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P3.04-016 Surgical Implications of the New Lung Adenocarcinoma Classification - Usefulness for Selecting Cases Undergoing Sublobar Resection
January 2017
P3.04-015 Usefulness of Carotid Ultrasonography for Postoperative Cerebrovascular Complication Prevention in Patients with Lung Cancer Topic: Miscellaneous I Sadanori Takeo, Koji Yamazaki, Tomoyoshi Takenaka, Naoko Miura Thoracic Surgery, National Kyusyu Medical Center, Fukuoka/Japan Background: In Japan, the incidence of postoperative cerebral infarction in lung cancer is approximately 0.9%. Reportedly, carotid artery arteriosclerosis reflects arteriosclerosis in the whole body. We aimed to assess whether carotid ultrasonography contributes to the prevention of cerebral infarction and cardiovascular events in postoperative lung cancer patients, and identify preoperative factors for its indication. Methods: We analyzed 1418 consecutive patients with NSCLC who underwent surgical resection at Kyushu Medical Center between 1994 and 2014. Between 1994 and 2000 (first event), 334 patients with NSCLC did not undergo carotid ultrasonography. From 2001 and on (second event), 1084 consecutive patients underwent carotid ultrasonography. In cases of moderate or severe carotid artery stenosis, we used heparin infusion as cerebral infarction prevention. Results: At the first event, postoperative cerebral infarction occurred in four patients (1.2%) who did not present preoperative cerebrovascular episodes. At the second event, four patients (0.36%) of 1084 presented postoperative cerebral infarction. We analyzed 130 patients (12.0%) of 1084 patients with over 30% carotid stenosis. Only 13 (10%) of 130 patients had preoperative cerebral infarction and 117 (90%) of 130 patients did not present preoperative cerebrovascular episodes. All 130 patients were aged >51 years. In total, 58 (44.6%) patients with mild stenosis (linear internal carotid artery [ICA] 30%e49%), 56 (43.0%) patients with moderate stenosis (linear ICA 50%e69%), and 16 (12.4%) patients with severe stenosis (linear ICA <70%) were identified. The stenosis rate increased with age. Severe stenosis was identified in 16 patients, of which 15 had no preoperative cerebrovascular episodes. At the second event, there were 74 (6.8%) cases of preoperative cerebral diseases; 303 (28.0%), hypertension; 72 (6.6%), coronary artery disease; 11 (1.0%), arrhythmia; 19 (1.8%), peripheral vascular diseases; 14 (1.3%), abdominal aortic aneurysm; and 121 (11.2%), diabetes mellitus. There was a significant correlation between carotid stenosis and hypertension and smoking and
Abstracts
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diabetes mellitus and smoking (p<0.001). The incidence of postoperative cerebro-cardiovascular comorbidity was 25 (7.4%) and 26 (2.3%) at the first and second events, respectively. There was a significant difference between the two occurrences of postoperative cerebral infarction (p¼0.008) and cardiovascular complications (p¼0.001). Conclusion: Carotid ultrasonography is recommended for patients aged above 50 years, with hypertension and smoking, and diabetes mellitus and smoking. Even without past cerebral infarction, the likelihood of carotid artery stenosis is high with increasing age. Carotid ultrasonography is simple, noninvasive, and useful as a preoperative assessment for preventing postoperative cerebro-cardiovascular complications in lung cancer patients. Keywords: Postoperative cerebro-cardiovascular complication, Prevention of postoperative cerebral infarction, Preoperative management, Carotid ultrasonography
P3.04-016 Surgical Implications of the New Lung Adenocarcinoma Classification Usefulness for Selecting Cases Undergoing Sublobar Resection Topic: Miscellaneous I Akira Shimamoto, Atsushi Ito, Aki Kobayashi, Motoshi Takao, Hideto Shimpo Department of Thoracic & Cardiovascular Surgery, Mie University Graduate School of Medicine, Tsu/Japan Background: The 2015 World Health Organization (WHO) Classification of Lung Tumors has just been published and it confirmed a new adenocarcinoma classification based on histomorphologic subtype. We evaluated an appropriateness of new classification in a series in our institute and whether the classification could be useful for selecting limited cases undergoing sublobar resection. Methods: We retrospectively reviewed clinical records of all patients operated on for non-small cell lung cancer from 1997 to 2014 (n¼1059). 382 patients (36.1%) had pathological stage IA adenocarcinoma of the lung classified. Pathologists performed histopathologic subtyping according to new 2015 WHO classification. Statistical analyses were made including KaplaneMeier and Cox regression. Results: Three overall prognostic groups were identified: low grade: adenocarcinoma in situ (AIS, n¼115,
