1. Highlights do WCLC 2017 Estadiamento e Cirurgia
Paula A. Ugalde
Associate Professor
Thoracic Oncology Research Program Director
Division Thoracic Surgery
Laval University
Quebec - Canadá

2. The authors declare no conflict of interest.
Management of local recurrence after segmentectomy for stage IA Lung Cancer
Takeshi Mori, Kosuke Fujino, Tatsuya Yamada, Hironobu Osumi, Yamato Motooka, Koei Ikeda, Kenji Shiraishi, Makoto Suzuki
Department of Thoracic Surgery, Kumamoto University, Graduate School of Medical Sciences, Kumamoto/Japan
The authors declare no conflict of interest.

3. Method
Patients with stage I NSCLC who underwent a segmentectomy between 2005 and 2009 were investigated retrospectively.
The criteria for segmentectomy (1). Peripheral-type and small size NSCLC.
(2). Intraoperative frozen sections of sentinel nodes identified with isotope showing no metastasis.
(). Surgical margins greater than 2cm.

4. Kaplan-Meier Curves of OS and DFS
5-year survival : 91.8%
OS (N=179)
DFS (N=179)
5-year DFS : 90.2%
Survival
Time(months)

5. Recurrent cases after segmentectomy
Age
Gender
CT findings
Pathological type ly v p
MIP
Size(clinical, mm)
Status OS
DFS
Pattern of recurrence
Additional treatment 63 M
Solid
SQC
non-kera ー ＋
25x19
Cancer death
21.9
6.5
Dissemination 79
24x16
Death of other disease
12.5
7.8
Dissemination, LN 80 F
24x13
93.7 10 LN
RT+BSC 61
kera
32x20
15.2
10.8
Contralateral chest wall 70
ADC
Acinar
0.1
18x15
Alive
81.6
11.9
Other lobe CL 58
0.2
9x7
44.6
13.1
PR+ Chemo 78
21x12 27
15.1
Other lobe, LN, Liver 74
16x8
55.6
29.4
Contralateral lung
15x10
81.7
37.8
Chemo
17x13
43.2
40.2
Contralateral lung, LN, Adrenal gland, bone 76
Part Solid
Lepidic
18x13
97.4
61.2
Local 62
18x10
93.9
62.2
Local, Dissemination
BSC 65
0.3
35x11
109.8
63.4
CL+ Chemo 81
Pap
95.7
70.4
RFA
16x16
117.3
98.8 RT

6. Conclusion
Management of recurrence after segmentectomy for stage IA non small cell lung cancer is important.
Local treatment, such as, completion lobectomy, radiation, or radio frequency ablation may effective for selected cases with recurrence after segmentectomy.

7. Seoul National University Bundang Hospital, South Korea.
Comparison of sublobar and lobar resection in octogenarians with early stage non-small cell lung cancer
Sira laohathai,MD.
Seoul National University Bundang Hospital, South Korea.

8. Goals Primary endpoint Secondary endpoint Recurrence-free survival
Overall survival
Recurrence-free survival
Complications
In octogenarians with pathologic stage I NSCLC
between sublobar resection and lobar resection

9. Methods Retrospective cohort 2003-2016 Inclusion criteria
- Age over 80
- Pathologic NSCLC stage I based on AJCC 8th ed.
- R0 resection
- No adjuvant RT or CTx

10. Overall survival rate P= 0.354 Time at risk Death death rate n (%)
median time (month)
Overall death
24 (31.2)
24.5
Lobar resection
17 (32.1)
19.7
Sublobar resection
7 (29.2)
34.2

11. Recurrence free survival
P= 0.623
Time at risk Recurrence
Incident rate n (%)
median time (month)
Overall recurrence
14 (18.2)
14.17
Lobar resection
8 (15.1)
12.37
Sublobar resection
6 (25.0)
19.2

12. Conclusion
Sublobar resection is an alternative treatment for early lung cancer in octogenarians which does not increase risk of recurrence or mortality after the operation.
Sublobar resection could benefit shorter hospital stay and complication after surgery.

