Complete Microscopic Resection Research Articles

P20.01.A CLINICAL APPLICATION OF RELATIONSHIP BETWEEN GENETIC ALTERATION AND INTRAOPERATIVE FLUORESCENCE ACTIVITY OF 5-AMINOLEVULINIC ACID IN BRAIN METASTASIS OF NON-SMALL CELL LUNG CANCER

Abstract BACKGROUND Distant metastasis into major organ is a major cause of death in cancer patients. Especially, metastasis to brain is known to duplicate the mortality of cancer patients because brain metastasis makes patients neurologically independent in daily activities. Despite surgical resection of brain metastasis is a core strategy for management, it is not possible for all brain metastasis due to eloquent location, multiple lesions, or clinical condition of patient. With advancement of technology in brain tumor surgery, fluorescence image, such as 5-aminolevulinic acid (5-ALA), can help detect the residual tumor during surgery. Recently, genetic alteration of cancer is additionally considered as prognostic factor with being added into traditional prognostic system, such as GPA scoring system. The primary objective of this study is to examine the fluorescence patterns of 5-ALA in brain metastasis surgery and investigate the results of genetic alteration in brain metastasis using next generation sequencing technique. MATERIAL AND METHODS Medical records of patients with brain metastasis of non-small cell lung cancer at our center from January 2017 to June 2022. Among them, the patients who were treated with surgical resection under 5-ALA fluorescence image and had NGS results were included in the analysis. RESULTS Total 72 patients were eligible for analysis. Mean follow-up duration was 12.36 months. Recurrence occurred in 28 (38.9%) patients and 46 (63.9%) patients succumbed to NSCLC. Mean recurrence-free survival (RFS) was 14.57 months and mean overall survival (OS) was 16.29 months. Strong fluorescence was obtained in 56 (77.8%) patients during surgery. In the NGS data of brain metastasis, genetic alteration of cell cycle regulation, DNA repair, tumorigenesis, proliferation, epigenetic regulation, and cancer immunology were detected in 73.6%, 44.4%, 56.9%, 66.7%, 30.6%, and 2.8%, respectively. In multivariate analysis, KPS, RPA class, extent of resection, modality of adjuvant treatment, genetic alteration of cell cycle regulation and cellular proliferation were associated with RFS. Additionally, age, KPS, status of NSCLC, RPA class, GPA score, modality of adjuvant treatment, genetic alteration of cell cycle regulation and cellular proliferation were associated with OS. CONCLUSION The presenting study suggested that microscopic complete resection with assist of fluorescence image could improve clinical outcome, and strong fluorescence image could reflect the genetic alteration of cell cycle regulation and cellular proliferation which are poor prognostic factors.

Combined endoscopic-microscopic trans-nasal trans-sphenoidal approach for pituitary adenomas

Objective. To obtain evidence that the use of endoscopy along with a microscope in the surgical management of pituitary tumours improves intraoperative visualization and significantly impacts operative outcomes in the trans-nasal approach. Material and methods. Each patient underwent endonasal transsphenoidal microscopic tumour resection. The procedure was modified by the use of intrasellar endoscopy as an adjunctive imaging modality. Following complete microscopic resection of tumour, rigid 0° and 30° 4.0-mm endoscopes were used to conduct a final survey of the sellar and parasellar spaces. Residual tumour fragments identified during this endoscopic examination were removed. Results. In 50 patients with pituitary macroadenomas, the rigid 30 ° angled rigid endoscope was found to be highly beneficial. Hidden areas could be visualized and tumour residues were detected. In the majority of the patients with detected tumour residues, adenomatous remnants were safely removed by meticulous endoscopic dissection under optimum visual control after the main part of the tumour had been removed with the operating microscope. Conclusions. Endoscopy provides distinct advantages over microscopy in imaging intrasellar and parasellar structures during pituitary tumour resection which are often missed by microscopy alone.

