Results from the survey of the Spanish Society of …oncology-bcn.com/web2017/pdf/presentacions/session-raul-embun.pdf · Resection of lung metastases also offers . 25–35 % 5-year

Dr Raúl Embún

Thoracic Surgery Department HU Miguel Servet & HCU Lozano Blesa

IIS Aragón Zaragoza University

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

Resection of lung metastases also offers 25–35 % 5-year survival rates in carefully selected patients. Surgical R0 resection should be performed for solitary or confined liver or pulmonary metastases (II, A).

Metastatic CRC 4 Prognostic Groups with treatment implications

Lung or liver metastases are clearly resectable (R0)

At first, lung or liver metastases are not resectable (Intensive induction CT should be consider prior to potential metastasectomy)

Unresectable metastases, adequate PS and bulky, symptomatic or biologically agressive disease = intensive first-line therapy

Grupo 2

Grupo 1

Grupo 0

Grupo 3

Unresectable metastases, por PS and no present or inminent symptoms = non-intensive therapy

National Survey PULMONARY METASTASECTOMY

Survey Monkey

399 thoracic surgeons and residents of thoracic surgery

18 questions type: multiple choice, ranking y rating scale

Link (https://es.surveymonkey.com/r/cirugiametastasispulmonares)

Active period from 12/3/17 to 10/4/2017

Participation 112 (28%)

23% participation

1. What is your professional experience as thoracic surgeon?

15,2%

48,2%

17,0% 19,6%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

MIR de cirugía torácica FEA cirujano torácico desdehace menos de 10 años

FEA cirujano torácico desdehace 10 a 20 años

FEA cirujano torácico desdehace más de 20 años

Responses: 112 Omissions: 0

Thoracic Surgery Resident

Thoracic Surgeon < 10y

Thoracic Surgeon 10-20y

Thoracic Surgeon > 20y

2. How many pulmonary metasasectomy procedures do you personally perform every year?

1,8%

15,5%

59,1%

20,0%

3,6%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

Ninguno Menos de 10 Entre 10 y 30 Entre 31 y 50 Más de 50

Responses: 110 Omissions: 2

None <10 10-30 31-50 >50

3. How do you consider the trend of this practice over the last five years?

69,7%

23,9%

3,7% 2,8%

Ascedente

Estable

Descendente

NS/NC

Responses: 109 Omissions: 3

Upward Steady Downward N/A

4. What do you think about the frequency this procedure is being performed at present?

1,0%

24,8%

58,1%

13,3%

2,9%

Es una práctica que debería deabandonarse

Debería de hacerse de forma másselectiva de lo que se realiza en la

actualidad

La frecuencia con la que se realizame parece adecuada

Debería de indicarse en un mayornúmero de casos

NS/NC

Responses: 105 Omissions: 7

It should be banned

It should be less frequent Adequate It should be

more frequent N/A

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 0 7 15 3 2 0 3,00 27

Opposition by other professionals (no thoracic surgeons)

1 3 6 12 5 0 3,63 27

Patient preferences 4 10 5 4 4 0 2,78 27

Really compliant recomendations by current Guidelines and literature in favor of metastasectomy

0 0 5 12 10 0 4,19 27

Responses: 27 Omissions: 0

6. What are the primary tumours more frequently behind a pulmonary metastasectomy in your department? The most frequent “1” & the less frequent “5” 1 2 3 4 5 Rating

(1-5) n

Breast 3 31 25 26 15 3,19

100

Sarcomas 4 30 26 29 11 3,13

100

Colorectal 88 1 1 0 10 1,43

100

Urologycal

1 27 37 28 7 3,13 100

Others

4 11 11 17 57 4,12 100

Responses: 100 Omissions: 12

7. How frequently do you use minimal invasive surgery for pulmonary metastasectomy?

57,0%

33,0%

1,0%

7,0% 2,0%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

Siempre quetécnicamente es factible

En casosseleccionados, nº delesiones pulmonares

En casosseleccionados,

histología

En casosseleccionados, otros

factores

Nunca

Responses: 100 Omissions: 12

Never Selectively (histology)

Selectively (other factors)

Selectively (number mtx)

Whenever technically feasible

82%

18%

Surgical approach GECMP-CCR n=522 patients

Toracotomía VATS

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?

62,2%

7,1%

30,6%

0%

10%

20%

30%

40%

50%

60%

70%

Resección atípicaVATS previo marcaje

Segment. anatómicaVATS +/- marcaje

Lobectomía VATS Resección atípicatoracotomía

Segment. anatómicatoracotomía

Lobectomíatoracotomía

Responses: 98 Omission: 14

VATS Wedge after marking

VATS Anatomic Seg +/- marking

VATS Lobectomy Open Wedge Open anatomic seg Open lobectomy

85%

10% 5%

Ongoing prospective cohort study. Anatomical lung resections (n=1510)

Carcinoma de pulmón Metástasis de origen extrapulmonar Otros diagnósticos

80%

20%

Type of lung resection Wedge-Segmentectomía Lobectomía-Neumonectomía

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 “6”.

