Virtual Library

Abstract:
When bronchoscopy is performed for peripheral pulmonary lesions (PPLs), a radial ultrasonic probe can be inserted from the working channel of the bronchoscope to reach the PPL[1]. We began using this technique of endobronchial ultrasonography (EBUS) in 1994. EBUS using a guide sheath (GS) also began in 1996[2]. We would like to explain the technique and advantages of diagnosing PPLs using EBUS, GS, Navigation, and etc. 1) Radial ultrasonic miniature-probe A radial probe emits US while being rotated 360°; the reflected US waveform is rendered as an image. The radial probe scans from the bronchial lumen to provide a short-axis image of the bronchial and para-bronchial tissue. 2) Analyzing the internal structure of peripheral pulmonary lesions with a radial mini-probe EBUS imaging before surgery has been compared with histopathologic findings of surgically resected tissue to determine the internal structures of PPLs that can be depicted by EBUS[3]. PPLs can be classified as heterogeneous or homogeneous based on irregularities in brightness within lesions seen on EBUS. Internal structures within peripheral lesions that can be identified by EBUS include patent blood vessels, patent bronchi, hemorrhage, calcification, dilated bronchi, necrosis, and small amounts of air in alveoli. 3) EBUS using a guide sheath (EBUS-GS)[ 1, 2] The GS-covered probe is advanced to the PPL, then after confirmation by EBUS that the lesion has been reached, the probe is removed before inserting the brush and biopsy forceps through the GS that is held in place in the lesion. This technique enables cytology and biopsy to be performed several times with minimal risk of bleeding. 4) Insertion of the bronchoscope (saline immersion technique) After observing the bronchial lumen, the bronchoscope should be advanced while visualizing the branches to the bronchus near the peripheral lesion. Upon reaching a position where further advancement is not possible, flushing of 1-ml saline (total 5-10 ml) several times is performed through the working channel of the bronchoscope; this is done to fill the bronchus, remove any sputum, and visualize the lumen. The GS-covered probe is then inserted from the working channel into the bronchus. In cases of ground glass nodule (GGN), we do not perform the saline immersion technique. Because the saline immersion technique will occur EBUS images of hyperechoic points which resemble EBUS image of GGN. 5) EBUS visualization The operator advances the US probe from the working channel of the 4-mm bronchoscope towards the periphery and stops when some resistance is felt. The duration of X-ray fluoroscopy should be limited as much as possible; also, an iris of the fluoroscopy machine should be used for fluoroscopy. Scanning while pulling back the probe from the distal site to the proximal site reduces strain on the probe and provides clear EBUS images. We have reported that EBUS imaging of PPLs can be used to diagnose and assess the degree of differentiation between benign and malignant lesions[3]. PPLs are classified as type I if the internal echoes are homogeneous, type III if the internal echoes are heterogeneous, and type II if there are mainly hyperechoic lines and dots near the probe. About 92% of type I lesions were benign, whereas 99% of type II and type III lesions were malignant. The positional relationship between the probe and a PPL is classified as "within" (probe placement within a lesion), when the 360° area around the probe is entirely surrounded by the lesion; and "adjacent to" (probe is in contact with a lesion) when a lesion is depicted, but the 360° area around the probe is not entirely surrounded by the lesion. Higher diagnostic yields have also been reported for lesions with a positive bronchus sign on computed tomography. Minezawa et al.[4] reported that the CT bronchus sign was a significant predictive factor for successful bronchoscopic diagnosis in the multivariate analysis. We believe that bronchoscopists should trace the accurate bronchus leading to the PPL on CT axial images. When the lesion located in the middle lobe, the lingular segment, or bilateral lower lobes, we inverse CT axial images right to left, or left to right for watching the bronchus from the cranial site. When the lesion located in the right upper lobe, we rotate CT axial images counterclockwise 90 degrees. When the lesion located in the left superior segment, we rotate CT axial images clockwise 90 degrees. While tracing the bronchus on CT images, we could draw the illustration of the bronchus leading to PPLs. We usually use virtual bronchoscopic navigation (VBN) and compare the hand-written illustration of the bronchus leading to PPLs. Asano et al.