Thoracoscopic Resection of Lung Nodules following CT-Guided Labeling in Children and Adolescents with Solid Tumors

Resection of lung metastases in children with solid tumors is regularly hampered by limited intraoperative detectability and relevant operative trauma of the open surgical access. The aim of this study was to analyze thoracoscopic resection of lung metastases in children following CT-guided labeling with coil wires. We retrospectively analyzed data of children and adolescents undergoing this approach at our institution between 2010 and 2022 with regard to technical aspects as well as surgical and oncological data. Within this period, we performed this procedure on 12 patients wherein we resected 18 lesions (1-5 per patient). The median age of patients was 178 months (51-265). The median duration of coil wire placement was 41 min (30-173) and the median surgery time was 53 min (11-157). No conversions were necessary and no intraoperative complications occurred. Complete microscopic resection (R0) was achieved in all labeled lesions and malignant tumor components were found in 5/12 patients. Our study shows that with a careful patient selection, thoracoscopic resection of lung metastases after coil wire labeling is a safe and reproducible procedure in children. Using this approach, lesions that are expected to have a reduced intraoperative detectability during open surgery become resectable. Patients benefit from the minimally invasive surgical access and reduced operative trauma.

Expression of Corticotropin-Releasing Hormone and Its Receptors May Be Associated With Survival Rate in Pancreatic Cancer.

Corticotropin-releasing hormone (CRH) is a major regulator of the stress response to internal and external factors. CRH and its receptors (CRHR1 and CRHR2) are expressed in the central nervous system and some cancer cells, suggesting the importance of CRH signaling in pancreatic cancers. However, the clinicopathological significance of CRH remains unknown because the immunolocalization of CRH, CRHR1, and CRHR2 has not been examined in pancreatic carcinoma tissues. We clarified the correlation of the expression of CRH and its receptors with overall survival in pancreatic cancer. This study evaluated 96 patients with pancreatic cancer who underwent microscopic complete resection (R0) but not neoadjuvant chemotherapy from 1988 to 2007 at Tohoku University Hospital, Japan. CRH, CRHR1, and CRHR2 immunoreactivity were detected in the pancreatic carcinoma cells. Overall survival curves were generated according to the Kaplan-Meier method. CRHR1 immunoreactivity was significantly associated with an increased risk of poorer prognosis in all patients (P= .038) and the adjuvant therapy group (P= .022). Overall survival was worse in the CRHR1-positive group than in the CRHR1-negative group among the 62 patients treated with gemcitabine hydrochloride (P= .046) and the 22 patients treated with other drugs (P= .047). CRHR1 expression was correlated with survival in univariate analysis but not in multivariate analysis. This study is the first to immunolocalize CRH, CRHR1, and CRHR2 in pancreatic carcinoma tissues and to examine the biological prognosis. This study revealed that survival in patients with pancreatic cancer was significantly associated with expression of CRHR1 by assessing biological progression according to CRH and the expression of its receptors. However, CRHR1 expression was correlated with survival in univariate analysis but not in multivariate analysis.

NUT Carcinoma in Children and Adolescents: The Expert European Standard Clinical Practice Harmonized Recommendations.

Nuclear protein of the testis ( NUT ) carcinoma (NC) is a rare and highly aggressive tumor mainly occurring in adolescents and young adults, defined by the presence of a somatic NUTM1 rearrangement. The aim is to establish internationally harmonized consensus recommendations for the diagnosis and treatment of adolescents and young adults with NC in the framework of the European Reference Network for Paediatric Oncology. The European Cooperative Study Group for Pediatric Rare Tumors developed recommendations according to the Consensus Conference Standard Operating procedure methodology and reviewed by external "experts." No evidence of level I to II exists. Recommendations were developed based on published prospective (level III), but more frequently retrospective series (level IV), case reports (level V), and personal expertise (level V). In addition, "strength" of recommendations were categorized by grading (grade A to E). Histology is mandatory for the diagnosis of NC, including immunolabeling with anti-NUT antibodies and molecular biology ( NUTM1 rearrangement) (level V; grade A). Treatment of NC usually combines aggressive approaches in multimodal regimens. Chemotherapy should be considered as first-line treatment (neoadjuvant vincristine-adriamycin-ifosfamide/cisplatin-adriamycin-ifsofamide or vincristine-doxorubicin-cyclophosphamide/ifosfamide-etoposide) for unresectable or metastatic tumor (ie, 3 courses), rapidly followed by local treatment (level IV; grade B). Referral to a specialized surgical oncology center is highly recommended (level V; grade A). In localized NC, a complete microscopic surgical resection should be attempted whenever and as soon as possible, followed by primary irradiation (60 to 70Gy) and involved lymph nodes area (level IV; grade B). For head and neck tumors, a systematic neck dissection might be considered, even if N0 (level V; grade C). Adjuvant postirradiation chemotherapy is recommended, for a total of 9 to 12 courses (level IV; grade B). For first-line resected tumors, concomitant adjuvant chemotherapy to radiotherapy may be discussed (level IV; grade B). Targeted therapies and immunotherapeutic regimens should be delivered in the setting of prospective trials (level V; grade B). This project leads to a consensus strategy based on international experience with this very rare disease.

