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Society of Thoracic Surgeons Annual Meeting–New Insights into Lung Cancer Surgery: Moving toward Less Invasive Procedures

Laino, Charlene

doi: 10.1097/01.COT.0000370076.09154.ed

FORT LAUDERDALE, FL—Lung cancer surgery was a major topic of discussion at the Society of Thoracic Surgeons (STS) Annual Meeting here.

One new study showed that the more invasive pneumonectomy procedure is the strongest predictor of mortality after resection for lung cancer.

Another showed that lobectomy, segmentectomy, and wedge resection are all associated with similar recurrence rates, suggesting that less invasive procedures work just as well as more invasive ones.

Other research gave new insight into the impact of comorbidities in older patients who undergo lobectomy.

Other researchers pinpointed five variables that predict postoperative atrial fibrillation after resection for lung cancer.

Yet another study showed that removal and evaluation of 21 or more N1 lymph nodes positively affects patient survival following resection for non-small cell lung cancer (NSCLC).

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Low Mortality

Benjamin D. Kozower, MD, Assistant Professor of Surgery and Public Health Sciences at the University of Virginia in Charlottesville, said his study was designed to create risk-adjusted models to help predict perioperative outcomes for lung cancer resection.

“We found some very powerful predictors of mortality and major morbidity that will help improve patient care in the future,” said Dr. Kozower, whose oral presentation was awarded the J. Maxwell Chamberlain Memorial Paper for General Thoracic Surgery at the meeting.

Dr. Kozower and colleagues queried the STS General Thoracic Database for all patients treated with resection for primary lung cancer at 111 centers between 2002 and 2008.

Perioperative mortality occurred in 413 (2.2%) of the 18,800 patients. The most common causes of major morbidity were pneumonia and reintubation, which occurred in 3.8% and 3.5% of patients, respectively.

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Predicting Mortality

The greatest predictor of mortality was pneumonectomy, which increased the risk of dying 3.9-fold, compared with lobectomy, Dr. Kozower reported.

Patients with poor physical status before surgery, defined as an American Society of Anesthesiology (ASA) score of 3 or greater, were 3.6 times more likely to die, compared with patients who had an ASA score of 1.

Poor performance status, defined as a Zubrod score of 3 or greater, increased mortality risk 3.1-fold vs patients with a Zubrod score of 0. “Induction chemoradiation therapy, but not induction chemotherapy alone, doubled the risk of death,” Dr. Kozower reported.

Poor performance status and ASA rating were also among the strongest predictors of major morbidity. Patients with a Zubrod score of 3 or higher were at 2.5-fold increased risk of major morbidity compared with patients with a score of 0. And patients with an ASA score of 4 or higher had double the risk, compared with patients with an ASA score of 1.

In addition, lobectomy doubled the rate of major morbidity, compared with use of a non-anatomic wedge resection, he said.

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‘Excellent Outcomes'

Study Discussant Joe B. (Bill) Putnam, MD, Professor and Chair of Thoracic Surgery at Vanderbilt-Ingram Cancer Center, said that the strengths of the study are its large size and use of a national databank.

“One weakness is that the study participants are predominantly white; we need diversity.

“Overall, outcomes are excellent after lung cancer resection,” he continued. “Mortality is almost as [low] as that observed in clinical research.

“The challenge is providing feedback to poor-performance hospitals so they can do better. Studies like this are the start.”

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Less Invasive Surgery

Yet another study was aimed at finding less invasive surgeries for lung cancer patients. “How do we do a lesser operation for lung cancer just as breast surgeons do a lesser operation for breast cancer?” Dr. Putnam asked in his discussion of that study, by University of Pittsburgh researchers.

The team compared the oncologic outcomes of 90 patients with Stage IA NSCLC 1 cm or less in diameter who underwent complete R0 surgical resection with systematic nodal sampling. A total of 29 patients underwent lobectomy, 38 had segmentectomy, and 23 had wedge surgery.

There were no operative or in-hospital deaths. At a mean follow-up of 27.8 months, 10% of patients in the lobectomy group, 11% in the segmentectomy group, and 13% in the wedge resection group had disease recurrence, a difference that was not significant.

The estimated five-year disease-free survival rates were also comparable between the cohorts: 84.3% for lobectomy, 83.5% for segmentectomy, and 82.9% for wedge resection.

Several large clinical trials are under way or planned to confirm the findings, Dr. Putnam noted.

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CVD vs Cancer

Other research gave new insight into the impact of comorbidities in older patients who undergo lobectomy.

Shawn S. Groth, MD, a resident in the Department of Surgery at the University of Minnesota, found that for patients age 70 and older with Stage I NSCLC, the risk of dying from NSCLC exceeds the risk of dying from chronic diseases at the time of lobectomy.