13. Robotic Surgery, VATS, and Open Surgery for Early Stage Lung Cancer: Comparison of Costs and Outcomes at a Single Institute

14. We retrospectively assessed 103 consecutive patients
Method:
We retrospectively assessed 103 consecutive patients
lobectomy or segmentectomy for clinical stage I or II NSCLC.
Three surgeons could choose VATS or open,
The fourth could choose between all three techniques.

15. Result:
33 pts robot
41 pts VATS
39 pts thoracotomy
Duration of surgery was 150, 191 and 116 minutes, by robotic, VATS and open approaches, respectively (p<0001).
Significantly more lymph node stations were removed (p<0.001), and median length of stay was shorter (4, 5 and 6 days, respectively; p<0.001) in the robotic than VATS and open groups.
Estimated costs were 82%, 69% and 68%, respectively, of the regional health service reimbursement for robotic, VATS and open approaches.

16. Is Video-Assisted Thoracic Surgery a safer procedure for Lung Cancer Patients? Maria Teresa Ruiz Tsukazan1,3, Ricardo M Terra2, Álvaro Vigo3, Gustavo Fortunato4, Spencer Camargo5, Humberto Oliveira6,, Darcy Pinto Filho7
1Hospital São Lucas da PUCRS, 2University of São Paulo Medical School, 3Universidade Federal do Rio Grande do Sul, 4Hospital Santa Isabel, 5Hospital Pavilhão Pereira Filho, 6Hospital de Base do Distrito Federal, 7Universidade de Caxias do Sul

17. Objective
The purpose of this study was to compare the outcomes of VATS versus open thoracotomy (OT) for anatomical lung resection in patients from the Brazilian Society of Thoracic Surgery (BSTS) database.

18. Methods
Propensity score analysis of 728 lung cancer patients who underwent anatomic lung resections (358 thoracotomies and 370 VATS). Pneumonectomies were excluded for analyses. Propensity-score model: age at surgery, gender, BMI, comorbidities, type of resection, staging according to 7th ed. Outcomes were mortality and complications.

19. VATS
Thoracotomy
OR (CI95%)
Mortality
3 (0.8%)
13 (3.63%)
4.75 ( )
Any Complication
111 (30.0%)
128 (35.7%)
1.08 ( )
Major Complication
48 (13.0%)
62 (17.3%)
1.32 ( )

20. VATS (%) Thoracotomy(%) Air leak> 5 days 26 (7%) 34 (9.5%)
Thoractomy
Air leak> 5 days
26 (7%)
34 (9.5%)
Atrial fibrillation
9 (2.4%)
20 (5.6%)
Atelectasis
17 (4.6%)
26 (7.3%)
Delirium
7 (1.9%)
13 (3.6%)
Pneumonia
25 (6.7%)
39 (10.9%)
VATS (%)
Thoracotomy(%)
VATS (%)
Thoracotomy(%)
Air leak> 5 days
26 (7%)
34 (9.5%)
Atrial fibrillation
9 (2.4%)
20 (5.6%)
Atelectasis
17 (4.6%)
26 (7.3%)
Delirium
7 (1.9%)
13 (3.6%)
Pneumonia
25 (6.7%)
39 (10.9%)

21. Conclusion
In Brazil, minimally invasive surgery (VATS) for anatomic lung resections is associated with a significantly lower rate of mortality when compared to conventional thoracotomy. 

22. The IASLC Lung Cancer Staging Project: Analysis of Resection Margin Status and Proposals for R Status Descriptors for Non-Small Cell Lung Cancer
John Edwards, Kari Chansky, Lynn Shemanski, Paul Van Schil, Hisao Asamura, Ramón Rami-Porta
PL IASLC Lung Cancer Staging Project: R Status Descriptors

23. less than 3 N1 or N2 node examined
Methods
14,712 patients undergoing NCSLC surgery, for whom full R status and survival data were available
Cases were reassigned to R (uncertain) if any of the following applied:
less than 3 N1 or N2 node examined
less than lobe-specific  Systematic Lymph Node Dissection
Extra-Capsular Invasion ( ECI ) of N2 nodes
positive highest lymph node station status of highest node unavailable
carcinoma in situ at bronchial resection margin currently R1(i.s.)
positive pleural lavage cytology currently R1(cy+)
PL IASLC Lung Cancer Staging Project: R Status Descriptors

