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Haruhiko Kondo
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MS11 - Addressing Challenges with Surgical Resection of Lung Cancer (ID 74)
- Event: WCLC 2019
- Type: Mini Symposium
- Track: Treatment in the Real World - Support, Survivorship, Systems Research
- Presentations: 6
- Now Available
- Moderators:Ramon Rami-Porta, Haruhiko Kondo
- Coordinates: 9/09/2019, 15:45 - 17:30, Vancouver (2003)
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MS11.01 - Neoadjuvant Chemotherapy or Neoadjuvant Chemoradiation for Potentially Resectable Nsclc - a Surgeon's Perspective (Now Available) (ID 3500)
15:45 - 17:30 | Presenting Author(s): Ricardo Mingarini Terra
- Abstract
- Presentation
Abstract
Early studies of neoadjuvant therapy compared chemotherapy alone to surgery alone. Later, the Intergroup 0139 study utilized concurrent chemotherapy and radiation as its induction strategy, and this was the basis for adding radiation in the neoadjuvant strategy. Both strategies, neoadjuvant chemotherapy and neoadjuvant chemoradiation are considered alternatives for patients with stage IIIA non-small cell lung cancer deemed operable.
However, the toxicity of combined chemotherapy and radiation is significant. Radiotherapy has an inflammatory effect that leads to a more difficult surgical procedure and increases the number of postoperative complications. Moreover, studies comparing both strategies failed to demonstrate superiority of any of the two strategies in terms of overall survival.
On top of that, due to the limited number of radiotherapy clinics in emerging countries, radiotherapy schedules might delay the beginning of the patient’s treatment. This is also an issue to be considered when offering neoadjuvant chemoradiation.
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MS11.02 - Role of Surgery in Oligometastatic NSCLC (Now Available) (ID 3501)
15:45 - 17:30 | Presenting Author(s): C S Pramesh
- Abstract
- Presentation
Abstract
Role of Surgery in Oligometastatic NSCLC
The management of oligometastatic non-small cell lung cancer (NSCLC) is controversial. Sixty percent of patients with NSCLC present with metastatic disease; 45% of those with initially localized disease eventually develop metastatic disease. With 15% of these being oligometastatic disease, this is a significant problem. Over the last two decades, several advances have occurred which frame this question better. First, advances in imaging techniques including improved PET-CT and MRI have helped identify what is likely to be truly oligometastatic disease. Second, there have been advances in local therapy including minimally invasive and robotic approaches and perioperative management, as well as advanced radiation techniques including stereotactic ablative radiotherapy (SABR) which have made it safer. Finally, systemic therapy has undergone major changes with targeted therapy and immunotherapy making considerable progress. Most patients with metastatic NSCLC would be treated with systemic therapy with local treatment being offered only for symptomatic palliation. However, recognition of a “oligometastatic” state (where metastases are limited in number and location) has led to series of patients being treated with potentially curative intent using local treatment options, predominantly surgical.
Randomized trials to evaluate the role of surgery in oligometastatic NSCLC have not been performed, compelling a reliance on several published case series and meta analysis of these studies. These series have included highly selected patients with oligometastases, typically 1-3 metastases, most commonly located in the brain, and long term outcomes have been highly variable. Overall median five year survival of a meta analysis of studies was 23.3 percent. Five year survivals in patients treated with surgery both for the primary and the metastases range from as low as <10% to as high as 80% - this wide range is more likely a reflection of selection criteria for patients undergoing surgery rather than true variations in care. Moreover, with the lack of a true comparator arm, these results should be interpreted with caution. Important favourable prognostic factors include definitive treatment of the primary tumour, negative mediastinal nodal status and a longer disease-free interval.
Lack of well conducted prospective studies make conclusive recommendations on surgery for treatment of oligometastatic disease difficult. This is especially true now when better radiation techniques like SABR and improved outcomes with systemic treatment in selected patients with targeted and immunotherapy are available. Given the available evidence, it appears reasonable to consider surgical treatment in patients with oligometastatic disease fulfilling the following criteria: good performance status, accurately staged, with PET-CT and MRI brain showing no other sites of metastases, metachronous disease with relatively long disease free interval, negative mediastinal nodes on invasive staging, and controlled primary disease. With randomized trials being unlikely in this setting, further studies are required which prospectively collect real-world data systematically, enabling better selection criteria for patients for surgery in oligometastatic NSCLC.
