- Email: [email protected]
38 Staging the brain in non-small cell lung cancer (NSCLC) – has NICE gone far enough?
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Posters, 10th Annual British Thoracic Oncology Group Conference, 2012: Diagnosis and Staging
icities are manageable and safety and tolerability are comparable with randomized studies.
Diagnosis and Staging
Reference(s) [1] Douillard JY, Rosell R, De Lena M, et al. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): a randomised controlled trial. Lancet Oncol. 2006; 7:719 727. [2] Arriagada R, Bergman B, Dunant A, Le Chevalier T, Pignon JP, Vansteenkiste J. Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer. N Engl J Med. 2004; 350:351 360.
37 Does T staging on PET/CT correlate with pathological size of specimen in resected lung cancer?
36 Oncologists’, physicians’ and surgeons’ opinions on the perceived value and appropriateness of the speciality to inform patients on adjuvant chemotherapy after radical surgery for non-small cell lung cancer F.W.D. Tai1 *, K.S. Khor1 , S. Popat2 , M. Beckles3 , M. Leung1 , E. Lim1 . 1 Imperial College and Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK, 2 Imperial College and Department of Oncology, The Royal Marsden Hospital, London, UK, 3 Department of Acute Medicine, The Royal Free Hospital, London, UK Introduction: The benefit of chemotherapy after surgery for lung cancer is established, but roles and responsibilities of discussing adjuvant chemotherapy are not established. Whilst risks are straight forward to convey, difficulties in conveying the benefit results from published hazard ratios as the benefit varies with stage and therefore needs to be calculated individually and conveyed in a language that is understood by the patient. Method: From 2010 to 2011, a survey was conducted of cancer physicians, oncologists and surgeons in the UK. Clinicians asked to rank the most appropriate speciality to discuss adjuvant chemotherapy with patients, to calculate expected survival given baseline survival probability of 80% and a hazard ratio of 0.80, and then surveyed for the additional expected gain in cohorts with a 5 year survival probability of 40%, 60% and 80% respectively before they would recommend adjuvant chemotherapy. Results: 202 responses were received from 27 surgeons, 77 physicians, 87 oncologists (11 unstated). The majority of surgeons (56%), physicians (79%) and oncologists (61%) felt oncologist the most appropriate clinician to discuss adjuvant chemotherapy with patients. 33% of surgeons, 53% of physicians and 73% of oncologists were able to correctly calculate the expected survival of patients. When asked about perceived value before recommending adjuvant chemotherapy with 5 year survival probabilities of 40%, 60% and 80%, clinicians reported an expected a mean gain (SE) of 20.8% (2.7), 15.6% (2.4) and 13.2% (2.1) against an expected of 12%, 8% and 4% respectively. Conclusions: Our survey suggest oncologists as the clinicians best able to calculate the individual benefit of adjuvant chemotherapy and the majority of specialities polled agreed oncologists as the most appropriate initial person to discuss adjuvant chemotherapy with patients after radical surgery for lung cancer. The perceived value prior to recommending adjuvant chemotherapy in clinicians greatly exceeds current published results.