24. Results: Conventional R statusR0 R1 R2
TOTAL
pT1
6,700 32 30
6,762
pT2
5,820
107 54
5,981
pT3
1577 93 35
1,705
pT4
196 31 37
264
14,293
263
156
14,712
Positive correlation between higher pT stage and positive R status (p<0.0001) R0 R1 R2
TOTAL
pN0
11,058
106 54
11,218
pN1
1,395 44 21
1,460
pN2
1800
105 75
1,980
pN3 40 8 6
14,293
263
156
14,712
R Status
Events / N
Median Survival
5 Year Surviva l
Hazard Ratio p R0
3632 / 14293 NR
73% 1 R1
149 / 263
33.0
36%
3.46
< R2
96 / 156
29.0
28%
4.12
0.18
Positive correlation between higher pN stage and positive R status (p<0.0001)
PL IASLC Lung Cancer Staging Project: R Status Descriptors

25. Highest Lymph Node Station Positive – pN2 cases only
Highest Station
/ R status N
Median
Survival
5 Year
NEGATIVE / R0
1062
55.0
48%
POSITIVE / R0
738
41.0
39%
NEGATIVE / R1 57
27.0
29%
POSITIVE / R1 48
26.0
22% R2 75
22.0
18%
R0 cases: Positive vs Negative: Hazard Ratio = 1.45 (p<0.0001)
PL IASLC Lung Cancer Staging Project: R Status Descriptors

26. Survival according to R status in N0 Cases
HR and p-values from Cox model adjusting for Asian cases. (there was not a significant interaction between asian cases and the R-factors. I.e. relationship statistically not different in Asian and non-Asian cases.
R status N
Median Survival HR p R0
4672 NR 1
R(un)
6391
1.08
0.08 R1
101
46.9
3.69
<0.0001 R2 54
39.0
4.28
0.53
R Status N
Median Survival
5 Years HR p R0
1413
70.0
55% 1
R(un)
1811
50.0
45%
1.27
<0.0001 R1
168
30.0
30%
2.13 R2
102
23.0
22%
2.56
0.25
PL IASLC Lung Cancer Staging Project: R Status Descriptors

27. Survival according to R Status for pT1a,b,c,T2a N0 cases (i. e
Survival according to R Status for pT1a,b,c,T2a N0 cases (i.e. no indication for adjuvant chemotherapy)
R status
Events / N
Median
Survival
5 Year HR P R0
487 / 3610 NR
87%
R01(un)
881 / 5185
83%
1.2 8
<0.0001 R1
11 / 28
57%
2.0 8
0.02 R2
6 / 16
67%
1.2 9
0.61
THESE P VALUES ARE PROVISIONAL AND NEED FURTHER CHECKING
PL IASLC Lung Cancer Staging Project: R Status Descriptors

28. R(un) accounted for 56% of cases
Results Summary :
R(un) accounted for 56% of cases
The majority of cases were R(un) due to intraoperative staging less rigorous than Systematic Lymph Node Dissection
In pN2 cases with the highest station positive, median survival was 14 months less compared to highest station negative cases
In N+ cases, median survival was 20 months less for those with R(un) status compared to R0
PL IASLC Lung Cancer Staging Project: R Status Descriptors

29. Optimal staging data also allows:
Conclusions:
The IASLC Proposed Definition for Complete Resection has relevance, according to the 8th Edition Database
High quality surgical staging gives the most accurate assignment of stage group and the most favorable survival data, stage by stage (partly due to stage migration)
Optimal staging data also allows:
the most appropriate decision making for routine adjuvant therapy
accurate interpretation of survival in adjuvant therapy clinical trials (LungART, PEARLS)
PL IASLC Lung Cancer Staging Project: R Status Descriptors

