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Esophageal and Lung Institute
Clinical Update
November 2014
A Message from the Director
In this inaugural issue of the Esophageal and Lung Institute’s
Blair Jobe, MD Co-Director ELI
Rodney J. Landreneau, MD Co-Director ELI
ELI surgeons
Toshitaka Hoppo, MD
Mathew VanDeusen, MD
Lana Schumacher, MD
Robert Keenan, MD
10) J Clin Oncol. 2014 Aug 10;32(23):2449-55. doi: 10.1200/JCO.2013.50.8762. Epub 2014 Jun 30. Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage I non-small-cell lung cancer: a propensity-matched
analysis.Et al.
ELI Pulmonary Medicine
Marvin Balaan MD
Abstract
ELI Gastroenterology
Hiteshi Thakker, MD
Abhijit Kulkarni, MD
Manish Dhawan, MD
Marcia Mitre, MD
PURPOSE:
Although anatomic segmentectomy has been considered a compromised procedure by many surgeons,
recent retrospective, single-institution series have demonstrated tumor recurrence and patient survival rates
that approximate those achieved by lobectomy. The primary objective of this study was to use propensity
score matching to compare outcomes after these anatomic resection approaches for stage I non-small-cell
lung cancer.
PATIENTS AND METHODS:
A retrospective data set including 392 segmentectomy patients and 800 lobectomy patients was used to
identify matched segmentectomy and lobectomy cohorts (n = 312 patients per group) using a propensity
score matching algorithm that accounted for confounding effects of preoperative patient variables. Primary
outcome variables included freedom from recurrence and overall survival. Factors affecting survival were
assessed by Cox regression analysis and Kaplan-Meier estimates.
RESULTS:
Perioperative mortality was 1.2% in the segmentectomy group and 2.5% in the lobectomy group (P = .38).
At a mean follow-up of 5.4 years, comparing segmentectomy with lobectomy, no differences were noted
in locoregional (5.5% v 5.1%, respectively; P = 1.00), distant (14.8% v 11.6%, respectively; P = .29), or overall
recurrence rates (20.2% v 16.7%, respectively; P = .30). Furthermore, when comparing segmentectomy
with lobectomy, no significant differences were noted in 5-year freedom from recurrence (70% v 71%,
respectively; P = .467) or 5-year survival (54% v 60%, respectively; P = .258). Segmentectomy was not found
to be an independent predictor of recurrence (hazard ratio, 1.11; 95% CI, 0.87 to 1.40) or overall survival
(hazard ratio, 1.17; 95% CI, 0.89 to 1.52).
CONCLUSION:
In this large propensity-matched comparison, lobectomy was associated with modestly increased freedom
from recurrence and overall survival, but the differences were not statistically significant. These results will
need further validation by prospective, randomized trials (eg, Cancer and Leukemia Group B 140503 trial).
Important Thoracic Cancer Treatment Protocols
at Allegheny Health Network Esophageal and Lung Institute
Alliance (CALGB) 140503
Radiation Oncology
David Parda, MD
Athanasios Colonias, MD
ELI Research
Ali Zaidi, MD
Emily Lloyd, CCRC
RTOG – 0839
Lead Physician Extender
Kim Swendsen, CRNP
AlCHEMIST trial
Registry trial for resected stage 1B through IIIA adenocarcinoma patients with determination of EGFR
mutations and EML-ALK rearrangements and subsequent randomization of patients with these mutations
to adjuvant EGFR inhibitors or crizitonib based upon individual patient genetic mutational signature.
In this issue, Dr. Landreneau focuses on the diagnosis and
treatment of early-stage lung cancer, highlighting the use of
low dose computed tomography as a screening measure in
at-risk patient populations. Lock-step with early detection,
minimally invasive thoracic surgical approaches, which reduce
post-operative pain and promote rapid recovery, are also
described for those with early stage disease.
Medical Oncology
Eugene Finley, MD
Moses Raj, MD
Scott Long, MD
Casey Moffa, DO
A phase III Randomized Trial of lobectomy versus sublobar resection for small ( < 2 cm ) peripheral
Non-small Cell lung Cancer.
Randomized Phase II Study of Pre-Operative Chemoradiotherapy +/- Panitubumab ( IND#110152) and
Surgical Resection Followed by Consolidation Chemotherapy I Potentially Operable Locally Advanced
(Stage IIIA, N2+) Non –Small Cell Lung Cancer.
Blair A. Jobe, MD, FACS,
Co-Director, Esophageal &
Lung Institute
Swallowing Center
Joan Schrenker, RN, CGRN
Speech Pathology
Paula Tirpak, MS,CCC/SLP
newsletter, Clinical Update, Dr. Rodney Landreneau discusses
the tremendous impact that lung cancer has on our population
today. As November is Lung Cancer Awareness month, it
is important for us to recognize that this form of cancer is
responsible for more deaths in men and women than the four
most common cancer types combined. Often stigmatized
because of the association with tobacco use, research in the field
of lung cancer has been woefully underfunded on a national
scale. Despite this, important advances have been made in
the arena of screening and early detection which is critically
important to achieving cure and long-term survival for all
cancers of the aerodigestive system.
