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27 10 years experience of malignant pericardial effusions from a tertiary referral centre
Posters, 9th Annual BTOG Conference, 2011: Diagnosis & Staging Diagnosis & Staging 25 EGFR mutation analysis in Welsh population F.T. Rimi1 , N. Ghosal1 , R.K. Shrimali2 , N. Stuart1 , J.F. Lester3 , C. Bale1 , R. Williams1 , A. Garcia1 . 1 North Wales Cancer Center,Betsi Cadwaladr University Health Board,North Wales, United Kingdom, 2 Department of Oncology,The Christie NHS Foundation Trust, Manchester, United Kingdom, 3 Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, United Kingdom Introduction: EFGR mutation analysis identifies sensitivity to Tyrosine Kinase Inhibitor (TKI) drugs and guides the choice of first line treatment in metastatic Non-Small-Cell Lung Cancer. The prevalence of the mutation in the general population is variable ranging from 1.6% to 59.7%. We endeavour to assess its prevalence in the Welsh population. Methods and Materials: We looked into the records of all the patients tested between July 2009 and July 2010. The data was obtained from the All Wales Molecular Genetics Laboratory, GP and hospital records. We looked for c.2573T>G (p.Leu858Arg), c.2582T>A (p.L861Q), c.2161G>A (p. Gly721ser), 15 bp deletion in exon 19 of EGFR gene, c.2236_2250del(15), c.2573T>G(p.Leu858Arg), L858R, L718Q mutations which were thought to be TKI sensitising mutations. Results: A total of 163 patients underwent EGFR mutation analysis. There were 87 males and 76 females. The median age was 66.5 yr (34 to 87). TKI sensitising EGFR mutations were noted in 19 (11.7%) patients. Split of the mutant population based on gender, smoking habits, ethnicity and histology is shown in Table 1. Table 1: Histological and demographic split in study population
Gender male female Smoking current ex non Ethnic white asian afrocar mixed Histo squam adeno large cell broncha others*
Mutant
Wild type
6 13
81 63
4 5 10
68 49 27
17 1 0 1
141 1 0 2
0 13 0
30 83 2
1 5
2 27
*Others = poorly differentiated and not specified. Twenty-four percent of the female non smokers (never smokers and ex-smoker >10yrs) showed mutation positivity in contrast to 3% of male current smokers. Also 13.5% of adenocarcinomas showed mutation compared to 0% of squamous cell carcinomas. EGFR mutation status was un-identifiable in 15 samples due to inadequate tissue sampling. Conclusion: EGFR mutation positive sub-groups in the predominantly white Caucasian population of Wales show similarity in terms of demographics, histology and smoking habits to the sub-groups in published literature. This data could be taken into account
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in identifying the indications of EGFR mutation analysis testing locally. Conflict of Interest: None declared by any author. 26 Improving patient comfort during medical thoracoscopy H.A. Powell, C. Collins, S. Rowe, K.J. Smith, C.I. Whale. Respiratory Medicine, Royal Derby Hospital, Derby, United Kingdom Introduction: Medical thoracoscopy is a safe procedure which can reduce symptoms, confirm diagnosis and provide effective palliation for patients with a pleural effusion. There has been rapid expansion of medical thoracoscopy services in recent years. In order to enhance patient experience of medical thoracoscopy, we assessed comfort during and after the procedure. Methods: We conducted a retrospective study of patients who underwent medical thoracoscopy at Royal Derby Hospital between November 2008 and May 2010. All procedures were performed via a single port and subjects received a standard regime of conscious sedation (midazolam 3 mg), analgesia (alfentanyl 250 mcg) and local anaesthetic (2% lignocaine). We invited patients to participate via postal questionnaire including an assessment of information received pre-procedure, a visual analogue scale (O = No pain to 10 = severe pain) to quantify peri- and post-procedure pain and a specific question asking whether patients would be prepared to have the procedure repeated. Results: Forty-one patients underwent medical thoracoscopy in 19 months. We posted questionnaires to 27 people, excluding deceased patients and those known to be in the terminal phase of illness, and received 17 replies. Most patients received adequate pre-procedure information and 14 out of 15 understood the information given. The median peri-procedure