Results from the survey of the Spanish Society of Thoracic Surgery

Transcription

1 Surgery for lung metastases of colorrectal cancer DO WE BELIEVE IN WHAT WE DO? Results from the survey of the Spanish Society of Thoracic Surgery Dr Raúl Embún Thoracic Surgery Department HU Miguel Servet & HCU Lozano Blesa IIS Aragón Zaragoza University

2 Resection of lung metastases also offers % 5-year survival rates in carefully selected patients. Surgical R0 resection should be performed for solitary or confined liver or pulmonary metastases (II, A).

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4 Metastatic CRC 4 Prognostic Groups with treatment implications Grupo 0 Lung or liver metastases are clearly resectable (R0) Grupo 1 At first, lung or liver metastases are not resectable (Intensive induction CT should be consider prior to potential metastasectomy) Grupo 2 Unresectable metastases, adequate PS and bulky, symptomatic or biologically agressive disease = intensive first-line therapy Grupo 3 Unresectable metastases, por PS and no present or inminent symptoms = non-intensive therapy

5 National Survey PULMONARY METASTASECTOMY Survey Monkey 399 thoracic surgeons and residents of thoracic surgery 18 questions type: multiple choice, ranking y rating scale Link ( Active period from 12/3/17 to 10/4/2017 Participation 112 (28%)

6 23% participation

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9 1. What is your professional experience as thoracic surgeon? Responses: 112 Omissions: 0 60,0% 50,0% 48,2% 40,0% 30,0% 20,0% 15,2% 17,0% 19,6% 10,0% 0,0% Thoracic Surgery Resident MIR de cirugía torácica Thoracic Surgeon < 10y FEA cirujano torácico desde hace menos de 10 años Thoracic Surgeon 10-20y FEA cirujano torácico desde hace 10 a 20 años Thoracic Surgeon > 20y FEA cirujano torácico desde hace más de 20 años

10 2. How many pulmonary metasasectomy procedures do you personally perform every year? Responses: 110 Omissions: 2 70,0% 60,0% 59,1% 50,0% 40,0% 30,0% 20,0% 15,5% 20,0% 10,0% 0,0% 3,6% 1,8% None < >50 Ninguno Menos de 10 Entre 10 y 30 Entre 31 y 50 Más de 50

11 3. How do you consider the trend of this practice over the last five years? Responses: 109 Omissions: 3 3,7% 2,8% 23,9% Ascedente Upward Estable Steady Descendente Downward 69,7% NS/NC N/A

12 4. What do you think about the frequency this procedure is being performed at present? Responses: 105 Omissions: 7 58,1% 24,8% 13,3% 1,0% 2,9% Es una práctica que debería de It should abandonarse be banned It should be Debería de hacerse de forma más selectiva de lo que se realiza en la less actualidad frequent La frecuencia con la que se realiza me parece adecuada Adequate Debería de indicarse en un mayor It should be número de casos more frequent NS/NC N/A

13 5. In case you think this practice should be banned or performed less frequently, how do you rate the influence of the following circumstances? Not important (1) Slightly important Moderately important Important Very important (5) N/A Rating (1-5) n Opposition by other thoracic surgeons ,00 27 Opposition by other professionals (no thoracic surgeons) Patient preferences Really compliant recomendations by current Guidelines and literature in favor of metastasectomy , , ,19 27 Responses: 27 Omissions: 0

14 6. What are the primary tumours more frequently behind a pulmonary metastasectomy in your department? The most frequent 1 & the less frequent Rating (1-5) n Breast , Sarcomas , Colorectal , Urologycal , Others , Responses: 100 Omissions: 12

15 7. How frequently do you use minimal invasive surgery for pulmonary metastasectomy? Responses: 100 Omissions: 12 60,0% 57,0% 50,0% 40,0% 33,0% 30,0% 20,0% 10,0% 7,0% 0,0% Whenever Siempre que técnicamente es factible technically feasible Selectively En casos seleccionados, nº de lesiones (number pulmonares mtx) 1,0% En casos Selectively seleccionados, (histology) histología Selectively En casos seleccionados, otros (other factores factors) 2,0% Nunca Never

16 Surgical approach GECMP-CCR n=522 patients Toracotomía VATS 18% 82%

17 8. In case of a patient with a single 10 mm peripheral pulmonary metastasis with a very low probability of being palpated by VATS and favourable prognostic factors (long DFI, normal CEA, no previous liver disease), what option would you choose? Responses: 98 Omission: 14 70% 60% 62,2% 50% 40% 30% 30,6% 20% 10% 7,1% 0% Resección VATS Wedge atípica VATS Segment. Anatomic anatómica Seg VATS after previo marking marcaje VATS +/- marking +/- marcaje Lobectomía VATS Resección atípica Segment. anatómica Lobectomía VATS Lobectomy Open Wedge Open anatomic seg Open lobectomy toracotomía toracotomía toracotomía

18 Type of lung resection Wedge-Segmentectomía Lobectomía-Neumonectomía Ongoing prospective cohort study. Anatomical lung resections (n=1510) Carcinoma de pulmón Metástasis de origen extrapulmonar Otros diagnósticos 20% 10% 5% 80% 85%

19 9. In case of pulmonary metastases from colorrectal cancer, rank the following prognostic factors according to their importance in surgical decision-making. The most important 1 & the least Ranking n CEA ,87 98 Disease-free interval ,07 98 Th. lymph node involvement ,41 98 Number ,46 98 Laterality ,83 98 Liver disease ,37 98 Responses: 98 Omissions: 14