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30.1%) and minimally invasive adenocarcinoma (MIA, n¼37, 9.7%) had 97.5% and 96.9% of disease-free survival at 5 years (DFS, median follow-up was 72 months); intermediate grade: non-mucinous lepidic adenocarcinoma (n¼72, 18.8%), acinar adenocarcinoma (n¼72, 18.8%), and papillary adenocarcinoma (n¼56, 14.7%), with 84.5%, 83.8%, and 63.1% of DFS; and high grade: invasive mucinous adenocarcinoma (n¼11, 2.9%), solid adenocarcinoma (n¼14, 3.7%) and micropapillary adenocarcinoma (n¼5, 1.3%), with 81.5% of DFS. DFS in low grade was significant better than in other two grades (P<.001), however, there was no significant difference between in intermediate and high grade groups. The recurrent cases in MIA, lepidic, and acinar adenocarcinomas were probably observed papillary component. Preoperative imaging examinations such as consolidation/tumor (C/T) ratio on high resolution CT and maximum standardized uptake value (SUVmax) by FDG-PET were correlated with histopathologic grade according to new classification (P<.05). Moreover, sublobar resection was undergone for 195 cases (51.0%), more cases had been identified small tumor, low C/T ration, low SUVmax, and low grade subtypes, and DFS in sublobar resection was 93.2% which was significant better than in lobectomy (79.5%, P¼.0034). Conclusion: Most of subtypes correlated with DFS, except of papillary adenocarcinoma and subtypes in high grade clinical aggressiveness, which may need more clinical investigation. As papillary components were observed in many recurrent cases, papillary is potentially higher malignancy and could be classified into high grade. Patients in low grade subtypes who underwent sublobar resection had better DFS, which can be predicted using tumor size and preoperative imaging examinations such as C/T ratio and SUVmax. So, the new classification has advantages for better selection of limited cases undergoing sublobar resection as a curative surgery. Keywords: sublobar resection, Adenocarcinoma, 2015 WHO Classification of Lung Tumors
P3.04-017 Wedge Resection for Clinical-n0 Non-Small Cell Lung Cancer Topic: Miscellaneous I Hiroaki Tsunezuka, Daishiro Kato, Satoru Okada, Tatsuo Furuya, Junichi Shimada, Masayoshi Inoue Division of Thoracic Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto/Japan
Journal of Thoracic Oncology
Vol. 12 No. 1S
Background: Sublobar resection is generally indicated for small ground-glass opacity (GGO)-dominant clinical T1 adenocarcinomas below 2 cm in diameter. Recently, some reports show that GGO-dominant clinical T2 adenocarcinomas measuring below 3 cm are also favorable prognosis after segmentectomy. The aim of this study was to evaluate the prognosis of the patients with nonsmall cell lung cancers after wedge resection. Methods: From 2008 to 2012, 66 patients underwent wedge resection for clinical-N0 lung cancer at Kyoto Prefectural University of Medicine. Patients who had multiple tumors or previously underwent lung surgeries were not included. The median age of the subjects was 73.0 years. High-resolution computed tomography (HRCT) was performed for preoperative staging of the entire lung cancer. The median tumor size was 2.2 cm. All tumors were evaluated to estimate the GGO on HRCT. We defined the ratio of the maximum diameter of the consolidation to the maximum tumor diameter as the consolidation-to-tumor ratio (CTR). All the patients who underwent wedge resection were followed up with HRCT every 6 months for the first 2 years and every 12 months for the subsequent 3 years. The median postoperative follow-up period was 41.5 months. The Kaplan-Meier method was used to assess recurrencefree survival (RFS) and 5-year overall survival (OS), which were statistically analyzed using the log-rank test. We set the significance level at p<0.05. Results: Twenty two (33.3%) of the 66 patients had GGO-dominant tumors with CTR of less than 50%, and have survived without recurrence. The 5-year OS, RFS and CSS of whole patients were 66.1%, 53.4% and 81.6% respectively. The 5-year OS significantly differed according to CTR and solid tumor size. The 5-year RFS significantly differed according to CTR, solid tumor size, CEA level, and histological type. No significant differences in sex, whole tumor size and Brinkman index were observed. Multivariate Cox proportional hazard model revealed that solid tumor size and CTR were independent prognostic factors for OS, RFS and CSS. Lung cancer death accounted for 10 of the 20 cause of death, leading cause of death of remaining half was 7 other malignant tumors. 18 patients experienced a recurrence of lung cancer. Site of recurrence was 8 lung parenchyma including 2 stump recurrences, 8 mediastinal lymph node, 4 pleural dissemination and 4 distant organ. Conclusion: A solid tumor size <1.2cm and CTR <50 might be a good, radiologically noninvasive indicator for performing wedge resection of clinical-N0 non-small cell lung cancer. Keywords: solid tumor size, wedge resection, non-small cell lung cancer, consolidation tumor ratio
