392 Endoscopic management of airway obstruction. 13 year experience in 158 patients

101

Therapy - Combined Modalit_v Therap!

10:30-l 2:30

Thursday, 14 August 1997 ORAL

SESSION

other cancers were unresectable. We have experienced no further tumor implantation. We reserve thoracoscopy for peripheral lesions which are intermediate I” suspicion for cancer. IOFNA deserves more frequent utilization at thoracoscopy.

Surgery

I390* I 388

Long-term

follow-up

study

of thymomas

Y. Takeuchi, S. Takeda, M. Minami, M. Okumura, H.-E. Yoon, H. Matsuda. 1st Dept. of Surg. Osaka Univ. Med. Sch., Osaka, Japan Two hundred one case of patients who underwent operate for thymoma were analyzed to asses the prognostic values if Masaoka’s clinical staging completeness of resection and postoperative radiation therapy in the periods from 1957 to 1995. There were 112 men, 89 women; 115 with myasthenia gravis (MG), 86 without MG; mean age 45 f 13.7 years. All patients received surgical procedure. Fieoperation for the recurrence were excluded from this study. Survival analysis was performed by Kaplan-Meier method. Postoperative radiation was administered to The majority of patients with stage III, IVa, IVb. were treated with ajuvant radiation therapy. Chemotherapy was mainly performed in patients with incomplete resection. Stage(n)

Surgical procedure(n) subtotal biopsy resection 0 0 8 4

I(75) li(42)

Ill (64) 1v.s (13) IVb (7)

1

0 0 5 9 6

Survival rate (%) 1oyr 15yr

complete resection

5 Y'

75 42

98 97 90 54 0 96

51 0 0

Ill complete (51)

100 50

Ill subtotal (5) III biopsy (8) IVa subtotal (9) IVa biopsy (4)

67 25

98 89 80 25 0 88 100

98 84 68 0 0 80 50

20yr 88 84 45 0 0 66 0

0

0

0

36 0

0 0

0 0

There were no significant differences m survival curve between the patients with stage Ill and stage Ill after complete resection. Complete resection result in high survival rate in patients with stage Ill compared to subtotal resection or biopsy (p < 0.05). In stage IVa, subtotal resection resulted in higher survival rate than in biopsy however it did not reach a statistic significance (p = 0.08). Our long-term follow-up study indicates that completeness of resection for stage Ill thymoma result in favorable outcome, similar to stage II, this supports the validity of aggressive surgical approach.

I

389*

Strategies to prevent at thoracoscopy

malignant

W.A. Fry, Daniel H. Shevrin, William G. Watkin, Northwestern Univ. Evanston, /I, USA

tumor

implantation

Miriam C. Christ.

Since we experienced a fatal malignant tumor implantation following thoracoscopic biopsy, we have developed a preventive strategy for lesions suspicious for cancer which we have elected to diagnose thoracoscopltally consisting of intraoperative fine needle aspiration (IOFNA), removal of the specimen in a receptical, and sterile water lavage. If the IOFNA, which is read immediately, is positive for cancer, the thoracoscopy is converted immediately to an axillaty thoracotomy for a definitive resection after sterile water lavage of all port sites as well as the thoracic cavity. If the IOFNA is negative, the lesion is resected by stapling and removed in a receptical and immediate frozen section is performed. If that is positive for cancer, the thoracoscopy is converted to an axillary thoracotomy for a completed, definitive resection afler a water lavage. We do not belive that definitive lung cancer resection should be done thoracoscopically. If we strongly suspect that a peripheral lesion is malignant, we will approach it by limited axillary thoracotomy and eschew thoracoscopy. Since our index case we have performed 39 thoracoscopies for susplcious peripheral lesions of which 28 were benign and 11 were malignant. Of the proven malignancies we performed 5 immediate lobectomies. The

How shall follow-up?

L.J. Kohman, USA

we measure

B. Bizoza.

the value

SUNY Health Science

of post-surgical Center,

Syracuse,

NY

While a great majority of surgeons (75%) who care for lung cancer patients have some sort of post-operative surveillance strategy to detect local recurrence, distant metastasis, and second primaries, there is no objective evidence favoring one scheme over any other. Few textbooks and no professional organizations give follow-up guidelines. Physicians and payers (increasingly cost-conscious) have only surgical dogma, personal experience, intuition and two recent, narrowly conceived and controversial studies to guide them. These retrospective, non-randomized analyses, the first in the literature, are methodologically flawed and conceptually limited. They attempted to address cost-effectiveness and overall or disease-free suIv/vaI, and concluded that close post-operative follow-up has no Impact on outcome in the resected lung cancer patient. However, neither study compared specific, standardized follow-up protocols, and neither considered a full accounting of benefits, which should Include factors beyond months of survival. In the post-surgical lung cancer patient, potential benefits include efflcient evaluation and care of recurrence; access to the latest in treatment options for recurrence; opportunities for patient education (e.g. smoking cessation); application of chemopreventive agents as they are discovered; opportunities for instituting new methods of detection; and improved patient rapport, reassurance and quality of life. Evaluations of care should also include those benefits which may accrue to entities other than the treated patient, including the body of medical knowledge, future patients, health care economics, the surgeon, and relationships with referring physicians and other practitioners. Since specialists are involved in all stages of cancer care beyond screenmg or initial detection (diagnosis, staging, treatment, and adjuvant therapy), they can be effective as well in follow-up. A surgeon, intimately familiar with the surgical circumstances, is well qualified to know what follow-up evaluations may yield results. For efficient, comprehensive cancer care we need a prospective, randomized study assessing the value of postsurgical follow-up. Such a study should define and thoroughly consider the relevant factors of benefit and cost.