B. Teo1 *, M. Awan2 , L. Coombes3 , S. Iles1 . 1 Royal Cornwall Hospital, Cornwall, Truro, UK, 2 Derriford Hospital, Plymouth, UK, 3 Peninsula College of Medicine & Dentistry, Plymouth, UK Introduction: One of the dependants of TNM staging for those with lung cancer is the size of the tumour. One assessment of size is by PET/CT. We studied the correlation between size of tumour identified on PET/CT compared with the size at resection. Method: 23 consecutive patients with lung cancer were referred to Derriford Hospital, Plymouth for lung surgery in 2010. The dimension reported on PET/CT scans was compared to the size of pathological specimens. We calculated a Pearson’s Product Moment Correlation Coefficient (2-tailed) to investigate the relationship between the variables using the SPSS 18 software package. Results: Of the 23 samples studied, 12 were smaller in size for the pathological specimens. This down staged the TNM stage in three. Two samples were changed from Stage IIb to IIa and 1 sample was changed from IIa to Ib. 10 specimens were bigger. This changed the TNM stage in 4 samples. Two samples were changed from Stage Ia to Ib, 1 sample was changed from Ib to Ia and 1 sample was changed from IIa to IIb. The relationship between the data from PET/CT scans and the size at resection is highly significant and positively correlated (r = 0.814, n = 23, p < 0.001). The r2 value of 0.663 suggests that just over 66% of the variance in one variable can be explained by the other. This implies that we may be able to predict reasonably well what the size of the cancer on resection will be based on PET/CT scans. Descriptive Statistics
N Mean Median Std. Deviation Minimum Maximum Range Interquartile Range
CT/PET
Pathology
23 40.96 30.00 26.53 17.00 118.00 101.00 41.00
23 38.87 26.00 21.93 15.00 85.00 70.00 34.00
Conclusions: Although there is a positive correlation between the size demonstrated on PET/CT scans compared to the pathological specimen, the staging of 7 (30%) samples had to be changed. 38 Staging the brain in non-small cell lung cancer (NSCLC) has NICE gone far enough? E. Khan, S. Ismail, R. Muirhead *. The Beatson, West of Scotland Cancer Centre, Glasgow, UK Introduction: Recently updated NICE guidance continues to suggest that staging the brain in patients with radically treatable NSCLC was optional. Our centre has used these guidelines for 2 years. We aim to identify the number of patients who presented with symptomatic brain metastases within 6 months of radical radiotherapy. In view of increasingly toxic radical treatment, this would guide us both locally and nationally whether NICE guidance is adequate. In addition, we hope this data will give us some indication of the potential benefit of PCI. Method: We reviewed all patients who had undergone radical radiotherapy for NSCLC in 2009 and 2010. The dose and
Posters, 10th Annual British Thoracic Oncology Group Conference, 2012: Diagnosis and Staging fractionation, pathology, stage, PET scan, and finally whether any imaging of the brain had been performed within 6 months of start date of radical radiotherapy. Results: 458 patients were identified. The total number of patients with brain metastases in the whole group was 3.7%. The proportion of brain metastases in Stage I, II and III NSCLC throughout both years was 2.8%, 1.0% and 5.7% respectively. The median follow up was 16 months (range 6 mths to 30 mths). The total number of patients who had developed symptomatic brain metastases within the follow up period available was 7.9%. Conclusions: Our current practice, of staging high-risk patients at the discretion of the clinician, is sufficient to identify the majority of patients who will suffer symptomatic brain metastases within 6 months. In addition the low rate of symptomatic brain metastases found in our study, brings into question the necessity for PCI. Finally, although there is a suggestion in the literature that identifying brain metastases earlier provides a better prognosis, this is currently unproven. Until this is studied further in a prospective trial, there is no robust rational for routine brain imaging in NSCLC patients undergoing work up for radical treatment. 39 Prevalence of supraclavicular lymph node metastases in N2 and N3 lung cancer using CT and PET/CT C. Clay1,2 *, J. Howells2,1 . 1 University of Manchester, Manchester, Greater Manchester, UK, 2 Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK Introduction: Lung cancer is the second most common malignancy in the UK, accounting for the highest proportion of cancerrelated deaths. Metastases to the supraclavicular lymph nodes are an indicator of advanced disease. Early detection and sampling of supraclavicular node involvement can eliminate the need for further invasive investigation. Routine ultrasound evaluation of the supraclavicular fossae with nodal biopsy has been proposed in all lung cancer patients, as it provides a simple and effective tool for diagnosis and staging [1,2]. However, the potential increase in the yield of malignant supraclavicular nodes needs to be established before significant investment is made in such a programme. Method: This study evaluated the prevalence of supraclavicular node involvement, using metabolic PET/CT imaging, in lung cancer patients with mediastinal lymphadenopathy (N2 or N3) at staging CT. The CT images of 571 patients were retrospectively reviewed, along with the PET/CT data in 112 cases. Results: Combining the results from both imaging modalities demonstrates supraclavicular or cervical node involvement in 21.0% of our study population. However, 108 of the 120 contrastenhanced CT and PET/CT positive nodes were visible and reported on the initial CT. In 457 patients with no extra-mediastinal lymphadenopathy on initial CT imaging, PET/CT demonstrated significant supraclavicular or cervical lymphadenopathy in only 12 patients. Previous studies suggest that the sensitivity of PET/CT for supraclavicular lymphadenopathy in lung cancer is 92% [3]. Using this sensitivity, we estimate that supraclavicular or cervical lymphadenopathy is present in up to 28.2% of otherwise N2 and N3 patients. Conclusions: It appears that, unless ultrasonography is substantially more sensitive than PET, routine ultrasonography of the neck and supraclavicular fossae adds little to the work up of this patient group. Further study is required to review the costs and benefits of routine supraclavicular node assessment if additional imaging will produce only a small increase in malignant yield. Reference(s) [1] Kumaran M., Benamore R.E., Vaidhyanath R., Muller S., Richards C.J., Peake M.D., Entwisle J.J. Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer. Thorax. 2005; 60(3): 229 233.
