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Role of Surgery in Combined Treatment at Stage III

Role of Surgery in Combined Treatment at Stage III. Asso.Prof.Hasan F.Batırel. Stage III disease Role of surgery in Stage III NSCLC Results of studies Current problems and solutions Conclusion. Stage III Disease. Stage III Disease. Stage III disease according to the 1997 system.

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Role of Surgery in Combined Treatment at Stage III

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  1. Role of Surgery in Combined Treatment at Stage III Asso.Prof.Hasan F.Batırel

  2. Stage III disease • Role of surgery in Stage III NSCLC • Results of studies • Current problems and solutions • Conclusion

  3. Stage III Disease

  4. Stage III Disease • Stage III disease according to the 1997 system. • IIIA ve IIIB • Before 1997 different staging system and results in series (T3N0).

  5. Which Stages? Stage IIIA – T3N1, T1-3N2 Stage IIIB – T4N0 Stage IIIB – T1-4N3

  6. Stage IIIA

  7. Role of Surgery in Stage III NSCLC

  8. Evolution of Surgery • 1982 Pearson – Cervical mediastinoscopy • Poor survival in N2 + pations 9% 5 yr survival (Pearson – 1982), 16% (Naruke – 1988) • So locoregional disease?

  9. Multimodal Treatments • Starting multimodality trials • 2 small series (60 pts each) by Roth and Rosell 1994. • Surgery + Adj / Neoadj Chemo + Surgery + Adj

  10. The Type of Preoperative Treatment • Chemotherapy – CALGB 8935 Sugarbaker 1995. • Chemoradiation – SWOG 8805 Albain 1995.

  11. No role for surgery? • Albain 2005 – INT 0139/RTOG 9309 • Van Meerbeck 2007 – EORTC 08941

  12. Results of Studies

  13. Pearson ve Naruke Pearson 1982 • N2+ diagnosed preop, 5 yr survival 9% (n=79). • N2+ found during surgery, 5 yr survival %24 (n=62). Naruke 1988 • Clinical N2 disease, 5 yr survival 16% (n=345)

  14. Roth and Rosell Studies • 60 patients each • T3N0 included in each series. • Routine mediastinoscopy only in Roth study. • Roth 36% vs 15% 5 yr survival. • Rosell 17% vs 0% 5 yr survival.

  15. Survival advantage continues at 7-8 year follow-up.

  16. Type of Preoperative Treatment • CALGB 8935 – Sugarbaker 1995, Neoadj Chemo + Surgery + Adj XRT Pathologic partial response 22%. • SWOG 8805 – Albain 1995, Concurrent Neoadj CRT, Surgery, Pathologic complete response 21%, Lymph node clearance 59%. • 3 year survival 23% ve 26%.

  17. SWOG 8805 • Even in the case of radiologically and clinical stable disease %25 pathologic complete response!!! • One of the most important findings to show the weaknesses of radiologic re-staging following neoadjuvant treatment…

  18. Metaanalysis – Stage III Neoadjuvant • Bergmans, Lung Cancer 2005.

  19. INT – 0139 Albain – JCO 2005

  20. INT – 0139 Compatison with Lobectomy

  21. INT – 0139 Surgical Results

  22. EORTC – 08941 – JNCI 2007 • %90 partial response, %7 pathologic complete response • %47 pneumonectomy

  23. Issues with EORTC and INT studies • The number of accrual is insufficient to show small differences. • The percent of pneumonectomies is very high in the EORTC study. • Long-term results of Intergroup study will be clinically important.

  24. Pneumonectomy following Neoadjuvant Treatment • Martin MSKCC 2001 Ann Thorac Surg - %11 (right side %26). • Albain INT 0139 2005 JCO - %26 (right side %39). • EORTC 08941 2007 JNCI - %7 (right side %5).

  25. Survival in Patients with Lymph Node Downstaging • CALGB 8935 – J Surg Oncol 2006. N0 patients 47.8, N2 patients 8.2 months. • Van Schil – EJCTS 2006. N0 patients 41, N2 patients 7 ay. Remediastinoscopy recommended. • Bueno – Ann Thorac Surg 2000. N0 patients 21.3, N2 patients 15.9 months. 5 year survival 36% vs 9%.

  26. Lymph Node and Primary Tumor Response

  27. Recommendations

  28. Current Problems and Solutions

  29. Staging Following Neoadjuvant Treatment • Remediastinoscopy, VAMLA • VATS • Transbronchial USG • PET

  30. Pathologic Complete/Partial Response • PET during neoadjuvant treatment? • Concurrent Chemotx + RT • Evaluation of complete response – Surgical specimen

  31. Conclusions

  32. Lessons Learned During Evolution of Surgery – 1 • N2 Stage IIIA NSCLC Surgery following neoadjuvant treatment > Surgery alone. • Persistence of N2 disease following neoadjuvant treatment – Surgery < Curative CRT

  33. Lessons Learned During Evolution of Surgery– 2 • Pneumonectomy required following neoadjuvant tx - Surgery < Curative CRT • Lymph node downstaging, resectable with lobectomy – Surgery offers excellent long term local control and survival when compared with other modalities.

  34. Conclusion • The boundaries and role of surgery is becoming more apparent in Stage IIIA NSCLC. • This patient group will probably be stratified to microscopic systemic and locally limited (not locally invasive) disease via molecular/pathologic markers. • There is no doubt that surgery is the best treatment in locally limited disease.

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