P3.04-015 Usefulness of Carotid Ultrasonography for Postoperative Cerebrovascular Complication Prevention in Patients with Lung Cancer Topic: Miscellaneous I Sadanori Takeo, Koji Yamazaki, Tomoyoshi Takenaka, Naoko Miura Thoracic Surgery, National Kyusyu Medical Center, Fukuoka/Japan Background: In Japan, the incidence of postoperative cerebral infarction in lung cancer is approximately 0.9%. Reportedly, carotid artery arteriosclerosis reflects arteriosclerosis in the whole body. We aimed to assess whether carotid ultrasonography contributes to the prevention of cerebral infarction and cardiovascular events in postoperative lung cancer patients, and identify preoperative factors for its indication. Methods: We analyzed 1418 consecutive patients with NSCLC who underwent surgical resection at Kyushu Medical Center between 1994 and 2014. Between 1994 and 2000 (first event), 334 patients with NSCLC did not undergo carotid ultrasonography. From 2001 and on (second event), 1084 consecutive patients underwent carotid ultrasonography. In cases of moderate or severe carotid artery stenosis, we used heparin infusion as cerebral infarction prevention. Results: At the first event, postoperative cerebral infarction occurred in four patients (1.2%) who did not present preoperative cerebrovascular episodes. At the second event, four patients (0.36%) of 1084 presented postoperative cerebral infarction. We analyzed 130 patients (12.0%) of 1084 patients with over 30% carotid stenosis. Only 13 (10%) of 130 patients had preoperative cerebral infarction and 117 (90%) of 130 patients did not present preoperative cerebrovascular episodes. All 130 patients were aged >51 years. In total, 58 (44.6%) patients with mild stenosis (linear internal carotid artery [ICA] 30%e49%), 56 (43.0%) patients with moderate stenosis (linear ICA 50%e69%), and 16 (12.4%) patients with severe stenosis (linear ICA <70%) were identified. The stenosis rate increased with age. Severe stenosis was identified in 16 patients, of which 15 had no preoperative cerebrovascular episodes. At the second event, there were 74 (6.8%) cases of preoperative cerebral diseases; 303 (28.0%), hypertension; 72 (6.6%), coronary artery disease; 11 (1.0%), arrhythmia; 19 (1.8%), peripheral vascular diseases; 14 (1.3%), abdominal aortic aneurysm; and 121 (11.2%), diabetes mellitus. There was a significant correlation between carotid stenosis and hypertension and smoking and
Abstracts
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diabetes mellitus and smoking (p<0.001). The incidence of postoperative cerebro-cardiovascular comorbidity was 25 (7.4%) and 26 (2.3%) at the first and second events, respectively. There was a significant difference between the two occurrences of postoperative cerebral infarction (p¼0.008) and cardiovascular complications (p¼0.001). Conclusion: Carotid ultrasonography is recommended for patients aged above 50 years, with hypertension and smoking, and diabetes mellitus and smoking. Even without past cerebral infarction, the likelihood of carotid artery stenosis is high with increasing age. Carotid ultrasonography is simple, noninvasive, and useful as a preoperative assessment for preventing postoperative cerebro-cardiovascular complications in lung cancer patients. Keywords: Postoperative cerebro-cardiovascular complication, Prevention of postoperative cerebral infarction, Preoperative management, Carotid ultrasonography
P3.04-016 Surgical Implications of the New Lung Adenocarcinoma Classification Usefulness for Selecting Cases Undergoing Sublobar Resection Topic: Miscellaneous I Akira Shimamoto, Atsushi Ito, Aki Kobayashi, Motoshi Takao, Hideto Shimpo Department of Thoracic & Cardiovascular Surgery, Mie University Graduate School of Medicine, Tsu/Japan Background: The 2015 World Health Organization (WHO) Classification of Lung Tumors has just been published and it confirmed a new adenocarcinoma classification based on histomorphologic subtype. We evaluated an appropriateness of new classification in a series in our institute and whether the classification could be useful for selecting limited cases undergoing sublobar resection. Methods: We retrospectively reviewed clinical records of all patients operated on for non-small cell lung cancer from 1997 to 2014 (n¼1059). 382 patients (36.1%) had pathological stage IA adenocarcinoma of the lung classified. Pathologists performed histopathologic subtyping according to new 2015 WHO classification. Statistical analyses were made including KaplaneMeier and Cox regression. Results: Three overall prognostic groups were identified: low grade: adenocarcinoma in situ (AIS, n¼115,
S1394
