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CLC073 ORAL Combined radiotherapy and chemotherapy (vinorelbine) in locally advanced, inoperable non small-cell lung cancer (NSCLC): a pilot study
Abstracts of the 5th International Congress on Lung Cancer, Patras, Greece, 24–27 January 2007 CLC069
POSTER
The use of staplers for vascular and bronchial ligation, in major lung resections Potaris K., Antypas G., Sakelaridis T., Antypas D., Grigorakos L. 2nd Department of Thoracic Surgery, ‘Sotiria’ General Hospital for Chest Diseases, Greece Background: Stapling of pulmonary vessels and bronchi has long been an interesting topic of controversy. The purpose of this study was to review our experience with the use of staplers in major lung resections. Methods: Between January 1990 and January 2005 a total of 3110 pneumonectomies and 6248 lobectomies were performed with only mechanical staplers (TA 35 mm, 2.5 - 4.8 mm, and since 2002 the Endo-GIA 35 mm, 2.5 - 4.8 mm, too), for the division of pulmonary arteries, veins and bronchi. Results: During the above 15 year period, a total of 9416 pulmonary artery divisions, 15904 (12,924 + 2980) vein divisions, and 9888 pulmonary bronchi closures were performed. The prevalence of mechanical stapling failure was as follows: a) in PA divisions 0.023% (2 out of 8556 TA firings), and nil (none of the 860 Endo-GIA firings), b) in PV divisions 0.018% (2 out of 10,714 TA firings), and 0.045% (1 out of the 2210 Endo-GIA firings), c) in bronchial divisions 0.13% (14 out of the 9184 TA firings), and nil (none of the 704 Endo-GIA firings). As regards the 14 patients in whom stapling failure was observed intra-operatively 7 of them developed a broncho-pleural fistula postoperatively. All these 7 patients had undergone pneumonectomy (0.28%). Conclusions: The use of staplers for vascular and bronchial division in major lung resections is safe and effective, with a negligible incidence of failure particularly regarding main pulmonary vessels.
CLC070
ORAL
The role of adjuvant radiotherapy in the management of thymic tumors Vassiliou V., Charoulis N., Tzelepi V., Salakou S., Zolota V., Dougenis D., Kardamakis D. University Hospital of Patras, Greece Purpose: To evaluate the role of postoperative radiotherapy in the management of thymic tumors. Patients and Methods: From 1989 to 2001, 22 patients with thymoma and 6 with thymic carcinoma (19 women, 9 men, mean age of 51.4 years) underwent surgery. 18 of these patients received adjuvant radiotherapy. The average dose applied was 5.2 Gy. Results: None of the stage I (Masaoka) thymoma patients (n=4) recieved radiotherapy. 6 out of 15 patients with stage II patients and all patients with stage III or IV thymomas also underwent radiotherapy (n=3). The same stood for patients with carcinoma (n=6). The 5 year actuarial and relapse free survival was 100% for stage I patients. Stage II patients who received radiotherapy had a 5-year actuarial and relapse free survival of 83.3%. The corresponding values for stage II patients who were not irradiated were 100%. From the 3 patients with stage III or stage IV thymoma one had a recurrence at 5-years (5-year relapse free survival: 66.6%). The actuarial 5-year survival for these patients was also 66.6%. The 5-year actuarial and relapse free survival was 50% for both stage III (n=4) and Stage IVa (n=2) patients. Prior to surgery 16/28 patients had myasthenia. After surgery, myasthenia was evident in 9/28 patients. Conclusions: From the results of this retrospective study it seems that adjuvant radiotherapy is not essential for the local control of stage I and II thymomas. On the contrary, it is beneficial for patients with stage III or IV thymomas and thymic carcinomas.