Rodney J. Landreneau, MD,
Co-Director, Esophageal and
Lung Institute, Chief of the
Division of Thoracic Surgery,
and System Director of
Thoracic Oncology
Thank you for participating in this important educational effort
provided by the Esophageal and Lung Institute within the
Allegheny Health Network.
Upcoming Topics
Jan Paraesophageal Hernia
Feb Stage III Lung Cancer
March Research Edition
April Esophageal Cancer Screening
May Pleural Disease
June Lung Cancer Edition
July August
Sept Oct Nov Dec Esophageal Motility Disorders
Mesothelioma
Swallowing Center Edition
Laryngopharyngeal Reflux
Alternatives to Pneumonectomy
Outcomes by Disease
ELI Clinical Update Mission:
To provide healthcare professionals with focused and timely coverage of important clinical topics which affect
the esophagus and lung.
Enhanced Diagnosis and Treatment of Early Stage Lung Cancer
Rodney J. Landreneau MD
Division Chief, General Thoracic Surgery
Co-Director, Esophageal and Lung Institute
Director of the Thoracic Oncology Program of the Allegheny
Cancer Institute
Lung cancer results in more cancer
related deaths than any other
malignancy among both women
and men in the United States
[ Figure 1]. Indeed, the national
death rate from lung cancer exceeds
the total of the other common
cancers combined [1]. However, the
funding for lung cancer research falls
far below that of other cancers
[Figure 2].
As with other efforts to minimize cancer death rates,
individual screening / surveillance measures aimed at
identifying early, curable disease are intuitively considered
an important strategy that has paid off with considerable
benefit for other cancers. The greatest benefit has been
noted with cervical cancer, however, frequent mammographic screening and complete colonoscopic examination
have become accepted as important surveillance measures
toward reducing death from breast and colon cancer.
Similar efforts aimed at improving the early diagnosis of lung
cancer go back several decades with studies conducted by
several institutions where patients with significant smoking
history were randomized to be investigated with chest x-Ray
and sputum cytology evaluation OR only careful clinical
observation alone. Although more early lung cancers were
identified among patients undergoing surveillance Chest
x-Rays and sputum cytology evaluation, this did not translate
into improved survival among the entire group of patients
undergoing these investigations compared to those patients
having close clinical observation alone.
More recently, results of the National Lung Screening
Trial (NLST) further supported the use of screening low
energy, fast CT imaging of patients with intermediate risk
for developing lung cancer. This study randomized over
50,000 patients to either low energy fast CT imaging or CxR
(as placebo) over a 3 year period followed by 4 subsequent
years of clinical observation. Importantly, the results of this
study demonstrated a 20% improvement in lung cancer
related mortatlity and a 6% overall survival advantage among
patients in the CT imaging arm of the trial [Figure 5] [3]. These
are important findings demonstrating — really for the first
time — a survival advantage with mass screening for lung
cancer. At the present time, CT surveillance is not covered
by most health insurance, however, these compelling results
will hopefully lead to acceptance of this strategy aimed at
improving overall survival from lung cancer [4].
References
Figure 6. Clinically early stage lung cancer easily resected by VATS
lobectomy indentified by low-dose CT scanning.
The treatment decisions for the lung nodule now come
into play. Although open thoracotomy and resection of the
malignant lung nodule is certainly an acceptable consideration,
minimally invasive video-assisted thoracoscopic surgical (VATS)
approaches are becoming a standard of care in the thoracic
oncologic community [Figures 7a-b] [Figure 8] .
Over the last decade, important investigation into the utility
of low-dose, fast Computed Tomographic (CT) screening for
patients with increased risk of developing lung cancer has
been performed [Figure 3]. The International Early Lung
Cancer Action Program (I-ELCAP) investigation demonstrated
a high likelihood of curing small lung cancers identified
through surveillance CT screening [Figure 4] [2] .
Finally, cancer management outcomes for lung cancer
depends on a team approach including pulmonary
medical specialists, thoracic surgeons, and medical and
radiation oncologists. Certainly expert cancer nursing care
must accompany the efforts of the physician lung cancer
specialists. Our lung cancer survival statistics fare well
against that of the National Cancer Database led by the
American College of Surgeons. We strongly believe these
outcomes are reflective of our “high volume clinical efforts”
to provide the lung cancer patient the highest level of
surgical and medical expertise and technical innovation [7-8].
Addressing the problem of lung cancer in our region and
nation remains a driving motivation of the Allegheny Health
Network’s Esophageal and Lung Institute.
identified by CT screening. Percutaneous biopsy of the lung
lesion should be attempted and mediastinal nodal staging
by Endoscopic Bronchial Ultrasound (EBUS) needle aspiration
biopsy or mediastinoscopy should follow for any suspicious
mediastinal and or hilar lymphadenopathy identified.