30. Is lobe-specific lymph node dissection in clinical N0-1 non-small cell lung cancer adequate for pathological nodal staging?
Apichat Tantraworasin1, Sophon Siwachat1, Narumon Tanatip1, Nirush Lertprasertsuke1, Sarawut Kongkarnka1, Juntima Euathrongchit1, Yutthaphan Wannasopha1, Emanuela Taioli2, Somcharoen Saeteng MD1
1 Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
2 Icahn School of Medicine at Mount Sinai, New York, NY, USA
Good afternoon everyone
I would like to present our study in the title of Is lobe-specific lymph node dissection in clinical N0-1 non-small cell lung cancer adequate for pathological nodal staging

31. Introduction
Lobe-specific lymph node dissection (L-SND) has been proposed for clinical T1a-2b N0-1 NSCLC
The benefits of this approach are still uncertain, especially for pathological nodal staging
AIM
To evaluate the percent detection of pN2 disease in L-SND and in systematic lymph node dissection (SLND)
First, some general background of the study.
Lobe-specific lymph node dissection (L-SND) was proposed for clinical T1a-2b N0-1 non-small cell lung cancer (NSCLC) since 1999 on the basis of lymphatic spreading pattern in each lobe of primary site , however, the benefit of this approach is still uncertain, especially for pathological nodal staging. In this study, we evaluated the percent detection of pN2 disease in L-SND and in systematic lymph node dissection (SLND).

32. Results
Pathological N2 status in lobe-specific dissection and systematic lymph node dissection
Location of primary tumor
Clinical N0-1 status
Pathologic N2 status (lobe-specific dissection)
Pathologic N2 status (Systematic dissection)
% difference of upstaged to N2 disease
Negative
Positive
RUL (n=67)
57 (85.1)
10 (14.9)
52 (77.6)
15 (22.4)
49 (73.1)
18 (26.9)
4.5
RLL (n=31)
29 (93.65)
2 (6.5)
24 (77.4)
7 (22.6)
23 (74.2)
8 (25.8)
3.2
LUL (n=51)
43(84.3)
8 (15.7)
37 (72.5)
14 (27.5)
36 (70.6)
15 (29.4)
1.9
LLL (n=29)
24 (82.8)
5 (17.2)
23 (79.3)
6 (20.7)
22 (75.9)
7 (24.1)
3.4
This table showed the percent difference of upstaged to N2 disease comparing between SLND and L-SLD.
Overall, the percent upstaged to N2 disease in SLND is higher than that in S-SLD.
You can see that for RUL, the percent difference of upstaged to N2 disease is 4.5 , for RLL is 3.2, for LUL is 1.9 and for LLL is 3.4.
However, there are no statistically significant difference between two procedures.

33. Results
Correlation between SLND and L-SLD ability to detect pN2 disease
pN2 status - SLND
pN2 status - L-SLD, N(%)
Total
Negative
Positive
130 (95.6)
0 (0)
130 (73.0)
6 (4.4)
42 (100)
48 (27.0)
136 42
Now lets look at the correlation between two procedures and detection of pN2 disease.
Six patients (4.4 %) who have negative pN2 status in L-SLD have positive result in SLND and 42 patients (100 %) who have positive pN2status in L-SLD have also positive in SLND.
the Kappa of agreement is 96.6 % and kappa is 0.911, that means, it is high correlation between two procedures.
Kappa of agreement = 96.63%, kappa = (95%CI; )

34. Conclusion
Lobe-specific LN dissection is as adequate as systematic LN dissection for pathological N2 staging in clinically early stage NSCLC surgery
Higher detection of pN2 disease is present in SLND
In conclusion
lobe-specific lymph node dissection is as adequate as SLND for pathological N2 staging in clinically early stage NSCLC surgery. However, systematic lymph node dissection achieved a higher detection of pN2 disease.

