10th ESO-ESMO Masterclass in Clinical Oncology         02-07 April 2011, Ermatingen                 NSCLC:                ...
Case 1   59 y, female, 40 py,   incidental finding on   chest X-ray
Questions• What is your diagnosis?• Further staging?• Lobectomy or sublobar resection?• Radiotherapy• Adjuvant therapy ind...
NSCLC - stages at presentation            7%          Stage II       31%                       Stage III         24%      ...
Stage-dependent survival for NSCLC5-y survival after state-of-the-art treatment     • Stage I 54-80%     • Stage II     38...
Personalized therapy                                                   • Local extension                                  ...
Lung cancer - treatment conceptsT 1- 3 N 0         Curative surgery                        ± adjuvant therapy      T 1 -3 ...
Surgical procedures• Standard lobectomy (pneumonectomy)  + mediastinal lymphadenectomy  Modifications:• Minimally invasive...
Minimally invasive (VATS) resections               2-4 incisions               30 – 70% of all lobectomies               i...
Limited resection vs lobectomy                „Limited“               Resections         Lobectomy               n=122 (%)...
Limited resection vs lobectomy                Nakamura H. et al. Brit. J. Cancer 2005; 92, 1033
The role of Tumor size                              5-Year-survival                        according to tumor diameter    ...
Tumor histology and Grading                    5-Y- survival after                   sublobar resection p-valueAdenocarcin...
Consequences of limited resection • Small functional advantage after   limited resection (<10 %) • More local recurrences ...
Lung saving (sleeve-) resections
T-stage
New staging system 68000 NSCLC, 1000 SCLC          World Conference          IASLC 2009
Chest wall infiltration ?
Chest wall infiltration• important only for planning of the   surgical procedure• 5-year survival up to 40% in T3N1with  a...
Pancoast tumors            (superior sulcus tumors)Tumor of the apex of the lungwith possible infiltration of thechest wal...
N-stageMicroscopic infiltration       or    bulky multilevel  disease?                S.P.1940 cT3N2
Lymph node status predicts outcome                         Naruke, Ann Thorac Surg 2001
Survival of patients with resected N2 Subgroups           Patients   5-yr Survival Minimal N2            354          29,5...
Incidental (occult) N2 disease          adjuvant treatment• adjuvant cisplantin – based chemotherapy is  recommended• adju...
N-stageMultilevel N2 disease –  primarysurgery not indicated
The stage III disease                              CT* + RT (61 Gy)                   N=194Pts with NSCLC,    IIIA, pN2   ...
RTOG 9309: Efficacy               100                                                                  100                ...
RTOG 9309: operative mortality• Lobectomy versus pneumonectomy• Mortality (n=15):   – Lobectomy 1% versus pneumonectomy 26...
Pneumonectomy after neoadjuvant      chemo- and radiotherapy176 patients, 122 males (69%) 56 years (33-74)3 cycles of cisp...
Morbidity and Mortality• 6 patients died (3%) (30 d mortality)         (3 pulmonary embolism, 2 ARDS, 2 cardiacfailure)• 2...
Survival according to clinical stage                              Weder, JTCS 2010
65 year old obese (BMI 25) female of RLL with metastases tolymph nodes # 10, 7, 4 R (tracheal infiltration)Patient receive...
Patient is alive after 5 years withNED, assessed clinically and by CT
‘Resectable N2‘ – which questions       have to be answered?• Is ‘N2‘ technically resectable?• Is surgery complete?• Is su...
Role of highest level N2 node                        Sakao, Ann Thorac Surg 2006
Single vs multilevel N2                          Decaluwé, EJCTS 2009
Role of mediastinal downstaging                         Betticher et al. , JCO 2003
Take home message I• NSCLC remains to be the cancer with the highest  cancer related mortality• Appropriate clinical and p...
Take home message II• Adjuvant chemotherapy is indicated for “fit patients“  with stages ≥ T2, N1• Patients with ipsilater...
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MON 2011 - Slide 22 - W. Weder - Surgery

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Transcript of "MON 2011 - Slide 22 - W. Weder - Surgery"

  1. 1. 10th ESO-ESMO Masterclass in Clinical Oncology 02-07 April 2011, Ermatingen NSCLC: Surgery Walter Weder MD Professor of Surgery University Hospital Zurich
  2. 2. Case 1 59 y, female, 40 py, incidental finding on chest X-ray
  3. 3. Questions• What is your diagnosis?• Further staging?• Lobectomy or sublobar resection?• Radiotherapy• Adjuvant therapy indicated?
