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General Thoracic Surgery
New This Year
In Case You Missed it!!!
General Thoracic Surgery
New This Year
Brief Review of a Few of my favorite studies
In Case You Missed it!!!
General Thoracic Surgery
New This Year
Brief Review of a Few of my favorite studies
I got to sit through ENJOY EVERY
presentation
Multimodality therapy for
locally advanced thymomas:
a cohort study of prognostic factors
from a European multicentric database
Dr. GIOVANNI LEUZZI
Department of Surgical Oncology
Thoracic Surgery Unit
“Regina Elena” National Cancer Institute, Rome, Italy
Background
 Locally-advanced Thymomas (LATs): 20-29 %
 Heterogeneous entity
o Different tumor size
o Different organ involvements
 Radical resection not usually feasible (50-78%)
 ~ 50 % LATs experience recurrence after
surgery
 Higher stage (III-IV) and R+ resection decrease
survival
Our experience
European Society of Thoracic Surgeons (ESTS) thymic database
(38 Institutions)
Stage I, II and IV
excluded
2317 surgically-treated
Thymic Tumors
(01/1990 – 01/2010)
370 Masaoka-Koga stage III
Thymomas
(WHO Histology A to B3)
Thymic carcinoma
and NETT excluded
Outcome & Treatment Strategy
1.0
Treatment strategy
(n=353)
Pts (%)
Surgery alone
66(18.7%)
IT + Surgery + AT
46(13.0%)
IT + Surgery
42(11.9%)
Probability of Survival
Probability of Survival)
.9
Surgery + AT 199(56.4%)
.8
.7
.6
.5
.4
.3
p=0.006
.2
Surgery alone
IT + Surgery + AT
IT + Surgery
Surgery + AT
.1
0.0
0
IT
Group
Primary Surgery
Group
p-value
CSS
85.0%
88.3%
0.82
RFS
77.9%
84.0%
0.31
30
60
CSS (months)
CSS (months)
90
120
Probability of Survival
Outcome & Adjuvant Therapy
p=0.0004
AT Group
No AT Group
p-value
CSS
91.1%
81.5%
0.0004
RFS
85.5%
79.3%
0.19
Conclusions
 Our analysis indicates that Induction Therapy is not associated with a
survival advantage.
 Administration of Adjuvant Therapy and Completeness of Resection
represent the most significant outcome predictors.
 Adjuvant Therapy should be administered whenever possible, especially
in those patients with specific pathological features (pT2/3 or tumor size
smaller than 5 cm) who may benefit the most from multimodality
treatment.
My Thoughts
 Very heterogeneous cohort of patients
 Induction Therapy in my Practice is reserved for Marginally
resectable patients
 This might be a very significant source of bias
The Impact of Adjuvant Chemotherapy in Pulmonary
Large Cell Neuroendocrine Carcinoma (LCNC)
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
LCNC
 Rare tumor (2% to 3% all resected
primary lung cancers)
 Preoperative diagnosis is often
impossible
 Clinical behavior and prognosis
similar to SCLC
 Surgery alone is insufficient to
treat LCNC, even in early Stages
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
Author
Year
N°
pts
5-y
OS
5-y OS
Stage I
Recurrence %
Garcia-Yuste et al. 2000 22
21 % 33 %
59 %
Takey et al.
2003 87
57 % 67 %
40 %
Battafarano et al.
2004 45
30 % 33 %
49 %
Paci et al.
2004 48
21 % 27 %
NA
Rossi et al.
2005 83
NA
33 %
65 %
Veronesi et al.
2006 144
42 % 52 %
40 %
NA
38 %
Pier Luigi Filosso, MD
Sarkaria et al.
2011 100
University of Torino, Department of Thoracic Surgery
58 %
2014:
14 Centres 2054 patients
Atypical Carcinoid
LCNC
Mixed Tumor
SCLC
Typical Carcinoid
Unspecified
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
Aim of the study
 To evaluate the possible adjuvant CT effect on LCNC survival
 To assess clinicopathologic prognostic factors in a surgicallybased population of patient with LCNC
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
No.