CLC071
POSTER
Biphasic blastoma of the lung Christopoulos Chr., Leivaditou A., Mantziou E., Puglisi M., Kosti P., Kenteposidis N., Kardamakis D. University Hospital of Patras, Greece Purpose: We present a case of biphasic blastoma of the lung and a review of the relevant literature. Patients and Methods: A 65 years old woman was referred to our Department on October 2006 with the diagnosis of biphasic blastoma of the lung. The patient initially referred progressively deterioration of dyspnea. Chest X rays and CT thorax confirmed the presence of a mass, occupying the right upper lobe. The patient underwent partial surgical excision of the mass which histologically confirmed to be a biphasic blastoma of the lung. The patient received 6 cycles of chemotherapy without any response and referred to our Department with the purpose to receive palliative radiotherapy. A confrontation of two chest radiograms, the first effectuated 15 days before the first visit to our Department, and the second during the simulation of the radiation therapy revealed
S17
a rapid increase of the mass (almost duplicated in dimensions). The patient underwent palliative radiotherapy, with no important radiological and clinical response. Discussion: Pulmonary blastoma is one of the rarest lung tumors accounting for 0.25% to 0.5% of all primary lung tumors. They consist of immature epithelial and mesenchymal components and histologically resemble the epithelial and stromal components of the fetal lung in the pseudoglandular stage of development. Histologically, the presence of malignant embryonal-like tissues differentiate this neoplasm from others with mixed epithelial and mesenchymal components. Pulmonary biphasic blastomas carry a bad prognosis. Chemotherapy and radiotherapy may achieve short-term disease control. Conclusion: The observation of this rare case stimulated our interest regarding this malignancy. Although there are individual reports of long-term tumor-free survival, approximately two thirds of patients with biphasic blastoma die within 2 years of diagnosis.
CLC072
POSTER
Granulocytic sarcoma or chloroma involving the mediastinum Christopoulos Chr., Mantziou E., Vassiliou V., Martinou M., Puglisi M., Spiridonidis A., Kardamakis D. University of Patras Medical School, Greece Purpose: To report a patient presented with granulocytic sarcoma or chloroma of the mediastinum and to review the literature for this rare condition. Patients and Methods: A 40 years old man was referred to our Department affected of mediastinal chloroma firstly diagnosed approximately a year before. The patient initially presented with a mass on the right and left cervical region. The patient underwent thorax and cervical CT which revealed enlarged cervical lymph nodes with central necrosis and a solid mass in the mediastinum which invaded the superior vena cava causing complete obstruction. A mediastinoscopy was performed and the histological specimen confirmed a mediastinal chloroma. A PET-CT scan confirmed active disease in the left cervical region, in the upper mediastinum and in the right submandibular region. The patient received chemotherapy and achieved a partial response. The patient was referred to our Department and received adjuvant radiotherapy to the mediastinum (41.4 Gy in 23 fractions using 6 MV photons). Complete remission of the disease was documented with a PET scan. Discussion: Granulocytic sarcoma or chloroma is a rare extramedullary collection of myeloblasts. This disease usually arises during the course of acute myelogenous leukemia, although it also occurs in chronic myelogenous leukemia and other myeloproliferative disorders. Conclusion: the mediastinum is rarely involved by granulocytic sarcoma and superior vena cava obstruction is an even rarer presentation (3 cases out of 11 patients with prominent mediastinal chloroma in the literature) Treating superior vena cava syndrome with radiotherapy regardless the underlying pathology has been criticized. Complete remission of the disease documented with PET scan can be achieved with radiotherapy. PET scan is of extreme importance, adding important information regarding active cells metabolism and helping phycisians to take further therapeutic decisions.
CLC073
ORAL
Combined radiotherapy and chemotherapy (vinorelbine) in locally advanced, inoperable non small-cell lung cancer (NSCLC): a pilot study Vomvas D., Vassiliou V., Pomoni M., Christopoulos Chr., Puglisi M., Katsarou Chr., Kardamakis D. Department of Radiation Oncology, University of Patras, Greece Purpose: Data from recent preclinical and clinical studies have shown that daily administration of vinorelbine (4-5 mg/m2 ), has radiosensitizing effects. Based on these data, we evaluated the activity and safety of external beam radiotherapy combined with oral vinorelbine, in patients with locally advanced NSCLC stage IIIb. Patients and Methods: Between April 2005 - May 2006, 13 patients with locally advanced NSCLC were treated with radiotherapy combined with chemotherapy. The median age was 68,77 years and the median ECOG performance status was 0-2. The total radiotherapy dose was 60 Gy given in 30 fractions over 6 weeks, with a two or three fields isocentric technique. All patients received six cycles of oral vinorelbine (20 or 30 mg three times weekly for six weeks). Results: 9/13 patients completed this combined therapy. Among them we observed 6 patients with PRs and 1 patient with SD initials who developed PD 4 months later. 1 patient died before the first evaluation from cardiovascular disease. At 12 months we observed 7/9 patients with PDs. 4 patients did not complete the combined treatment schedule, 1 because of PD, 1 because of TBC infection, 1 because of esophagitis grade II due to the treatment and 1 because of upper abdominal pain attributed to chemotherapy.
S18
Abstracts of the 5th International Congress on Lung Cancer, Patras, Greece, 24–27 January 2007
Discussion: Concurrent chemo-radiotherapy has been shown to improve survival in inoperable NSCLC patients, with main severe side effect esophagfitis. We conclude that the combination of vinorelbine and radiotherapy is feasible at these doses.