  4. 4. NSCLC - stages at presentation 7% Stage II 31% Stage III 24% Stage I 38% Stage IV Fry, Cancer 1996
  5. 5. Stage-dependent survival for NSCLC5-y survival after state-of-the-art treatment • Stage I 54-80% • Stage II 38-60% • Stage IIIA 10-30% • Stage IIIB <10% • Stage IV <5% Tsuboi, World Conference IASLC 2009
  6. 6. Personalized therapy • Local extension Surgery TNM • Timing Radiotherapy • UndeterminedParadigm shift from empiric to integrated therapy adapted from D. Gandara, World Conference IASLC 2009
  7. 7. Lung cancer - treatment conceptsT 1- 3 N 0 Curative surgery ± adjuvant therapy T 1 -3 N 1T 1 -3 N2 Chemo-/(radio-)therapy and surgery T 4 N 0-1 T 1 -2 N 3T 4 N3 M1 Palliative therapy
  8. 8. Surgical procedures• Standard lobectomy (pneumonectomy) + mediastinal lymphadenectomy Modifications:• Minimally invasive lobectomy (VATS)• Sublobar resections• Sleeve resections
  9. 9. Minimally invasive (VATS) resections 2-4 incisions 30 – 70% of all lobectomies in experienced centers may preserve immunologic response and better compliance for adjuvant therapy
  10. 10. Limited resection vs lobectomy „Limited“ Resections Lobectomy n=122 (%) n=125 (%) p-valueRecurrence 38 (31.1) 23 (18.4) 0.02Locoregional 21 (17.2) 8 (6.4) 0.01recurrenceDistant 17 (13.9) 15 (12.0) 0.67metastasesDeath 48 (39.3) 38 (30.4) 0.08 Lung Cancer Study Group: Ann. Thorac. Surg., 60, 615, 1995
  11. 11. Limited resection vs lobectomy Nakamura H. et al. Brit. J. Cancer 2005; 92, 1033
  12. 12. The role of Tumor size 5-Year-survival according to tumor diameter < 20mm 21-30 mm > 30 mmLobectomy 92% 87% 81%Segmentectomy 96% 85% 63%Wedge resection 86% 39% 0% Okada et al. J. Thorac. Cardiovasc. Surg. 2005; 129, 87
  13. 13. Tumor histology and Grading 5-Y- survival after sublobar resection p-valueAdenocarcinoma 66 %(n=76)Squamous cell 59 % 0.75carcinoma (n=21)G1 (=52) 84 %G2-3 (n=45) 46 % 0.001 Nakamura H. et. al., Lung Cancer, 2004; 44, 61
  14. 14. Consequences of limited resection • Small functional advantage after limited resection (<10 %) • More local recurrences after sublobar resections • Small survival disadvantage (3.6%)
  15. 15. Lung saving (sleeve-) resections
  16. 16. T-stage
  17. 17. New staging system 68000 NSCLC, 1000 SCLC World Conference IASLC 2009
  18. 18. Chest wall infiltration ?