35. Significance of Spread through Air Spaces in Resected Pathological Stage I Lung Adenocarcinoma
Presenting Author(s): Gouji Toyokawa  |  Author(s): Y. Yamada, T. Tagawa, F. Kinoshita, Yuka Kozuma, T. Matsubara, Naoki Haratake, Shinkichi Takamori, Takaki Akamine, Kazuki Takada, F. Hirai, Y. Oda, Y. Maehara

36. Method: STAS was assessed in a total of 276 patients with resected pathological stage I adenocarcinoma.
Classified as either no STAS, low STAS (1-4 single cells or clusters of STAS), or high STAS (≥5 single cells or clusters of STAS) using a 20x objective and a 10x ocular lens.
We evaluated the association between STAS and the clinico pathological characteristics and postoperative survivals.

37. Conclusion: STAS was associated with clincopathologically invasive features and was predictive of a worse survival. Figure 1

38. Evaluation of the safety and efficacy of VATS pneumonectomy in the treatment of locally advanced lung cancer
Dr Joshua Goldblatt, Mr Naveed Alam, Dr Reece Davies, Dr Janaka Lovell, Associate Professor Gavin Wright
St Vincent’s Hospital Melbourne, Australia
University of Melbourne, Melbourne, Victoria, Australia
Background
Methods
Results
Conclusion
VATS technique are being increasingly used worldwide for the management of lung cancer1. VATS lobectomy has been shown to be superior to traditional open lobectomy with shorter length of stay, fewer perioperative complications and improved quality of life1. There are understandable concerns regarding the use of VATS for larger oncological resections including pneumonectomy and sleeve resections. We add more confirmatory data to several retrospective cohort studies demonstrating the safety of VATS pneumonectomy in selected patients1,2.
With ethics approval, a retrospective cohort study was performed at a single-centre in Melbourne, Australia. It included all patients who had undergone a pneumonectomy between 1999 and 2017.
The primary outcome was overall survival (OS). Secondary outcomes included: 30-day and 90-day mortality, disease-free survival (DFS) and length of stay.
Univariate and multivariate analysis was performed using the Cox-proportional hazard regression model for OS and DFS. Multivariate analysis was performed for any variable that had a p<0.20 in univariate analysis. For OS this included: age, tumour side, R1 resection status and access (VATS versus open). For DFS this included: age, R1 resection status, tumour side, nodal status and tumour diameter.
The allocation of approach was surgeon dependent, and made on a case-by-case basis.
Eighty patients underwent pneumonectomy between 1999 and VATS approach was used for 27 patients. There were 77 patients with NSCLC, two with carcinoid and one with melanoma. This represented ~5% of lung resections for NSCLC. There was no difference in the tumour size between the two cohorts (VATS median 47mm versus open median 50mm, p=0.07). There was no significant difference in node positive disease between the two cohorts (p=0.16).
The 30-day and 90-day mortality rate was 3.8% and 5% respectively, with no events occurring in the VATS cohort. Median overall survival for all patients was 27 months, with a median disease-free survival of 19 months. There was no statistically significant difference in overall survival depending on operative access (median survival VATS 86 months versus open 26.2 months, p=0.11) (Figure 1). There was no difference in disease-free survival in patients with NSCLC between the two groups (VATS median 86 months versus open median DFS 15.6 months, p=0.18) (Figure 2). The median length of stay was significantly shorter in the VATS cohort (7 days versus 8 days, p=0.006).
Multivariate analysis of OS and DFS found no difference in outcome with VATS surgery, (OS: OR 0.80, p=0.55; DFS: OR 0.91, p=0.82). Age (each year increase) was associated with a worse OS (OR1.03, p=0.048). With R1 resection, the odds ratio was 2.42 for OS, however this did not reach statistical significance (p=0.81). Tumour diameter was associated with worse DFS (OR 1.013, p=0.04). Positive R1 status was associated with worse DFS, with an odds ratio of 2.92, however this did not reach statistical significance (p=0.06).
The number of lung cancer cases performed as VATS at our institution has increased from 41% between 2002 and 2011 to 84% since The rate of VATS pneumonectomy has increased from 18% between 2002 and 2011 to 58.6% since 2014, however this increase lagged four years behind less major resections (i.e. lobectomy) (Figure 3).
In concordance with other recent retrospective cohort studies, our study demonstrates both the safety of VATS pneumonectomy and the oncological efficacy in appropriately selected patients.
Interestingly, in our practice, the adoption of the VATS approach for pneumonectomy lagged four years behind other lung resection surgery. This likely reflects the surgical learning curve associated with a new access technique.
Figure 3: figure representing the increasing utilisation of VATS as access for thoracic resections. Each period refers to two-years. Note the utilisation of VATS for pneumonectomy lagged approximately four years behind lobectomy. Furthermore, currently almost all lobectomy cases are performed via VATS, whereas the number of pneumonectomy performed via VATS has plateaued at roughly 60%.
References
Figure 1: five-year overall survival of VATS pneumonectomy (blue) versus open pneumonectomy (red) for all patients.
Sahai RK, Nwogu CE, Yendamuri S et al. Is thorascopic pneumonectomy safe? Ann Thorac Surg. 2009;88:
Nagai S, Imanishi N, Matsuoka et al. Video-assisted thorascopic pneumonectomy: retrospective outcome analysis of 47 consecutive patients. Ann Thorac Surg. 2014;97(6):
Disclosure
Nil conflicts of interest
Figure 2: five-year disease-free survival of VATS pneumonectomy (blue) versus open pneumonectomy for patients with non-small cell lung cancer (red).

