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Walter Klepetko



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    EP1.01 - Advanced NSCLC (ID 150)

    • Event: WCLC 2019
    • Type: E-Poster Viewing in the Exhibit Hall
    • Track: Advanced NSCLC
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/08/2019, 08:00 - 18:00, Exhibit Hall
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      EP1.01-82 - 10 Years Single Center Experience with Resection of the Superior Vena Cava in Locally Advanced Non-Small Cell Lung Cancer (Now Available) (ID 2814)

      08:00 - 18:00  |  Author(s): Walter Klepetko

      • Abstract
      • Slides

      Background

      In patients with locally advanced T4 non-small cell lung cancer (NSCLC) invading the superior vena cava (SVC), combined multimodality treatment including surgery is indicated. However, this treatment approach warrants careful patient selection and adequate postoperative management. We aim to review our institutional experience with SVC resection in advanced NSCLC.

      Method

      Between 2006 and 2017, surgery for NSCLC including SVC resection has been performed in 21 patients at our department. We defined “SVC resection” as resection of the SVC and replacement with ring-enforced tube grafts and “SVC reconstruction” as partial resection with direct closure or reconstruction with a bovine pericardial patch. Clinical parameters and long-term outcome were analyzed.

      Result

      Overall, 15 male and 6 female patients have been included. Induction treatment was performed in 16 patients, 8 patients received chemoradiation therapy and the other 8 patients had chemotherapy alone. Pulmonary resection included 8 sleeve pneumonectomies, 4 pneumonectomies, 3 lobectomies and 4 sleeve-lobectomies of the right upper lobe, 1 extraanatomical resection of the right upper lobe and one mediastinal tumor debulking. Two patients required cardiopulmonary bypass during surgery. An additional extended resection including chest wall (n=1), phrenic nerve (n=3), pericardium or right atrium (n=4) was performed in 8 patients. Overall 5 patients underwent SVC reconstruction whereas 16 patients had complete SVC resection and replacement. The 90-day-mortality rate was 4.8% (n=1). Major complications occurred in 8 patients (38%) with no difference between patients undergoing SVC resection or reconstruction. Oncological long-term outcome will be presented at the conference.

      Conclusion

      Our results suggest that an extended resection including SVC replacement or reconstruction is a feasible and safe procedure for carefully selected patients with NSCLC and SVC involvement with acceptable postoperative morbidity and mortality rates.

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    EP1.12 - Small Cell Lung Cancer/NET (ID 202)

    • Event: WCLC 2019
    • Type: E-Poster Viewing in the Exhibit Hall
    • Track: Small Cell Lung Cancer/NET
    • Presentations: 1
    • Moderators:
    • Coordinates: 9/08/2019, 08:00 - 18:00, Exhibit Hall
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      EP1.12-23 - Surgery Is Associated with Favorable Outcome in Patients with Early Stage SCLC – Retrospective Institutional Experience (ID 1949)

      08:00 - 18:00  |  Author(s): Walter Klepetko

      • Abstract
      • Slides

      Background

      Small-cell lung cancer (SCLC) is characterized by rapid growth, early metastases and dismal outcome. Only few patients are diagnosed in early stages and thus might be candidates for potentially curative treatment. However, the value of surgery within multimodal treatment of early stage SCLC remains under debate. The aim of this study was to evaluate long-term outcome in patients with early stage SCLC undergoing curative intent surgery.

      Method

      Eligible patients with SCLC who underwent curative intent surgery at the Medical University of Vienna between 2006 and 2016 were retrospectively analyzed focusing on treatment modalities and long-term outcome.

      Result

      A total of 31 patients were included (male, n=20 (65%); median age 63.9 years). Clinical TNM-8 staging at diagnosis was stage I in 20 (65%), stage II in 5 (16%) and stage IIIA in 6 (19%) patients. 4 patients (13%) received induction chemotherapy. Sublobar resection was performed in 14 (45%) patients whereas 9 (29%) underwent lobectomy, 4 (13%) bilobectomy and 4 (13%) pneumonectomy. 24 (77%) patients received adjuvant treatment (chemotherapy, n=17 (55%); radiotherapy, n=1 (3%), chemoradiotherapy, n=5 (16%); PCI: n=8 (26%)). Median overall survival (OS) of all patients was 43.5 months, 3-years OS 58% and 5-years OS 42%, retrospectively. Patients undergoing sublobar resection had decreased median OS compared to patients undergoing lobectomy/bilobectomy/pneumonectomy (25.5 vs. 89 months, p=ns). Importantly, patients with TNM-8 stage I undergoing adjuvant chemotherapy had significantly improved OS compared to patients without adjuvant treatment (median OS 44 vs. 12 months, p=0.01).

      Conclusion

      This institutional experience shows good long-term outcome after adequate surgical resection followed by adjuvant treatment in selected patients with early stage SCLC. Our data indicate that sublobar resection should be avoided, however, well designed prospective trials are required to define the optimal treatment modalities in these patients.