[5 ]reported that the diagnostic yield by EBUS-GS and VBN was between 63.3 and 84.4% in reports on VBN for PPLs searched in PubMed as of November 2013. When the ultrasonic probe advanced to the different bronchus a little far from the target lesion, EBUS image is invisible. In this case, we should change the direction of the tip of the bronchoscope using the up and down lever of the bronchoscope under fluoroscopy. We select the direction of the tip of the bronchoscope for facing the target lesion, and pull back and push the probe/GS for trying to insert the target lesion. When the ultrasonic probe advanced to the bronchus adjacent to the target lesion, EBUS image is called as “adjacent to”. In this case, we could change the direction of the tip of the bronchoscope using the up and down lever of the bronchoscope under the EBUS image. We use the up or down lever of the bronchoscope for changing the position of the probe and GS (probe/GS) to be close to the target lesion on EBUS image. Then we keep the same angle of the tip of the bronchoscope, and pull back and push the probe/GS for trying to insert the target lesion. 6) Cytology and tissue biopsy from the guide sheath The GS tip is placed within or adjacent to the PPL before passing the brush and biopsy forceps through the GS. References Kurimoto N, Fielding D, Musani A. Endobronchial Ultrasonography. 2011, Willy Blackwell Kurimoto N, Miyazawa T, Okimasa S, Maeda A, Oiwa H, Miyazu Y, Murayama M. Endobronchial ultrasonography using a guide sheath increases the ability to diagnose peripheral pulmonary lesions endoscopically. CHEST 2004; 126: 959-65. Kurimoto N, Murayama M, Yoshioka S, Nishisaka T. Analysis of the internal structure of peripheral pulmonary lesions using endobronchial ultrasonography. CHEST 2002; 122: 1887-94 Minezawa T, Okamura T, Yatsuya H, et al. Bronchus sign on thin-section computed tomography is a powerful predictive factor for successful transbronchial biopsy using endobronchial ultrasound with a guide sheath for small peripheral lung lesions: a retrospective observational study. BMC Med Imaging. 2015 21; 15:21 Asano F, Eberhardt R, Herth F. Virtual Bronchoscopic Navigation for Peripheral Pulmonary Lesions. Respiration 2014; 88: 430-440

Abstract:
Despite the advances in surgical treatment and multimodality treatment, lung cancer is still the leading cause of death from malignant disease worldwide. Accurate staging is important not only to determine the prognosis but also to decide the most suitable treatment plan. During the staging process of non-small cell lung cancer (NSCLC), mediastinal lymph node staging is one of the most important factors that affect the patient outcome. Non-invasive staging such as computed tomography (CT) and positron emission tomography (PET) indicate size and metabolic activity, respectively. However imaging alone is inaccurate and therefore tissue sampling is the preferred and most reliable. Surgical staging by mediastinoscopy has been the gold standard for mediastinal lymph node staging but requires general anesthesia and complications cannot be ignored. Endoscopic ultrasound techniques provide a minimally invasive alternative for surgical staging. The current available endoscopic ultrasound techniques for mediastinal staging include transesophageal endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). Both procedures can be performed in an outpatient setting under local anesthesia. EUS-FNA is a sensitive and safe method of evaluating the inferior mediastinal nodes (stations 7, 8, and 9) and some parts of the anterior mediastinal nodes if the lymph nodes are accessible from the esophagus. However, in spite of the strength of EUS-FNA for evaluating the inferior mediastinal nodes, its ability to evaluate lesions anterior to the trachea is limited. On the other hand, EBUS-TBNA has reach to the paratracheal and subcarinal (stations 2R, 2L, 4R, 4L, 7), as well as the N1 lymph nodes (stations 10, 11, 12). In experienced hands, EBUS can be used through the esophagus for a EUS-like approach to the inferior mediastinal lymph nodes. Thus, EUS-FNA and EBUS-TBNA are complementary methods for lymph node staging in lung cancer and most of the mediastinum and the hilum can be evaluated with these endoscopic procedures. Aortic nodes (stations 5 and 6) are exceptions and must be evaluated by surgical methods (anterior mediastinotomy, VATS, thoracotomy). Based on the current evidence, EBUS-TBNA and EUS-FNA presents a minimally invasive endoscopic procedure as an alternative to mediastinoscopy for mediastinal staging of NSCLC with discrete N2 or N3 lymph node enlargement, provided negative results are confirmed by surgical staging. EBUS-TBNA can access all lymph nodes accessible by mediastinoscopy as well as hilar (N1) lymph nodes. EUS-FNA has access to the inferior mediastinal lymph nodes not accessible by mediastinoscopy. EBUS-TBNA and/or EUS-FNA have in fact replaced mediastinoscopy in many patients with diffuse mediastinal adenopathy, where a simple tissue diagnosis is required to determine treatment. When combined the techniques offer safe and accurate assessment of mediastinum, with accuracy surpassing that of the pervious gold standard – cervical mediastinoscopy. EBUS-TBNA and/or EUS-FNA can also be repeated with ease and have been used for mediastinal restaging in patients who underwent neoadjuvant therapy in preparation for definitive surgical intervention. Ultrasound image analysis of lymph nodes may assist bronchoscopists during EBUS-TBNA or EUS-FNA. Standard sonographic classification of lymph nodes can help characterize mediastinal and hilar lymph nodes as benign or malignant, which may guide the decision on which lymph nodes to sample. Newer imaging technology such as elastography can potentially enhance US guided image analysis of the lymph nodes.