Within five years after lobectomy, however, cardiovascular disease (CVD) becomes an important cause of mortality, indicating that CVD risk factor modification is essential for elderly cancer survivors, he said.

Using the NCI's Surveillance Epidemiology and End Results (SEER) database, the researchers identified 22,518 patients age 50 and older who underwent lobectomy for Stage I NSCLC from 1988 through 2005.

For patients 70 to 79, the CVD-specific survival rate and the cancer-specific survival rates were both 80% five years after lobectomy.

“By seven years later, the risk of dying of CVD was greater than the risk of dying of lung cancer,” Dr. Groth said. One surprising finding was that the point at which the risk of dying of CVD was greater than dying of lung cancer was the same for T1 and T2 tumors.”

During the question-and-answer period, one attendee said, “What's you're doing is fleshing out in numerical form what our clinical judgment tells us when evaluating patients.”

Commented Dr. Putnam: “Diseases of the elderly don't go away because we are treating them for lung cancer. The whole patient must be considered.”

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Predicting Atrial Fibrillation

Multivariable logistic analysis identified increasing age, increasing extent of operation, male gender, nonblack race, and N1-positive tumors as predictive of postoperative atrial fibrillation after lung cancer resection, reported Mark W. Onaitis, Assistant Professor of Cardiac and Thoracic Surgery at Duke University Medical Center.

Dr. Onaitis and his colleagues queried the STS National Database for all lobectomy and pneumonectomy patients with a diagnosis of lung cancer. A total of 13,906 patients who underwent resection for lung cancer at participating institutions had complete information for atrial fibrillation outcome. Of these, 1,755 (12.6%) experienced postoperative atrial arrhythmia.

Commented Dr. Putnam: “If a patient is undergoing lung surgery, he probably should be considered for some type of beta blocker prophylaxis.”

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Lymph Node Removal

For patients with NSCLC, removal and evaluation of 21 or more N1 lymph nodes were found to have a positive impact on survival following resection, according to a study reported by Akif Turna, MD, PhD of the Department of Thoracic Surgery at Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery in Istanbul.

While mediastinal lymph node dissection has been proven to be essential in surgery for NSCLC, there is continued controversy regarding the number of lymph nodes that need to be removed and evaluated for proper staging or therapeutic purposes, Dr. Turna explained.

He and his co-researchers conducted a retrospective review of 979 consecutive patients who underwent resectional surgery for NSCLC between January 1998 and August 2008. The mean number of resected mediastinal lymph nodes was 8.1, and the mean number of evaluated N1 nodes was 10.2.

The five-year survival rate was 56% in patients in whom fewer than 21 N1 nodes were evaluated, compared with 83% in patients who had more than 21 or more N1 nodes analyzed; however, the difference was not statistically significant.

“In lobectomy patients, however, survival was significantly longer if the number of evaluated N1 nodes was more than 20,” Dr. Turna said.

The researchers then looked at the impact of the number of evaluated N1 nodes on survival for all patients in a multivariate model adjusted for stage, histology, and gender. Patients in whom fewer than 21 N1 nodes were evaluated were 24% more likely to die, compared with patients in whom more N1 nodes were analyzed.

There appeared to be no incremental improvement in survival rates with evaluation of more than 21 lymph nodes, Dr. Turna said.

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New Lung Cancer Book from LWW!

The fourth edition of Principles and Practice of Lung Cancer, edited by Harvey I. Pass, MD; David P. Carbone, MD, PhD; David H. Johnson, MD; John D. Minna, MD; Giorgio V. Scagliotti, MD; and—OT's own “Turrisi Takes on the Movies” columnist—Andrew T. Turrisi III, MD, is now available.

The book, also the Official Reference Text of the International Association for the Study of Lung Cancer (IASLC), has been thoroughly revised and updated, with contributions from the world's foremost surgeons, radiation oncologists, medical oncologists, pulmonologists, and basic scientists.

Included is information on combined-modality therapy for small-cell and non-small cell lung cancer and on complications of treatment and management of metastases. Emphasis is also given to early detection, screening, prevention, and new imaging techniques, as well as expanded information on thoracic oncology, targeted agents, and newer radiotherapy techniques.

Other highlights include more international contributors and greater discussion of changes in lung cancer management in each region of the world, coordinated by Dr. Scagliotti, of the University of Turin, a new editor for this edition.

A companion website includes the full text online and an image bank.

Further information about the 1040-page book with 330 illustrations (ISBN-10: 0-7817-7365-2) can be found at or

© 2010 Lippincott Williams & Wilkins, Inc.
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