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

Surgery after induction vs. definitive therapy and paranchym preserving vascular techniques. Alper Toker, MD İstanbul University , İ stanbul Medical School Department of ThoracicSurgery. Neoadjuvant treatment. Invasion to vital organs To have Easier resectability ,

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

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  1. Surgeryafterinduction vs. definitivetherapyandparanchympreservingvasculartechniques Alper Toker, MD İstanbul University, İstanbul Medical School Department of ThoracicSurgery 12th April, 2012 Antalya

  2. Neoadjuvanttreatment • Invasiontovitalorgans • TohaveEasierresectability, • Toachievenegativemargins • Topreventseeding • Topreventradioresistanceduetopossiblehypoxemiaofthetissue • Rectum, • Lareynx, • Osephagus, • Prostate, • Softtissuesarcomas • Pancreas. • . 12th April, 2012 Antalya

  3. Preoperativetherapy • Induction CT + surgery • Induction CT + RT (45Gy) + surgery • Vs. • DefinitiveCxRT (60Gy) + surgery Definitive RT: Advantages Definitive RT: disadvantages 12th April, 2012 Antalya

  4. 3 D treatments – Calculatingthearea 12th April, 2012 Antalya

  5. Decreasingtheradiotherapydoseofhealthytissues 12th April, 2012 Antalya

  6. Respiratorygatingandcalculation of thetarget 12th April, 2012 Antalya

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  9. 12th April, 2012 Antalya

  10. 12 Nisan, 2012 Toraks Kongresi Antalya

  11. 12 Nisan, 2012 Toraks Kongresi Antalya

  12. 12 Nisan, 2012 Toraks Kongresi Antalya

  13. 12 Nisan, 2012 Toraks Kongresi Antalya

  14. BromleyandSzur 1955 • Bleordan 1965 • Shields 1972 • No survivaladvantage, • Increasedmorbidity • Mortality 22 % • Technical achievements in radiotherapy • Surgery • Personalizedapproaches 12th April, 2012 Antalya

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  19. Mortalityafterinductionchemo-radiotherapy Grup XRT N (lobx –pneux) Mortalite SWOG 880545Gy 38/51 7,9/15,7 INT 13945Gy 98/54 1,0/25,9 Maryland 45Gy 51/29 0,0/3,4 Stamatis (Essen)45Gy 255/133 3,6/7,1 12th April, 2012 Antalya

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  22. NeoadjuvantCh-RT 12th April, 2012 Antalya

  23. Adjdose RT -CT 12th April, 2012 Antalya

  24. 12th April, 2012 Antalya

  25. CT and RT 12th April, 2012 Antalya

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  29. NeoadjuvantCh-RT 12th April, 2012 Antalya

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  33. Not after RT 12th April, 2012 Antalya

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  37. IstanbulMedical School LungOncologyGroup • N2-T4 primarylungcancer • Inductionchemotherapyandchemoradiotherapy (45 Gy / 60 Gy) andlungresection • Morbidity • Mortality • Survival 12th April, 2012 Antalya

  38. Patientsandmethods • December 2002 – December 2011 • 154 patients • Age • Gender • Cytology (Epidermoid / Nonepidermoid) • Inductiontreatment (CT / CT-RT45 / CT-RT60) • PulmonaryfunctionTests ( >%80, %80-60, <%60) • CO diffusion test ( >%80, %80-60, <%60) • Resectiontype • Mortality • Morbidity • Survival • Prospectivelyrecorded data 12th April, 2012 Antalya

  39. Patientsandmethods • Treatmentmodalities • CT: 89 patients • CT-RT 45: 46 patients • CT-RT 60: 19 patients • Patientsoperatedwithinthepast 24 monthswereexcluded (119/154 patients) 12th April, 2012 Antalya

  40. Results I • Meanage 55.8 (minimum:36, maximum:76) • Histopathology • Epidermoid % 69 • Non-epidermoid %31 • Mean FEV1 : 2530 cc (%83.5) • Mean DLCO : %80 • FEV1, FEV1%, FVC, FVC%, DLCO% (p>0.05) • Resectiontyppe • CT group: 21 left / 12 rightpneumonectomy • CT-RT 45 group: 5 left/ 1 rightpneumonectomy • CT-RT 60 group: 2 left/ 1 rightpneumonectomy 12th April, 2012 Antalya

  41. Results II • MajorMorbidity: • Hemorrhage • Ampyeme • Bronkopleuralfistul • Chylothorax • Transientischemicattack • Myocardialinfarction • ARDS • Majormorbidity 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) • Pneumonectomymortality % 4.8 • Lobectomymortality % 3.6 (p>0.05) 12th April, 2012 Antalya

  42. Results III • Medianfollowup: 31 monnths • (Minimum 24 mts – maximum 108 mts) • Mediansurvival :27 mts • Induction CT (n:76) 24 mts • Induction CT-RT (n:43) 33 mts (Kaplan Meier, p: 0.595) • A correctsurvivalanalyze is impossibleduetonon-homogenousoperativeperiods of groups. 12th April, 2012 Antalya

  43. Discussion • Surgeryafterinductiontreatmentfor N2 or T4 disease • Type of inductiontreatment (CT & CT-RT 45 & CT-RT 60) • PFT - DLCO • Histopathology • Type of resection (Lobectomy & pneumonectomy) were not differentstatistically in terms of majormorbidityandmortality. 12th April, 2012 Antalya

  44. Conclusion Lungresectionafterinductiontreatment; Acceptablemorbidity ve mortality rate. CT- RT 60 Gydid not have a negatife effect on mortalityandmorbidity. Mediansurvivalseemsto be longer in CT-RT patients, however,difference is statisticallyinsignificantwhencomparedto CT only. Pneumonectomydecisionneedsto be judgedcarefully. Patientselection ! 12th April, 2012 Antalya

  45. Induction vs. definitive • Evidencebasedmedicine: • No concreteevidence • Resultsderivedfromstudies: • 1- A reliablemodality, • 2- ↑rate of mediastinalsterilization, • 3- ↑ pathologiccompleteresponse rate, • 4- Possiblebettersurvival rate. • 5-Morbidity andmortalityratesarehighercomparedtostandartsevenstatistically not significant. Personalview: 1- Wechoose fit patients, 2- Technicallyandmedicallypossible, 3- Bettersurvival, 4- Recurrencecomesfrombrain, 5- Experiencedteam, 6- Personalizedtreatment(Patientanddoctor). 12th April, 2012 Antalya

  46. 3 rekonstrüksiyon 4 anastomoz Toker A, GKDC Dergisi 2009 12th April, 2012 Antalya

  47. Bronchovascularsleeveresections 12th April, 2012 Antalya

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