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200 The natural history of carcinoma-in-situ at the bronchial resection margin
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Poster abstracts, 12th Annual British Thoracic Oncology Group Conference, 2014: Surgery
years), complete data for all factors enabled subsequent analysis. The table identifies poor prognostic factors from univariate analysis Table: Factors identified as poor prognostic factors in univariate analysis Blood test
HR
95% CI
Serum fibrinogen >4g/dL Haemoglobin <13.1g/dL Platelet count >370×109 or <140×109 ALT >63 IU/L or <17 IU/L Total protein >80g/L or <60g/L Albumin >48g/L or <35g/L Globulin >36g/L or <18g/L Cholesterol <5 mmol/L Age Male gender Nodal stage Tumour size Completeness of resection Histological grade
1.478 1.491 1.508 1.347 2.634 1.594 1.816 1.451 1.029 0.748 1.428 1.011 1.625 1.365
1.085 1.145 1.124 1.014 1.677 1.157 1.259 1.089 1.014 0.573 1.190 1.005 1.063 1.086
p 1.906 1.942 2.024 1.791 4.137 2.195 2.618 1.933 1.045 0.976 1.714 1.017 2.483 1.715
0.011 0.003 0.006 0.039 <0.001 0.005 0.001 0.011 <0.001 0.033 0.001 0.001 0.025 0.008
In multivariate analysis, total protein (HR 2.263 95% CI 1.357 3.775, p = 0.002), globulin (HR 1.507 95% CI 1.015 2.238 p = 0.042), and haemoglobin (HR 1.462 95% CI 1.091 1.958 p = 0.011) were poor prognostic factors. Including stage, age and gender in the model, stage (HR 1.286 95% CI 1.164 1.442 p < 0.001), age (HR 1.028 95% CI 1.011 1.046 p = 0.001), gender (HR 1.419 95% CI 1.048 1.920 p = 0.024), total protein (HR 2.503 95% CI 1.465 4.274 p = 0.001) and haemoglobin (HR 1.500 95% CI 1.110 2.026 p = 0.008) remained independent prognostic factors. Conclusion: Although survival data are not yet fully mature, preoperative anaemia and an abnormal serum total protein level are adverse prognostic factors for survival following lung cancer surgery, being independent of other variables including stage, age and gender. Further work is required to determine the clinical implications of these findings. 200 The natural history of carcinoma-in-situ at the bronchial resection margin H. Apperley1 *, J.M. Brown2,3 , N. Navani2,3,4 , J.P. George2,3 , S.M. Janes2,3 . 1 Bristol Medical School, University of Bristol, UK, 2 Lungs for Living Research Centre, University College London, UK, 3 Department of Thoracic Medicine, University College London Hospital, UK, 4 MRC Clinical Trials Unit, London, UK Introduction: Carcinoma-in-situ (CIS) at the surgical resection margin is a rare phenomenon with an estimated frequency of 0.05 2.5% in published series. The natural history of residual CIS following lobectomy is currently unknown. Methods: Retrospective review of patients referred to University College London Hospital for surveillance of CIS shown histologically at the surgical resection margin performed for N0M0 squamous cell carcinoma (1999 2012). Patients were followed with interval autofluoresence bronchoscopy (AFB) and biopsy; presence of CIS at the initial bronchoscopy, lesional destiny and development of further endobronchial CIS or invasive foci were assessed longitudinally. Results: A total of 22 patients were identified (Figure 1); 9 (41%) had no evidence of CIS on biopsy of the bronchial resection margin at initial AFB, the median interval from surgery to initial bronchoscopy was 6 months (range 3 9). 1 patient in this group developed a distant second primary lung cancer that was surgically resected and none developed CIS at any site during a median surveillance time of 37 months (range 19 126).
The initial post-surgical AFB of 2 patients (9%) demonstrated CIS that has persisted but not progressed to invasion after follow-up of 36 and 45 months. Both patients have however developed CIS at sites distant to the anastomosis. 11 patients (50%) had CIS confirmed at the resection site at initial bronchoscopy that subsequently progressed to invasion in a median time of 37 months (range 4 85). In this group 5 patients developed a total of 8 invasive cancers at sites distant to the resection margin and 9 had at least 1 CIS lesion at a distant site.