CLC074
ORAL
NSCLC in a Thoracic Surgery Department. What was the TNM stage? Hountis P., Moraitis S., Koletsis E., Douzinas M. Thoracic Surgery Department, the Athens Naval and Veterans Hospital, Athens, Greece Aim: The aim of our study was to assess, retrospectively, the intra-operational stage, of non small cell lung cancer patients that were operated in our department. It is believed that although the strict inherence on well-accepted basic knowledge, the advent of new staging procedures and the implementation of finest radiological techniques, an important number of patients are either understaged or upstaged due to various reasons. This has a profound impact on their rate of recurrence, delay in the best therapeutic option and long-term quality of life and survival. Materials and Methods: We evaluated retrospectively records from 84 NSCLC patients that were subjected in a resection for therapeutic reasons during the years1999 to 2003. A standard staging protocol was followed for all patients. We
compared the pre-op TNM stage according to which the patient was subjected to the operation with the pathology examination after that. In these operations, we followed the same lymph node sampling as a routine. Patients were subjected to adjuvant therapy according to our recognized protocol and patients that were subjected to neo-adjuvant therapy were not included in this study. The mean age of the patients were 66.3±11.6 years (mean±SD). 76 (90,4%) men and 8 (9,6%) women. Results: We performed 24 pneumonectomies, 34 lobectomies, 22 bilobectomies, 13 wedge resections or segmentectomies. 7 patients were unresectable. Of the 84 cases with NSCLC there was a significant discrepancy in the N state before and after the operation as was confirmed by the histology report. The pre and post-op TNM stage was I in 30,6%-19%, II=67%-11%, IIIA=2,4%24%, IIIB=0%-34,8% IV=0%-11,2%. The follow up period was 3-5 years mean (4±1). Survival rates were essentially the same as in other studies although 80,3% of our patients required adjuvant chemotherapy and 20,1% radiotherapy. No examination was able to predict or raise queries from the preoperational phase this discrepancy. PET scan is not feasible in our institution at present. Conclusion: Our results show with the most prominent way that although lung cancer is a major concern in our communities an important part of our patients was understaged although in advanced stage. It is impossible to succeed in reducing the recurrences with the current strategies even with the most accurate staging systems. Newer biochemical markers or the wide use of PET scan may play an important role in the early detection and a therapeutic planning that will be ‘early’ in biological terms for the patient.
POSTER
The use of staplers for vascular and bronchial ligation, in major lung resections Potaris K., Antypas G., Sakelaridis T., Antypas D., Grigorakos L. 2nd Department of Thoracic Surgery, ‘Sotiria’ General Hospital for Chest Diseases, Greece Background: Stapling of pulmonary vessels and bronchi has long been an interesting topic of controversy. The purpose of this study was to review our experience with the use of staplers in major lung resections. Methods: Between January 1990 and January 2005 a total of 3110 pneumonectomies and 6248 lobectomies were performed with only mechanical staplers (TA 35 mm, 2.5 - 4.8 mm, and since 2002 the Endo-GIA 35 mm, 2.5 - 4.8 mm, too), for the division of pulmonary arteries, veins and bronchi. Results: During the above 15 year period, a total of 9416 pulmonary artery divisions, 15904 (12,924 + 2980) vein divisions, and 9888 pulmonary bronchi closures were performed. The prevalence of mechanical stapling failure was as follows: a) in PA divisions 0.023% (2 out of 8556 TA firings), and nil (none of the 860 Endo-GIA firings), b) in PV divisions 0.018% (2 out of 10,714 TA firings), and 0.045% (1 out of the 2210 Endo-GIA firings), c) in bronchial divisions 0.13% (14 out of the 9184 TA firings), and nil (none of the 704 Endo-GIA firings). As regards the 14 patients in whom stapling failure was observed intra-operatively 7 of them developed a broncho-pleural fistula postoperatively. All these 7 patients had undergone pneumonectomy (0.28%). Conclusions: The use of staplers for vascular and bronchial division in major lung resections is safe and effective, with a negligible incidence of failure particularly regarding main pulmonary vessels.
