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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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  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

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  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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