Figure 1. Flow diagram of patients with residual CIS confirmed histologically at the resection margin stratified by lesional destiny with longitudinal AFB surveillance and presence of metachronous CIS and invasive lesions.
Conclusion: This is the largest longitudinal study of residual CIS post-resection. Patients with CIS that persists at the bronchial resection margin are at very high risk of local progression and development of multi focal metachronous CIS and invasive cancers. 201 Surgical resection rates for early stage non-small cell lung cancer following PETCT B. Thomas *, S. Babu, P. Fielding. Velindre Cancer Centre of Velindre NHS Trust, Wales, UK Background: NICE clinical guideline 121: Lung Cancer, the diagnosis and treatment of lung cancer (2011) states that all patients with early stage non-small cell lung cancer (NSCLC) potentially suitable for curative treatment should be offered PET-CT. Patients who are medically fit should be offered surgical resection as the treatment of first choice. If unsuitable for surgery, radical radiotherapy should be considered. Data from the National Lung Cancer Audit (NLCA) 2012 show that surgical resection rates in Wales are lower than in England (10.3% versus 15%). The aim of this audit was to establish the proportion of patients with potentially resectable disease on PET-CT not undergoing surgery and the reasons behind this. Methods: A retrospective case note review of all patients undergoing PET-CT imaging prior to potential radical surgery for NSCLC in South Wales in 2011 was carried out. The inclusion criteria were 1. Histological or radiological diagnosis of NSCLC 2. Patient had undergone a PET-CT scan 3. MDT review confirmed stage I or II disease. Results: 137 patients were identified. 118/137 (86%) received radical treatment: 70/137 (51%) underwent surgical resection and 48/137 (35%) received radical radiotherapy. 19/137 (14%) received palliative treatment: one declined radical treatment, 10 had too poor a performance status and eight had co-morbidities excluding radical treatment. Conclusion: The National Lung Cancer Audit recommends that surgical resection rates for NSCLC below the England and Wales average of 14% should be reviewed. Resection rates in South Wales for those patients potentially operable on PET-CT are high. It is likely that overall resection rates in Wales are below the national average because patients present later with advanced disease and have multiple co-morbidities, making them unsuitable for curative surgery.
Poster abstracts, 12th Annual British Thoracic Oncology Group Conference, 2014: Surgery
years), complete data for all factors enabled subsequent analysis. The table identifies poor prognostic factors from univariate analysis Table: Factors identified as poor prognostic factors in univariate analysis Blood test
HR
95% CI
Serum fibrinogen >4g/dL Haemoglobin <13.1g/dL Platelet count >370×109 or <140×109 ALT >63 IU/L or <17 IU/L Total protein >80g/L or <60g/L Albumin >48g/L or <35g/L Globulin >36g/L or <18g/L Cholesterol <5 mmol/L Age Male gender Nodal stage Tumour size Completeness of resection Histological grade
1.478 1.491 1.508 1.347 2.634 1.594 1.816 1.451 1.029 0.748 1.428 1.011 1.625 1.365
1.085 1.145 1.124 1.014 1.677 1.157 1.259 1.089 1.014 0.573 1.190 1.005 1.063 1.086
p 1.906 1.942 2.024 1.791 4.137 2.195 2.618 1.933 1.045 0.976 1.714 1.017 2.483 1.715
0.011 0.003 0.006 0.039 <0.001 0.005 0.001 0.011 <0.001 0.033 0.001 0.001 0.025 0.008
In multivariate analysis, total protein (HR 2.263 95% CI 1.357 3.775, p = 0.002), globulin (HR 1.507 95% CI 1.015 2.238 p = 0.042), and haemoglobin (HR 1.462 95% CI 1.091 1.958 p = 0.011) were poor prognostic factors. Including stage, age and gender in the model, stage (HR 1.286 95% CI 1.164 1.442 p < 0.001), age (HR 1.028 95% CI 1.011 1.046 p = 0.001), gender (HR 1.419 95% CI 1.048 1.920 p = 0.024), total protein (HR 2.503 95% CI 1.465 4.274 p = 0.001) and haemoglobin (HR 1.500 95% CI 1.110 2.026 p = 0.008) remained independent prognostic factors. Conclusion: Although survival data are not yet fully mature, preoperative anaemia and an abnormal serum total protein level are adverse prognostic factors for survival following lung cancer surgery, being independent of other variables including stage, age and gender. Further work is required to determine the clinical implications of these findings. 200 The natural history of carcinoma-in-situ at the bronchial resection margin H. Apperley1 *, J.M. Brown2,3 , N. Navani2,3,4 , J.P. George2,3 , S.M. Janes2,3 . 