39. Surgeon Practices for Post Resection Lung Cancer Surveillance: Comparisons of STS and ESTS Members
Leah Backhus, Prasha Bhandari, Cecilia Pompili, Nuria Novoa, Alex Brunelli, Keith Naunheim, Melanie Edwards
Thank you Dr. Lee and Dr. Chang

40. Screening Surveillance Screen-detected nodule Tumor Board
Surgical Resection
Post-Operative Clinic
Follow-Up
Screening
Surveillance
The adoption of LC screening will result in more patients with early stage disease but really screening represents the very beginning of a long care continuum which involves defintive care, often including surgery, followed by active surveillance. And while there are national and international guidelines in existence surrounding routine surveillance, these are largely based on consensus opinion since consistent high level evidence is lacking.

41. Background Objective Hypothesis
To compare contemporary practice patterns and attitudes toward post-resection surveillance among members of Society of Thoracic Surgeons (STS) and of European Society of Thoracic Surgeons (ESTS).
Hypothesis
Significant variation between groups regarding :
Surveillance strategies
Attitudes regarding surveillance

42. Results: Clinical examinations routinely performed for asymptomatic patients
ESTS
STS
p value
History and physical
75%
78%
0.26
CT chest*
71%
73%
0.61
Chest x-ray
46%
34%
0.02
Low-dose CT chest
16%
18%
0.51
PET/CT
12% 7%
0.12
HRQOL Survey
0.14
Bronchoscopy
10% 1%
<0.01
Bone scan 5%
0.01
Brain MRI 3%
Brain CT 6%
ESTS and STS respondents were similar in their frequent use of history and physical examination (75% vs 78%, p=0.26) and CT chest (71% vs 73%, p=0.61)
ESTS members reported using CXR more commonly than STS respondents and ESTS members reported more frequent use of testing NOT recommended by guidelines (for asymptomatic patients) including CXR (46% vs 34%, p=0.02) bronchoscopy (10% vs 1% p<0.01), bone scan (5% vs 0, p<0.01), brain CT (6% vs 0, p<0.01), and brain MRI (3% vs 0%, p=0.01)
Note: CT Chest* = Contrast or Non-Contrast Chest CT

43. Conclusions
European surgeons report a more optimistic belief in significant survival benefit from early detection of both recurrent and second primary NSCLC thus adopting more aggressive surveillance practices.
This is in spite of a lack of definitive evidence-based literature underscoring the need for both better prospective studies and joint recommendations to standardize practice.