400 pts
%
Age (median – IQR-)
66 (58-72)
Gender (male)
252
63
Smokers (current/former)
99
25
Previous malignancy
99
25
I
185
48
II
110
29
III
76
20
IV
12
3
53 (44 CT; 9 RT)
13
146
37
pTNM
Induction therapy
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
Adjuvant CT
Overall survival
1.00
Median OS: 43 months
0.75
0.50
3-y surv rate: 54 %
5-y surv rate: 45 %
0.25
0.00
0
12
24
36
48
400
292
202
149
110
60
72
Months
84
96
108
120
54
35
25
22
At risk:
94
70
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
OS according to
adjuvant CT administration
A slight improvement in OS was observed
in those who received adjuvant CT
(HR 0.82; 95%CI: 0.62-1.09, P=0.17)
1.00
0.75
0.50
0.25
No
Yes
0.00
0
At risk:
No 254
Yes 146
12
24
36
48
60
Months
72
84
96
108
120
182
110
126
76
92
57
68
42
59
35
42
28
33
21
22
13
19
6
17
5
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
 We observed a signal of an improved survival in LCNC patients
treated with adjuvant CT
 We did not identify a particular subset of patients in which
adjuvant CT might be more appropriate
 Prospective data collection (ESTS prospective database),
will hopefully help to define more tailored treatment
strategy for such aggressive neoplasm
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
My Thoughts
Very Large Study of LCNC
We All expected as much
Adjuvant Chemotherapy Should be a Small Cell Regimen
Cis/Etoposide
PCI?
Pier Luigi Filosso, MD
University of Torino, Department of Thoracic Surgery
Routine Venous
Thromboembolism Screening after
Pneumonectomy: The More You
Look, the More You See
Department of Thoracic and Cardiovascular
Surgery
Cleveland Clinic Foundation
AATS 2015
STS Database
General Thoracic Surgery Database
DVT req.
Rx
Pulmonary
Embolism
1%
1.2%
2011-13
Practice Change
Routine screening pre discharge after
pneumonectomy was initiated in 2006 as part
of a quality improvement initiative
Objectives
• Ascertain the prevalence of VTE after
pneumonectomy
• Assess risk of developing VTE
• Identify risk factors for VTE
• Determine effect of VTE on survival
Patients
Pneumonectomy
For Malignancy
VTE Screened
2006 – 2012
n = 112
VTE Not Screened
1990 – 2001
n = 336
VTE Events
Total
n = 112
VTE
20 patients
50% In-hospital Discharge In 30 days 20%
10
4
Risk of VTE
1.0
%/day
0.75
Screened
0.5
Not screened
0.25
0
7
14
21
28
35
42
Days after Pneumonectomy
Survival and VTE
100
Survival before VTE
80
%
60
40
Survival after VTE
20
0.0
0.5
1.0
1.5
Years
2.0
2.5
My Thoughts
DVT post Px is a bad thing
DVT is a Marker for an Unclear Mechanism of
Mortality
Right Heart failure
Advanced Cancer
Limited Pulmonary Reserve
Giving Induction Radiation in Addition to Chemotherapy
Is Not Associated with Improved Survival of NSCLC Patients
with Operable Mediastinal Nodal Disease
Chi-Fu Jeffrey Yang MD, Brian Gulack MD, Paul Speicher MD, Xiaofei Wang PhD, Mark Onaitis MD, David
Harpole MD, Thomas D’Amico MD, Mark Berry MD, Matthew Hartwig MD
Duke Cancer Institute
Durham, NC
Objective

Assess outcomes of patients with operable stage IIIA-N2 disease who
received induction chemotherapy (Chemo) vs induction chemoradiation
(ChemoRT)

National Cancer Data Base

Hypothesis: No significant improvement would be observed with the addition
of radiation to induction chemotherapy
Down-staging
Variable
T stage down-staging
N2 to N0/N1 down-staging
Chemo
(N = 528)
Chemo+RT
(N = 834)
p-value
24%
46%
38%
58%
<0.01
<0.01
• T stage down-staging was more common with induction chemoradiation
• Nodal down-staging from N2 to N1/N0 was more common with the induction
chemoradiation
Overall Survival of Patients with Operable N2 NSCLC who Underwent Induction
Chemotherapy vs. Induction Chemoradiation
Treatment
Median survival
5-year survival
Induction CRT
3.3 years
41.4 %
Induction CT
3.4 years
40.8 %
p = 0.78
Induction CRT – 834
Induction CT – 528
698
445
533
341
406
278
356
227
299
188
205
130
110
62
49
29
My Thoughts

There is almost always an association between downstaging (especially N) and survival improvement

This relationship does not appear to hold true here
Randomized Trial of Digital Versus Analog Pleural Drainage in
Patients With or Without a Pulmonary Air Leak after Lung
Resection.