Efficacy and safety of intraoperative cone-beam CT-guided localization of small pulmonary nodules.

OBJECTIVESThis study aimed to evaluate the efficacy and safety of intraoperative cone-beam computed tomography-guided video-assisted thoracoscopic surgery wedge resection of impalpable small pulmonary nodules.METHODSThis was a single-centre phase 2 trial conducted between April 2018 and March 2019. Peripheral small pulmonary nodules, defined as either ground-glass opacity-dominant (>50%) nodules measuring ≤3 cm in diameter (ground-glass opacity-dominant type) or nodules measuring ≤2 cm in diameter located deeper than the nodule diameter from the visceral pleura (deep solid type), were eligible for resection using a cone-beam computed tomography-guided thoracoscopic manner. The primary end-point was macroscopic complete resection, and secondary end-points were: nodule extraction rate, operation time, localization time, marking accuracy, microscopic complete resection and safety.RESULTSTwenty-two nodules, in 9 men and 11 women with a mean age of 64.3 years, were visualized and resected. The nodules were located in the right upper, middle and lower lobes in 3, 1 and 5 patients, respectively, and in the left upper and lower lobes in 5 and 8 patients, respectively. Seven nodules were ground-glass opacity-dominant types, and 15 were deep solid types. Cone-beam computed tomography could clearly image all nodules. The mean time for localization was 17.4 min. The mean operation time was 110.7 min. Macroscopic complete resection was accomplished in 21 nodules (95.5%). Microscopic complete resection was achieved in all nodules (100%). Postoperative air leakage and bleeding were observed in 1 patient (5%).CONCLUSIONSCone-beam computed tomography might be a safe and useful guide for video-assisted thoracoscopic surgery wedge resection of impalpable peripheral pulmonary nodules.Date and number of IRB approval15 November 2017, 381.Clinical trial registration numberUMIN 000030388.

Locoregional Control and Survival in Children, Adolescents, and Young Adults With Localized Head and Neck Alveolar Rhabdomyosarcoma-The French Experience.

IntroductionThe head and neck (HN) are the most frequent sites of pediatric rhabdomyosarcoma (RMS). Alveolar RMS (ARMS) represents ~20% of all RMS cases and frequently spread to lymph nodes (LNs). The aim was to report locoregional control, event-free survival (EFS), and overall survival (OS), according to clinical and pathological features, LN staging, and treatment modalities.MethodsThe study included all patients prospectively enrolled in EpSSG RMS 2005 study under 21 years of age with localized HN ARMS and diagnosed between 2005 and 2016 in France. Medical data including imaging, surgical report, and radiation therapy planes were analyzed.ResultsForty-eight patients (median age 6 years; range 4 months−21 years), corresponding to 30 parameningeal and 18 non-parameningeal ARMS, were included. There were 33 boys (69%). Tumor locations included the following: orbit (n = 7) among which four cases had bone erosion, paranasal sinuses and nasal cavity (n = 16), deep facial spaces (n = 10), nasolabial fold (n = 8), and other non-parameningeal HN sites (n = 7). A fusion transcript of PAX3-FOXO1 or PAX7-FOXO1 was expressed in 33 of the 45 cases (73%) with molecular analysis. At diagnosis, 10 patients had primary resection of the primary tumor (PRPT) (none with microscopic complete resection) and 9 had LN staging. After induction chemotherapy, 26 patients (54%) had secondary resection of the primary tumor (SRPT) and 13 patients (27%) had cervical LN dissection. A total of 43 patients (90%) were treated with radiation therapy.With a median follow-up of 7 years (range 2–13 years), 5-year OS and EFS were 78% (95% CI, 63–88%) and 66% (95% CI, 51–78%), respectively. We observed 16 events (10 deaths): 4 local, 4 regional, 1 local and regional, and 7 metastatic. In univariate analysis, OS was only superior for patients under 10 years of age (p = 0.002), while FOXO1-negative ARMS, SRPT for parameningeal ARMS, and LN surgery were associated with significantly better EFS.ConclusionOur study confirms a better outcome for fusion-negative ARMS and ARMS in children under 10 years. Moreover, LN surgery and SRPT of parameningeal tumor may improve EFS of ARMS. Larger studies are needed to confirm our findings.

