surgery after induction vs. definitive therapy and paranchym preserving vascular techniques

12th April, 2012 Antalya

Surgery after induction vs. definitive therapy and paranchym preserving vascular

techniques

Alper Toker, MDİstanbul University, İstanbul Medical School

Department of ThoracicSurgery


Neoadjuvant treatment

Invasion to vital organs • To have Easier resectability,• To achieve negative margins• To prevent seeding• To prevent radioresistance due to possible hypoxemiaof the tissue

• Rectum, • Lareynx,• Osephagus,• Prostate,• Soft tissue sarcomas• Pancreas.

.


Preoperative therapy

• Induction CT + surgery • Induction CT + RT (45Gy) + surgery

• Vs.

• Definitive CxRT (60Gy) + surgery

Definitive RT: Advantages Definitive RT: disadvantages


3 D treatments – Calculating the area


Decreasing the radiotherapy doseof healthy tissues


Respiratory gating and calculation of the target

12 Nisan, 2012 Toraks Kongresi Antalya


• Bromley and Szur 1955• Bleordan 1965• Shields 1972

No survival advantage, Increased morbidity Mortality 22 %

• Technical achievements in radiotherapy

• Surgery • Personalized approaches


Mortality after induction chemo-radiotherapy

Grup XRT N (lobx –pneux) Mortalite

SWOG 8805 45Gy 38/51 7,9/15,7INT 139 45Gy 98/54 1,0/25,9Maryland 45Gy 51/29 0,0/3,4Stamatis (Essen) 45Gy 255/133 3,6/7,1


Neoadjuvant Ch-RT


Adj dose RT -CT


CT and RT


Neoadjuvant Ch-RT


Not after RT


N2-T4 primary lung cancerInduction chemotherapy and chemoradiotherapy

(45 Gy / 60 Gy) and lung resection

• Morbidity• Mortality• Survival

Istanbul Medical School Lung Oncology Group


Patients and methods

December 2002 – December 2011 154 patients

– Age– Gender– Cytology (Epidermoid / Non epidermoid)– Induction treatment (CT / CT-RT45 / CT-RT60)– Pulmonary function Tests ( >%80, %80-60, <%60)– CO diffusion test ( >%80, %80-60, <%60)– Resection type– Mortality– Morbidity– Survival

– Prospectively recorded data


Patients and methods

Treatment modalities– CT: 89 patients– CT-RT 45: 46 patients– CT-RT 60: 19 patients

Patients operated within the past 24 months were excluded (119/154 patients)


Results IMean age 55.8 (minimum:36, maximum:76)

Histopathology– Epidermoid % 69– Non-epidermoid %31

Mean FEV1 : 2530 cc (%83.5)Mean DLCO : %80FEV1, FEV1%, FVC, FVC%, DLCO% (p>0.05)

Resection typpe– CT group: 21 left / 12 right pneumonectomy – CT-RT 45 group: 5 left/ 1 right pneumonectomy – CT-RT 60 group: 2 left/ 1 right pneumonectomy


Results IIMajor morbidity rate % 8.3

– CT % 7.7 (7/89)– CT-RT45 % 8.6 (4/46)– CT-RT60 % 10.5 (2/19) (p>0.05)

Mortality rate % 3.9– CT % 4,4 (4/89)– CT-RT45 % 4,3 (2/46)– CT-RT60 % 0 (0/19) (p>0.05)

– Pneumonectomy mortality % 4.8– Lobectomy mortality % 3.6 (p>0.05)

Major Morbidity:

•Hemorrhage•Ampyeme•Bronkopleural fistul•Chylothorax•Transient ischemic attack•Myocardial infarction•ARDS


Results III

Median followup: 31 monnths– (Minimum 24 mts – maximum 108 mts)

Median survival :27 mts– Induction CT (n:76) 24 mts– Induction CT-RT (n:43) 33 mts

(Kaplan Meier, p: 0.595)

– A correct survival analyze is impossible due to non-homogenous operative periods of groups.


DiscussionSurgery after induction treatment for N2 or T4 disease

– Type of induction treatment (CT & CT-RT 45 & CT-RT 60)

– PFT - DLCO – Histopathology– Type of resection (Lobectomy &

pneumonectomy) were not different statistically in terms of major morbidity and mortality.


Conclusion

Lung resection after induction treatment;Acceptable morbidity ve mortality rate.CT- RT 60 Gy did not have a negatife effect on mortality and morbidity.Median survival seems to be longer in CT-RT patients, however,difference is statistically insignificant when compared to CT only. Pneumonectomy decision needs to be judged carefully.

Patient selection !


Induction vs. definitiveEvidence based medicine:No concrete evidence

Results derived from studies:1- A reliable modality,2- ↑rate of mediastinal sterilization,3- ↑ pathologic complete response rate,4- Possible better survival rate. 5-Morbidity and mortality rates are higher compared to standarts even statistically not significant.

Personal view:1- We choose fit patients,2- Technically and medically possible, 3- Better survival,4- Recurrence comes from brain,5- Experienced team,6- Personalized treatment(Patient and doctor).


3 rekonstrüksiyon 4 anastomoz Toker A, GKDC Dergisi 2009


Bronchovascular sleeve resections


Technical differences Double sleeve

İsolated vascular sleevePatch Plasty


Lung tumor after Neoadjuvant CT


anastomoz


Double sleeve after CT-RT


Positive bronchial margins


Isolated patch plasty

• Technically easier Available materials (pericardium, vascular grefts, veins, etc)

• Lesser rate of complication.• No need to anticoagulate.

• Surgical margins, always trouble

• Posterior part sutures• Placing the patch may

need vascular technique experience.


Technics


Isolated Patch Plasty


Sol santral lezyon


87 year-old patient with left hilar mass


Bronchial sleeve and patch plasty

Bronchus first,Approximate and control the pulmonary artery when the lung is inflated,Select the proper reconstructive material,Air leak control,A viable tissue between the sutures of bronchus and pulmonary artery.


Bronchial sleeve and patch plasty


Carinal right upper lobectomy with patch plasty


Patch to trifucation


Patch to main right PA


Neoadjuvant CT-RT 60


After induction treatment


Post operatif


Pulmonary arterial patch brings the chance for another operation to contralateral primary lung tumor


2nd operation Right upper sleeve lobectomy


Tumor thrombus to main left PA

surgery after induction vs. definitive therapy and paranchym preserving vascular techniques

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