112. Intraoperative Challenges After Induction Therapy for NSCLC: Impact of Nodal Disease on Technical Complexity

Objective
Neoadjuvant therapy has been theorized to increase the complexity of pulmonary resections for non-small cell lung cancer (NSCLC); however, specific factors contributing to intraoperative challenges after induction therapy haven't been well-described. We aimed to characterize the impact of nodal involvement and nodal treatment response on surgical complexity after neoadjuvant therapy.
Methods
A prospectively maintained institutional database was used to identify patients who were treated with neoadjuvant therapy followed by anatomic lung resection for cN+ NSCLC between 2010-2020. Pathologic lymph nodes were identified, and patients were classified as having N1 vs N2 disease. Further, in order to evaluate impact of size reduction in pathologic hilar nodes, thoracic radiologists measured histologically confirmed malignant station 10/11 nodes before and after receipt of induction therapy. Percent reduction in size was noted. Operative reports were used to identify presence of technical challenges specifically related to nodal disease. We evaluated the influence of extent of nodal response on surgical challenges, particularly those involving the pulmonary artery (PA), as well as the impact of location of pathological nodes on such intraoperative findings. Categorical outcomes were compared using the chi-squared test.
Results
126 patients met inclusion criteria, with 38 (30.2%) having N1 and 88 (69.8%) having N2 disease. The majority of patients were treated with neoadjuvant chemotherapy (85.7%, n=108), while chemoradiation (n=9) and targeted therapy (n=9) were less common. In cases performed for patients with N1 disease, we found that 7/38 (18.4%) required proximal PA control, while this was necessary in only 3/88 (3.4%) of N2 cases (p=0.004). Likewise, sleeve resection and arterioplasty were needed more frequently during resection of N1 disease (6/38, 15.8%) vs N2 disease (1/88, 1.1%, p<0.001, Table). Further, for pathologically positive hilar lymph nodes, median reduction in nodal size was 30%. Nodal reduction ≥30% (n=19) was associated with more frequent intraoperative technical challenges than when nodal reduction was <30% (n=17). In these cases, nodal disease led to more frequent: intraoperative change in vascular approach (31.6% vs 11.8%), need for proximal PA control (21.1% vs 17.6%), unexpected sleeve or arterioplasty (21.1% vs 5.9%), inability to resect node from PA (21.1% vs 17.6%), and tear from node stuck to PA (5% vs 0%).
Conclusions
The presence of N1 disease was associated with greater likelihood of requiring complex surgical maneuvers compared to N2 disease after induction therapy. Similarly, substantial treatment response of hilar nodes was associated with increased intraoperative technical challenges. Recognizing such factors enables surgical teams to engage in safer operative planning for these frequently complex cases.

Hope Feldman (1), Nicolas Zhou (1), Wayne Hofstetter (1), Ravi Rajaram (1), Myrna Godoy (1), Chad Strange (1), Mara Antonoff (1), (1) The University of Texas MD Anderson Cancer Center, Houston, TX

Lana Schumacher

Invited Discussant

Dr. Lana Schumacher is the Director of Thoracic Robotic Surgery for Massachusetts General Hospital Network, Program Director for Robotic Surgical Education at Massachusetts General Hospital and Thoracic Director of the MGH SHED program for foregut disorders.  She is an Assistant Professor in the Department of Surgery at Harvard School of Medicine.  Dr. Schumacher received her medical degree from UCLA School of Medicine in Los Angeles, CA. She completed her surgical internship and residency at Stanford University Hospital in Stanford, CA. and her cardiothoracic fellowship at the University of Pittsburgh Medical Center in Pittsburgh, PA. She also did further training at Memorial Sloan Kettering Cancer Center, NY.

 

Dr. Schumacher is board certified by the American Board of Surgery and the American Board of Thoracic Surgery. She has extensive experience in minimally invasive approaches to esophageal and lung diseases. Her expertise lies in advancing robotic thoracic techniques for the treatment of lung cancer, esophageal cancer, benign esophageal disorders and mediastinal diseases.  Dr. Schumacher runs a scholarship for the Women in Thoracic Surgery for Robotic surgery training. She also serves on faculty for the American Association for Thoracic Surgery Graham Foundation Robotic Fellowship.   

 

Dr. Schumacher’s research focuses are on the utilization of artificial intelligence for deep dive analysis of neural networks for robotic thoracic surgery.  In addition, she researches the utilization of near infrared imaging and nanoparticles in the detection of micro-metastatic disease for lung and esophageal cancer.   Her third area of interest is the outcomes in robotic surgery for lung cancer and esophageal cancer.

 

Recent honors/distinctions include participation in the 2018 AATS Leadership Academy and recipient of Intuitive Surgical Foundation Grant.