Pancreaticoduodenectomy with Total Mesopancreas Excision for Pancreatic Head Cancer. Impact on Overall Survival

Introduction: The pancreatic ductal head adenocarcinoma (PDHAC) is a lethal disease with poor prognosis. Surgical resection with complete microscopic resection (R0 status) in association with multimodal treatment currently represents the only strategy potentially resulting in long-term survival and cure. 5-year survival rate is only 20% to 25% and median survival is between 10 and 20 months. Total mesopancreas excision (TMpE) is a modified surgical technique that try to improve the rate of R1 resections at Superior Mesenteric Artery resection margin. The purpose of this study was to evaluate the impact of TMpE on the 1, 3 and 5-year overall survival (OS) rate and median survival (MS). Methods: This study included 93 patients with PDHAC who were treated in the Hepatobiliary Surgery Department of Miguel Servet University Hospital in Saragossa, Spain, during 7-year period (between October 1, 2010 and December 31, 2017). They were divided into two groups: Group A included patients who underwent PD treatment with TMpE resection of the arterial priority approach and Group B included patients who underwent standard PD (S-PD). The collected data were prospectively collected and statistically analyzed by SPSS 19.0 statistical software package. Results: See Table. There wasn’t significant difference between the two groups (p›0.05). Conclusions: TMpE improves overall survival rate and median survival on months but there wasn’t significant difference.Tabled 1EP02C-01812 months36 months60 monthsGroup AGroup BGroup AGroup BGroup AGroup BOS75%60%43.7%26.7%25%17.8%OM121224182817 Open table in a new tab

Impact of Total Mesopancreas Excision on the Superior Mesenteric Artery Margin Status

Introduction: Pancreatic ductal head adenocarcinoma (PDHAC) is a lethal disease with poor prognosis and surgical resection with complete microscopic resection (R0) in association with multimodal treatment currently represents the only curative strategy. The dissected margins around the superior mesenteric artery (SMA) are reported to be the most favorable R1 site for PDHAC. Therefore, modifications have been made to the classic surgical technique (Whipple) to improve the rate of R1 resections, such as the total mesopancreas excision (TMpE). The purpose of this study was to evaluate the impact of TMpE on the SMA margin status. Methods: This study included 93 patients with PDHAC who were treated in the Hepatobiliary Surgery Department of Miguel Servet University Hospital in Saragossa, Spain, during a 7-years period (2010-2017). They were divided into two groups. Group A included patients who underwent pancreaticoduodenectomy (PD) with TMpE and group B included standar PD (S-PD). The collected data were prospectively collected and statistically analyzed by SPSS 19.0 statistical software package. Results: The R0 resection rate was 52.1% (25/48) in Group A and 31.1% (14/45) in Group B. There was significant difference in the R0 resection rate between the two groups (p=0.027). The R1 SMA resection margin rate was 18. Conclusions: TMpE improves the oncological results of PD for pancreatic head adenocarcinoma as it halves the rate of R1 resections at the SMA resection margin.

Pancreaticoduodenectomy with Total Mesopancreas Excision for Pancreatic Head Cancer. Impact on Postoperative Complications

Introduction: Pancreatic ductal head adenocarcinoma (PDHAC) is a lethal disease with poor prognosis and surgical resection with complete microscopic resection (R0) in association with multimodal treatment currently represents the only curative strategy. Classical pancreaticoduodenectomy (PD) has a postoperative mortality of 5% and postoperative complications can be as high as 25-70%.