44. 18th World Conference on Lung Cancer
 New TNM and WHO Classification
Staging and Pathology of Multiple Nodules Presenting in the Lungs
18th World Conference on Lung Cancer
Yokohama, Japan
16th October 2017
Professor Andrew G Nicholson, DM, FRCPath
Consultant Histopathologist, Royal Brompton and Harefield NHS Foundation Trust Professor of Respiratory Pathology National Heart and Lung Division Imperial College, London, United Kingdom

45. 8th TNM classification of multiple tumour nodules
Separate primary lung cancers (SPLC) – staged using the highest category, e.g. pT2a(2) or pT1c(m)
Intrapulmonary metastasis (separate tumour nodule)
T3 – nodule(s) in same lobe as primary tumour
T4 – nodule(s) in different lobe in the same lung
M1a – nodule(s) in contralateral lung

46. WHAT IS THE BEST METHOD FOR STAGING MULTIPLE TUMOUR NODULES ?
CLINICAL
IMAGING
HISTOPATHOLOGY
IMMUNOHISTOCHEMISTRY
MOLECULAR PATHOLOGY

47. Peripheral lepidic components in both tumors in non-mucinous ADC
UPDATED COMPREHENSIVE HISTOLOGICAL ASSESSMENT
Multiple tumors
Same tumor type
Different tumor type
Second primary lung cancer
Both ADC
Both SQCC/LCC/LCNEC/SCLC
Same major
histologic pattern
Different major
histologic pattern
Similar cytologic*
features
Different cytologic*
features
Second primary lung cancer
Second primary lung cancer
Intrapulmonary metastasis
Differing other
histologic patterns,
Cytologic* features.
Peripheral lepidic components in both tumors in non-mucinous ADC
Similar other
histologic patterns,
Cytologic* features.
*Statistically significant cytologic features
Nuclear pleomorphism
Cell size
Nucleolar size
Mitotic rate
Intrapulmonary metastasis
Interobserver Variation Among Pathologists And Refinement Of Criteria In Distinguishing Separate Primary Tumours From Intrapulmonary Metastases In Lung. JTO - submitted
Second primary lung cancer

48. Cancers with multiple lesions
Multiple primary tumours:
One TNM for each tumour
Separate tumour nodules:
T3, T4, M1a
Multiple adenos with GGO/lepidic features:
Highest T (#/m) N M
Pneumonic type adenocarcinoma:
Detterbeck F et al. J Thorac Oncol 2016; 11 (5):

49. Conclusions Overall staging is the same in 8th TNM compared to 7th TNM
Advances in imaging, pathology and molecular data have led to two additional proposed groups
(GGO/L and pneumonic/IMA)
Data suggest these have clinical relevance, but need strict pathological definitions to be applied for IMA and ADCs with lepidic components. More data need to be accumulated.
Best approach to accurate grouping is multidisciplinary assessment of clinical, imaging, histopathological, immunohistochemical and molecular data
The IASLC Lung Cancer Staging Project: Summary of Proposals for Revisions of the Classification of Lung Cancers with Multiple Pulmonary Sites of Involvement in the Forthcoming Eighth Edition of the TNM Classification. Detterbeck FC, Nicholson AG, Franklin WA, Marom EM et al. Journal of Thoracic Oncology, 2016;11:639-50

50. What type of surgery should be selected for GGO-containing tumors?
P. De Leyn, H. Decaluwé and W. Dewever
Department of Thoracic Surgery and Radiology
University Hospitals Leuven

51. Definition
More often found with screening

52. Pure GGO

53. Mixed type : Part-solid nodule

54. Impact for the surgery?
MIA or invasive adenocarcinoma with predominantly lepidic pattern rarely nodal involvement, good prognosis with limited resection
Follow-up?
Wedge-segmentectomy- lobectomy?
Nodal dissection?