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MS11.03 - Minimizing Peri-Operative Morbidity with Pneumonectomy (Now Available) (ID 3502)
15:45 - 17:30 | Presenting Author(s): Shun-ichi Watanabe
- Abstract
- Presentation
Abstract
1. Introduction
The incidence of surgical morbidity after standard pneumonectomy is reportedly 30 to 60%. Many previous studies have addressed several risk factors for surgical morbidity after pneumonectomy, including age, cardiovascular disease, recent body weight loss, high smoking index, low FEV1.0 value, chronic obstructive pulmonary disease (COPD), right pneumonectomy, massive blood loss during surgery, long operation time, neoadjuvant therapy and so on. Although surgical morbidity after pneumonectomy easily lead to patients’ mortality. When pneumonectomy seems to be inevitable to remove the tumor, surgeons sometimes intraoperatively weigh the oncological benefit of pneumonectomy against the postoperative poor QOL and high morbidity rate.
In this paper, the cause and proper management of postpneumonectomy complications are discussed to minimize peri-operative morbidity with pneumonectomy as for especially following two life-threatening categories, cardiovascular and respiratory complications.
2. Type of Complications
2.1 Cardiovascular Complications
2.1.1 Supraventricular Arrhythmias
Most of supraventricular arrhythmias present 1 to 4 days after standard pneumonectomy, but it sometimes present even a week after surgery. The incidence of supraventricular arrhythmia after pneumonectomy is reportedly 4 to 25%. Risk factors for supraventricular arrhythmias include old age, right pneumonectomy, intrapericardial pneumonectomy, major co-morbidities, and so on. For patients who are considered to be high risk for postoperative atrial fibrillation, following prevention strategies are indicated. According to the 2014 AATS guidelines, continuing β blockers in patients taking β-blockers before surgery, using intravenous magnesium supplementation if serum magnesium levels are low, using diltiazem in those patients with preserved cardiac function who were not taking β-blockers preoperatively, or using amiodarone in patients at an intermediate to high risk of developing postoperative atrial fibrillation. For hemodynamically stable patients with new onset atrial fibrillation, intravenous β-blockers or calcium channel blockers are used to reduce a heart rate down to 100 beats per minute. When patients are hemodynamically unstable, direct current cardioversion should be used. And for patients with refractory atrial fibrillation, systemic anticoagulation therapy should be used carefully weighing benefits against the risk of bleeding, especially after EPP.
2.1.2 Ischemic Heart Disease
Ischemic heart disease is known to be an independent risk factor for severe complications after pneumonectomy. The risk of a myocardial infarction after pneumonectomy is reportedly approximately 0.2 to 2.1%. Patients who are candidates for pneumonectomy should undergo careful preoperative assessment to screen for untreated coronary ischemic disease.
2.1.3 Cardiac Herniation
Cardiac herniation is a rare complication after intrapericardial pneumonectomy. Patients develop cardiac herniation when the intrathoracic pressure changes rapidly by severe cough or vomit with decubitus position. Rapid and severe hemodynamic collapse following a change in patient positioning should heighten the clinical suspicion. Chest X-ray and electric cardiogram clearly show the abnormal position of the heart (Figure 1 and 2). Correction of the cardiac herniation should be conducted immediately by re-thoracotomy after successful resuscitation. Sewing the patch to the weak tissues around the pericardium rather than the pericardium itself after intrapericardial pneumonectomy could increase the risk of cardiac herniation.
2.2 Respiratory Complications
2.2.1 Pneumonia
The incidence of pneumonia after pneumonectomy is reportedly 2 to 10%. Since pneumonia after pneumonectomy could be a life-threatening complication, care must be taken to lessen the risk of pneumonectomy. Preoperative smoking cessation, chest physiotherapy by nurses or respiratory therapists, use of enough amount of post-thoracotomy painkillers, and bronchial toilet by bronchoscope are important practical factors for minimizing the risk of pneumonia.
2.2.2 Acute Respiratory Distress Syndrome (ARDS)
According to the previous literatures, ARDS occurs in 2.7 to 3.1% of patients after standard pneumonectomy with very high mortality of 50 to 70%. Treatment of ARDS is supportive. Mechanical ventilation with small tidal volumes of less than 6 mg/kg body weight should be used to minimize the barotrauma, and the FiO2 level should be decreased to the lowest level to minimize the oxidative trauma. There has been no evidence that steroids improve the prognosis of patients developing ARDS.