Sebastien Gilbert1,2 MD,
Anna L McGuire3 MD MSc, Sonam Maghera4 BSc, Donna E Maziak1 MD MSc, Andrew J Seely1,2 MD
PhD, Farid M Shamji1 MD, Sudhir Sundaresan1 MD,
and P James Villeneuve1,2 MD PhD
1Division of Thoracic Surgery, The Ottawa Hospital
2The Ottawa Hospital Research Institute
3University of British Columbia
4Faculty of Medicine, University of Ottawa
Ottawa, Canada
Objective
 Compare digital and analog pleural drainage:
 Length of stay (primary)
 Duration of chest tube drainage (secondary)
 Take into account postoperative air leak status
Hypothesis
 Digital pleural drainage = ↓length of stay (LOS)
 Regardless of postoperative air leak status
Outcomes
Group 1:
Air leak absent (n=87)
Analog
Digital
(n=43)
(n=44)
p
Group 2:
Air leak present (n=85)
Analog
Digital
(n=42)
(n=43)
p
LOS
4.3
(3.3-5.2)
4.0
(3.2-5.1)
0.09
6.2
(5.2-9.1)
6.2
(4.3-8.1)
0.36
CT Drainage
3.0
(2.9-4.9)
2.9
(2.2-3.9)
0.05
5.6
(4.0-8.9)
4.9
(3.1-6.4)
0.11
Median number of days with interquartile range
My Thoughts
 Control Group had extreme non-standard of care air leak
assessment (2 independent observers with a 3rd to break the
tie)
 Fair comparison?
 Chest Tube removal is a daylight procedure.
Accelerated hemithoracic radiation followed by
extrapleural pneumonectomy
for malignant pleural mesothelioma
Marc de Perrot, Ronald Feld, Natasha B Leighl, Andrew Hope, Thomas K
Waddell, Shaf Keshavjee, BC John Cho
Toronto Mesothelioma Research Program
University Health Network
Toronto, Canada
Rational
• Optimal delivery of radiation to the primary
tumor based on PET and CT scan findings
• Sterilization of the edges of the tumor before
surgery to decrease the risk of seeding
• Short treatment
• Potential immunogenic benefit
Postoperative grade 3+ complications (n=24)
Atrial fibrillation
Empyema
Pulmonary emboli
Pneumonia
Chylothorax
Hemothorax
Wound problem
Patch dehiscence
Others
0
2
4
6
8
Number of patients*
*6 patients had more than one grade 3+ complication
10
12
Postoperative grade 3+ complications
Rate of grade 3+ complications decreased over time
p=0.02
Percentage of grade 3+
complications
70
60
50
40
Other complications
than atrial fibrillation
45%
30
12%
20
10
Atrial fibrillation alone
15%
17%
First 20 patients
Last 42 patients
0
Pathological stage
94% stage III and IV
52% N2+
Overall survival
Intention-to-treat analysis (n=62)
Percent survival
100
80
60
40
20
Median survival 36 months
0
0
12
24
36
48
Months after start of treatment
60
Overall survival by histologic subtypes
cT1-3N0M0 treatment naive (n=56)
Overall survival (%)
100
Epithelial
76%
80
Biphasic
60
p=0.001
40
29%
Median survival:
Epithelial 51 mo
Biphasic 10 mo
20
0
0
12
24
36
48
Months after start of treatment
60
My Thoughts
Very Novel Treatment
Superb Results
100% Resectability rate because the Lung has
to come out!
52
Is surgical resection justified for myasthenia gravis?
Long-term results in over 1000 cases.