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[2] Sihoe A.D.L., Lee T.W., Ahuja A.T., Yim A.P.C. Should cervical ultrasonography be a routine investigation for lung cancer patients with impalpable cervical lymph nodes? Eur J Cardiothorac Surg. 2004; 25(4): 486 491. [3] Sung Y.M., Lee K.S., Kim B., Kim S., Kwon O.J., Choi J.Y., Yang S. Nonpalpable Supraclavicular Lymph Nodes in Lung Cancer Patients: Preoperative Characterization with 18F-FDG PET/CT. AJR. 2008; 190: 246 252. 40 Audit of patients undergoing bronchoscopy or CT guided biopsy L. Holland *, L. Parker, R. Reddy. Kettering General Hospital, Kettering, Northants, UK Introduction: This audit explores the views of patients who have undergone bronchoscopies and CT Guided Lung biopsies in May August 2010, It identifies where examples of good practice are demonstrated, and makes suggestions where care can be improved to enable better patient satisfaction. Method: A questionnaire was developed to look at two specific issues; • The information patients received • Patients personal experience of the procedure The questionnaires were given to 50 patients post procedure on discharge 31 patients returned the questionnaire, a return rate of 62% 9 CT guided biopsy 22 Bronchoscopy. Results: The results were very positive, they showed that all patients had been offered information, that it was appropriate and easy to read. Patients felt able to ask questions. 2 patients felt they had to wait too long from arriving in the department to having the procedure. Tolerability of the procedure varied and the scores demonstrated a variety of uncomfortable symptoms, the biggest distressing symptom was pain. 4 patients did think something could be done to improve the situation. Conclusions: Recommended actions: 1. Respiratory doctors to follow the BTS Guidelines re; stepping up of sedation with bronchoscopy patients. 2. Use Alfentanyl as an alternative to Midazolam for bronchoscopy patients with a cough. 3. Use combination of Alfentanyl and Midazolam for bronchoscopy patients with cough during procedure, and severely anxious young patients. 4. During the lung biopsy the radiologists to consider the use of additional local anaesthesia. 5. Ensure patient receives appropriate pain control post procedure. 6. Prevent any delays or long waits for lung biopsy patients in the radiology department. 7. Explore the issue of using a pre-med to reduce anxiety before lung biopsy. 41 Lung cancer mimics and significant incidental findings in patients undergoing fast track pre-clinic computed tomography S. Hobbins *, C. Russell, S. Phillips, C. Walker, I. Woolhouse. University Hospital Birmingham NHS Foundation Trust, Birmingham, UK Introduction: Pre-clinic computed tomography (CT) for fast track lung cancer clinics is associated with a reduction in diagnostic times and more efficient use of clinic appointments. However, a significant proportion of patients on this pathway will not have lung cancer but may have other clinically significant findings. The aim of this report is to determine causes for non lung cancer chest x-ray (CXR) abnormalities and assess the incidence of other significant incidental findings.