2.2.3 Bronchopleural Fistula (BPF)
The incidence of BPF, which is a life-threatening complication, is reportedly 2 to 11%. The mortality of BPF after pneumonectomy is very high rate of around 40%. Risk factors for BPF includes diabetes mellitus, malnutrition, long stump (especially for left side), right pneumonectomy, preoperative chemoradiation therapy, and so on. When a patient develop the BPF, open window technique should be applied to control thoracic cavity infection which can lead the patient to death.
3. Conclusion
The mortality and morbidity rates after pneumonectomy are very high compared with those after lobectomy, simply because the patients have less cardio-pulmonary reservations. Therefore, when complications occur, surgeons must aggressively treat them not to lose the patient with taking abovementioned knowledge into consideration.
Figure 1
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MS11.04 - Surgical Resection of SCLC - Not so Obsolete Any Longer (Now Available) (ID 3503)
15:45 - 17:30 | Presenting Author(s): Gustavo Lyons
- Abstract
- Presentation
Abstract
More than 2 million new lung cancer cases were detected worldwide in 2018, and small cell lung cancer (SCLC) represents about 13-15 % of all lung cancers.
Although surgery was initially regarded as the treatment of choice for all types of lung cancer, it was abandoned for SCLC almost 30 years ago after the results of the Medical Research Council (MRC) randomized trial conducted by Fox et al. in 1973, which showed poor mean survival for the surgical group when compared to the RT group (6.5 months vs. 10 months, P = 0.04). (1) These results led to the abandonment of surgery as a standard treatment in favor of chemotherapy. Two subsequent meta-analyses revealed that the addition of thoracic radiation to systemic chemotherapy improved survival, and that has become the standard of care. (2)
After the introduction of TNM classification, investigators proposed that surgery was postulated to be indicated in limited-SCLC, particularly stage T1, N0, with 5-year survival rates of as high as 52.6% for stage 1 disease. (3) Further, surgical resection after induction chemoradiotherapy demonstrated a control of local relapse in almost 100% of the patients and 5- and 10-year survival rates for patients with stage IIB to IIA were 39% and 35%, respectively, for all patients (resected or not) and 44% and 41% for patients treated with a trimodality approach including adjuvant surgery. (4) Another argument for surgical resection is that the final histology of SCLC might reveal a component of NSCLC in 11-25% cases. (5)
In a recent series of Wakeam et al. including 2,089 patients with SCLC undergoing surgery who were matched 1:1 to those undergoing NST, surgery was associated with longer survival for stage I (median overall survival [OS] 38.6 months vs. 22.9 months), for stage II (median OS 23.4 months vs. 20.7 months), and stage IIIA (median OS 21.7 vs. 16.0 months. In analyses by T and N stage, longer OS was observed in resected patients with stage T3/T4 N0 (median OS 33.0 vs. 16.8 months, p=0.008) and node positivity (N1+ 24.4 vs. 18.3 months p=0.03; N2+ 20.1 vs. 14.6 months p=0.007). (6)
A recent meta-analysis that included a total of 41,483 patients concluded that surgical resection was associated with superior OS in stage I (HR = 0.56, 95% CI: 0.49–0.64, p< 0.001), stage II (HR = 0.75, 95% CI: 0.57–0.99, P = 0.04), and stage III diseases (HR = 0.70, 95% CI: 0.56–0.88, P = 0.002). (11) Unlike stage I disease, there is no consensus for surgery in stage II and stage IIIA SCLC.
Surgical resection is concordant with NCCN and ASCO guidelines; however, evidence shows that in the vast majority of T1 and T2 N0M0 patients, surgery is not offered in the absence of any documented contraindication. Rostadt et al., in a series of 2,442 patients with SCLC, found out that 26% were stages IA and IB and thus candidates for surgical resection, while only 38 patients (1.5%) underwent surgical therapy. (8)
CT screening identifies SCLC at an earlier stage – with better survival – than usual care and offers the hope that more SCLC patients may become long-term survivors. Austin et al. carried out a multinational study of baseline and annual repeat CT screenings of 48,037 volunteers at risk for lung cancer. (9) They found 48 SCLC cases, 92% of which were asymptomatic at diagnosis. Clinical stage was IA in 16 patients (33%), II in 5 (11%), III in 20 (42%), and IV in 7 (15%). Estimated cure rates were 36% overall and 54% for the clinical stage I cases.