pain score was 5, (Mean 4.7, SD 3.0), and the median post-procedure pain score was 0.5, (Mean 2.6, SD 3.4). Two patients commented that medical thoracoscopy was more painful than expected. Thirteen out of 16 respondents would have the procedure again if necessary. Discussion: Medical thoracoscopy performed under conscious sedation is generally well tolerated. It is reassuring to establish that most patients received adequate information and would be prepared to have the procedure repeated. Mean pain scores were higher than expected, suggesting potential to improve the current regime. Further research focussed on enhancing pain control during and after medical thoracoscopy is needed. 27 10 years experience of malignant pericardial effusions from a tertiary referral centre C. Coyle1 , N. Singh2 , L. Nolan1 . 1 Department of Medical Oncology, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, United Kingdom, 2 Department of histopathology, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, United Kingdom Introduction: Malignant pericardial effusions are in infrequent complication of metastatic malignancy. Pericardial paracentesis can provide rapid resolution of haemodynamic compromise but there is very little evidence on how best to manage this problem in the medium to long term. Methods: The histopathology data base from Southampton General Hospital was searched for all of cases of pericardial effusions aspirated and sent for cytological analysis from October 2000 to October 2010. The Medical records of all recorded cases with malignant cytology were accessed for information pertaining to diagnosis and subsequent treatment. Results: There were 200 samples sent for cytological analysis. 35 cases with malignant cytology were identified. The median age was 61 years (range 44 78) with 15 male and 20 female. The associated malignancies were non small cell lung cancer (NSCLC)
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Posters, 9th Annual BTOG Conference, 2011: Diagnosis & Staging
(68%), mesothelioma (6%), breast cancer (23%) and diffuse large B cell non Hodgkin’s lymphoma (DLBCL) (3%). 23% of cases had a reoccurrence of their pericardial effusion, but only 14% had a pericardial window inserted. Of those patients with NSCLC, 48% had the pericardial fluid as their presenting feature. The median survival for all cases was 2.4 months (range 0 46.5 months). Tumour specific median survival was 53.5 days for NSCLC and 505.5 days for breast cancer. Conclusions: This retrospective cohort confirms the poor prognosis resulting from clinically meaningful pericardial effusions associated with NSCLC. However when associated with a more chemoresponsive malignancy the prognosis is much more favourable. It appears that pericardial windows are not frequently utilised and repeat drainage is not often required. 28 CT guided lung biopsy providing patient information in a multidisciplinary setting D. Borthwick1 , F.C. Minns2 , A. Ni Mhuineachain2 , J. Murcheson2 . Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, United Kingdom, 2 Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom 1
Introduction: CT guided lung biopsies are commonly performed to aid diagnosis of a lung cancer. Patients are often given verbal information reinforced by local written information. A number of leaflets are available but no consensus currently exsists. The SCAN (South-East Scottish Cancer network) wanted to standardise information for patients undergoing this procedure. The aim was to establish current practice in NHS Lothian, assess patients impressions of the usefulness of the leaflets already in existence and design and develop a new leaflet for the Network. Methods: Questionnaires were designed by year 1 Edinburgh University medical students and distributed across NHS Lothian to patients once they had undergone a CT guided biopsy. Results: Fifty-five percent of patients received information (80% by post, 20% by a nurse). Of those that received written information, all found it useful. Forty-five percent of patients did not receive any written information. All of patients who did not receive a leaflet would have liked one. Conclusion: Fifty-five percent of patients attending for biopsy did not receive a leaflet, making information variable and incomplete for some patients. Only one of the current leaflets includes information about complication rates. Fifty percent