Extended surgical interventions in children with retinoblastoma invasion into the optic nerve

Introduction. Standard eye enucleation (EE) may not always guarantee a sufficient length of resection of the optic nerve (ON) so that the tumor cells do not spread along the optic nerve at the intersection line. Surgical access and the scope of surgical intervention are determined by the spread and localization of the tumor, as well as the qualification of the operating team.Purpose— to evaluate the role of extended surgical interventions in the spread of extraocular tumors on the ON.Materials and methods. The study included 9 patients with retinoblastoma (RB) and macroinvasion of the ON during primary magnetic resonance imaging (MRI) and/or micromorphological invasion of the ON resection line after EE. 4 of the 9 patients were treated with primary/secondary EE, induction chemotherapy (CT) and high-dose CT (HDCT), radiation therapy (RT). 5 out of 9 patients underwent secondary extended surgical interventions: exenteration of the orbit (n = 1), osteoplastic lateral orbitotomy with precanal resection of the ON (n = 2) in combination with EE in one case, subfrontal craniotomy (n = 1) and orbitozygomatic craniotomy (n = 1) with prechiasmal resection of the ON and EE with adjuvant RT (excluding the latter case) and CT, without HDCT.Results. It should be noted that the overall survival (OS) of 5 patients with complete microscopic resection (R0) after extended secondary operations was 75 ± 0.217 % with an average follow-up period of 77.25 ± 18.8 months, while in 4 patients with R1 (n = 4) without secondary extended operations with HDCT reached only 50 ± 0.25 % with an average follow-up period of 57 ± 24.8 months.Conclusion. MRI is mandatory for the primary diagnosis of RB, especially when there is a risk of the tumor spreading through the ON. Secondary surgery with R0-resection has a positive effect on survival. The need for adjuvant RT and CT after surgery should be discussed.

Endoscope-assisted fluorescence-guided resection allowing supratotal removal in glioblastoma surgery.

Several studies have proven the benefits of a wide extent of resection (EOR) of contrast-enhancing tumor in terms of progression-free survival (PFS) and overall survival (OS) in patients with glioblastoma (GBM). Thus, gross-total resection (GTR) is the main surgical goal in noneloquently located GBMs. Complete tumor removal can be almost doubled by microscopic fluorescence guidance. Recently, a study has shown that an endoscope with a light source capable of inducing fluorescence allows visualization of remnant fluorescent tumor tissue even after complete microscopic fluorescence-guided (FG) resection, thereby increasing the rate of GTR. Since tumor infiltration spreads beyond the borders of contrast enhancement on MRI, the aim of this study was to determine via volumetric analyses of the EOR whether endoscope-assisted FG resection enables supratotal resection beyond the borders of contrast enhancement. The authors conducted a retrospective single-center analysis of a consecutive series of patients with primary GBM presumed to be noneloquently located and routinely operated on at their institution between January 2015 and February 2018 using a combined microscopic and endoscopic FG resection. A 20-mg/kg dose of 5-aminolevulinic acid (5-ALA) was administered 4 hours before surgery. After complete microscopic FG resection, the resection cavity was scanned using the endoscope. Detected residual fluorescent tissue was resected and embedded separately for histopathological examination. Nonenhanced and contrast-enhanced 3D T1-weighted MR images acquired before and within 48 hours after tumor resection were analyzed using 3D Slicer. Bias field-corrected data were used to segment brain parenchyma, contrast-enhancing tumor, and the resection cavity for volume definition. The difference between the pre- and postoperative brain parenchyma volume was considered to be equivalent to the resected nonenhancing but fluorescent tumor tissue. The volume of resected tumor tissue was calculated from the sum of resected contrast-enhancing tumor tissue and resected nonenhancing tumor tissue. Twelve patients with GBM were operated on using endoscopic after complete microscopic FG resection. In all cases, residual fluorescent tissue not visualized with the microscope was detected. Histopathological examination confirmed residual tumor tissue in all specimens. The mean preoperative volume of brain parenchyma without contrast-enhancing tumor was 1213.2 cm3. The mean postoperative volume of brain parenchyma without the resection cavity was 1151.2 cm3, accounting for a mean volume of nonenhancing but fluorescent tumor tissue of 62.0 cm3. The mean relative rate of the overall resected volume compared to the contrast-enhancing tumor volume was 244.7% (p < 0.001). Combined microscopic and endoscopic FG resection of GBM significantly increases the EOR and allows the surgeon to achieve a supratotal resection beyond the borders of contrast enhancement in noneloquently located GBM.