30.1%) and minimally invasive adenocarcinoma (MIA, n¼37, 9.7%) had 97.5% and 96.9% of disease-free survival at 5 years (DFS, median follow-up was 72 months); intermediate grade: non-mucinous lepidic adenocarcinoma (n¼72, 18.8%), acinar adenocarcinoma (n¼72, 18.8%), and papillary adenocarcinoma (n¼56, 14.7%), with 84.5%, 83.8%, and 63.1% of DFS; and high grade: invasive mucinous adenocarcinoma (n¼11, 2.9%), solid adenocarcinoma (n¼14, 3.7%) and micropapillary adenocarcinoma (n¼5, 1.3%), with 81.5% of DFS. DFS in low grade was significant better than in other two grades (P<.001), however, there was no significant difference between in intermediate and high grade groups. The recurrent cases in MIA, lepidic, and acinar adenocarcinomas were probably observed papillary component. Preoperative imaging examinations such as consolidation/tumor (C/T) ratio on high resolution CT and maximum standardized uptake value (SUVmax) by FDG-PET were correlated with histopathologic grade according to new classification (P<.05). Moreover, sublobar resection was undergone for 195 cases (51.0%), more cases had been identified small tumor, low C/T ration, low SUVmax, and low grade subtypes, and DFS in sublobar resection was 93.2% which was significant better than in lobectomy (79.5%, P¼.0034). Conclusion: Most of subtypes correlated with DFS, except of papillary adenocarcinoma and subtypes in high grade clinical aggressiveness, which may need more clinical investigation. As papillary components were observed in many recurrent cases, papillary is potentially higher malignancy and could be classified into high grade. Patients in low grade subtypes who underwent sublobar resection had better DFS, which can be predicted using tumor size and preoperative imaging examinations such as C/T ratio and SUVmax. So, the new classification has advantages for better selection of limited cases undergoing sublobar resection as a curative surgery. Keywords: sublobar resection, Adenocarcinoma, 2015 WHO Classification of Lung Tumors
P3.04-017 Wedge Resection for Clinical-n0 Non-Small Cell Lung Cancer Topic: Miscellaneous I Hiroaki Tsunezuka, Daishiro Kato, Satoru Okada, Tatsuo Furuya, Junichi Shimada, Masayoshi Inoue Division of Thoracic Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto/Japan
Journal of Thoracic Oncology
Vol. 12 No. 1S
Background: Sublobar resection is generally indicated for small ground-glass opacity (GGO)-dominant clinical T1 adenocarcinomas below 2 cm in diameter. Recently, some reports show that GGO-dominant clinical T2 adenocarcinomas measuring below 3 cm are also favorable prognosis after segmentectomy. The aim of this study was to evaluate the prognosis of the patients with nonsmall cell lung cancers after wedge resection. Methods: From 2008 to 2012, 66 patients underwent wedge resection for clinical-N0 lung cancer at Kyoto Prefectural University of Medicine. Patients who had multiple tumors or previously underwent lung surgeries were not included. The median age of the subjects was 73.0 years. High-resolution computed tomography (HRCT) was performed for preoperative staging of the entire lung cancer. The median tumor size was 2.2 cm. All tumors were evaluated to estimate the GGO on HRCT. We defined the ratio of the maximum diameter of the consolidation to the maximum tumor diameter as the consolidation-to-tumor ratio (CTR). All the patients who underwent wedge resection were followed up with HRCT every 6 months for the first 2 years and every 12 months for the subsequent 3 years. The median postoperative follow-up period was 41.5 months. The Kaplan-Meier method was used to assess recurrencefree survival (RFS) and 5-year overall survival (OS), which were statistically analyzed using the log-rank test. We set the significance level at p<0.05. Results: Twenty two (33.3%) of the 66 patients had GGO-dominant tumors with CTR of less than 50%, and have survived without recurrence. The 5-year OS, RFS and CSS of whole patients were 66.1%, 53.4% and 81.6% respectively. The 5-year OS significantly differed according to CTR and solid tumor size. The 5-year RFS significantly differed according to CTR, solid tumor size, CEA level, and histological type. No significant differences in sex, whole tumor size and Brinkman index were observed. Multivariate Cox proportional hazard model revealed that solid tumor size and CTR were independent prognostic factors for OS, RFS and CSS. Lung cancer death accounted for 10 of the 20 cause of death, leading cause of death of remaining half was 7 other malignant tumors. 18 patients experienced a recurrence of lung cancer. Site of recurrence was 8 lung parenchyma including 2 stump recurrences, 8 mediastinal lymph node, 4 pleural dissemination and 4 distant organ. Conclusion: A solid tumor size <1.2cm and CTR <50 might be a good, radiologically noninvasive indicator for performing wedge resection of clinical-N0 non-small cell lung cancer. Keywords: solid tumor size, wedge resection, non-small cell lung cancer, consolidation tumor ratio