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    EP1.17 - Treatment of Early Stage/Localized Disease (ID 207)

    • Event: WCLC 2019
    • Type: E-Poster Viewing in the Exhibit Hall
    • Track: Treatment of Early Stage/Localized Disease
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/08/2019, 08:00 - 18:00, Exhibit Hall
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      EP1.17-15 - Comparison of Long-Term Outcome of Wedge Resection, Anatomical Segmentectomy and Lobectomy in Stage I-II Non-Small Cell Lung Cancer (Now Available) (ID 2423)

      08:00 - 18:00  |  Author(s): Walter Klepetko

      • Abstract
      • Slides

      Background

      In patients with early stage non-small cell lung cancer (NSCLC) lobectomy is still considered the treatment of choice, whereas sublobar resection is more frequently performed in patients with reduced lung function and high perioperative risk. We investigated long term outcome of patients undergoing either lobectomy or anatomical segmentectomy or wedge resection for early stage NSCLC.

      Method

      In this retrospective cohort study patients with early stage NSCLC who underwent either lobectomy or anatomical segmentectomy or wedge resection at our center between 2006 and 2018 were analyzed. Primary endpoint was overall survival (OS) and disease-free survival (DFS).

      Result

      383 patients with peripherally located stage I or II NSCLC (TNM 8) who underwent curative intent surgery were identified. Patients undergoing neoadjuvant or adjuvant treatment or with centrally located tumors were excluded. 325 patients (84.8%) received lobectomy, 26 patients (6.8%) anatomical segmentectomy and 32 patients (8.4%) wedge resection. Pathological stage was IA 221 (57.7%), IB 93 (24.3%), IIA 48 (12.5%), IIB (3.9%). Histology revealed adenocarcinoma in 285 (74.4%), squamous cell lung cancer 98 (25.6%). There was no significant difference regarding OS and DFS between all three groups. Interestingly, in patients with tumors larger than 2cm there was also no significant difference in OS and DFS between all groups.

      Conclusion

      The relevance of sublobar resection in early stage NSCLC patients is still controversial. In our cohort study the long-term outcome of anatomical segmentectomy and wedge resection was comparable to outcome after lobectomy. However, well-designed prospective randomized studies are necessary to confirm the value of sublobar resections for stage I and II NSCLC.

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    IBS10 - Tracheal Tumours (Ticketed Session) (ID 47)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Thymoma/Other Thoracic Malignancies
    • Presentations: 1
    • Now Available
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      IBS10.01 - Surgerical Treatment of Tracheal Tumours (Now Available) (ID 3363)

      07:00 - 08:00  |  Author(s): Walter Klepetko

      • Abstract
      • Presentation
      • Slides

      Abstract

      Tracheal tumors are relatively rare and account only for <1% of all malignant diseases.1 The most common types of primary tracheal tumors are squamous cell carcinoma and adenoid cystic carcinoma, which represent together two thirds of all primary tracheal tumors.2 Additionally, patients with secondary tracheal tumors might benefit from resection of the tumor including the trachea.

      Surgical procedures involving the trachea require a meticulous pre-operative planning, advanced surgical techniques and infrastructural prerequisites. Therefore, surgical resections of tracheal tumors are highly elective procedures at specialized centers. The preoperative work-up includes the histological verification of the tumor via bronchoscopy, which is usually combined with the determination of the estimated extend of resection. Moreover, radiologic imaging, preferably PET-CT, completes the tumor staging. Patients with locally advanced and initially unresectable tracheal tumors might be candidates for neoadjuvant therapy. Usually, neoadjuvant treatment consisting of sole chemotherapy is preferred, as radiation therapy may negatively impact the anastomotic healing. If the patient received induction therapy, the radiological imaging as well as the bronchoscopic evaluation has to be repeated after completion of the induction therapy to confirm the response to the therapy and to plan the surgical procedure.

      The most common approaches for tracheal resection include cervicotomy, partial or complete sternofissure, and posterolateral thoracotomy. The optimal surgical approach has to be chosen according the location and extent of the tumor. During surgery, special care should be taken to preserve the lateral blood supply of the trachea, to protect the recurrent nerves and to avoid excessive tension on the anastomosis. Inadequate surgical technique increases the risk for anastomotic insufficiency, which is a potentially life-threatening complication. In the literature, anastomotic complications (i.e. partial or complete dehiscence, granuloma or re-stenosis) occur in approximately 9% cases after tracheal surgery. The risk for anastomotic complications increases with the length of resection, diabetes mellitus and previous treatments.3 As the airway in tracheal surgery has to be shared with the anesthesiologist, an appropriate ventilation strategy during induction of anesthesia, surgical preparation and at the end of the surgical procedure has to be defined. Although the double-lumen tube is routinely used in thoracic surgery, it has only a negligible role in airway surgery. The preferably used devices in airway surgery are the laryngeal mask, single-lumen endotracheal tube, high-frequency jet ventilation catheters and cross-table ventilation using a sterile endotracheal tube. Moreover, extracorporal membranoxygenation (ECMO) support is a valid option for selected, complex resections. It provides the advantage to operate on the patient without any airway device in the surgical field. A veno-venous ECMO is sufficient to fully substitute respiration. However, cardiorespiratory support by a veno-arterial ECMO configuration might be a valid option in some patients. In summary, the ventilation strategy is dependent on the location of the location, availability of devices, experience of the team and personal preferences. Therefore, planning the ventilation strategy is crucial for a successful surgical procedure.

