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Câncer de Pulmão Estádio IA. Quais os limites da ressecção sublobar? Carlos Antônio Stabel Daudt Joinville, Santa Catarina.

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Presentation on theme: "Câncer de Pulmão Estádio IA. Quais os limites da ressecção sublobar? Carlos Antônio Stabel Daudt Joinville, Santa Catarina."— Presentation transcript:

1 Câncer de Pulmão Estádio IA. Quais os limites da ressecção sublobar? Carlos Antônio Stabel Daudt Joinville, Santa Catarina

2 Ginsberg RJ, Rubenstein LV for the Lung Cancer Study Group. Randomized trial of lobectomy vs. limited ressection for T1N0 non-small cell lung cancer. Ann Thorac Surg 1995;60: Recidiva local 3 vezes maior

3 O uso de ressecção sub-lobar e segmentectomia é aceito para doenças benignas e carcinoma metastático. Também é aceito como um procedimento razoável para ressecção em pacientes com câncer e função pulmonar comprometida.

4 Qual é a controvérsia? Quem ainda acha que a lobectomia é o “padrão ouro” para Estadio IA? CALGB

5 Pubmed: sublobar resection lung cancer 124 citações

6 Nakamura H, Kawasaki N, Taguchi M, Kabasawa K. Survival following lobectomy vs. limited resection for stage I lung cancer: a meta-analysis. Br J Cancer 2005;92:1033–1037. Sem diferença estatisticamente significativa pacientes, , 14 estudos, 12 retrospectivos. Muita heterogeneidade no estudo, pelo longo tempo avaliado, e as diferentes indicações para ressecções sub-lobares.

7 Lobectomy versus sublobar resection for small (2 cm or less) non-small cell lung cancers. Wolf ASWolf AS, Richards WG, Jaklitsch MT, Gill R, Chirieac LR, Colson YL, Mohiuddin K, Mentzer SJ, Bueno R, Sugarbaker DJ, Swanson SJ. Ann Thorac Surg Nov;92(5): ; discussion Epub 2011 Oct 31.Richards WGJaklitsch MTGill RChirieac LR Colson YLMohiuddin KMentzer SJBueno RSugarbaker DJSwanson SJ Ann Thorac Surg. Estudo retrospectivo de 2000 a 2005 – Tendência para maior recidiva local. Pacientes no grupo sub-lobar eram mais velhos e com função pulmonar pior.

8 J Natl Cancer Inst.J Natl Cancer Inst Nov 2;103(21): Epub 2011 Sep 29. Predictors and outcomes of limited resection for early-stage non-small cell lung cancer. Billmeier SE, Ayanian JZ, Zaslavsky AM, Nerenz DR, Jaklitsch MT, Rogers SO. Source Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. Abstract BACKGROUND: Lobectomy is considered the standard treatment for early-stage non-small cell lung cancer (NSCLC); however, more limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection and compared postoperative and long-term outcomes between sublobar and lobar resections. METHODS: A population- and health system-based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals was observed for a median of 55 months, through May 31, Predictors of limited resection and postoperative outcomes were compared using unadjusted and propensity score-weighted analyses. All P values are from two-sided tests. RESULTS: One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted analyses of patient-specific factors, smaller tumor size (P =.004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P =.02), more severe lung disease (P.05). Over the course of the study, a non-statistically significant trend toward improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P =.05). CONCLUSIONS: Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be associated with the choice of surgical resection. Billmeier SEAyanian JZZaslavsky AMNerenz DRJaklitsch MTRogers SO J Natl Cancer Inst. Billmeier SEAyanian JZZaslavsky AMNerenz DRJaklitsch MTRogers SO

9 smaller tumor size (P =.004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P =.02), more severe lung disease (P <.001), and a history of stroke (P =.049) were associated with receipt of limited resection. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P =.02), non-fee-for-service compensation (P =.008), and National Cancer Institute cancer center designation (P =.006) were associated with higher odds of limited resection smaller tumor size (P =.004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P =.02), more severe lung disease (P <.001), and a history of stroke (P =.049) were associated with receipt of limited resection. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P =.02), non-fee-for-service compensation (P =.008), and National Cancer Institute cancer center designation (P =.006) were associated with higher odds of limited resection

10 Sublobar resection provides an equivalent survival after lobectomy in elderly patients with early lung cancer. Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Kodama K. Ann Thorac Surg Nov;90(5): Sublobar resection provides an equivalent survival after lobectomy in elderly patients with early lung cancer. Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Kodama K. Ann Thorac Surg Nov;90(5): Okami JIto YHigashiyama MNakayama TTokunaga TMaeda J Okami JIto YHigashiyama MNakayama TTokunaga TMaeda J grupos: idosos (=> 75 anos); jovens (<75 anos) IA

11 Sublobar resection provides an equivalent survival after lobectomy in elderly patients with early lung cancer. Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Kodama K. Ann Thorac Surg Nov;90(5): Sublobar resection provides an equivalent survival after lobectomy in elderly patients with early lung cancer. Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Kodama K. Ann Thorac Surg Nov;90(5): Idosos n: 133Jovens n: lobectomias e 54 sub-lobares 74,3% e 67,6% (ns p<0.92) Recidiva local 1,3% e 11,1% 539 lobectomias e 92 sub-lobares Sobrevida 90,9% e 64% (p<0.0001) Recidiva local 12.0% e 1,5%

12 PAPEL DA RESSECÇÃO LIMITADA NA CIRURGIA DO CÂNCER DE PULMÃO Paulo de Biasi PAPEL DA RESSECÇÃO LIMITADA NA CIRURGIA DO CÂNCER DE PULMÃO Paulo de Biasi Livro Virtual Livro 01 - Tópicos de atualização em cirurgia torácica Vários autores - 61 capítulos disponíveis em PDF. < 2cm.