  19. 19. Chest wall infiltration• important only for planning of the surgical procedure• 5-year survival up to 40% in T3N1with adjuvant chemotherapy Burkhardt, JTCVS 2002• similar success rates in pancoast tumors following induction radio-chemotherapy and complete resection Rusch, JCO 2007
  20. 20. Pancoast tumors (superior sulcus tumors)Tumor of the apex of the lungwith possible infiltration of thechest wall brachial plexus,stellate ganglion, ribs, vertebae< 5% of all bronchogeniccarcinoma PET/CT for staging (mediastinum, distant metastases) Determination of the radiation field
  21. 21. N-stageMicroscopic infiltration or bulky multilevel disease? S.P.1940 cT3N2
  22. 22. Lymph node status predicts outcome Naruke, Ann Thorac Surg 2001
  23. 23. Survival of patients with resected N2 Subgroups Patients 5-yr Survival Minimal N2 354 29,5% - One Level 244 34% - Multiple Levels 78 11% Clinical N2 332 7% - One Level 118 8% - Multiple N2 122 3% Andre, JCO 2000
  24. 24. Incidental (occult) N2 disease adjuvant treatment• adjuvant cisplantin – based chemotherapy is recommended• adjuvant postoperative radiotherapy should be considered to reduce local recurrence ACCP Guidelines, Chest 2007
  25. 25. N-stageMultilevel N2 disease – primarysurgery not indicated
  26. 26. The stage III disease CT* + RT (61 Gy) N=194Pts with NSCLC, IIIA, pN2 resectable N=202 CT* + RT (45 Gy) Surgery CT* * Cisplatin 50 mg/m2 d1/8/29/36 Etopophos 50 mg/m2 d1-5, d29-33 Albain, Lancet 2009
  27. 27. RTOG 9309: Efficacy 100 100 Death/total Death/totalSurvival probability (%) CT/RT/C 145/202 CT/RT/S 57/90 Survival probability (%) 75 CT/RT 155/194 75 CT/RT 74/90 50 p=0.002 50 25 p=0.24 0 0 12 24 36 48 60 25 CT/RT/S CT/RT MS 34 months 22 months 5-year S 36% 18% RR=0.87 (0.70; 1.10) Months 0 0 12 24 36 48 60 Months Albain, Lancet, 2009
  28. 28. RTOG 9309: operative mortality• Lobectomy versus pneumonectomy• Mortality (n=15): – Lobectomy 1% versus pneumonectomy 26% – Right pneumonectomy (n=11; 79%) – Etiology: ARDS (n=11) Albain, Lancet, 2009
  29. 29. Pneumonectomy after neoadjuvant chemo- and radiotherapy176 patients, 122 males (69%) 56 years (33-74)3 cycles of cisplatin-doublets (n=35, 20%)3 cycles of cisplatin-doublets (n=141, 80%) +45 Gy (1.5 Gy, bi-daily) to primary tumor and mediastinum (fourth cycle cisplatin-doublets in Essen)• pneumonectomy (n=176), 86 (49%) right 138 (78%) extended Weder JTCS 2010
  30. 30. Morbidity and Mortality• 6 patients died (3%) (30 d mortality) (3 pulmonary embolism, 2 ARDS, 2 cardiacfailure)• 23 major complications (13%) in 22 patients 6 pneumonia / ARDS 5 broncho-pleural fistula (4R, 1L) 5 empyema 3 pulmonary embolism 2 hemothorax 1 heart failure 1 gastric hernia Weder, JTCS 2010
  31. 31. Survival according to clinical stage Weder, JTCS 2010
  32. 32. 65 year old obese (BMI 25) female of RLL with metastases tolymph nodes # 10, 7, 4 R (tracheal infiltration)Patient received 2 cycles of induction with CDDP/GEM. Toleratedchemotherapy very poorlyRestaging with PET/CT SD (± PD)MRI of brain without metastasis
  33. 33. Patient is alive after 5 years withNED, assessed clinically and by CT
  34. 34. ‘Resectable N2‘ – which questions have to be answered?• Is ‘N2‘ technically resectable?• Is surgery complete?• Is surgery indicated from an oncological point of view?• What is the risk for the patient?• Does the patient tolerate pulmonary resection? risk-benefit ratio
  35. 35. Role of highest level N2 node Sakao, Ann Thorac Surg 2006
  36. 36. Single vs multilevel N2 Decaluwé, EJCTS 2009
  37. 37. Role of mediastinal downstaging Betticher et al. , JCO 2003
  38. 38. Take home message I• NSCLC remains to be the cancer with the highest cancer related mortality• Appropriate clinical and pathological staging (including tissue diagnosis) is key to an “individualized“ treatment• Lobectomy with systematic mediastinal lymph node dissection is the standard surgical procedure for most T1 – T3, N0 – N1 tumors• Minimal invasive lobectomy by VATS is performed more and more frequent in specialized centers since morbidity and mortality is reduced and adjuvant therapy better tolerated
  39. 39. Take home message II• Adjuvant chemotherapy is indicated for “fit patients“ with stages ≥ T2, N1• Patients with ipsilateral mediastinal lymph node metastasis (N2 disease) are best treated with neaoadjuvant chemo(-radio)therapy followed by surgery preferentially as part of “clinical trial“• surgical resection after induction chemoradiotherapy should be limited to a lobectomy - whenever possible• surgical resection for NSCLC should be complete and the treatment related mortality within an acceptable range.

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