Galal Ghaly

Anatomical Segmentectomy and Wedge Resections Are Associated with Comparable Outcomes for Patients with Small cT1N0 Non–Small Cell Lung Cancer

Objectives Sublobar resection is advocated for patients with NSCLC and compromised cardiopulmonary reserve, and for selected patients with early stage disease. Anatomic segmentectomy (AS) has traditionally been considered superior to wedge resection (WR), but well‐balanced comparative studies are lacking. We hypothesize that WR and AS are associated with comparable oncologic outcomes for patients with cT1N0 NSCLC. Methods A retrospective review of a prospective database was performed (2000–2014) for cT1N0 patients, excluding patients with multiple primary tumors, carcinoid tumors, adenocarcinoma in situ, and minimally invasive adenocarcinoma. Demographic, clinical, and pathological data were reviewed. Overall survival (OS) and disease‐free survival (DFS) were estimated using the Kaplan‐Meier method and differences compared using log‐rank test. Multivariable analysis (MVA) of factors affecting DFS was performed by Cox regression analysis. For further comparison of the effect of resection type on survival, propensity score matching (i.e., by age, sex, Charlson comorbidity index, percent forced expiratory volume in 1 second (FEV1%), clinical tumor size, and tumor maximum standardized uptake value) was performed to obtain balanced cohorts of patients undergoing WR and AS (n = 76 per group). Results Two hundred eighty‐nine patients met our selection criteria, including WR in 160 and AS in 129. Poor performance status and limited cardiopulmonary reserve were the primary indications for sublobar resection in 76% of WR patients and in 62% of AS patients (p = 0.011). Thirteen patients (4.5%) had pN1/2 disease. Patients undergoing AS were more likely to have nodal sampling/dissection [123 (95%) versus 112 (70%); p < 0.001], more stations sampled (3 versus 2; p < 0.001), and more total nodes resected (7 versus 4; p = 0.001). However, there was no difference between patients undergoing WR versus AS in local recurrence [15 versus 14; p = 0.68] or 5‐year DFS (51% versus 53%; p = 0.7; median follow‐up 34 months). Univariate analysis showed no effect of extent of resection on DFS [hazard ratio 1.07 (95% confidence interval 0.74–1.56); p = 0.696]. MVA showed that only tumor maximum standardized uptake value was associated with worse DFS [hazard ratio 1.07 (95% confidence interval 1.01–1.13); p = 0.016]. In the propensity‐matched analysis of balanced subgroups, there was also no difference (p = 0.950) in 3‐ or 5‐year DFS in cT1N0 patients undergoing WR (65% and 49%) or AS (68% and 49%). Conclusions Our data show that WR and AS are comparable oncologic procedures for carefully staged cT1N0 NSCLC patients. Although AS is associated with a more thorough lymph node dissection, this did not translate to a survival benefit in this patient population with a low rate of nodal metastases.

Lobectomy for Non-Small Cell Lung Cancer by Video-Assisted Thoracic Surgery: Effects of Cumulative Institutional Experience on Adequacy of Lymphadenectomy

BACKGROUND Because video-assisted thoracic surgery (VATS) lobectomies are increasingly being performed by thoracic surgeons, the adequacy of lymph node clearance by VATS compared with thoracotomy has been questioned, raising the possibility that patients are being understaged. One factor that may be overlooked in published studies is the learning curve of the surgeons and surgical volume in the adoption of VATS lobectomy. This study examined the effect of cumulative institutional VATS lobectomy experience on the adequacy of lymphadenectomy. METHODS We retrospectively reviewed a prospective database to identify 500 consecutive patients who underwent VATS lobectomy for non-small cell lung cancer (NSCLC) at our institution between 2002 and 2012. For comparative purposes, the cohort was divided into halves, with an early group (first 250 cases) vs a late group (next 250 cases). Clinical and pathologic factors were analyzed. A propensity-matching analysis controlling for age, gender, pathologic stage, and percentage of forced expiratory volume in 1 second was done to compare survival and adequacy of lymphadenectomy. RESULTS Patients operated on in the late group were significantly older (72 vs 69 years, p = 0.001) and had worse pulmonary functions (median forced expiratory volume in 1 second 83% vs 91%, p < 0.001; median diffusion capacity of the lung for carbon monoxide, 76% vs 85%, p < 0.001). Clinical and pathologic tumor sizes were significantly larger in the late group compared with the early group, with a median of 2.0 vs 1.8 cm (p = 0.002) for clinical T size and median of 2.1 vs 2.0 cm (p = 0.003) for pathologic T size. Patients in the late group had significantly more advanced clinical and pathologic stage distribution. The total number of lymph nodes and the number of nodal stations removed were significantly greater in the late group (p = 0.012) than in the early group (p < 0.001), and same results were obtained after propensity matching. No difference was seen in disease-free survival between the propensity-matched early vs late groups at 3 years (82% vs 85%, p = 0.187). CONCLUSIONS For patients with NSCLC resected by VATS lobectomy, cumulative institutional experience significantly and positively affects the adequacy of lymphadenectomy. This may be related to the initial surgeons learning curve with VATS lobectomy. As the experience with VATS lobectomy becomes more mature, the procedure is increasingly being performed on older patients, often with more compromised pulmonary function and more advanced stage disease. Despite the expanded inclusion of older and sicker patients for VATS lobectomy, no compromise was seen in their disease-free survival.