Posters, 10th Annual British Thoracic Oncology Group Conference, 2012: Diagnosis and Staging
icities are manageable and safety and tolerability are comparable with randomized studies.
Diagnosis and Staging
Reference(s) [1] Douillard JY, Rosell R, De Lena M, et al. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): a randomised controlled trial. Lancet Oncol. 2006; 7:719 727. [2] Arriagada R, Bergman B, Dunant A, Le Chevalier T, Pignon JP, Vansteenkiste J. Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer. N Engl J Med. 2004; 350:351 360.
37 Does T staging on PET/CT correlate with pathological size of specimen in resected lung cancer?
36 Oncologists’, physicians’ and surgeons’ opinions on the perceived value and appropriateness of the speciality to inform patients on adjuvant chemotherapy after radical surgery for non-small cell lung cancer F.W.D. Tai1 *, K.S. Khor1 , S. Popat2 , M. Beckles3 , M. Leung1 , E. Lim1 . 1 Imperial College and Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK, 2 Imperial College and Department of Oncology, The Royal Marsden Hospital, London, UK, 3 Department of Acute Medicine, The Royal Free Hospital, London, UK Introduction: The benefit of chemotherapy after surgery for lung cancer is established, but roles and responsibilities of discussing adjuvant chemotherapy are not established. Whilst risks are straight forward to convey, difficulties in conveying the benefit results from published hazard ratios as the benefit varies with stage and therefore needs to be calculated individually and conveyed in a language that is understood by the patient. Method: From 2010 to 2011, a survey was conducted of cancer physicians, oncologists and surgeons in the UK. Clinicians asked to rank the most appropriate speciality to discuss adjuvant chemotherapy with patients, to calculate expected survival given baseline survival probability of 80% and a hazard ratio of 0.80, and then surveyed for the additional expected gain in cohorts with a 5 year survival probability of 40%, 60% and 80% respectively before they would recommend adjuvant chemotherapy. Results: 202 responses were received from 27 surgeons, 77 physicians, 87 oncologists (11 unstated). The majority of surgeons (56%), physicians (79%) and oncologists (61%) felt oncologist the most appropriate clinician to discuss adjuvant chemotherapy with patients. 33% of surgeons, 53% of physicians and 73% of oncologists were able to correctly calculate the expected survival of patients. When asked about perceived value before recommending adjuvant chemotherapy with 5 year survival probabilities of 40%, 60% and 80%, clinicians reported an expected a mean gain (SE) of 20.8% (2.7), 15.6% (2.4) and 13.2% (2.1) against an expected of 12%, 8% and 4% respectively. Conclusions: Our survey suggest oncologists as the clinicians best able to calculate the individual benefit of adjuvant chemotherapy and the majority of specialities polled agreed oncologists as the most appropriate initial person to discuss adjuvant chemotherapy with patients after radical surgery for lung cancer. The perceived value prior to recommending adjuvant chemotherapy in clinicians greatly exceeds current published results.