of patients receiving information thought a diagram would be helpful. A leaflet has now been produced for use across SCAN. 29 In the absence of EBUS, blind TBNA is an important tool for patients with suspected thoracic malignancy K. Shepherd, L. Brown, P. Bishop, L. Joseph, H. Doran, J. Martin, P.V. Barber, R. Booton. North West Lung Centre, Wythenshawe, Manchester, England, United Kingdom Introduction: The National Lung Cancer Audit (2009) suggests that no network is achieving the required CT prior to bronchoscopy standard of 90%. Consequently the opportunity to confirm diagnosis, to pathologically stage radiologically enlarged lymph nodes or access central disease outside the major airways is missed. In centres without access to endobronchial ultrasound (EBUS), the use of CT scanning prior to bronchoscopy facilitates the blind targeting of such disease. We report our six month experience of blind transbronchial needle aspiration (TBNA) prior to the introduction of an EBUS service. Methods: We reviewed the bronchoscopy unit database between September 2009 and February 2010 and identified patients who had undergone transbronchial aspirates for suspected thoracic malignancy. Histological reports and case records were reviewed. Results: Blind TBNA was performed in 20 patients post CT scan. No endobronchial abnormality was seen in 11 patients. Sampling was
performed for diagnosis in 65% and diagnosis/stage in 35%. TBNAnode was performed in 17 patients station 7 (75%), station 10R (5%), station 11 (5%). TBNA-mass was performed in 3 patients (15%). A diagnosis was attained in 66% TBNA-mass (adenocarcinoma 1, small cell 1) and 47% TBNA-node (small cell 2, adenocarcinoma 4, NSCLC 2). In patients with non-diagnostic trans-bronchial sampling, a final diagnosis was available in all patients (tuberculosis [1], gastric carcinoma [1], clinical [2], NSCLC [6] (4 diagnosed on endobronchial biopsy at time of TBNA, 1 on pleural fluid, 1 on EBUS-TBNA). Additional investigations were required in 20% (pleural aspiration [1], OGD [1], mediastinoscopy [1], EBUS-TBNA [1]). No adverse bronchoscopy related events were noted. Conclusions: CT scanning prior to bronchoscopy allows blind TBNA of radiologically significant lymph nodes/masses. This safe procedure can yield diagnostic and staging information for patients with likely thoracic malignancy and should be a core skill in centres without access to EBUS. 30 Neck ultrasound and cervical lymph node sampling reduces time to diagnosis for lung cancer N. Wilsmore, C.M. Free, S. Agrawal, V. Raj, A. Bajaj, J.A. Bennett. Department of Respiratory Medicine, Glenfield Hospital, Leicester, United Kingdom Introduction: Neck Ultrasound (US) with FNA of lymph nodes is established in the pathway for diagnosis/staging of lung cancer. Neck US is a simple, low cost technique with potential for rapid cytological results. We reviewed our lung cancer database to determine whether neck US+/ FNA reduced time from referral to diagnosis. Methods: Retrospective audit of all lung cancer presentations from Leicestershire and Rutland January 2008 to December 2009. Patients were obtained via LUCADA, cross-referencing with radiology database, online radiology and pathology reporting systems for neck US patients. Patients with IASLC (6th Edn ) CT stage 3A, or higher underwent neck US. Time to diagnosis post referral to the MDT was recorded. Patients with an established diagnosis prior to referral were excluded. Results: 978 patients identified (678 no US (nUS), 300 yes US). 104 nUS patients excluded due to diagnosis before referral. 16 US patients excluded for previous diagnosis. Of those with US, 116/284 (40.85%) had identifiable nodes, of which all but 4 were sampled. Mean time (days) to Dx from referral for the nUS group was 25.76 vs. 18.27 for those with US (p = 0.0004), vs. those with FNA 16.64 (p = 0.03). However, this difference disappeared once the nUS group was matched for stage of disease, with time to Dx of 19.55, suggesting that the difference above may reflect more advanced stage of the US group. There was still a significant difference when the FNA group were compared (19.55 days vs. 16.64 days p = 0.03). Matching to histology, there was a suggestion of increased benefit in the subgroup with adenocarcinoma (12.19 (95% CI 8.7 15.68) vs. 25.69 (95% CI 18.57 32.8) p = 0.07), however, this did not reach statistical significance.