13 Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients? Chamogeorgakis T, Ieromonachos C, Georgiannakis E, Mallios D. Interact Cardiovasc Thorac Surg Mar;8(3): Epub 2008 Jul 18. PMID: [PubMed - indexed for MEDLINE] Free full text Chamogeorgakis TIeromonachos CGeorgiannakis EMallios D Interact Cardiovasc Thorac Surg. Chamogeorgakis TIeromonachos CGeorgiannakis EMallios D Interact Cardiovasc Thorac Surg. 4. Search strategy Medline 1950 to May 2008 using OVID interface (Limited resection.mp OR sublobar.mp OR wedge resection.mp OR limited pulmonary resection.mp OR limited lung resection. mp OR conservative resection.mp OR conservative pulmonary resection.mp OR wedge excision.mp OR segmentectomy. mp) AND (Carcinoma, Non-Small-Cell Lungyor non-small cell lung cancer.mp) Resultado: 255 publicações, dos quais 19 apresentavam melhor evidência.

14 Journal of Thoracic Oncology: October Volume 5 - Issue 10 - pp Sublobar Resection: A Movement from the Lung Cancer Study Group Blasberg, Justin D. MD*; Pass, Harvey I. MD†‡¶; Donington, Jessica S. MD†¶

15 Table 7 TABLE 7. Tumor, Resection, and Patient Characteristics Associated with Improved Survival After Sublobar Resection for NSCLC Copyright © 2012 Journal of Thoracic Oncology. Published by Lippincott Williams & Wilkins.15 Sublobar Resection: A Movement from the Lung Cancer Study Group Sublobar Resection: A Movement from the Lung Cancer Study Group Blasberg, Justin D.; Pass, Harvey I.; Donington, Jessica S. Journal of Thoracic Oncology. 5(10): , October doi: /JTO.0b013e3181e77604

16 Qual é a controvérsia? Quem ainda acha que a lobectomia é o “padrão ouro” para Estadio IA? CALGB

17 Phase III Randomized Study of Lobectomy Versus Sublobar Resection in Patients With Small Peripheral Stage IA Non-Small Cell Lung Cancer Objectives Primary Compare the disease-free survival of patients with small (≤ 2 cm) peripheral stage IA non-small cell lung cancer undergoing lobectomy vs sublobar resection (wedge resection or segmentectomy). Secondary -Compare the overall survival of patients undergoing lobectomy vs sublobar resection. -Compare the rates of loco-regional and systemic recurrence in patients undergoing lobectomy vs sublobar resection. -Compare the pulmonary function of these patients, as measured by expiratory flow rates at 6 months postoperatively. -Explore the relationship between characteristics of the primary lung cancer, as revealed by pre- operative CT scan and positron emission tomography (PET) imaging, and outcomes. -Determine the false-negative rate of preoperative PET scan for identification of involved hilar and mediastinal lymph nodes. -Assess the utility of annual follow-up CT scan after surgical resection in these patients.

18 Entry Criteria Disease Characteristics: Suspected or proven non-small cell lung cancer (NSCLC), meeting both preoperative and intraoperative criteria: Preoperative criteria -Peripheral lung nodule ≤ 2 cm by CT scan -Center of the tumor must be located in the outer third of the lung in either the transverse, coronal, or sagittal plan -Tumor location must be suitable for either lobar or sublobar resection (wedge resection or segmentectomy) -No pure ground opacities or pathologically confirmed N1 or N2 disease Intraoperative criteria Histologically confirmed NSCLC -Confirmation of N0 status by frozen section examination of nodal levels 4, 7, and 10 on the right side and 5, 6, 7, and 10 on the left side* -Levels 4 and 7 nodes may be sampled by mediastinoscopy, endobronchial ultrasound (EBUS), and/or endoscopic ultrasound (EUS), or at the time of thoracotomy or video-assisted thoracoscopic surgery (VATS) exploration* [Note: *Nodes previously sampled by mediastinoscopy (or EBUS and/or EUS) either immediately before or within 6 weeks of the definitive surgical procedure (thoracotomy or VATS) do not need to be resampled] -No evidence of locally advanced or metastatic disease

19 Outline This is a multicenter, randomized study. Patients are stratified according to tumor size ( cm) (based on the maximum dimension determined from the preoperative scan), histology (squamous cell carcinoma vs adenocarcinoma vs other), and smoking status (never smoked [smoked 100 cigarettes AND quit ≥ 1 year ago] vs current smoker [quit cm) (based on the maximum dimension determined from the preoperative scan), histology (squamous cell carcinoma vs adenocarcinoma vs other), and smoking status (never smoked [smoked 100 cigarettes AND quit ≥ 1 year ago] vs current smoker [quit < 1 year ago or currently smokes]). Patients are randomized to 1 of 2 treatment arms. Arm I: Patients undergo lobectomy by open thoracotomy or video- assisted thoracoscopic surgery (VATS). Arm II: Patients undergo a wedge resection or anatomical segmentectomy by open thoracotomy or VATS. After completion of study treatment, patients are followed up every 6 months for 2 years and then annually for 5 years.

20 CALGB CALGB /03/2012 Aproximadamente 300 randomizados, faltam 392. n: 692.

21 Novo Estadiamento: T1a (= 2-3cm). Ambos são 1A

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