Spinal hemangioblastoma: surgical procedures, outcomes and review of the literature.

total removal of spinal hemangioblastomas with satisfactory clinical outcomes remains a challenge. We aimed to evaluate the surgical outcomes of our spinal hemangioblastomas patients, summarize our experiences with this condition and review-related literature. records of 18 spinal hemangioblastoma patients who underwent microsurgical resection were analyzed retrospectively. Clinical features, surgical procedures and outcomes were reviewed to assess the prognosis of their spinal hemangioblastomas. The McCormick classification method was used to evaluate spinal function and MR scans used to assess location and features of the tumor pre-surgically, tumor recurrence and syringomyelia status post-surgically. total resection of 37 tumors was achieved in all 18 cases. Of those patients, two (11%) were accompanied with von Hippel-Lindau (VHL). Of the 37 tumors, 3 (8.1%) were completely intramedullary, 16 (43.2%) intramedullary-extramedullary and 18 (48.6%) primarily extramedullary. Tumors accompanied with syringomyelia were present in 17 (94.4%) patients. Clinical symptoms such as pain were reduced within 48h after surgery in 16 patients. Post-operative neurological functions improved in all cases at 3months post-surgery. Over the subsequent 3-18month follow-up period, pre-operative symptoms improved in all 18 patients and no tumor recurrence was present. Syringomyelia was reduced or absent within 3-6months. our results indicated that a complete microscopic resection was effective in eliminating symptoms in these spinal hemangioblastoma patients, who showed a good prognosis after surgery. These improvements in clinical symptoms may be associated with the blood flow changes, but not with reductions and/or eliminations of syrinx after surgery.

Treatment and outcome of the patients with rhabdomyosarcoma of the biliary tree: Experience of the Cooperative Weichteilsarkom Studiengruppe (CWS)

BackgroundBiliary rhabdomyosarcoma (RMS) is the most common biliary tumor in children. The management of affected patients contains unique challenges because of the rarity of this tumor entity and its critical location at the porta hepatis, which can make achievement of a radical resection very difficult.MethodsIn a retrospective chart analysis we analysed children suffering from biliary RMS who were registered in three different CWS trials (CWS-96, CWS-2002P, and SoTiSaR registry).ResultsSeventeen patients (12 female, 5 male) with a median age of 4.3 years were assessed. The median follow-up was 42.2 months (10.7–202.5). The 5-year overall (OS) and event free survival (EFS) rates were 58% (45–71) and 47% (34–50), respectively. Patients > 10 years of age and those with alveolar histology had the worst prognosis (OS 0%). Patients with botryoid histology had an excellent survival (OS 100%) compared to those with non-botryoid histology (OS 38%, 22–54, p = 0.047). Microscopic complete tumor resection was achieved in almost all patients who received initial tumor biopsy followed by chemotherapy and delayed surgery.ConclusionPositive predictive factors for survival of children with biliary RMS are age ≤ 10 years and botryoid tumor histology. Primary surgery with intention of tumor resection should be avoided.

Management of advanced uni- or bilateral retinoblastoma with macroscopic optic nerve invasion.