Number of patients Mean Days to Dx 95% CI
No US
No US matched to stage (3A+)
Yes US
Yes US and FNA
Yes US and FNA (AdenoCa)
No US (AdenoCa)
574 25.76 22.99 28.52
398 19.55 16.96 22.13
284 18.27 16.51 20.02
116 16.64 13.59 19.69
21 12.19 8.7 15.68
89 25.69 18.57 32.8
Conclusion: These results suggest a shortened time to diagnosis in patients being referred for lung cancer assessment when undergoing cervical US guided FNA.
Gender male female Smoking current ex non Ethnic white asian afrocar mixed Histo squam adeno large cell broncha others*
Mutant
Wild type
6 13
81 63
4 5 10
68 49 27
17 1 0 1
141 1 0 2
0 13 0
30 83 2
1 5
2 27
*Others = poorly differentiated and not specified. Twenty-four percent of the female non smokers (never smokers and ex-smoker >10yrs) showed mutation positivity in contrast to 3% of male current smokers. Also 13.5% of adenocarcinomas showed mutation compared to 0% of squamous cell carcinomas. EGFR mutation status was un-identifiable in 15 samples due to inadequate tissue sampling. Conclusion: EGFR mutation positive sub-groups in the predominantly white Caucasian population of Wales show similarity in terms of demographics, histology and smoking habits to the sub-groups in published literature. This data could be taken into account
S9
in identifying the indications of EGFR mutation analysis testing locally. Conflict of Interest: None declared by any author. 26 Improving patient comfort during medical thoracoscopy H.A. Powell, C. Collins, S. Rowe, K.J. Smith, C.I. Whale. Respiratory Medicine, Royal Derby Hospital, Derby, United Kingdom Introduction: Medical thoracoscopy is a safe procedure which can reduce symptoms, confirm diagnosis and provide effective palliation for patients with a pleural effusion. There has been rapid expansion of medical thoracoscopy services in recent years. In order to enhance patient experience of medical thoracoscopy, we assessed comfort during and after the procedure. Methods: We conducted a retrospective study of patients who underwent medical thoracoscopy at Royal Derby Hospital between November 2008 and May 2010. All procedures were performed via a single port and subjects received a standard regime of conscious sedation (midazolam 3 mg), analgesia (alfentanyl 250 mcg) and local anaesthetic (2% lignocaine). We invited patients to participate via postal questionnaire including an assessment of information received pre-procedure, a visual analogue scale (O = No pain to 10 = severe pain) to quantify peri- and post-procedure pain and a specific question asking whether patients would be prepared to have the procedure repeated. Results: Forty-one patients underwent medical thoracoscopy in 19 months. We posted questionnaires to 27 people, excluding deceased patients and those known to be in the terminal phase of illness, and received 17 replies. Most patients received adequate pre-procedure information and 14 out of 15 understood the information given. The median peri-procedure pain score was 5, (Mean 4.7, SD 3.0), and the median post-procedure pain score was 0.5, (Mean 2.6, SD 3.4). Two patients commented that medical thoracoscopy was more painful than expected. Thirteen out of 16 respondents would have the procedure again if necessary. Discussion: Medical thoracoscopy performed under conscious sedation is generally well tolerated. It is reassuring to establish that most patients received adequate information and would be prepared to have the procedure repeated. Mean pain scores were higher than expected, suggesting potential to improve the current regime. Further research focussed on enhancing pain control during and after medical thoracoscopy is needed. 27 10 years experience of malignant pericardial effusions from a tertiary referral centre C. Coyle1 , N. Singh2 , L. Nolan1 . 