1 2 3 4 5 6 Ranking n CEA

5 5 8 13 16 51 4,87 98

Disease-free interval 21 18 21 17 13 8 3,07 98 Th. lymph node involvement

38

19

17

15

5

4

2,41

98

Number

27 28 24 10 8 1 2,46 98

Laterality 5 13 17 33 19 11 3,83 98 Liver disease

2 15 11 10 37 23 4,37 98

Responses: 98 Omissions: 14

44,9

29,6

13,3

4,1

8,2

17,0

31,9

22,3

10,6

18,1

0

5

10

15

20

25

30

35

40

45

50

Ninguna Sampling selectivo Sampling sistemático Disección ganglionarlobulo-específica

Disección ganglionarsistemática

% re

spon

ses

Resección atípica Segment. Anatómicac

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: 14

None Selective sampling Systematic sampling Lobe-specific Radical Lymphadenectomy

Radical Lymphadenectomy

c Wedge Anatomical resection

11. In case of, recently diagnosed, multiple and bilateral potentially resectable pulmonary metastases of CRC, what do you consider the best management?

2,1%

55,7%

42,3%

Definitive systemic therapy

Induction therapy + surgery/SBRT +/- adjuvant therapy

Surgery and/or SBRT +/- adjuvant therapy

Responses: 97 Omissions: 15

Metastatic CRC 4 Prognostic Groups with treatment implications

Lung or liver metastases are clearly resectable (R0)

At first, lung or liver metastases are not resectable (Intensive induction CT should be consider prior to potential metastasectomy)

Unresectable metastases, adequate PS and bulky, symptomatic or biologically agressive disease = intensive first-line therapy

Grupo 2

Grupo 1

Grupo 0

Grupo 3

Unresectable metastases, por PS and no present or inminent symptoms = non-intensive therapy

New-onset resectable pulmonary metastases with no-favourable prognostic factors

0,0%

13,4%

33,0%

89,7%

7,2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% re

spon

ses

Estabilidad en el tamaño y número demetástasis pulmonares

Aumento de tamaño de las metástasispulmonares

Aumento del número de metástasispulmonares (aun siendo factible unaresección completa de todas ellas)

Nueva aparición o progresión deenfermedad extrapulmonar

Ninguna de las situaciones anteriorescontraindicaría la cirugía pulmonar

12. In case of potentally resectable CRC pulmonary metastases treated with induction therapy, when would you rule out a subsequent surgery?

Responses: 97 Omissions: 15

PM Steady in size and number PM Increased in size PM Increased in number (although still feasible R0)

Progression or new-onset of extrapulmonary disease None of the previous would rule out surgery

13. How do you usually determine the best treatment choice for patients with CRC pulmonary metastases in your centre?

Comité Multidisciplinar de Carcinoma Colo-

Rectal; 8,3%

Comité Multidisciplinar de

Tórax (CON oncólogo médico dedicado al

carcinoma colo-rectal); 59,4%

Comité Multidisciplinar de Tórax (SIN oncólogo médico dedicado al

carcinoma colo-rectal); 28,1%

Otros ; 4,2%

Responses: 96 Omissions: 16

Others 4,2% CRC Tumour Board

8,3% Thoracic

Tumour Board (WITHOUT CRC-dedicated

oncologist) 28,1%

Thoracic Tumour Board

(WITH CRC-dedicated oncologist)

59,4%

2,2%

39,6% 36,3%

13,2%

8,8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Abandono de la cirugía demetástasis pulmonares

Importante disminución enla indicación quirúrgica

Moderada disminución enla indicación quirúrgica

Escasa o nula repercusiónsobre la indicación

quirúrgica

NS/NC

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

No more surgery

Important decrease in surgery

Moderate decrease in surgery

Little/no decrease in surgery N/A

6,6%

31,9%

4,4%

34,1%

23,1%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Biopsia líquida SBRT u otrastécnicas locales no

quirúrgicas

Nuevas técnicas deimágen

Terapias sistémicas Ensayo clínicoPulMiCC

15. Which of the following breakthroughs could influence in a shorter term on pulmonary metastasectomy practice?

Responses: 91 Omissions: 21

SBRT or other local therapies

Liquid biopsy Image Techniques

Systemic Therapies

PulMiCC Trial

16. How would you consider the inclusion of prognostic factors other than resectability in the treatment algorithms of current guidelines?

Responses: 89 Omissions: 23

Interesting 39,3%

Essential 57,3%

Superfluous 1,1%

N/A 2,2%

17. Do you consider that the development of a multidisciplinary national consensus statement could help in treatment decision-making of CRC metastatic disease?

No; 1,1%

N/A; [VALOR]

Responses: 89 Omissions: 23

Yes, and I would be delighted

to take part 71,9%

Yes, but I would not be interested in

taking part 19,1%

Predictive Model of Survival after Pulmonary Metastasectomy of Colorectal Cancer. A nationwide prospective cohort study

Disease-Specific SURVIVAL Group Median 2y DSS 95% CI 4y DSS 95% CI

1 Not reached 89 87-92 69 65-74 2 52 83 80-87 55 49-60 7 31 62 55-69 21 15-26 8 22 45 37-53 7 4-11

Extrapulm disease= History of extrapulmonary disease DFI < vs > 12 months ct-LNI= Pathological thoracic lymph node involvement

Variables in theEquation

B p HR 95,0% CI forExp(B) 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)=h0(t)xe(0,7xDFI + 0,77xct-LNI + 0,501xExtrapulm)

Thank You