Abstract not provided

Abstract:
Lung cancer is the second most common cancer in both men and women In men prostate cancer, while in women breast cancer is more common. About 14% of all new cancers are lung cancers. The American Cancer Society’s estimates for lung cancer in the United States for 2016 are: About 224,390 new cases of lung cancer (117,920 in men and 106,470 in women) About 158,080 deaths from lung cancer (85,920 in men and 72,160 in women) Lung cancer is by far the leading cause of cancer death among both men and women; about 1 out of 4 cancer deaths are from lung cancer. Each year, more people die of lung cancer than of colon, breast, and prostate cancers combined. One third of the new lung cancer cases are candidates for surgery, and about half of the rest develops some kind of major airways involvement. This can be endobronchial tumor, extrinsic compression or combined. Besides lung cancer, metastases from other types of tumors are also candidates for intrabronchial treatments. There are different methods available for treating endobronchial malignancies, in most of the cases the combination of two or more procedure needed to reach optimal result. To reestablish the airway patency improves quality of life, and provides sufficient time to apply different lung cancer treatment, chemo, radio and immunotherapy Methods available include mechanical debulking, use of different types of laser, electrocautery, cryotherapy, intraluminal brachytherapy, argon-plasma coagulation, and microvawe instruments. Different types of silicon and self expandable metallic stents are useful for keeping the airways open after successful reopening. Balloon dilatation may help to insert stent to the compressed airways. The use of locally installed substances like chemo, different angiogenesis inhibitors are in the focus again. With the use of endobronchial ultrasound the needle can easily be inserted into the peripheral or central tumor, and lymphnodes. Most of the procedures are done under general anesthesia, with the use of rigid bronchoscope. Ideally the bronchoscopist can choose from the different methods available, using the best appropriate one in the given situation. Sufficient training is necessary before starting each new method. Simulation, low fidelity models are available to learn without having the unnecessary risk in a real case. One has to be prepared for treating different complications, such as heavy bleeding from the tumor, or bleeding caused by the procedure itself. Well trained personnel is a must to start with these kind of procedures. Anesthesiologist, assistants trained in endoscopic procedures are essential before starting the procedure.