CLC070
ORAL
The role of adjuvant radiotherapy in the management of thymic tumors Vassiliou V., Charoulis N., Tzelepi V., Salakou S., Zolota V., Dougenis D., Kardamakis D. University Hospital of Patras, Greece Purpose: To evaluate the role of postoperative radiotherapy in the management of thymic tumors. Patients and Methods: From 1989 to 2001, 22 patients with thymoma and 6 with thymic carcinoma (19 women, 9 men, mean age of 51.4 years) underwent surgery. 18 of these patients received adjuvant radiotherapy. The average dose applied was 5.2 Gy. Results: None of the stage I (Masaoka) thymoma patients (n=4) recieved radiotherapy. 6 out of 15 patients with stage II patients and all patients with stage III or IV thymomas also underwent radiotherapy (n=3). The same stood for patients with carcinoma (n=6). The 5 year actuarial and relapse free survival was 100% for stage I patients. Stage II patients who received radiotherapy had a 5-year actuarial and relapse free survival of 83.3%. The corresponding values for stage II patients who were not irradiated were 100%. From the 3 patients with stage III or stage IV thymoma one had a recurrence at 5-years (5-year relapse free survival: 66.6%). The actuarial 5-year survival for these patients was also 66.6%. The 5-year actuarial and relapse free survival was 50% for both stage III (n=4) and Stage IVa (n=2) patients. Prior to surgery 16/28 patients had myasthenia. After surgery, myasthenia was evident in 9/28 patients. Conclusions: From the results of this retrospective study it seems that adjuvant radiotherapy is not essential for the local control of stage I and II thymomas. On the contrary, it is beneficial for patients with stage III or IV thymomas and thymic carcinomas.
CLC071
POSTER
Biphasic blastoma of the lung Christopoulos Chr., Leivaditou A., Mantziou E., Puglisi M., Kosti P., Kenteposidis N., Kardamakis D. University Hospital of Patras, Greece Purpose: We present a case of biphasic blastoma of the lung and a review of the relevant literature. Patients and Methods: A 65 years old woman was referred to our Department on October 2006 with the diagnosis of biphasic blastoma of the lung. The patient initially referred progressively deterioration of dyspnea. Chest X rays and CT thorax confirmed the presence of a mass, occupying the right upper lobe. The patient underwent partial surgical excision of the mass which histologically confirmed to be a biphasic blastoma of the lung. The patient received 6 cycles of chemotherapy without any response and referred to our Department with the purpose to receive palliative radiotherapy. A confrontation of two chest radiograms, the first effectuated 15 days before the first visit to our Department, and the second during the simulation of the radiation therapy revealed
S17
a rapid increase of the mass (almost duplicated in dimensions). The patient underwent palliative radiotherapy, with no important radiological and clinical response. Discussion: Pulmonary blastoma is one of the rarest lung tumors accounting for 0.25% to 0.5% of all primary lung tumors. They consist of immature epithelial and mesenchymal components and histologically resemble the epithelial and stromal components of the fetal lung in the pseudoglandular stage of development. Histologically, the presence of malignant embryonal-like tissues differentiate this neoplasm from others with mixed epithelial and mesenchymal components. Pulmonary biphasic blastomas carry a bad prognosis. Chemotherapy and radiotherapy may achieve short-term disease control. Conclusion: The observation of this rare case stimulated our interest regarding this malignancy. Although there are individual reports of long-term tumor-free survival, approximately two thirds of patients with biphasic blastoma die within 2 years of diagnosis.
CLC072
POSTER
Granulocytic sarcoma or chloroma involving the mediastinum Christopoulos Chr., Mantziou E., Vassiliou V., Martinou M., Puglisi M., Spiridonidis A., Kardamakis D. University of Patras Medical School, Greece Purpose: To report a patient presented with granulocytic sarcoma or chloroma of the mediastinum and to review the literature for this rare condition. Patients and Methods: A 40 years old man was referred to our Department affected of mediastinal chloroma firstly diagnosed approximately a year before. The patient initially presented with a mass on the right and left cervical region. The patient underwent thorax and cervical CT which revealed enlarged cervical lymph nodes with central necrosis and a solid mass in the mediastinum which invaded the superior vena cava causing complete obstruction. A mediastinoscopy was performed and the histological specimen confirmed a mediastinal chloroma. A PET-CT scan confirmed active disease in the left cervical region, in the upper mediastinum and in the right submandibular region. The patient received chemotherapy and achieved a partial response. The patient was referred to our Department and received adjuvant radiotherapy to the mediastinum (41.4 Gy in 23 fractions using 6 MV photons). Complete remission of the disease was documented with a PET scan. Discussion: Granulocytic sarcoma or chloroma is a rare extramedullary collection of myeloblasts. This disease usually arises during the course of acute myelogenous leukemia, although it also occurs in chronic myelogenous leukemia and other myeloproliferative disorders. Conclusion: the mediastinum is rarely involved by granulocytic sarcoma and superior vena cava obstruction is an even rarer presentation (3 cases out of 11 patients with prominent mediastinal chloroma in the literature) Treating superior vena cava syndrome with radiotherapy regardless the underlying pathology has been criticized. Complete remission of the disease documented with PET scan can be achieved with radiotherapy. PET scan is of extreme importance, adding important information regarding active cells metabolism and helping phycisians to take further therapeutic decisions.
