SESSION TITLE: Unusual Problems and Thoracic Surgical Solutions
SESSION TYPE: Original Investigation Slide
PRESENTED ON: Tuesday, October 29, 2013 at 04:30 PM - 05:30 PM
PURPOSE: Complete (R0) anatomic resection affords the best opportunity for cure in patients with resectable NSCLC. Some tumors exhibit more aggressive tumor biology, resulting in encroachment on bronchial and vascular surgical margins of resection. Margin involvement determined only on final pathologic analysis several days after surgery poses a particular management dilemma. We evaluate the impact on recurrence and survival of microscopically positive surgical margins found on final pathology in resected NSCLC.
METHODS: Retrospective review of 2,466 patients undergoing anatomic lung resection for NSCLC from 1998-2012 to identify all patients with microscopically positive resection margins noted only on final pathology. A matched cohort of patients with negative margins was identified accounting for age, gender, tumor size, tumor location, clinical stage, use of induction therapy and operation performed. Primary outcomes were incidence and patterns of recurrence. Kaplan-Meier actuarial freedom from recurrence and overall survival estimates were performed.
RESULTS: Microscopically positive final pathologic margins were identified in 63 patients (2.6%) - lobectomy=42 (66.7%), bi-lobectomy=4(6.3%), sleeve resection=7(11.1%), pneumonectomy=10(15.9%). The median age was 67.2y (range: 35-87), mean tumor size was 4.8 ± 2.4cm. 76.1% stage 2B or above. 44.4% were adenocarcinoma and 41.3% squamous carcinoma. Involved margins were bronchial (n=39, 61.9%), vascular (n=20, 31.7%), parenchymal (n=6, 9.5%) or peribronchial/perivascular (n=5, 7.9%). 15 patients (23.8%) received neoadjuvant therapy and 52 (82.5%) adjuvant therapy. Margin positive patients had significantly increased rates of pathologic upstaging (66.7% vs 30.2%, p=0.0001) and use of adjuvant therapy (82.5% vs 41.3%, p=0.0001). No significant difference was noted in the patterns of recurrence between groups. Despite more aggressive therapy, patients with positive margins had significantly worse median (36 vs 19 months) and five year (37% vs 12%, p=0.009) overall survival.
CONCLUSIONS: Microscopically positive surgical margins (R1) on final pathology are associated with increased rates of pathological upstaging and a worse overall survival. This finding portends aggressive disease biology and a poor prognosis irrespective of treatment strategy.
CLINICAL IMPLICATIONS: Positive final pathologic margin appears to be a harbinger of advanced disease rather than a by-product of inadequate surgical therapy. Aggressive surgical re-resection may not be warranted in these patients.
DISCLOSURE: The following authors have nothing to disclose: David Odell, Joseph Wizorek, Matthew Schuchert, Kristen McCormick, David Wilson, Jill Siegfried, James Luketich, Rodney Landreneau
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