Retinoblastoma with macroscopic optic nerve (ON) invasion depicted by imaging at diagnosis remains a major problem and carries a poor prognosis. We sought to describe the treatment and outcome of these high-risk patients. Retrospective mono-institutional clinical, radiological, and histological review of patients with uni- or bilateral retinoblastoma with obvious ON invasion, defined by radiological optic nerve enlargement (RONE) depicted by computed tomography scan or magnetic resonance imaging (MRI), was performed. Between 1997 and 2014, among the 936 patients with retinoblastoma treated at Institut Curie, 11 had detectable RONE. Retinoblastoma was unilateral in 10 and bilateral in one. Median age at diagnosis was 28 months (range, 11-96). ON enlargement extended to the orbital portion in three patients, to the optic canal in five, to the prechiasmatic portion in two, and to the optic chiasm in one. Nine patients received neoadjuvant chemotherapy and partial response was obtained in all. Enucleation was performed in 10/11 patients-by an anterior approach in three and by anterior and subfrontal approaches in seven. Three patients had a positive ON resection margin (2/3 after primary enucleation). All enucleated patients received adjuvant treatment (conventional chemotherapy: 10, high-dose chemotherapy: seven, radiotherapy: five). Leptomeningeal progression occurred in four patients. Seven are in first complete remission (median follow up: 8 years [3.5-19.4]). Neoadjuvant chemotherapy and microscopic complete resection have a pivotal role in the management of retinoblastoma with RONE. MRI is recommended for initial and pre-operative accurate staging. Surgery should be performed by neurosurgeons in case of posterior nerve invasion. Radiotherapy is required in case of incomplete resection.

PC01.01 PRO Intrapleural Chemotherapy Is It the Future?

PC01.01 PRO Intrapleural Chemotherapy Is It the Future?

P1.16-36 Real-Time Ct Guided Video Assisted Thoracoscopic Partial Resection of Peripheral Small-Sized Lung Tumors

As pulmonary resection for small and grand-grass opacity (GGO) dominant pulmonary nodules have been increasing, various navigation systems to detect these nodules have been reported. The aim of this study is to evaluate feasibility of real-time CT guided pulmonary resection for impalpable small pulmonary nodules. From July to November in 2017, 11 patients were eligible for pulmonary resection for lung cancer or malignancy suspected lesions, which was expected to be difficult to detect during operation. These nodules were defined as GGO-dominant (>50%) tumor with a diameter of 3cm or lower (GGO-dominant type), and tumor with a diameter of 2cm or lower, which is located deeper than the diameter of the tumor from visceral pleura (deep solid type). First, we put several surgical clips as first marker on the visceral pleura of the tumor-located lobethrough 3-ports VATS approach. The tumor and the first markers were visualized by cone beam CT, then the second marker was put just on the tumor based on the image. Pulmonary resection was performed according to second marker guided by automated staplers. CT scanning was also performed for confirmation of the complete resection. These procedures were performed for 4 men and 7 women (mean age: 58 years (39-71)). Tumors were located in the right upper lobe/right lower lobe/left upper lobe/left lower lobe in 5/2/2/2 patients. Diameters of tumors were 1.5cm or less. Six tumors were GGO-dominant types whereas 5 were solid types located in the deep from the visceral pleura; therefore all tumors couldn’t be detected by video-scopic observation. The average number of cone beam CT scanning is 2.7 times. All patients accomplished macroscopic and microscopic complete resection with no adverse events during perioperative periods. This feasibility study suggested that cone beam CT was safe and useful guide forvideo assisted thoracoscopic partial resection for impalpable peripheral pulmonary nodules.

AB016. LA01. Impact of lymph node dissection on thymic malignancy: The Korean Association for Research on the Thymus (KART) Database Study

: Macroscopic and microscopic complete resection is the most important goal of surgical treatment in thymic malignancy. Radical thymectomy of thymic tumor and surrounding thymic tissue is the best way to achieve complete resection. It has been established as the standard treatment for thymic malignancy. However, whether additional lymph node dissection (LND) is necessary during thymectomy remains controversial because actual incidence of lymph node metastasis has not been well known and the therapeutic role of LND in thymic malignancies has not been established yet. Considering that LND is an important surgical procedure for staging and treatment in patients with many other solid malignancies, the need to establish the role of LND in thymic malignancies has been increasing. In 2013, the International Thymic Malignancy Interest group (ITMIG) and the International Association for Study of Lung Cancer (IASLC) proposed a new lymph node map and separate N stage in the eighth edition of TNM stage classification system for thymic malignancies. Systematic lymph node sampling in thymoma and LND in thymic carcinoma were suggested by ITMIG. However, evidence supporting routine LND during thymectomy is insufficient. To address the issue of LND in thymic malignancy, in this collaborative effort, authors of this study collected data on 1,597 patients who underwent surgical resection for primary thymic malignancies between 2000 and 2013 from the Korean Association for Research on the Thymus (KART) Database Study. The objective of the present study was to verify prognostic implications of lymph node metastases and the role of LND in thymic malignancies by retrospectively reviewing multi-center database in a large scale.