      Similar to the surgical treatment of other solid malignancies, the major aim of tracheal surgery is the radical resection of the tumor including all loco-regional lymph nodes. The adenoid-cystic carcinoma represents an exemption from this rule. Due to its low-malignant tumor biology and the susceptibility to radiotherapy, even incomplete resection is acceptable in this tumor entity. As the adenoid-cystic carcinoma is characterized by a longitudinal, submucosal growth pattern (Figure 1), there might be a discrepancy between the resection length needed to obtain a complete resection and the technical possibility to perform a tension-free anastomosis. An incomplete resection combined with an adjuvant radiation therapy is therefore a valid treatment option in patients with adenoid-cystic carcinoma. Radiotherapy can be initiated as bronchoscopy confirms complete healing of the anastomosis approximately 6-8 weeks after surgery.

      Although the treatment of patients with tracheal tumors is demanding, an excellent perioperative and long-term outcome of patients with tracheal tumors can be achieved. In experienced hands, the peri-operative mortality after tracheal resection is <1%.4 Moreover, surgery in multimodality treatment concept provides a very good long-term overall survival, which is especially true for adenoid- cystic carcinoma in which a 5-year overall survival up to 91% can be achieved.5

      In summary, the surgical treatment of tracheal tumors is technically demanding and should therefore be performed at high-volume centers. Within the heterogeneity of tracheal tumors, the adenoid-cystic carcinoma represents a unique tumor entity. Embedded in a multimodal treatment concept, excellent long-term outcome can be achieved despite incomplete surgical resection. After careful planning by a multidisciplinary team, even extended tracheal resections for malignant disease can be performed safely with a very low morbidity and mortality.

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      Figure 1: Computed tomography of a 70 year-old with adenoid cystic carcinoma of the trachea. Note the longitudinal tumor growth pattern (red bracket).

      1. Grillo HC. Surgery of the trachea and bronchi. Hamilton, Ont. ; Lewiston, NY: BC Decker; 2004.

      2. Mallick S, Benson R, Giridhar P, Rajan Singh A, Rath GK. Demography, patterns of care and survival outcomes in patients with malignant tumors of trachea: A systematic review and individual patient data analysis of 733 patients. Lung Cancer. 2019;132:87-93.

      3. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. The Journal of thoracic and cardiovascular surgery. 2004;128(5):731-739.

      4. Auchincloss HG, Wright CD. Complications after tracheal resection and reconstruction: prevention and treatment. J Thorac Dis. 2016;8(Suppl 2):S160-167.

      5. Urdaneta AI, Yu JB, Wilson LD. Population based cancer registry analysis of primary tracheal carcinoma. Am J Clin Oncol. 2011;34(1):32-37.

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    P2.15 - Thymoma/Other Thoracic Malignancies (ID 185)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Thymoma/Other Thoracic Malignancies
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.15-11 - Favorable Long Term Survival After Initially Palliative Resection for a Giant Primary Rib Osteosarcoma with Severe Mediastinal Shifting  (Now Available) (ID 2440)

      10:15 - 18:15  |  Author(s): Walter Klepetko

      • Abstract
      • Slides

      Background

      Osteosarcoma is the most common malignancy of the bone with high morbidity and mortality. Treatment of choice is chemotherapy (CHT) followed by surgery and adjuvant CHT. Primary rib osteosarcoma is a rare disease. We present a case of a young patient with a giant primary rib osteosarcoma undergoing palliative resection.

      Method

      A 29-year-old woman presented with dyspnea and pain in the left chest wall in August 2012. Computed tomography (CT) showed a large lesion destructing the 3rdleft rib with extension to the left upper lobe. Biopsy revealed an osteoplastic osteosarcoma and staging examinations showed no distant metastases (DM).

      Result

      CHT by the EURAMOS-1-protocol was started but was discontinued by the patient after 1 cycle due to side effects. 1.5 years later without any treatment or follow up, the patient was re-admitted with massive thoracic pain, severity of dyspnea and in a very limited general condition. CT showed a major tumor progression with severe mediastinal shift and total atelectasis of the left lung. Due to extreme large tumor size and lack of treatment alternatives, surgery in palliative intent was performed: clamshell incision, complete resection of the tumor including chest wall reconstruction. The postoperative course was challenging but she recovered well and was discharged after several months with no evidence of disease in combined positron-emission-tomography/CT. Thereafter, the patient again refused any further treatment and checkups. 4.5 years later she presented again with local recurrence in the left chest wall and in excellent overall condition without evidence for DM. Accordingly, a re-thoracotomy, partial resection of ribs 6-9, left diaphragm and pericardium and reconstruction was performed. The postoperative course was without complications and the surgery was well-tolerated.

      Conclusion

      This case report shows an unexpected favorable outcome after resection in palliative intent for a giant primary rib osteosarcoma with severe mediastinal shifting. Currently, 7 years after diagnosis, the patient is free from disease.

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