B. Teo1 *, M. Awan2 , L. Coombes3 , S. Iles1 . 1 Royal Cornwall Hospital, Cornwall, Truro, UK, 2 Derriford Hospital, Plymouth, UK, 3 Peninsula College of Medicine & Dentistry, Plymouth, UK Introduction: One of the dependants of TNM staging for those with lung cancer is the size of the tumour. One assessment of size is by PET/CT. We studied the correlation between size of tumour identified on PET/CT compared with the size at resection. Method: 23 consecutive patients with lung cancer were referred to Derriford Hospital, Plymouth for lung surgery in 2010. The dimension reported on PET/CT scans was compared to the size of pathological specimens. We calculated a Pearson’s Product Moment Correlation Coefficient (2-tailed) to investigate the relationship between the variables using the SPSS 18 software package. Results: Of the 23 samples studied, 12 were smaller in size for the pathological specimens. This down staged the TNM stage in three. Two samples were changed from Stage IIb to IIa and 1 sample was changed from IIa to Ib. 10 specimens were bigger. This changed the TNM stage in 4 samples. Two samples were changed from Stage Ia to Ib, 1 sample was changed from Ib to Ia and 1 sample was changed from IIa to IIb. The relationship between the data from PET/CT scans and the size at resection is highly significant and positively correlated (r = 0.814, n = 23, p < 0.001). The r2 value of 0.663 suggests that just over 66% of the variance in one variable can be explained by the other. This implies that we may be able to predict reasonably well what the size of the cancer on resection will be based on PET/CT scans. Descriptive Statistics
N Mean Median Std. Deviation Minimum Maximum Range Interquartile Range
CT/PET
Pathology
23 40.96 30.00 26.53 17.00 118.00 101.00 41.00
23 38.87 26.00 21.93 15.00 85.00 70.00 34.00
Conclusions: Although there is a positive correlation between the size demonstrated on PET/CT scans compared to the pathological specimen, the staging of 7 (30%) samples had to be changed. 38 Staging the brain in non-small cell lung cancer (NSCLC) has NICE gone far enough? E. Khan, S. Ismail, R. Muirhead *. The Beatson, West of Scotland Cancer Centre, Glasgow, UK Introduction: Recently updated NICE guidance continues to suggest that staging the brain in patients with radically treatable NSCLC was optional. Our centre has used these guidelines for 2 years. We aim to identify the number of patients who presented with symptomatic brain metastases within 6 months of radical radiotherapy. In view of increasingly toxic radical treatment, this would guide us both locally and nationally whether NICE guidance is adequate. In addition, we hope this data will give us some indication of the potential benefit of PCI. Method: We reviewed all patients who had undergone radical radiotherapy for NSCLC in 2009 and 2010. The dose and
Posters, 10th Annual British Thoracic Oncology Group Conference, 2012: Diagnosis and Staging fractionation, pathology, stage, PET scan, and finally whether any imaging of the brain had been performed within 6 months of start date of radical radiotherapy. Results: 458 patients were identified. The total number of patients with brain metastases in the whole group was 3.7%. The proportion of brain metastases in Stage I, II and III NSCLC throughout both years was 2.8%, 1.0% and 5.7% respectively. The median follow up was 16 months (range 6 mths to 30 mths). The total number of patients who had developed symptomatic brain metastases within the follow up period available was 7.9%. Conclusions: Our current practice, of staging high-risk patients at the discretion of the clinician, is sufficient to identify the majority of patients who will suffer symptomatic brain metastases within 6 months. In addition the low rate of symptomatic brain metastases found in our study, brings into question the necessity for PCI. Finally, although there is a suggestion in the literature that identifying brain metastases earlier provides a better prognosis, this is currently unproven. Until this is studied further in a prospective trial, there is no robust rational for routine brain imaging in NSCLC patients undergoing work up for radical treatment. 39 Prevalence of supraclavicular lymph node metastases in N2 and N3 lung cancer using CT and PET/CT C. Clay1,2 *, J. Howells2,1 . 1 University of Manchester, Manchester, Greater Manchester, UK, 2 Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK Introduction: Lung cancer is the second most common malignancy in the UK, accounting for the highest proportion of cancerrelated deaths. Metastases to the supraclavicular lymph nodes are an indicator of advanced disease. Early detection and sampling of supraclavicular node involvement can eliminate the need for further invasive investigation. Routine ultrasound evaluation of the supraclavicular fossae with nodal biopsy has been proposed in all lung cancer patients, as it provides a simple and effective tool for diagnosis and staging [1,2]. However, the potential increase in the yield of malignant supraclavicular nodes needs to be established before significant investment is made in such a programme. Method: This study evaluated the prevalence of supraclavicular node involvement, using metabolic PET/CT imaging, in lung cancer patients with mediastinal lymphadenopathy (N2 or N3) at staging CT. The CT images of 571 patients were retrospectively reviewed, along with the PET/CT data in 112 cases. Results: Combining the results from both imaging modalities demonstrates supraclavicular or cervical node involvement in 21.0% of our study population. However, 108 of the 120 contrastenhanced CT and PET/CT positive nodes were visible and reported on the initial CT. In 457 patients with no extra-mediastinal lymphadenopathy on initial CT imaging, PET/CT demonstrated significant supraclavicular or cervical lymphadenopathy in only 12 patients. Previous studies suggest that the sensitivity of PET/CT for supraclavicular lymphadenopathy in lung cancer is 92% [3]. Using this sensitivity, we estimate that supraclavicular or cervical lymphadenopathy is present in up to 28.2% of otherwise N2 and N3 patients. Conclusions: It appears that, unless ultrasonography is substantially more sensitive than PET, routine ultrasonography of the neck and supraclavicular fossae adds little to the work up of this patient group. Further study is required to review the costs and benefits of routine supraclavicular node assessment if additional imaging will produce only a small increase in malignant yield. Reference(s) [1] Kumaran M., Benamore R.E., Vaidhyanath R., Muller S., Richards C.J., Peake M.D., Entwisle J.J. Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer. Thorax. 2005; 60(3): 229 233.