Locally advanced esophageal cancer: What becomes of 5-year survivors?

OBJECTIVE To determine the long-term outcomes of patients with locally advanced esophageal cancer (LAEC) who underwent esophagectomy and survived at least 5 years, and the predictors of disease-free survival (DFS) beyond 5 years. METHODS This was a retrospective review of a prospective database to identify patients with clinical stage T2N0M0 or higher LAEC. Medical records were reviewed to obtain demographic, clinical, and pathological characteristics, as well as data on recurrence and survival. Multivariable analysis of predictors of DFS beyond 5 years was performed using a Cox regression model. RESULTS Between 1988 and 2009, 355 of 500 patients underwent esophagectomy for cT2N0M0 or higher disease. Of these 355 patients, 126 were alive and disease-free at the 5-year follow-up, for an actuarial 5-year DFS of 33%. Recurrent esophageal cancer developed in 8 patients after 5 years. Among the 126 surviving patients, the actuarial overall survival was 94% at 7 years and 80% at 10 years. On multivariable analysis, the sole significant predictor of DFS after the 5-year time point was non-en bloc resection at the original operation (P = .006). Pulmonary-related deaths accounted for 10 out of 22 noncancer deaths. A second primary cancer developed in 23 of the 126 surviving patients. CONCLUSIONS Prolonged survival can be obtained in one-third of patients with LAEC. An en bloc resection at the original operation is the most significant predictor of prolonged survival. Survivors experience a high rate of second primary cancer and an apparently high rate of deaths from pulmonary disease. Careful follow-up is necessary for these patients, even after the 5-year mark.

Survival in Good Performance Malignant Pleural Mesothelioma Patients; Prognostic Factors and Predictors of Response

Purpose: Malignant pleural mesothelioma (MPM) has a poor prognosis in general. Here we sought to evaluate prognostic factors and predictors of response to chemotherapy in good performance (PS=0-I) patients. Methods: We retrospectively reviewed our database and enrolled patients with MPM who received platinum containing chemotherapy (2012-2014). Clinico-pathological and laboratory data were retrieved and Cox and logistic regression multivariate analyses (MVA) were respectively used to identify predictors of survival and response to chemotherapy. Comparison of good vs poor performance status (PS≥II) was accomplished using the Chi (X2) test. Kaplan–Meier survival curves were also obtained and propensity-score matching was performed for survival comparison. Results: Among 114 patients listed during the study period, 82 had good PS=0-I (median age 45years, 43 men, 30 smokers, median weight=77Kg, pretreatment haemoglobin (Hb) level=12g/dL, platelet count=372,000/μL, leukocytes=9,700/μL, neutrophils=6,100/μL, lymphocytes=1,890/μL and neutrophil/lymphocyte ratio (NLR)=3.60). Some 65 had asbestosis, 23 had chronic disease, 55 (67.1%) were responders to platinum containing first line chemotherapy. A total of 49 (59.8%) had epithelial MPM. Median-OS and PFS in good PS cases were 17 and 9 months, respectively, as compared to 16 and 8 months for the poor PS group. After matching, better OS was observed among good PS vs poor PS patients (p=0.024) but there was no PFS difference (p=0.176). Significant decrease in PFS was observed among those with advanced nodal N disease (median PFS in N0 and N+ was 10 and 5 months, respectively), non-responders (p=0.012), NLR (p=0.026) and those with an epithelial pathology (p=0.062). MVA demonstrated that advanced (N) status (p=0.015), being a non-responder (p<0.001), NLR (p=0.015) and smoking (p=0.07) adversely affected the prognosis. The only predictor of response was absence of metastasis (M0; p=0.04). Conclusions: In addition to previously recognized factors, like nodal status, response, smoking and NLR, better median survival was evident in our patients with a good PS. Early detection before development of metastasis warrants greater focus to allow better responses to be obtained.