Abstract not provided

Abstract:
Angiogenesis is an important process in the development and progression of tumours. Across a range of tumour types markers of angiogenesis, such as elevated VEGF levels or increased micro vessel density, have been shown to be associated with poorer patient outcomes. The recognition that VEGF mediated signalling is a key driver of angiogenesis within tumours led to the development of a range of anti-angiogenic approaches targeting this biological process. These approaches have included monoclonal antibodies (bevacizumab, ramucirumab), decoy receptors (aflibercept), and receptor tyrosine kinase inhibitors (nintedanib, sorafenib, sunitinib, motesanib, vandetanib, cediranib, pazopanib), all of which have been evaluated in lung cancer. Despite this volume of clinical research, only three of these agents have been shown to produce benefit in patients with advanced non-small cell lung cancer (NSCLC): bevacizumab, ramucirumab and nintedanib. No antiangiogenic agent has to date been shown to be of benefit in small cell lung cancer. Bevacizumab, an anti-VEGF monoclonal antibody, was the first antiangiogenic therapy to be evaluated in NSCLC. Early studies identified that patients with squamous cancers were at risk of increased toxicity due to haemorrhage so randomised trials have been restricted to patients with non-squamous tumours. The ECOG 4599 randomized trial evaluated treatment with carboplatin and paclitaxel with or without bevacizumab[1]. In this study, as in most other studies of antiangiogenics, bevacizumab was continued in a maintenance phase following the conclusion of chemotherapy. The study demonstrated an improvement in overall survival (HR 0.79, 95% CI 0.67 – 0.92 p = 0.003). A second phase 3 study, AVAiL, evaluated the addition of two different doses of bevacizumab to the combination of gemcitabine and cisplatin, in a double blind manner[2]. The study demonstrated an improvement in progression free survival, but with no difference in overall survival. Based on the results of these two trials, bevacizumab received approval in several jurisdictions, but there remained some doubts over the benefit to patients given the lack of a confirmatory trial showing improved overall survival. A recent meta-analysis[3] incorporating these and other randomised studies has shown that bevacizumab produces a modest, but statistically significant improvement in overall survival (HR 0.90, 95% CI 0.81 – 0.99; p=0.03). Subsequently, a further randomised trial, BEYOND[4], has been published, with bevacizumab added to the combination of carboplatin and paclitaxel in a purely Asian population. This trial showed an improvement in overall survival (HR 0.68, 95% CI 0.50 – 0.93 p=0.015), with median OS increasing from 17.7 to 24.3 months. Bevacizumab has also been evaluated in the second line setting in combination with erlotinib (in patients unselected for EGFR mutations), without significant impact on overall survival in the BeTa study[5]. Ramucirumab is a monoclonal antibody directed against the VEGFR2 receptor. It has been evaluated in a randomised trial in the second line setting. Patients were randomised to receive treatment with docetaxel with or without ramucirumab[6]. Treatment was continued till progression, with monotherapy ramucirumab continued if toxicity developed to docetaxel (and vice versa). The primary endpoint of the study was overall survival, and the results indicated an improvement in overall survival for patients receiving ramucirumab (HR 0.86, 95% CI 0.75 – 0.98; p=0.023), with median survival increasing from 9.1 to 10.5 months. By contrast to the various studies of bevacizumab, this study included patients with squamous cell cancer, as well as those with non-squamous tumours, with the magnitude of benefit being similar in both histologic types. Addition of ramucirumab resulted in an increase in toxicity, with more hypertension, bleeding, and febrile neutropenia. However the rate of serious adverse events and of deaths due to adverse events were similar between the two study arms. The results of this study led to the approval of ramucirumab for patients with previously treated in NSCLC in some parts of the world, including the USA and Europe. However, subsequently, the results of trials of immune checkpoint inhibitors in the same patient population has resulted in many of these patients not receiving docetaxel chemotherapy, making it difficult to assess the appropriate role for this agent. The addition of a tyrosine kinase inhibitor to chemotherapy has been evaluated extensively in patients with advanced NSCLC in both the first and second line settings. The results of these trials have been disappointing, with none of them demonstrating an overall survival benefit. Many, however, did show some improvement in progression free survival. Only one of these agents, nintedanib, is approved (in Europe) for the treatment of patients with NSCLC. This is based on the results of the LUME-1 study, which compared treatment with docetaxel alone with docetaxel plus nintedanib in patients with previously treated NSCLC[7]. In this study, progression free survival (the primary endpoint) was longer with the addition of nintedanib (3.4 vs. 2.7 