1 391* 1 Second treatment V. Beltrami, ltaly

primary lung cancer: and prognosis

F. Santobuono,

E. Mascitelli.

Possible

prediction,

Dept. of Surgery,

Univ. of Chieti,

Occurrence of a second primary lung cancer was increasing in last years. Up to december 1996 -in our series including 3596 lung cancers and 1403 operations -we observed 20 of such cases: the interval between the two occurrences went from 17 to 144 months (average 81). Characteristics of man and tumour at the time of first operation were compared with the data of the general statistic. Age, sex, performance status, previous lung pathology and smoking, as well as site of cancer, histology, stadlation and type of surgical resection, were considered. No significant independent factor could be isolated for a prediction of the new cancer at the time of first operation. Surgical retreatment was done in 12 cases (average interval in these patients: 75 months). New resection was successful1 and up to new survival was of 10 to 120 months (average 42.5).

I

392

G. Ladas,

Endoscopic management of airway year experience in 158 patients P. Solli, P. Goldstraw.

We present our experience tracheobronchial obstruction

Royal Brornpton

in the management between January

obstruction.

Hospital,

London,

13 UK

of 158 patients (pts) with 1984 and January 1997 at

102

Therapy - Combined Modality

I3%

the Royal Brompton Hospital, using a variety of endoscopic techniques. There were 88 men and 70 women with a mean age of 54.5 years (range 1 day-84 years). Malignant airway obstruction was diagnosed in 91 pts whilst in 67 pts the cause of the obstruction was a benign disease process. 39 of these patients (24.6%) presented as medical emergencies with life threatening airway obstruction. In 85 of them (53.8%) other modalities (chemotherapy, external radiotherapy, laser, surgical resection, stenting), had been previously used elsewhere in order to relieve the obstruction. All patients underwent rigid bronchoscopy under general anesthesia using the jet venturi for ventilation and pulse oxymetry monitoring. Following the initial bronchoscopic assessment the obstruction was treated during the same session using multiple modalities in 33% of the patients in the malignant group and 24% of the patients in the benign group. The airway lumen was disobliterated in 72 pts using the diathermy resectoscope, bougienage was used in 30 pts, and the cryoprobe in two pts. In 95 patients we also inserted a total of 193 airway stents of various types to achieve or maintain airway patency. Radioactive gold grains were implanted in 16 pts with malignant obstruction during the era before afterloading became available. 71 pts (44.9%) required further bronchoscopic follow up. There were no intraoperative deaths and only 3 major complications. 154 patients (97.4%) reported immediate symptomatic relief. The longest survivor with malignant obstruction in our series is still alive and well 9.5 years after the initial stenting session.

I

393

Princess Margaret Hospital (PMH) experience thymomas over a 28-year period

A. Bezjak’, T. Panzarella’, D. Payne ‘, W.J. Simpson ‘Toronto Hospital-Genera/

Outcome

in sofi tissue sarcomas

of the chest wall

B. O’Sullivan, C. Catton, T. Panzarella, M. Johnston, R. Bell, J. Wunder. Princess Margaret Hospital, Univ. of Toronto, Canada This study was undertaken to assess the local control, metastatic failure and cause specific survival for all adult cases of non-metastatic soft tissue sarcoma (STS) of the chest wall registered at out centre from January 1980 until December 1994 and to assess the impact of the introduction of a comprehensive multidisciplinary management approach during the middle of the period of study. During the period 66 non-metastatic lesions were registered. The median follow-up was 5.2 years (range 0.34 to 16.2 years). A variety of histopathologic types were seen, with malignant fibrous histiocytoma the most frequent (24 or 36.4%). Size was 55 cm in 25 (38%), 5-10 cm in 27 (41%), and >lO cm in 14 (21%). Tumor grade was high in 50 and low in 16; 31 were superficial while 35 arose deep to the investing fascia. Treatment consisted of chemotherapy in 14, surgery in 60. while 47 received radiotherapy. The S-year actuarial local relapse free rate was 78%, cause specific survival 72% and distant relapse free rate 68%. The most apparent prognostic factors for time to cause-specific death were performance status (p = O.OOl), lesion size (p c O.OOOl), and local extension (p c 0.0001). Patients treated between 1980 and 1987 were compared to those treated in the second half of the study, when management changed to a multidisciplinary approach to assessment and treatment. The actuarial local relapse free rate was 89% in the later period compared to 71% in the early time period, despite an equal distribution of prognostic factors for both groups. Similarly, metastatic failure improved (82% relapse-free vs. 56%, p < 0.05), as did cause specific survival (84% vs. 60%, p = 0.02). These results demonstrate that high rates of control should be expected in STS of the chest wall. In addition they support a policy of referral of these rare tumors to a multidisciplinary setting for definitive management as this strategy is associated with an improvement in tumor outcome.