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21 10. Depending on the extent of the lung resection, what type of mediastinal lymphadenectomy do you perform more frequently in case of pulmonary metastasectomy? Responses: 98 Omissions: ,9 40 % responses ,0 29,6 31,9 22,3 18, ,3 10,6 8,2 5 4,1 0 None Ninguna Selective Sampling sampling selectivo Systematic Sampling sistemático sampling Lobe-specific Disección ganglionar Radical Lymphadenectomy lobulo-específica Wedge c Resección atípica Anatomical c resection Segment. Anatómica Disección Radical ganglionar Lymphadenectomy sistemática

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23 11. In case of, recently diagnosed, multiple and bilateral potentially resectable pulmonary metastases of CRC, what do you consider the best management? Responses: 97 Omissions: 15 2,1% Definitive systemic therapy 42,3% Surgery and/or SBRT +/- adjuvant therapy Induction therapy + surgery/sbrt +/- adjuvant therapy 55,7%

24 Metastatic CRC 4 Prognostic Groups with treatment implications Grupo 0 Lung or liver metastases are clearly resectable (R0) Grupo 1 At first, lung or liver metastases are not resectable (Intensive induction CT should be consider prior to potential metastasectomy) New-onset resectable pulmonary metastases with no-favourable prognostic factors Grupo 2 Unresectable metastases, adequate PS and bulky, symptomatic or biologically agressive disease = intensive first-line therapy Grupo 3 Unresectable metastases, por PS and no present or inminent symptoms = non-intensive therapy

25 12. In case of potentally resectable CRC pulmonary metastases treated with induction therapy, when would you rule out a subsequent surgery? Responses: 97 Omissions: % 90% 80% 89,7% Estabilidad PM Steady en in el size tamaño and y number número de metástasis pulmonares 70% Aumento PM Increased de tamaño in size de las metástasis pulmonares % responses 60% 50% 40% 30% 33,0% PM Increased in number Aumento del número de metástasis (although still feasible R0) pulmonares (aun siendo factible una resección completa de todas ellas) Nueva Progression aparición or o new-onset progresión de of enfermedad extrapulmonary extrapulmonar disease 20% 13,4% Ninguna None of de the las previous situaciones would anteriores rule out contraindicaría surgery la cirugía pulmonar 10% 7,2% 0% 0,0%

26 13. How do you usually determine the best treatment choice for patients with CRC pulmonary metastases in your centre? Responses: 96 Omissions: 16 Comité Multidisciplinar de Tórax (SIN oncólogo médico dedicado al carcinoma colo-rectal); 28,1% Thoracic Tumour Board (WITHOUT CRC-dedicated oncologist) 28,1% Others 4,2% Otros ; 4,2% Comité CRC Multidisciplinar de Carcinoma Colo- Rectal; 8,3% 8,3% Tumour Board Thoracic Tumour Board (WITH CRC-dedicated Comité Multidisciplinar de Tórax (CON oncólogo médico oncologist) dedicado al carcinoma colo-rectal); 59,4% 59,4%

27 14. If the results of the PulMiCC trial could not ascribe a real benefit to CRC pulmonary metasectomy, what do you consider the consequences in your centre would be? Responses: 91 Omissions: 21 45% 40% 35% 30% 39,6% 36,3% 25% 20% 15% 10% 13,2% 8,8% 5% 2,2% 0% Abandono No de more la cirugía de metástasis surgery pulmonares Importante disminución decrease en la indicación surgery quirúrgica Moderada Moderate disminución decrease en la indicación surgery quirúrgica Escasa Little/no o nula decrease repercusión sobre in la surgery indicación quirúrgica NS/NC N/A

28 15. Which of the following breakthroughs could influence in a shorter term on pulmonary metastasectomy practice? Responses: 91 Omissions: 21 40% 35% 30% 31,9% 34,1% 25% 23,1% 20% 15% 10% 5% 6,6% 4,4% 0% Biopsia Liquid biopsy líquida SBRT or u otras other técnicas local therapies locales no quirúrgicas Nuevas Image técnicas de Techniques imágen Terapias Systemic sistémicas Therapies Ensayo PulMiCC clínico PulMiCC Trial

29 16. How would you consider the inclusion of prognostic factors other than resectability in the treatment algorithms of current guidelines? Responses: 89 Omissions: 23 Superfluous 1,1% N/A 2,2% Interesting 39,3% Essential 57,3%

30 17. Do you consider that the development of a multidisciplinary national consensus statement could help in treatment decision-making of CRC metastatic disease? Responses: 89 Omissions: 23 Yes, but I would not be interested in taking part 19,1% N/A; [VALOR] No; 1,1% Yes, and I would be delighted to take part 71,9%

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32 Predictive Model of Survival after Pulmonary Metastasectomy of Colorectal Cancer. A nationwide prospective cohort study Variables in theequation 95,0% CI forexp(b) B p HR Lower Upper Extrapulm disease 0,501 0,006 1,651 1,158 2,352 DFI 12m 0,7 <0,001 2,013 1,419 2,856 ct-lni 0,77 0,009 2,159 1,211 3,852 H(t;x)=h 0 (t)xe(0,7xdfi + 0,77xct-LNI + 0,501xExtrapulm) Extrapulm disease= History of extrapulmonary disease DFI < vs > 12 months ct-lni= Pathological thoracic lymph node involvement Disease-Specific SURVIVAL Group Median 2y DSS 95% CI 4y DSS 95% CI 1 Not reached

33 Thank You