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Giulia Veronesi



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    IBS16 - Invasive Diagnosis and Surgery in Lung Cancer Screening Participants (Ticketed Session) (ID 41)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Screening and Early Detection
    • Presentations: 1
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      IBS16.01 - Lung Cancer Screening and Its Effect on Surgery (ID 3344)

      07:00 - 08:00  |  Presenting Author(s): Giulia Veronesi

      • Abstract
      • Slides

      Abstract

      The diagnostic revolution started in 1999 when the group of Prof. Henschke in New York published the results of Elcap study showing that Low Dose CT scan had 7 times higher sensitivity than chest-Xray to detect stage I lung cancer in 1000 high risk individuals. Subsequently in 2006 the I-elcap published 80% cancer specific survival rate at 10 years of the 484 patients with a screening cancers detected in 31.000 screened subjects.

      More evidence was required by before implementing Lung Cancer Screening on a wider scale, and the US randomised controlled trial NLST released data in 2012. The investigators reached the objective of 20% mortality rate reduction in the screening arm so that they stopped the trial and suggested to partecipants of the control arm to be screened.We needed to wait additional 6 years to have the released data of Nelson study, the European largest RCT, which mortality reduction was unexpectedly better than NLST with a mortality reduction 26-39% in men and women at 10 years for the screening arm with LDCT compared to no screening.

      Despite the evidence is available, in Europe only few countries have started a national implementation. One of the potential obstacle is related to uncertainties on sustainability. In Italy to stimulate a policy maker decision, our group have calculated the potential economical impact to implement LDCT in the population at risk (the analysis was presented at WCLC in Toronto). In collaboration with the Bocconi university we have found one of the lowest ICER for LDCT screening, 3049 for QALY.

      In Italy the potential target population of LDCT program includes 2.166.000 millions high risk individuals (smokers or former smokers, 55 years or older with 30 packs year smoking history) and 120 milions euros /year is the potential cost to screen all the high risk individuals according to this preliminary CEA analysis.

      The other obstacle is related to safety of LDCT screening on a large scale outside the academic environment.

      How characteristic of lung cancer changed with introduction of screening? and which is the impact on surgical approaches? In our experience and other screening programs most cancer cases were diagnosed in stage I with a mean size of 1.6 cm. In addition recall rate was very low, 5-10 % compared to 20-27% on NLST, risk of overdiagnosis was very limited around 10% of screening cancers; Estimated risk of lung cancer due to LDCT radiation exposure was less than 1 out of 108 detected in the worst scenario, false positive cases less than 2 %.

      It was clear that traditional open lobectomy was an overtreatment and minimally invasive lung sparing resection was required.

      Different retrospective studies have shown that sublobar resection are adequate oncological operation for very early stage lung cancers (in particular subsolid, slow growing or low suv tumors). More data on this topic will come from the two ongoing randomised trials in Us and Japan comparing lobectomy and segmentectomies for stage Ia and Ib NSCLC.

      In this scenario among the different types of minimally invasive approaches the robotic technique has recognised a wide diffusion all over the world with a great success due to the indisputable technical advantages including optimal 3D view, increased degrees of freedom, motion scaling, stable camera platform. We described in 2014 the technique and results of robotic approach to afford typical segmentectomies and concluded that robotic system by improving ergonomic, surgeon view and precise movements, may make minimally invasive segmentectomy easier to adoptand perform.

      In addition many surgeons find very useful to inject the ICG ev after isolation and resection to better define the intersegmental plane and thus perform a more radical resection according to the technique we described in 2014. In this way many small centrally located tumors with high suspiciousness of malignancy can be treated with a diagnostic and therapeutic resection using MIS and lung sparing procedure.

      One of the most discussed issue in the treatment of lung cancer is related to extension of lymph node dissection. We analysed a consecutive series of clinical N0 screen detected cancers to identify predictive criteria of nodal involvement and found that in very small (less than 1 cm) or PET negative tumorslymph node dissection can be avoided with no risk of nodal involvement.

      Major goals of surgical participation in lung cancer screening programs include: 1. Optimization of the management of screen detected nodules; 2. Reduction of false positive rates and surgical diagnosis of benign diseases; 3. Reduction of surgical incision-related trauma; 4.Avoid overtreatment and favor tailored resection; 5. Collect sample for biomarker research for diagnostic and prognostic molecular non-invasive tests; 6. Participate to multidisciplinary meeting with radiologists; 7. Participate in national or international registries for quality control.

      Henschke, C. I. et al., Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet 354 (9173), 99 (1999)

      Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.

      De Koning H et al PL02.05 Effects of Volume CT Lung Cancer Screening: Mortality Results of the NELSON Randomised-Controlled Population Based Trial. J Thoracic Oncology, 2018;13,10: Supp.S185. DOI: https://doi.org/10.1016/j.jtho.2018.08.012.

      Veronesi G, et al. Analysis indicates low incremental cost-effectiveness ratio for implementation of lung cancer screening in Italy. WCLC 2018 Toronto

      Veronesi G, et al. Diagnostic performance of low-dose computed tomography screening for lung cancer over five years. J Thorac Oncol. 2014;9(7):935-9.

      Nakamura k, et al. A phase III randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (jcog0802/wjog4607l). jpn j clin oncol. 2010;40:271-274.

      Altorki NK , et al. Perioperative mortality and morbidity after sublobar versus lobar resection for early-stage non-small-cell lung cancer: post-hoc analysis of an international, randomised, phase 3 trial (calgb/alliance 140503). lancet respir med. 2018;6:915-924.

      Pardolesi A, et al. Use of indocyanine green to facilitate intersegmental plane identification during robotic anatomic segmentectomy. JTCVS , 148, 737-738

      Veronesi G, Maisonneuve P, Pelosi G et al. Screening-detected lung cancers: is systematic nodal dissection always essential? J Thorac Oncol. 2011;6(3):525-30.

      Osarogiagbon RU, etr al. Early-Stage NSCLC: Advances in Thoracic Oncology 2018. JTO1556-0864

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    OA13 - Ideal Approach to Lung Resection and Novel Perioperative Therapy (ID 146)

    • Event: WCLC 2019
    • Type: Oral Session
    • Track: Treatment of Early Stage/Localized Disease
    • Presentations: 1
    • Now Available
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      OA13.09 - Robert J. Ginsberg Lectureship Award for Surgery (Now Available) (ID 3899)

      11:30 - 13:00  |  Presenting Author(s): Giulia Veronesi

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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