with

A. Fyles’, J. Sturgeon ‘, F.G. Pearson’, ’ ‘Princess Margaret Hospital, Toronto, Ont; Division, Toronto, Ont, Canada

Background: Thymomas are rare mediastinal tumors and their management remains controversial. A retrospective review of all thymomas referred to a large cancer center was undertaken to examine patient outcome, role of treatment and potential prognostic factors. Patients and Methods: Charts of 115 patients (pts) referred to PMH for management of their primary thymoma in the period 1963-90 were reviewed. Charts were abstracted to define the extent of disease at diagnosis, treatment given and clinical outcome. Results: Of the 115 pts, 59 were female; median age was 49 (range 15-80); 26 presented with myasthenia gravis. 94 cases had extracapsular invasion, extrathoracic metastases were present in 9 and nodal involvement was rare (3). Surgery (S) was the primary treatment in most pt (93); 8 had S alone and 73 had S plus radiation (RT) - 46 postoperative RT, 27 preoperative RT. Chemotherapy (CT) was utilized in 19 more advanced cases (in 6 with RT, in 10 with RT + S, in 2 CT + S, in 1 CT alone). RT alone was utilized in 14 pt and 1 pt had no treatment. Median follow-up was 11.7 yrs. The 5 year overall survival (OS) was 71%, 10 year OS 53%; 5 year cause specific survival (CSS) 84%, 10 years 74%. Low dose hemithorax or thorax RT was administered to 55% of pts given RT (whether preop or postop) with the intent of decreasing the incidence of pleural relapse; despite that, their actuarial incidence of pleural relapse was no different from pts given mediastinal RT alone (12% vs 8%, p = 0.41). Comparison of pts given preop vs. postop RT revealed that the preop group had lower stage of disease at time of surgery (44% stage I vs. 5%), more complete resection (74% complete vs. 21%) and reduced incidence of pleural relapse (3.7% vs. 12.5%). In univariate analysis, modified Masaoka stage was statistically significant for CSS (p = 0.003) & relapse free rate (RFR, p = 0.0008), as was the presence of gross residual tumour after surgery (CSS p c 0.0001; RFR p < 0.0001). There was no obvious difference in outcome between pts with no vs. microscopic residuum. Conclusions: Patients referred to our institution are not comparable to patients in surgical series as most of them had extracapsular invasion. Stage and postop gross residuum were prognostic of relapse and CSS. Hemithorax RT did not appear effective in decreasing the rate of pleural elapse. The role of preop RT needs to be further elucidated.

Therapy

I

3%

T. Shiota, Municipal

Management of malignant tracheobronchial stenosis with airway stenting - Which type of stent should be used? M. Kanaoka, S. Otsuki, Hospital. Ako, Japan

Y. Yokoyama,

T. Magaribuchi.

Ako

Purpose: Various types of tracheobronchial stent currently used in the treatment of malignant tracheobronichal stenosis. To investigate which type of stent should be used in which cases, we reviewed our experience with airway stenting, retrospectively. Patients: In 10 patients with malignant airway stenosis, 7 times of DUMON stent placement, 2 times of Dynamic stent insertion and 2 times of Gianturco Z-stent insertion were performed. The primary disease was lung cancer in 7 patients, esophageal cancer in 2 patients and metastatic lung cancer in 1 patient. Results: The stents significantly improved the quality of life. Seven patient died 3 to 6 months after airway stenting. Three patients are alive. No serious complication was observed during surgery. Two patients developed inflammatory garanulation or tumor regrowth at the tip of the prosthesis. One patient complained symptomatic retention of secretion. Conclusion: Compared with other prostheses, DUMON stent presents the following advantage:existence of a wide range of prosthesis of different diameter and lengths, enabling most conditions, and little chance of migration, and cheaper than others. On the other hand, following disadvantage can be noted general anesthesia required, performed without direct visual-endoscopic guidance (using a rigid bronchoscope) and so required extensive training. In the case of stenosis of tracheal bifurcation, Dynamic stent could be inserted without risk of migration under general anesthesia, but this stent is expensive. GianturCo T-stent can be placed with the use of topical anesthesia alone, but repositioning and extraction of the released stent are difficult, and expensive. Considering the palliative nature of the procedures, the cheaper prosthesis should be used if the efficacy, safety and rate of complication are compatible. But, We should be familiar with various types of stents.