55. Role of limited resection (lesions ≤ 2 cm)?
Disease free survival
Overall survival
Okada et al., J Thorac Cardiovasc Surg 2006;4:

56. Incidence of N2 disease in T1-T2N0 NSCLC (TNM 7th Edition)
N= 280 patients
Mediastinoscopy/EBUS or systematic nodal dissection
No of patients
Radiographic appearance
% N2 disease
119
Pure solid
12,6% 94
Semi solid
4,3% 67
Pure GGO
1,5%
Gao et al., Lung Cancer 2017;109:36-41

57. Partsolid nodules
When in a GGO lesion a solid part is present, risk on invasive adenocarcinoma increases.

58. Survival outcomes of Japan Clinical Oncology Group 0201
T1a (≤2 cm)
C/T Ratio ≤0.25
Asamura et al., J Thorac Cardiovas Surg 2013;146:24-30

59. Survival outcomes of Japan Clinical Oncology Group 0201
T1a-b (≤3cm)
C/T Ratio ≤ 0.5
Asamura et al., J Thorac Cardiovas Surg 2013;146:24-30

60. Consolidation/Tumor ratio
C/T ratio
Suzuki et al., JTO 2011;6:

61. Ongoing JCOG trials
Presented bij Asamura, IASLC World Conference on Lung Cancer2017

62. Intra-operative challenges
GGO lesions difficult to palpate. Effective marking techniques required during VATS
For central lesions, often segmentectomy/lobectomy is necessary

63. Left Upper Lobe GGO Tattoo prior to Segmentectomy

64. Complete Resection Minimally-invasive predominates (VATS or Robotic)
Lobectomy
Kohno et al. Tokyo Japan Ann Thoracic Surg 2010
N=738 T1 GGO lobectomy No local recurrence Standard of care
Segmentectomy versus Lobectomy
Cao et al., Ann Cardiovasc Surg 2014
Meta-analysis 2800 patients for < 2.0 cm Adenocarcinomas / GGOs No difference in segmentectomy versus lobectomy
Required node dissection in all!

65. Wedge Resection? Tsuytani et al. Hiroshima Japan Chest 2014
N=610 T1A GGO resected lobe or segment or wedge
Outcomes improved for lobe or segment except:
Wedge resection effective for all T1a 1.0cm or less
Wedge resection effective for pure GGO <2.0 cm
Berry et al. Duke / Stanford US National Cancer Database
Prospective T1 GGO Segmentectomy or wedge resection
Propensity-matched 1231 in each group
Multi-variable survival advantage for segmentectomy:
All patients
Even T1 1.0 cm or less!

66. Overall Survival Results: Propensity-score-matched Analysis
This is the Overall Survival of Patients with clinical stage T1a N0 NSCLC who Underwent wedge resection vs segmentectomy
Median follow-up was 2.9 years (IQR 1.7 to 4.5 years)
The blue line represents the wedge resection group
The red line represents the segmentectomy group.
Patients treated with segmentectomy had improved survival compared with those treated with wedge resection
Kaplan–Meier analysis demonstrated a 5-year survival of 64.9% for the segmentectomy group and a 5-year survival of 58.6% for the wedge resection group

67. Survival of Patients with Tumors ≤ 1 cm: Propensity-score-matched Analysis
We then performed a separate propensity-matched analysis on the subpopulation of patients with very small tumors less than 1 cm. There were 468 matched patients and 234 patients in each group. After propensity score matching, covariates were well-balanced between the groups
Segmentectomy was again found to be associated with improved survival when compared to wedge resection. The 5-year survival was 78.2% for the segmentectomy group and 56.8% for the wedge resection group.

68. Outcomes Based on ultimate TNM histopathology
Pure GGOs have excellent long-term survival that decreases with increasing percentage of solid component (invasive adenocarcinoma)
Margin status
Moon et al.,World J Surg 2016
N=91 GGO-based invasive cancers T cm
All anatomic resections
Margins > 0.5 cm adequate for GGO > 50% on CT
Margins >1.0 cm for Solid predominate lesions

69. Summary
GGO - containing CT lesions require a multi-modality team including Thoracic Imaging to select most appropriate surgical candidates
Localization techniques are often useful for minimizing resection size for diagnosis
Resections with node dissection required for TNM:
>3.0 cm size: Lobectomy
cm size: Consider segmentectomy or lobectomy
<1.0 cm size with significant solid component: Wedge may be adequate (small pure GGOs should be followed)
Resection margins should be > 1.0 cm from CT-sized mass