Andrew J. Kaufman, MD; Justin Palatt, MD; Mark Sivak, MD, Peter Raimondi, BS, Dong-Seok
Lee, MD; Andrea Wolf, MD, MPH; Fouad Lajam, MD, Faiz Bhora, MD; Raja M. Flores MD.
Department of Thoracic Surgery, Mount Sinai School of Medicine
Andrew J. Kaufman MD
Assistant Professor, Thoracic Surgery
Mount Sinai School of Medicine
Chief, Thoracic Surgery Mount Sinai Beth Israel
New York, New York
Methods
• Retrospective review of a prospectively maintained database of
thymectomy patients from 1941-2013.
• 1002 included in study.
• Inclusion Criteria:
• Thymectomy
• Age at time of surgery
• Gender
• Duration of symptoms before surgery
• Osserman Classification before and after surgery
• Surgical technique
• Presence of thymoma
• Date of remission, and status at last follow-up
Interval-censored Kaplan-Meier estimate of time to complete
stable
remission
Estimated Failure Probability
Probability of CSR
Cumulative
Failure Probability
0.5
0.4
0.3
Time Interval in Years Estimate of CSR Estimate of Non-CSR Standard Error
0-2
15.99%
84.01%
1.42%
3-7
19.39%
80.61%
1.49%
8-8
19.43%
80.57%
1.49%
9-10
27.68%
72.32%
1.72%
11-15
29.14%
70.86%
1.74%
16-24
32.17%
67.83%
1.89%
25-39
36.65%
63.35%
2.25%
40-50
47.31%
52.69%
8.98%
0.2
0.1
0.0
0
10
20
30
Time
Time to Remission in years
40
50
My Thoughts
• 60 year Study
• Lessens the impact
• Data not particularly granular
• But, very large study with important bottom line
Adjuvant Radiation is Not Associated with Improved Survival in
Patients with Positive Margins Following Lobectomy for Stage I & II
Non-Small Cell Lung Cancer
Brian C Gulack, MD; Jeffrey Chi-Fu Yang, MD; Paul J Speicher, MD, MHS; H. Volkan Kara,
MD; Thomas A D’Amico, MD; Mark F Berry, MD, MHS; Matthew G Hartwig, MD
57
Background
• Lobectomy
– Most common surgical procedure performed for stage I or II NSCLC.
– 4-6% associated with positive margins.
• Current NCCN guidelines for positive margins:
– Re-resection +/- chemotherapy (preferred).
– Adjuvant radiation +/- chemotherapy.
– Based on limited data.
• Reviewed the National Cancer Data Base (NCDB) in order to better
guide therapy for this clinical scenario.
– Hypothesis: Significant benefit from adjuvant XRT
58
Methods
Lobectomy for Stage I or II
NSCLC
Negative Margins
Positive Margins
Adjuvant
Radiation
No Adjuvant
Radiation
Adjuvant
Radiation
Pneumonectomy
Propensity Match
59
Results
No Adjuvant Radiation
Adjuvant Radiation
Adjusted
HR: 1.08 (95% CI: 0.88, 1.32)
P = 0.009
Covariates included in adjustment: age, sex, race, insurance status, Charlson/Deyo
comorbidity index, pathologic grade, pathologic stage.
Results
Pneumonectomy
Lobectomy w/XRT
16
My Thoughts
• Very Ambitious Study
• Is the Database really capable of answering
question
• Pneumonectomy inclusion is hard sell
• Good place to start
62
Demographics associated with POSVT
Variables: Demographic
OR
CI
P-value
Male gender
1.46
1.33-1.59
<0.0001
55-64
2.35
1.84-2.96
<0.0001
65-74
4.23
3.29-5.43
<0.0001
>75
6.33
4.89-8.19
1.52
1.34-1.73
Age
(18-54 referent)
White race
<0.0001
<0.0001
“Uncomplicated” POSVT
Outcome
No SVT,
uncomplicated
course (n=12,064)
Isolated SVT, no
other
complications
(n=1,116)
p-value
Postoperative stroke
0.2%
<1.0%
<0.05*
In-hospital mortality
0.2%
<1.0%
>0.70*
Median length of stay
(Q1;Q3)
5 (4;6)
6(5;8)
<0.001
90-day readmission
16.6%
20.3%
0.003
90-day readmission with
stroke
0.6%
1.4%
0.006
My Thoughts
• Typical Non-Surgical Risks (Age, COPD, CHF)
• Slightly Increased with Thoracotomy
• Surprising Stroke Risk
• No information on Treatment/prophylaxis
Unexpected Readmission after Lung Cancer
Surgery:
A Benign Event?
