0 6.4±1.7 0.161
      Histology Thymoma 15 (57.7) 29 (55.8) 0.889
      Thymic Carcinoma 11 (42.3) 23 (44.2)
      pT T2 8 (30.8) 14 (26.9) 0.722
      T3 18 (69.2) 38 (73.1)
      pN N0 25 (96.2) 51 (98.1) 1.0
      N1 1 (3.8) 1 (1.9)
      pM M0 21 (80.8) 45 (86.5) 0.506
      M1a 5 (19.2) 7 (13.5)
      Operation time min 136±50 134±47 0.85
      Blood lose ml 127±90 219±150 0.005
      Chest tube drainage day 3±1.2 5±4.7 0.005
      Length of hospital stay day 5.9±3.1 9.6±5.1 0.000
      Morbidity yes 4 (15.4) 9 (17.3) 0.830
      Figure 1. Overall survivals between the VATS and the Open groups after propensity-score matching. Figure 1 Figure 2. Cumulative incidences of recurrence after propensity-score matching in completely resected patients in the VATS and the Open groups. Figure 2

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    P2.16 - Surgery (ID 717)

    • Event: WCLC 2017
    • Type: Poster Session with Presenters Present
    • Track: Surgery
    • Presentations: 1
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      P2.16-018 - Phrenic Nerve Injury After Lung Surgery: An Underestimated Problem (ID 9979)

      09:30 - 16:00  |  Author(s): Wentao Fang

      • Abstract
      • Slides

      Inadvertent phrenic nerve injury (PNI) during lung cancer surgery is not well-studied. It is not always easy to make a clear-cut diagnosis with routine methods. Very few cases have been reported in literature. The aim of our study is to find an easily accessible and precise way to diagnose PNI and then to evaluate the incidence and its impact in early-stage lung cancer patients undergone minimally invasive surgery.

      The first step was to examine the extent of diaphragm elevation in patients with invasive thymomas in whom phrenic nerve was certainly divided. The distance between the diaphragm and the apex of the chest was calculated on chest X-Ray before (DB: Distance before) and after (DA: Distance after) surgery. The following formula was used: [(DB-DA)/DB]x100. The result (mean+SD) was used as criteria for diagnosing PNI. The second step was to study PNI in early-stage lung cancer patients undergone VATS lobectomy using the above criteria.

      Diaphragm elevation was found to be 24.24 +/- 6.2% in 22 invasive thymoma-patients and therefore, 30% was adopted as criteria for the diagnosis of PNI. Among 567 consecutive patients with early-stage lung cancer recruited from January 2014 to December 2016, 43 (7.6%) were diagnosed to have PNI (Table 1). No correlation was detected between PNI and location of the lesion or extent of lymph node dissection. Neither was there any difference in post-operative complications or length of hospital stay. But comparing spirometry data before and 6 months after surgery, reduction in FEV1, FVC, and DLCO was significantly greater in patients with PNI.Figure 1

      We found an easily accessible way to diagnose precisely PNI in lung cancer patients receiving VATS lobectomy. Inadvertent PNI during minimally invasive surgery seems to be underestimated, and it is associated with significant reduction in pulmonary function of the patient.

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