PS01.44: 1,000 Video-Assisted Thoracoscopic Lobectomies: A Single institution’s Experience: Topic: Surgery

Age, in years 71(63-77) Gender Female 630(62.4%) Male 379(37.6%) Smoking No 271(26.9%) Yes 738(73.1%) Charlson’s Comorbidity Index CCI>2 182(18%) Clinical Stage Stage I 871(86.3%) Stage II 130(12.9%) Stage III 116(11.5%) PFTs FEV% (Median, IQR) n1⁄4965 90 (77-104) FVC% (Median, IQR)n1⁄4952 91 (80-102) DLCO% (Median, IQR)n1⁄4780 83 (68-99) Resected lobe laterality Rt side 612 (60.7%) Lt side 397 (39.3%) S296 Journal of Thoracic Oncology Vol. 11 No. 11S

PS01.52: New Chemotherapy Regimen: Does it Really Work for Esophageal Cancer Adenocarcinoma?: Topic: Medical Oncology

Background: With modern investigative procedures such as PET-Imaging, molecular profiling (e.g. Epidermal growth Factor Receptor (EGFR) and Anaplastic Lymphoma Kinase (ALK)) and radiotherapy techniques such as Stereotactic Body Radiotherapy (SBRT), the radiotherapy treatment outcomes of Lung cancer patients is expected to improve. Hence, we reviewed the clinical outcomes and prognostic factors in patients treated with radical radiotherapy for primary lung adenocarcinoma in the modern era in a tertiary referral centre. Methods: All stage IA-IIIB lung adenocarcinoma patients treated with radical radiotherapy from Feb 2009 to July 2015 were retrospectively reviewed. Patients were identified using department electronic records and the details of patient characteristics, diagnosis, treatments and follow-up were collected. Survival distributions were estimated using Kaplan-Meier method. Coxregression and logistic-regression analyses were performed. Results: A total of 162 (42 Stage IA/B, 9 Stage IIA/B, 111 Stage IIIA/B) patients were analysed. Median follow-up was 24.2 months. Mean age at diagnosis was 67.1 years. PET-staging was used in 98 (60.5%) patients. 111 patients were tested for EGFR mutations of which 41 (36.9%) were positive. 64 were tested for ALK mutation and 5 (7.8%) were positive. 37 patients received SBRT. At time of analysis, 105 patients had relapsed and 95 patients had died of which 81 were due to lung cancer progression. The 2 year overall survival (OS) was 62.7%, cancer-specific survival (CSS) 65.6% and recurrence-free survival (RFS) 44.5%. The median OS was 34 months (95% CI: 28.9-39.1), CSS 35.8 months (95% CI: 29.6-42.0), RFS 16.7 months (95% CI: 11.4 -22.1). Only PET-staging was associated with improved OS (HR 1.73, 95% CI: 1.16-2.95). On univariate analysis, stage, gender, tumour & nodal stage, PET-staging, BED (a/b1⁄410) and RT technique was associated with improved CSS. On multivariate analysis only Female gender (HR 0.45, 95% CI: 0.24-0.83) and PET-staging (HR 1.93, 95% CI: 1.173.18) remained significant factors for improved CSS. Over the time period studied, there was a significant decrease in 1-year incidence of recurrence. There was no trend in survival improvements. ALK mutation and a higher nodal stage were associated with a worst local control. On multivariate analysis, ALK remained a significant factor (HR 4.2, 95% CI: 1.18-15.1). Conclusion: Although the 1-year recurrence rates have decreased with time, this did not translate to an improvement in OS in our analysis. PET-staging and female gender were significantly associated with an improvement in CSS. The presence of ALK mutations appears to be associated with a worst local control. This may be due to an increased radio-resistance which should be evaluated by further studies.