CLC073
ORAL
Combined radiotherapy and chemotherapy (vinorelbine) in locally advanced, inoperable non small-cell lung cancer (NSCLC): a pilot study Vomvas D., Vassiliou V., Pomoni M., Christopoulos Chr., Puglisi M., Katsarou Chr., Kardamakis D. Department of Radiation Oncology, University of Patras, Greece Purpose: Data from recent preclinical and clinical studies have shown that daily administration of vinorelbine (4-5 mg/m2 ), has radiosensitizing effects. Based on these data, we evaluated the activity and safety of external beam radiotherapy combined with oral vinorelbine, in patients with locally advanced NSCLC stage IIIb. Patients and Methods: Between April 2005 - May 2006, 13 patients with locally advanced NSCLC were treated with radiotherapy combined with chemotherapy. The median age was 68,77 years and the median ECOG performance status was 0-2. The total radiotherapy dose was 60 Gy given in 30 fractions over 6 weeks, with a two or three fields isocentric technique. All patients received six cycles of oral vinorelbine (20 or 30 mg three times weekly for six weeks). Results: 9/13 patients completed this combined therapy. Among them we observed 6 patients with PRs and 1 patient with SD initials who developed PD 4 months later. 1 patient died before the first evaluation from cardiovascular disease. At 12 months we observed 7/9 patients with PDs. 4 patients did not complete the combined treatment schedule, 1 because of PD, 1 because of TBC infection, 1 because of esophagitis grade II due to the treatment and 1 because of upper abdominal pain attributed to chemotherapy.
S18
Abstracts of the 5th International Congress on Lung Cancer, Patras, Greece, 24–27 January 2007
Discussion: Concurrent chemo-radiotherapy has been shown to improve survival in inoperable NSCLC patients, with main severe side effect esophagfitis. We conclude that the combination of vinorelbine and radiotherapy is feasible at these doses.
CLC074
ORAL
NSCLC in a Thoracic Surgery Department. What was the TNM stage? Hountis P., Moraitis S., Koletsis E., Douzinas M. Thoracic Surgery Department, the Athens Naval and Veterans Hospital, Athens, Greece Aim: The aim of our study was to assess, retrospectively, the intra-operational stage, of non small cell lung cancer patients that were operated in our department. It is believed that although the strict inherence on well-accepted basic knowledge, the advent of new staging procedures and the implementation of finest radiological techniques, an important number of patients are either understaged or upstaged due to various reasons. This has a profound impact on their rate of recurrence, delay in the best therapeutic option and long-term quality of life and survival. Materials and Methods: We evaluated retrospectively records from 84 NSCLC patients that were subjected in a resection for therapeutic reasons during the years1999 to 2003. A standard staging protocol was followed for all patients. We
compared the pre-op TNM stage according to which the patient was subjected to the operation with the pathology examination after that. In these operations, we followed the same lymph node sampling as a routine. Patients were subjected to adjuvant therapy according to our recognized protocol and patients that were subjected to neo-adjuvant therapy were not included in this study. The mean age of the patients were 66.3±11.6 years (mean±SD). 76 (90,4%) men and 8 (9,6%) women. Results: We performed 24 pneumonectomies, 34 lobectomies, 22 bilobectomies, 13 wedge resections or segmentectomies. 7 patients were unresectable. Of the 84 cases with NSCLC there was a significant discrepancy in the N state before and after the operation as was confirmed by the histology report. The pre and post-op TNM stage was I in 30,6%-19%, II=67%-11%, IIIA=2,4%24%, IIIB=0%-34,8% IV=0%-11,2%. The follow up period was 3-5 years mean (4±1). Survival rates were essentially the same as in other studies although 80,3% of our patients required adjuvant chemotherapy and 20,1% radiotherapy. No examination was able to predict or raise queries from the preoperational phase this discrepancy. PET scan is not feasible in our institution at present. Conclusion: Our results show with the most prominent way that although lung cancer is a major concern in our communities an important part of our patients was understaged although in advanced stage. It is impossible to succeed in reducing the recurrences with the current strategies even with the most accurate staging systems. Newer biochemical markers or the wide use of PET scan may play an important role in the early detection and a therapeutic planning that will be ‘early’ in biological terms for the patient.