Varun Puri, Aalok P Patel, Traves D Crabtree, Jennifer M Bell, Stephen R Broderick,
Daniel Kreisel, A Sasha Krupnick, G Alexander Patterson, Bryan F Meyers
Objectives
• Study incidence and predictors of unanticipated postoperative
readmission after lung resection for cancer
• Assess short- and long-term implications
• Hypothesis - Unexpected readmission will be associated with a risk of
short-and long-term mortality
Objectives
• Study incidence and predictors of unanticipated postoperative
readmission after lung resection for cancer
• Assess short- and long-term implications
• Hypothesis - Unexpected readmission will be associated with a risk of
short-and long-term mortality
Results
Path. Stage I
Path. Stage II
Path. Stage III
All p <0.001
Conclusions
• Unplanned readmissions (4.3%) are not infrequent after lung
resection
• These events are associated with elevated risk of short- and longterm mortality
• Greater resource allocation to high risk patients
• Consider regionalization of care
My Thoughts
• Readmission is surrogate for something
• Patient performance status?
• Surprising late effect
• Hazard Function
Development of a Nomogram for Predicting
Outcomes after Sublobar Resection for Lung
Cancer
An Analysis of ACOSOG Z4032
Michael Kent, MD
on behalf of the ACOSOG Z4032 Investigators
AATS Annual Meeting, 2015
Introduction
ACOSOG Z4032
•
Z4032 was a randomized,
prospective trial
•
Compared sublobar resection to
sublobar resection with
brachytherapy
•
Accrual 2006-2010 (n=224)
•
Included 41 centers and 48
surgeons
Results
Baseline Demographics
•
Median age: 70
•
Median F/U: 4.4 years
•
Mean DLCO: 46% predicted
•
Wedge resection: n 129 (74.6%)
•
No LN sampling: n 61 (35.3%)
Overall Survival
Multivariate Analysis
Factors
Hazard Ratio
p-value
Age
1.03 (1.00,1.06)
0.04
Baseline DLCO%
0.97 (0.95,0.99)
<0.01
Margin Tumor Ratio
0.83 (0.53,1.28)
0.39
Maximum Tumor Diameter
1.29 (1.00.1.68)
0.05
Histology Type
1.24 (0.76,2.02)
0.39
My Thoughts
•
Excellent 5 yr survival
•
Independent from LN status and Margin
•
Most Dependent on Gas exchange
•
Turns out there are worse things than Lung Cancer
Spotlight on Esophageal Perforation –
A multinational study using the Pittsburgh Esophageal Perforation Severity
Scoring System
Michael Schweigert
Department of Thoracic Surgery
The Pittsburgh PSS
Points are given to each variable according to the following scale:
• 1 = age > 75 years, tachycardia (> 100 bpm), leukocytosis ( > 10000 WBC/ml),
pleural effusion (on chest x-ray, CT or barium swallow);
• 2 = fever (> 38.5 °C), noncontained leak (on barium swallow or CT), respiratory
compromise (respiratory rate > 30, increasing oxygen requirement or need of
mechanical ventilation), time to diagnosis > 24 hours;
• 3 = presence of cancer, hypotension
79
Results: Etiology & Site
• Etiology:
• Spontaneous
119 (41.3%)
• Iatrogenic (instrumentation)
85 (29.5%)
• Traumatic perforation
84 (29.2%).
• Site of perforation:
• Cervical
45 (16%)
• Thoracic
202 (71.6%)
• Abdominal
35 (12.4%).
80
Results: PSS Groups
In accordance with the original publication we divided the study population into three
groups:
81
My Thoughts
• You don’t get a second chance to make a first impression on
perforation
• Choose Well
• This Scoring system can help
25.04.2014
Verfasser
82
Final Thoughts
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missed…”
Too Bad
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