P2.17-16 Radical en Bloc Resection for Lung Cancer Invading the Spine

About 30% of patients with non-small cell lung cancer(NSCLC) have locally advanced cancer at the time of presentation. The best local control for resectable tumors is obviously achieved by surgical intervention, provided the resection is complete and respectful of oncologic principles.However,locally advanced NSCLC with vertebral invasion have been considered a contraindication to surgical resection for a long time and thus associated with a poor prognosis. In the present study, we review 11 cases in our 16-year experience with en bloc partial and hemi vertebrectomy for lung cancer invading the spine and report outcome and survival. Eleven patients with lung cancers involving the spine who underwent en bloc resection. Ten patients underwent radiation therapy(40Gy, in daily fractions of 1.8 Gy, 5 times per week). Preoperative chemotherapy regimens were as follows. Four patients received 2 cycles of cisplatin(80mg/m2 on day1) plus UFT(400-600mg/m2 daily for 14 days), three patients received 2 cycles of cisplatin(80mg/m2 on day1) plus S-1(60-120mg/m2 daily for 14 days), three patients received 2 cycles of carboplatin(AUC5-6) plus paclitaxel(200mg/m2 on day1), one patient with interstitial pneuminitis received no preoperative chemoradiotherapy.The criteria for resection were(1) a histologic diagnosis of NSCLC; (2) a tumor fixed to the vertebral column;(3) absence of mediastinal nodal involvement; and (4) no distant metastasis. Lobectomy was performed in 11 patients. Hemivertebrectomy was performed in 5 patients, and partial vertebrectomy was performed in 6 patients. The number of resected vertebral bodies was 2 or 3 (2,n=4; 3,n=7). Combined resection of the spine and descending aorta was performed in two patients. There was no immediate postoperative mortality. Morbidity was observed in 3 patients, including 1 (27%) complications related to the spinal surgery. The median hospital stay was 30 days. Five patients were alive after a mean follow-up of 112 months (range, 89-132 months). The 1- and 5-year survivals are 64% and 45%, respectively. Two local recurrences were observed.Tumor stage was IIIB in 1 patient, IIIA in 10patients.Surgical nodal status was N0 in 10 patients, N2 in 1 patient. Complete macroscopic and microscopic resection was achieved in 9 (82%) patients. Our results suggest that en bloc vertebrectomy for non–small cell lung cancers attached to the spine may be performed with low morbidity, and long-term disease-free survival can be achieved even in patients with T4 invasion of the vertebral body. En block vertebral resection with preoperative chemoradiotherapy is a treatment option for highly selected patients with NSCLC invading the spine.

Surgical technique of pleurectomy/decortication

Malignant pleural mesothelioma (MPM) is an aggressive and fatal thoracic malignancy associated with exposure to asbestos. Although there is no strong evidence to support how surgery can improve prognosis, multimodal therapy, including curative intent surgery, has been utilized in patients with resectable MPM. Two different approaches exist for curative intent surgery. Extrapleural pneumonectomy (EPP) is the well-established approach in which the lung is sacrificed with en bloc resection of the parietal pleura, ipsilateral lung, diaphragm, and pericardium. Pleurectomy/decortication (P/D) is the lung sparing surgery that involves the resection of parietal and visceral pleura. As neither EPP nor P/D obtain microscopic complete resection because of anatomical aspects, the goal of curative intent surgery for MPM is defined as macroscopic complete resection. This article describes the current status of P/D along with our observations. Regarding the surgical technique, which still remains considerably varied, our approach consists mainly of blunt dissection especially with cotton gloves or swabs. P/D is still a highly invasive surgery, though less so than EPP. Further reduction of invasiveness in the surgical approach is required to achieve better survival and postoperative quality of life.