Figure 8. Healed small incisions seen in the patients armpit area
following VATS lung resection for lung cancer.
patients suffering from lung cancer, it would be foolhardy
to neglect the importance of tobacco product avoidance
among our youth and cessation of tobacco use among present
smokers in our country. Never starting smoking is an obvious
public health care initiative, however, quitting smoking also
has important implications on cardiovascular health and
cancer risk reduction. Although the risk of developing lung
cancer is always a concern among former smokers, that risk
is substantially reduced the longer one is abstinent from
smoking [Figure 9].
Figure 3. “High Risk” patient group – Prime Candidates for low-dose
CT scan surveillance.
Figure 2. “Death Rate” and Federally funded Research dollars spent
“per disease specific cancer death” in United States
Figure 4. Survival advantage of Stage I lung cancers identified by CT
surveillance screening. The international Early Lung Cancer Action
Program Investigators. NEJM 2006;355:1763-1771.
A team of pulmonary specialists, thoracic surgeons,
pulmonary radiologists and nurse specialists and
administrators have come together this fall to establish
a robust multispecialty effort for lung cancer screening /
surveillance for patients at “high risk” for development of
lung cancer based upon the criteria of the NLST trial. This is a
unique effort directed for the patients of our region provided
by a clinical grant from Highmark at no cost to the patient.
To date over 250 patients have enrolled into the program
and several suspicious lung lesions are being evaluated.
Additionally, patients are introduced to a tobacco cessation
program aimed at reducing further risk of development
of lung cancer and other tobacco related illnesses. This
“center of excellence” approach where each patient’s CT
scan is reviewed by a team of experts prior to providing a
recommendation of follow-up or care is really a differentiating
characteristic of the Esophageal and Lung Institute program.
Once the suspicious lung lesion is identified [Figure 6] ,
the next important consideration is obtaining definitive
diagnosis and providing the most effective means of cure
of the cancer. Certainly, PET/CT imaging has become the
standard of care for the suspicious peripheral lung nodule
2) Survival of Stage I Lung Cancer Detected on CT Screening. The
international Early Lung Cancer Action Program Investigators. NEJM
2006;355:1763-1771.
3) National Lung Screening Trial Research Team. Reduced
Lung-Cancer mortality with Low-Dose Computed Tomographic
Screening. NEJM 2011;365:395-409.
4) Jaklitsch MT, Jacobson FL, Austin JHM, et al. The American
Association for Thoracic Surgery Guidelines for Lung Cancer
Screeningusing low-dose Computed tomographic Scans for Lung
Cancer Survivors and Other High Risk Groups. J Thorac Cardiovasc
Surg 2012:144:33-38.
5) Landreneau RJ, Herlan DB, Johsnon JA, Boley TM, Nawarawong
W, Ferson PF. Thoracoscopic Neodynium: Yttrium-Aluminum garnet
laser-assisted pulmonary resection. Ann Thorac Surg 1991;52:11761178.
Figure 5. Improved identification of lung cancer (a) and enhanced
lung cancer survival (b) among patients undergoing low-dose CT
screening. National Lung Screening Trial. NEJM 2011;365:395-409.
Figure 1. “Death Rates” from leading causes of Cancer in the
United States (2012)
1) Cancer Facts and Figures. American Cancer Society 2012.
6) Schuchert MJ, Pettiford BL, Pennathur A, Abbas G, Awais O, Close
J, Kilic A, Jack R, Landreneau JR, Landreneau JP, Wilson DO, Luketich
JD, Landreneau RJ. J Thorac Cardiovasc Surg 2009;138:1318-1325.
7) Bach PB, Cramer LD, Schrag D, Downey R, Gelfand SE, Begg CB.
The Influence of Hospital Volume on Survival After Resection for
Lung Cancer. NEJM 2001;345:181-188.
RJ. J Thorac Cardiovasc Surg 2009;138:1318-1325.
Figure 7a. Small incisions used for Videoscopic lung resection (VATS)
compared to the large incisions of open thoracotomy noted in dotted line
of this drawing.
8) Landreneau RJ, Normolle DP, Christie NA, et al. Recurrence
and survival outcomes after Anatomic segmentectomy versus
lobectomy for clinical stage 1 non- small cell lung cancer: a
propensity matched analysis. J Clinical Oncology 2014;32:24492455.
Figure 7b. Usual videoscopic camera position and VATS instrument
positioning for minimally invasive lung cancer resection.
The thoracic surgical team at Allegheny Health Network’s
Esophageal and Lung Institute has significant expertise with
this minimally invasive approach to lung cancer resection. In
addition, they have considerable experience with the VATS
approach to anatomic lung resection (lobectomy and anatomic
segmentectomy) for early stage lung cancer. The use of these
minimal incisional approaches for early stage lung cancer,
which in the case of anatomic segmentectomy, can also
result in significant preservation in lung function without
compromising long term survival compared to lobectomy [6].
As we seek to improve the therapeutic outcomes of our
Figure 9. Illustration of the difference in cancer risk among light and heavy
smokers and also the reduction in lung cancer risk over time with abstinence
from cigarettes.