Conclusions
Surgical resection is indicated in SCLC in stages I and IIA after precise staging including mediastinoscopy. Patients should receive systemic therapy after resection and mediastinal radiation therapy in cases with nodal metastases. Surgical resection in stages I and IIA SCLC is concordant with NCCN and ASCO guidelines; however, surgery is offered only in one-third of the patients in the absence of any documented contraindication. CT screening identifies SCLC at an earlier stage and offers the hope that more SCLC patients may be candidates for surgical resection and become long-term survivors. Selected cases in stages IIB and IIIA may be candidates for surgery as part of the multidisciplinary treatment.
References
1) Fox W, Scadding JG. Medical Research Council comparative trial of surgery and radiotherapy for primary treatment of small-celled or oat-celled carcinoma of bronchus. Ten-year follow-up. Lancet. 1973; 2: 63–5.)
2) Pignon JP, Arriagada R, Ihde DC, et al. A meta-analysis of thoracic radiotherapy for small-cell lung cancer. N Engl J Med. 1999;341:476-484. Warde P, Payne D. Does thoracic irradiation improve survival and local control in limited-stage small-cell carcinoma of the lung? A meta-analysis. J Clin Oncol. 1992;10:890-895.)
3) Schreiber D, Rineer J, Weedon J, Vongtama D, Wortham A, Kim A, et al. Survival outcomes with theuse of surgery in limited-stage small cell lung cancer: should its role be re-evaluated? Cancer. 2010;116: 1350–57.
4) Eberhardt W, Korfee S. New approaches for small-cell lung cancer: Local treatments. Cancer Control 2003;10:289-96.
5) Asamura H, Kameya T, Matsuno Y, Noguchi M, Tada H, Ishikawa Y, et al. Neuroendocrine neoplasms of the lung: A prognostic spectrum. J Clin Oncol 2006;24:70-6.)
6) Wakeam E, Acuna SA, Leighl NB, Giuliani ME, Finlayson SRG, Varghese TK, et al. Surgery Versus Chemotherapy and Radiotherapy For Early and Locally Advanced Small Cell Lung Cancer: A Propensity-Matched Analysis of Survival. Lung Cancer. 2017; 109: 78–88.
7) Liu T, Chen Z, Dang J, Li G (2018) The role of surgery in stage I to III small cell lung cancer: A systematic review and meta-analysis. PLoS ONE 13(12): e0210001.
8) Hans Rostadt, Anne Naalsundb, Randi Jacobsena, Trond Eirik Stranda, Helge Scottc, Erik Heyerdahl Strømc, Jarle Norsteina. Should more patients have been offered surgical therapy? European Journal of Cardio-thoracic Surgery 26 (2004) 782–786)
9) Austin JH, Yip R, D'Souza BM, Yankelevitz DF, Henschke CI, International Early Lung Cancer Action Program Investigators. Small-cell carcinoma of the lung detected by CT screening: stage distribution and curability. Lung Cancer. 2012 76(3): 339-43.)
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MS11.05 - Pathological Reporting of Resected Lung Cancer - the Importance of Using Additional TNM Descriptors (Now Available) (ID 3504)
15:45 - 17:30 | Presenting Author(s): Ellen Caroline Toledo Nascimento
- Abstract
- Presentation
Abstract
Context. The anatomopathological examination aims to establish a specific diagnosis of the tumor and to provide essential information related to cancer staging, patient management and prognosis. Such information, as histologic type, lymphovascular invasion, spread through air spaces, margins, treatment effect, and TNM descriptors should be disclosed concisely, following previously defined protocols, and correlate satisfactorily with radiological exams and clinical aspects in order to allow the best management for the patient.
Histopathological (macroscopic and microscopic evaluation) combined with complementary immunohistochemical and molecular studies, provides prognostic and predictive information on tumor biology and clinical behavior. The TNM staging classifies the tumors according to the anatomic extent with an important prognostic impact. In addition, it allows the establishment of criteria for inclusion and exclusion of patients in protocol studies and subgroups of treatment, cancer registry, epidemiology and multidisciplinary management.