1 Bristol Medical School, University of Bristol, UK, 2 Lungs for Living Research Centre, University College London, UK, 3 Department of Thoracic Medicine, University College London Hospital, UK, 4 MRC Clinical Trials Unit, London, UK Introduction: Carcinoma-in-situ (CIS) at the surgical resection margin is a rare phenomenon with an estimated frequency of 0.05 2.5% in published series. The natural history of residual CIS following lobectomy is currently unknown. Methods: Retrospective review of patients referred to University College London Hospital for surveillance of CIS shown histologically at the surgical resection margin performed for N0M0 squamous cell carcinoma (1999 2012). Patients were followed with interval autofluoresence bronchoscopy (AFB) and biopsy; presence of CIS at the initial bronchoscopy, lesional destiny and development of further endobronchial CIS or invasive foci were assessed longitudinally. Results: A total of 22 patients were identified (Figure 1); 9 (41%) had no evidence of CIS on biopsy of the bronchial resection margin at initial AFB, the median interval from surgery to initial bronchoscopy was 6 months (range 3 9). 1 patient in this group developed a distant second primary lung cancer that was surgically resected and none developed CIS at any site during a median surveillance time of 37 months (range 19 126).
The initial post-surgical AFB of 2 patients (9%) demonstrated CIS that has persisted but not progressed to invasion after follow-up of 36 and 45 months. Both patients have however developed CIS at sites distant to the anastomosis. 11 patients (50%) had CIS confirmed at the resection site at initial bronchoscopy that subsequently progressed to invasion in a median time of 37 months (range 4 85). In this group 5 patients developed a total of 8 invasive cancers at sites distant to the resection margin and 9 had at least 1 CIS lesion at a distant site.
Figure 1. Flow diagram of patients with residual CIS confirmed histologically at the resection margin stratified by lesional destiny with longitudinal AFB surveillance and presence of metachronous CIS and invasive lesions.
Conclusion: This is the largest longitudinal study of residual CIS post-resection. Patients with CIS that persists at the bronchial resection margin are at very high risk of local progression and development of multi focal metachronous CIS and invasive cancers. 201 Surgical resection rates for early stage non-small cell lung cancer following PETCT B. Thomas *, S. Babu, P. Fielding. Velindre Cancer Centre of Velindre NHS Trust, Wales, UK Background: NICE clinical guideline 121: Lung Cancer, the diagnosis and treatment of lung cancer (2011) states that all patients with early stage non-small cell lung cancer (NSCLC) potentially suitable for curative treatment should be offered PET-CT. Patients who are medically fit should be offered surgical resection as the treatment of first choice. If unsuitable for surgery, radical radiotherapy should be considered. Data from the National Lung Cancer Audit (NLCA) 2012 show that surgical resection rates in Wales are lower than in England (10.3% versus 15%). The aim of this audit was to establish the proportion of patients with potentially resectable disease on PET-CT not undergoing surgery and the reasons behind this. Methods: A retrospective case note review of all patients undergoing PET-CT imaging prior to potential radical surgery for NSCLC in South Wales in 2011 was carried out. The inclusion criteria were 1. Histological or radiological diagnosis of NSCLC 2. Patient had undergone a PET-CT scan 3. MDT review confirmed stage I or II disease. Results: 137 patients were identified. 118/137 (86%) received radical treatment: 70/137 (51%) underwent surgical resection and 48/137 (35%) received radical radiotherapy. 19/137 (14%) received palliative treatment: one declined radical treatment, 10 had too poor a performance status and eight had co-morbidities excluding radical treatment. Conclusion: The National Lung Cancer Audit recommends that surgical resection rates for NSCLC below the England and Wales average of 14% should be reviewed. Resection rates in South Wales for those patients potentially operable on PET-CT are high. It is likely that overall resection rates in Wales are below the national average because patients present later with advanced disease and have multiple co-morbidities, making them unsuitable for curative surgery.