S13
[2] Sihoe A.D.L., Lee T.W., Ahuja A.T., Yim A.P.C. Should cervical ultrasonography be a routine investigation for lung cancer patients with impalpable cervical lymph nodes? Eur J Cardiothorac Surg. 2004; 25(4): 486 491. [3] Sung Y.M., Lee K.S., Kim B., Kim S., Kwon O.J., Choi J.Y., Yang S. Nonpalpable Supraclavicular Lymph Nodes in Lung Cancer Patients: Preoperative Characterization with 18F-FDG PET/CT. AJR. 2008; 190: 246 252. 40 Audit of patients undergoing bronchoscopy or CT guided biopsy L. Holland *, L. Parker, R. Reddy. Kettering General Hospital, Kettering, Northants, UK Introduction: This audit explores the views of patients who have undergone bronchoscopies and CT Guided Lung biopsies in May August 2010, It identifies where examples of good practice are demonstrated, and makes suggestions where care can be improved to enable better patient satisfaction. Method: A questionnaire was developed to look at two specific issues; • The information patients received • Patients personal experience of the procedure The questionnaires were given to 50 patients post procedure on discharge 31 patients returned the questionnaire, a return rate of 62% 9 CT guided biopsy 22 Bronchoscopy. Results: The results were very positive, they showed that all patients had been offered information, that it was appropriate and easy to read. Patients felt able to ask questions. 2 patients felt they had to wait too long from arriving in the department to having the procedure. Tolerability of the procedure varied and the scores demonstrated a variety of uncomfortable symptoms, the biggest distressing symptom was pain. 4 patients did think something could be done to improve the situation. Conclusions: Recommended actions: 1. Respiratory doctors to follow the BTS Guidelines re; stepping up of sedation with bronchoscopy patients. 2. Use Alfentanyl as an alternative to Midazolam for bronchoscopy patients with a cough. 3. Use combination of Alfentanyl and Midazolam for bronchoscopy patients with cough during procedure, and severely anxious young patients. 4. During the lung biopsy the radiologists to consider the use of additional local anaesthesia. 5. Ensure patient receives appropriate pain control post procedure. 6. Prevent any delays or long waits for lung biopsy patients in the radiology department. 7. Explore the issue of using a pre-med to reduce anxiety before lung biopsy. 41 Lung cancer mimics and significant incidental findings in patients undergoing fast track pre-clinic computed tomography S. Hobbins *, C. Russell, S. Phillips, C. Walker, I. Woolhouse. University Hospital Birmingham NHS Foundation Trust, Birmingham, UK Introduction: Pre-clinic computed tomography (CT) for fast track lung cancer clinics is associated with a reduction in diagnostic times and more efficient use of clinic appointments. However, a significant proportion of patients on this pathway will not have lung cancer but may have other clinically significant findings. The aim of this report is to determine causes for non lung cancer chest x-ray (CXR) abnormalities and assess the incidence of other significant incidental findings.