The T component analysis is complex because it has many elements: presence or absence of invasion, tumor size, endobronchial location, atelectasis / pneumonitis and invasion of the various anatomical structures around the lung. The determination of the largest tumor diameter requires accurate measurements since in the eighth edition TNM stage classification for lung cancer each centimeter separates tumors with different prognoses from 1 to 5 centimeters (cm). Appropriate size measurement is especially important when it comes to subsolid tumors since the correlation with the computed tomographic imaging in this context is of great value. Tumors measuring larger than 5 cm up to 7 cm (T3 in the eighth edition) had a worse prognosis than found in the seventh edition of the TNM classification. Tumors larger than 7 cm (T4 in the eighth edition) have similar prognosis to other descriptors in the T4 category. Atelectasis or pneumonitis involving the whole lung (T3 in the seventh edition) has the same prognosis for partial atelectasis / pneumonitis (T2 descriptor in the seventh edition). Endobronchial tumor location less than 2 cm from carina (a T3 descriptor in the seventh edition), but without carina involvement, had the same prognosis as the endobronchial location further than 2 cm from carina (a T2 descriptor in the seventh edition). In the eighth edition, tumors involving the main bronchus and associated with atelectasis / pneumonitis are classified as T2. On the other hand, diaphragm invasion (a T3 descriptor in the seventh edition was upstaged to T4 in the eighth edition) since it has similar prognosis of T4 tumors.
No changes to the N descriptors were proposed in the 8th TNM as the four N categories (N0, N1, N2, N3). The reassessment of the M component validated the proposed M1a category descriptors in the seventh edition and separated the distant metastases into two categories with different prognoses, M1b (single metastatic tumor in one organ), and M1c (multiple metastases in either single organ or multiple organs).
Objective. To review and discuss the 8th edition of the TNM classification of lung cancer with an emphasis on prognostic relevance and implications for the pathologist's report.
Data Sources. The review is based on the available literature.
Conclusion. The TNM (tumor-node-metastasis) classification system for lung cancer is the strongest prognostic indicator and fundamental for decisions on therapy. The eighth edition of the TNM classification of lung cancer enhances the prognostic discrimination of the different T categories and differentiates unique extrathoracic metastasis (better prognosis) from multiple metastases in one or several organs providing better definition of oligometastatic disease. Thus, the eighth edition of TNM improves the understanding of tumor anatomic extent and stratification of tumors for clinical trials.
References:
1) Rami-Porta R, Call S, Dooms C, Obiols C, Sanchez M, Travis WD et al. Lung cancer staging: a concise update. Eur Respir J. 2018;51(5).
2) Rami-Porta R, Bolejack V, Crowley J, Ball D, Kim J, Lyons G et al. The IALSC lung cancer staging project: proposals for the revisions of the T descriptors in the forthcoming eighth edition of the TNM classification for lung cancer. J Thorac Oncol. 2015;10(7):990-1003.
3) Detterbeck FC. The eighth edition TNM stage classification for lung cancer: what does it mean on main street? J Thorac Cardiovasc Surg. 2018;155(1):356-359.
4) Eberhardt WE, Mitchell A, Crowley J, Kondo H, Kim YT, Turrisi A 3rd et al. The IALSC lung cancer staging project: proposals for the revision of the M descriptors in the forthcoming eighth edition of the TNM classification of lung cancer. J Thorac Oncol. 2015;10(11):1515-1522.
5) Kay FU, Kandathil A, Batra K, Saboo SS, Abbara S, Rajiah P. Revisions to the tumor, node, metastasis staging of lung cancer (8th edition): rationale, radiologic findings and clinical implications. World J Radiol. 2017;9(6):269-279.
6) Rami-Porta R, Asamura H, Travis WD, Rusch VW. Lung cancer – major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(2):138-155.
7) Nicholson AG, Tsao MS, Travis WD, Patil DT, Galateau-Salle F, Marino M et al. Eight edition staging of thoracic malignancies: implications of the reporting pathologist. Arch Pathol Lab Med. 2018;142(5):645-661.
8) Aokage K, Miyoshi T, Ishii G, Kusumoto M, Nomura S, Katsumata S et al. Clinical and pathological staging validation in the eighth edition of the TNM classification for lung cancer: correlation between solid size on thin-section computed tomography and invasive size in pathological findings in the new T classification. J Thorac Oncol. 2017;12(9):1403-1412.
9) Butnor KJ, Beasley MB, Dacic S, Berman M, Flieder D, Jones K et al. Protocol for the examination of specimens from patients with primary non-small cell carcinoma, small cell carcinoma or carcinoid tumor of the lung. Version: Lung 4.0.0.3. 2017. https://documents.cap.org/protocols/cp-thorax-lung-2017-protocol-4003.pdf
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MS11.06 - The Impact of Prehabilitation on Patients Having Lung Cancer Surgery (Now Available) (ID 4060)
15:45 - 17:30 | Presenting Author(s): David Sanchez-Lorente
- Abstract
- Presentation
Abstract not provided
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