1 Department of Medical Oncology, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, United Kingdom, 2 Department of histopathology, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, United Kingdom Introduction: Malignant pericardial effusions are in infrequent complication of metastatic malignancy. Pericardial paracentesis can provide rapid resolution of haemodynamic compromise but there is very little evidence on how best to manage this problem in the medium to long term. Methods: The histopathology data base from Southampton General Hospital was searched for all of cases of pericardial effusions aspirated and sent for cytological analysis from October 2000 to October 2010. The Medical records of all recorded cases with malignant cytology were accessed for information pertaining to diagnosis and subsequent treatment. Results: There were 200 samples sent for cytological analysis. 35 cases with malignant cytology were identified. The median age was 61 years (range 44 78) with 15 male and 20 female. The associated malignancies were non small cell lung cancer (NSCLC)
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Posters, 9th Annual BTOG Conference, 2011: Diagnosis & Staging
(68%), mesothelioma (6%), breast cancer (23%) and diffuse large B cell non Hodgkin’s lymphoma (DLBCL) (3%). 23% of cases had a reoccurrence of their pericardial effusion, but only 14% had a pericardial window inserted. Of those patients with NSCLC, 48% had the pericardial fluid as their presenting feature. The median survival for all cases was 2.4 months (range 0 46.5 months). Tumour specific median survival was 53.5 days for NSCLC and 505.5 days for breast cancer. Conclusions: This retrospective cohort confirms the poor prognosis resulting from clinically meaningful pericardial effusions associated with NSCLC. However when associated with a more chemoresponsive malignancy the prognosis is much more favourable. It appears that pericardial windows are not frequently utilised and repeat drainage is not often required. 28 CT guided lung biopsy providing patient information in a multidisciplinary setting D. Borthwick1 , F.C. Minns2 , A. Ni Mhuineachain2 , J. Murcheson2 . Edinburgh Cancer Centre, Western General Hospital, Edinburgh, Scotland, United Kingdom, 2 Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom 1
Introduction: CT guided lung biopsies are commonly performed to aid diagnosis of a lung cancer. Patients are often given verbal information reinforced by local written information. A number of leaflets are available but no consensus currently exsists. The SCAN (South-East Scottish Cancer network) wanted to standardise information for patients undergoing this procedure. The aim was to establish current practice in NHS Lothian, assess patients impressions of the usefulness of the leaflets already in existence and design and develop a new leaflet for the Network. Methods: Questionnaires were designed by year 1 Edinburgh University medical students and distributed across NHS Lothian to patients once they had undergone a CT guided biopsy. Results: Fifty-five percent of patients received information (80% by post, 20% by a nurse). Of those that received written information, all found it useful. Forty-five percent of patients did not receive any written information. All of patients who did not receive a leaflet would have liked one. Conclusion: Fifty-five percent of patients attending for biopsy did not receive a leaflet, making information variable and incomplete for some patients. Only one of the current leaflets includes information about complication rates. Fifty percent of patients receiving information thought a diagram would be helpful. A leaflet has now been produced for use across SCAN. 29 In the absence of EBUS, blind TBNA is an important tool for patients with suspected thoracic malignancy K. Shepherd, L. Brown, P. Bishop, L. Joseph, H. Doran, J. Martin, P.V. Barber, R. Booton. North West Lung Centre, Wythenshawe, Manchester, England, United Kingdom Introduction: The National Lung Cancer Audit (2009) suggests that no network is achieving the required CT prior to bronchoscopy standard of 90%. Consequently the opportunity to confirm diagnosis, to pathologically stage radiologically enlarged lymph nodes or access central disease outside the major airways is missed. In centres without access to endobronchial