52. Superior Sulcus Non-Small Cell Lung Cancers (Pancoast tumors): The Importance of Multidisciplinary Management

Objective: Despite standard neoadjuvant chemoradiotherapy (chemoRT), Pancoast tumors still present unique technical and oncologic challenges with substantial risks of incomplete resection, local (LR) and distant (DR) recurrence. To optimize outcomes, during the past 20 years we have used a multidisciplinary care paradigm with Medical and Radiation Oncology, and pre- and intraoperative involvement of Spine Neurosurgery (SNS) for most T3 and all T4 tumors. SNS involvement permitted resection of transverse process for T3 and vertebral body resection for T4 tumors in addition to chest wall and pulmonary resection.
Methods: Retrospective analysis of single institution, prospectively managed database, including patients (pts) undergoing curative-intent resection for a Pancoast tumor. Pts were grouped as clinical (c) T3 with combined resection with SNS, cT3 without SNS, and all cT4 patients. R0 resection, overall survival (OS), progression-free survival (PFS), LR, and DR were evaluated. OS, PFS compared between groups using log-rank test. Cumulative incidence of LR and DR compared using Gray's test.
Results: From 2000-2018, 166 pts underwent surgery: median age 58 years, 88 (53%) male, 164 current or former smokers (median 49 pack years). Median tumor size on CT (n=157) and PET SUV (n=129) were 4.9cm and 12.8 for cT3; 7.8cm and 15.9 for cT4. Adenocarcinoma was most common histology (n=76, 46%). 52 (31%) tumors were cT3 with SNS, 43 (26%) cT3 without SNS, 71(43%) cT4. Most pts received neoadjuvant concurrent platinum-based chemoRT (n=137, 83%), median dose 50 Gy, while 11 pts (7%) had chemo only, 1 pt (0.6%) RT only. Lobectomy was most common form of lung resection (n=138, 83%). Final pathology showed, complete (CR) or major pathologic response (MPR, <10% viable tumor) in 75 (45%) pts. 52 (31%) tumors were cT3 with SNS, 43 (26%) cT3 without SNS, 71(43%) cT4, and R0 resection was achieved in 49 (94%), 37 (86%) and 60 (85%) respectively (p=0.2). No significant differences were noted in OS (p=0.801), PFS (p=0.399) or DR (p=0.454) among the 3 groups. A lower cumulative incidence of LR was seen in the cT3 SNS versus the cT3 non-SNS pts (pairwise comparison, p=0.031).
Conclusions: Our multidisciplinary treatment paradigm was associated with a high frequency of R0 resection, CR or MPR, and outcomes for T4 tumors that were indistinguishable from those for T3 tumors. cT3 tumors managed without SNS involvement were associated with higher rates of LR.

Kaitlin McLoughlin (1), Kay See Tan (1), Mark Bilsky (1), Jamie Chaft (1), Andreas Rimner (1), William Travis (1), Joe Dycoco (1), Manjit Bains (1), Robert Downey (1), James Huang (1), James Isbell (1), Daniela Molena (1), Bernard Park (1), David Jones (1), Valerie Rusch (1), (1) Memorial Sloan Kettering Cancer Center, New York, NY

Ara Vaporciyan, MD

Invited Discussant

Dr. Vaporciyan is chair of Thoracic and Cardiovascular Surgery at The University of Texas MD Anderson Cancer Center and  holds the M.G. & Lillie A. Johnson Chair for Cancer Treatment and Research.

In 1985, Dr. Vaporciyan received a bachelor’s degree in cellular and molecular biology from the Honors College at the University of Michigan.  In 1989 he graduated from the University of Michigan Medical School and Began his general surgery residency at the John P. and Kathrine G. McGovern Medical School. During that training he took 2 years off to complete postgraduate training in pathology at the University of Michigan, where he studied inflammatory mediators of lung injury.  In 1996 he began fellowship training in cardiothoracic surgery at MD Anderson and the Texas Heart Institute, with an emphasis in general thoracic surgical oncology. In 1998, he joined the faculty at MD Anderson and has risen through the ranks to full professor.  Dr. Vaporciyan also earned a master’s degree in health professions education from the University of Illinois while on staff at MD Anderson.

With the completion of his master’s degree he quickly expanded his research interests into education.  Dr. Vaporciyan is focused on developing innovative educational techniques such as virtual simulations, improved diversity in our field through recognition and management of unconscious bias, alternative approaches to assessment and novel online teaching strategies — for students and faculty at various stages of cardiothoracic training. His efforts have resulted in the first online learning platform developed and implemented nationally for all cardiothoracic surgical North American trainees. In conjunction with this effort has been the development of professionally sponsored online textbooks for cardiothoracic surgery.

Finally, Dr Vaporciyan is involved in all areas of thoracic surgical oncology with a focus in pulmonary metastases and tumors involving cardiovascular structures.

Valerie Rusch

Abstract Presenter

Dr. Valerie Rusch has been a member of the Thoracic Surgery Service at MSKCC since March, 1989. A native New Yorker, she is a graduate of Vassar College and Columbia University College of Physicians and Surgeons. She completed her general surgery and cardiothoracic surgery residencies at the University of Washington in Seattle. After an additional year of experience in thoracic oncology at MD Anderson Cancer Center, she returned to the University of Washington where she served on the faculty for six years prior to her appointment at MSKCC. Dr. Rusch was Chief of the MSK Thoracic Service from 2000 to 2013, and is a past President of the American College of Surgeons.

Specialties: General Thoracic, Thoracic, Lung, Procedures, Anatomy and Conditions, Lung--Cancer, Lung--Other, Treatment/Procedure/Operation/Surgery, Lung, Lung--Cancer, Lung--Other