ultrasound (EBUS), the use of CT scanning prior to bronchoscopy facilitates the blind targeting of such disease. We report our six month experience of blind transbronchial needle aspiration (TBNA) prior to the introduction of an EBUS service. Methods: We reviewed the bronchoscopy unit database between September 2009 and February 2010 and identified patients who had undergone transbronchial aspirates for suspected thoracic malignancy. Histological reports and case records were reviewed. Results: Blind TBNA was performed in 20 patients post CT scan. No endobronchial abnormality was seen in 11 patients. Sampling was
performed for diagnosis in 65% and diagnosis/stage in 35%. TBNAnode was performed in 17 patients station 7 (75%), station 10R (5%), station 11 (5%). TBNA-mass was performed in 3 patients (15%). A diagnosis was attained in 66% TBNA-mass (adenocarcinoma 1, small cell 1) and 47% TBNA-node (small cell 2, adenocarcinoma 4, NSCLC 2). In patients with non-diagnostic trans-bronchial sampling, a final diagnosis was available in all patients (tuberculosis [1], gastric carcinoma [1], clinical [2], NSCLC [6] (4 diagnosed on endobronchial biopsy at time of TBNA, 1 on pleural fluid, 1 on EBUS-TBNA). Additional investigations were required in 20% (pleural aspiration [1], OGD [1], mediastinoscopy [1], EBUS-TBNA [1]). No adverse bronchoscopy related events were noted. Conclusions: CT scanning prior to bronchoscopy allows blind TBNA of radiologically significant lymph nodes/masses. This safe procedure can yield diagnostic and staging information for patients with likely thoracic malignancy and should be a core skill in centres without access to EBUS. 30 Neck ultrasound and cervical lymph node sampling reduces time to diagnosis for lung cancer N. Wilsmore, C.M. Free, S. Agrawal, V. Raj, A. Bajaj, J.A. Bennett. Department of Respiratory Medicine, Glenfield Hospital, Leicester, United Kingdom Introduction: Neck Ultrasound (US) with FNA of lymph nodes is established in the pathway for diagnosis/staging of lung cancer. Neck US is a simple, low cost technique with potential for rapid cytological results. We reviewed our lung cancer database to determine whether neck US+/ FNA reduced time from referral to diagnosis. Methods: Retrospective audit of all lung cancer presentations from Leicestershire and Rutland January 2008 to December 2009. Patients were obtained via LUCADA, cross-referencing with radiology database, online radiology and pathology reporting systems for neck US patients. Patients with IASLC (6th Edn ) CT stage 3A, or higher underwent neck US. Time to diagnosis post referral to the MDT was recorded. Patients with an established diagnosis prior to referral were excluded. Results: 978 patients identified (678 no US (nUS), 300 yes US). 104 nUS patients excluded due to diagnosis before referral. 16 US patients excluded for previous diagnosis. Of those with US, 116/284 (40.85%) had identifiable nodes, of which all but 4 were sampled. Mean time (days) to Dx from referral for the nUS group was 25.76 vs. 18.27 for those with US (p = 0.0004), vs. those with FNA 16.64 (p = 0.03). However, this difference disappeared once the nUS group was matched for stage of disease, with time to Dx of 19.55, suggesting that the difference above may reflect more advanced stage of the US group. There was still a significant difference when the FNA group were compared (19.55 days vs. 16.64 days p = 0.03). Matching to histology, there was a suggestion of increased benefit in the subgroup with adenocarcinoma (12.19 (95% CI 8.7 15.68) vs. 25.69 (95% CI 18.57 32.8) p = 0.07), however, this did not reach statistical significance.
Number of patients Mean Days to Dx 95% CI
No US
No US matched to stage (3A+)
Yes US
Yes US and FNA
Yes US and FNA (AdenoCa)
No US (AdenoCa)
574 25.76 22.99 28.52
398 19.55 16.96 22.13
284 18.27 16.51 20.02
116 16.64 13.59 19.69
21 12.19 8.7 15.68
89 25.69 18.57 32.8
Conclusion: These results suggest a shortened time to diagnosis in patients being referred for lung cancer assessment when undergoing cervical US guided FNA.