months, HR 0.79, 95% CI 0.68 – 0.92; p=0.0019). Although there was no difference in overall survival in the whole study population, in the predefined subset of patients with adenocarcinoma and progression within 9 months of initial therapy median overall survival increased from 7.9 to 10.9 months (HR 0.75, 95% CI 0.60 – 0.92; p=0.007). Similar, though less extreme results occurred in all patients with adenocarcinoma. There was no effect on survival of patients with squamous histology. The combination resulted in an increase in the rate of adverse events, predominantly diarrhoea, liver function abnormalities and vomiting. To date, no biomarker of angiogenesis that allows the selection of patients for treatment with has been identified. As a consequence, patient selection (for bevacizumab) is based on the avoidance of toxicity, by excluding groups of patients known to be at higher risk (e.g. those with squamous cell histology, or a history of haemoptysis). Furthermore the inability to identify those patients most likely to benefit, along with the relatively small improvements in survival means that from an economic viewpoint, the cost per life year gained is high. This has resulted in antiangiogenics not being widely used in some countries. References 1. Paclitaxel Carboplatin alone or with bevacizumab for non-small-cell lung cancer. Sandler et al. N Engl J Med 2006; 355: 2542 – 2550 2. Phase III trial of cisplatin plus gemcitabine with either placebo or bevacizumab as first-line therapy for non-squamous non-small-cell lung caner: AVAiL. Reck et al. J Clin Oncol 2009; 27: 1227 – 1234 3.Systematic review and meta-analysis of randomised, phase II/III trials adding bevacizumab to platinum based chemotherapy as first-line treatment in patients with advanced non-small cell lung cancer. Soria et al. Ann Oncol 2013; 24: 20 – 30. 4. BEYOND: A randomized, double-blind, placebo-controlled, multicentre phase III study of first-line carboplatin/paclitaxel plus bevacizumab or placebo in Chinese patients with advanced or recurrent non-squamous non-cell lung cancer. Zhou et al. J Clin Oncol 2015; 33: 2197 – 2204 5. Efficacy of bevacizumab plus erlotinib versus erlotinib alone in advanced non-small-cell lung cancer after failure of standard first-line chemotherapy (BeTa): a double-blind placebo-controlled phase 3 trial. Herbst et al. Lancet 2011; 377: 1846 – 1854 6. Ramucirumab plus docetaxel versus placebo plus docetaxel for second-line treatment of stage IV non-small-cell lung cancer after disease progression on platinum-based therapy (REVEL): a multicentre double-blind randomised phase 3 trial. Lancet 2014; 384: 665 – 673 7. Docetaxel plus nintedanib versus docetaxel plus placebo in patients with previously treated non-small-cell lung cancer (LUME-1): a phase 3 double blind , randomised controlled trial. Reck et al. Lancet Oncol 2014; 15: 143- 155

Abstract:
The concept of tumor-induced neoangiogenesis has been shown to be a relevant factor for tumor proliferation and metastasis already a couple of years ago (1). Therefore interaction with proangiogenic pathways appears to be a promising therapeutic target across several solide tumors. In eligible patients with advanced non-squamous NSCLC the addition of the anti vascular endothelial growth factor (anti VEGF) antibody bevacizumab to platinum based chemotherapy has shown consistent improvement of response, progression free survival (PFS) and overall survival. However also the combination did increase the incidence of characteristic adverse events like hypertension, arterial and venous vascular events, bleeding events, proteinuria and other (2). Recently two large randomised phase III trials revealed a significant increase in efficacy by the combination of antiangiogenic agents and chemotherapy in pretreated patients with advanced NSCLC. In the LUME 1 trial the combination of the oral angiokinase inhibitor nintedanib and docetaxel revealed a significant improvement of PFS (median PFS 3.4 vs 2.7 months, HR 0.79, 95% CI 0.68-0.92) and OS in patients with adenocarcinoma histology (median OS 12.6 vs 10.3 months, HR 0.82, 95% CI 0.7-0.99) compared to docetaxel (3). The combination of the anti VEGF receptor 2 antibody ramucirumab and docetaxel did show a significant improvement of response (response rate: 23% versus 14%, p<0.0001), PFS (median PFS 4.5 versus 3.0 months, HR 0.76, 95% CI 0.68-0.86) and OS (median OS 10.5 versus 9.1 months, HR 0.86, 95% CI 0.75-0.98) compared to docetaxel in pretreated patients with NSCLC regardless of histology (4). The identification of potential predictive biomarkers remains a challenge due to the complexity of angiogenesis, the interaction between the tumor and the host and due to dynamic changes of the system. In a very large trial (Abigail), specifically designed to identify potential tissue based or blood based markers of efficacy, no predictive markers could be determined. However the relevant prognostic nature of angiogenesis marker could be confirmed (5). Recent analyses revealed that besides molecular markers clinical factors like rapid progressive diseases or tumors refractory to conventional chemotherapy could be associated with improved outcomes of angiogenesis inhibitors. Preplanned as well as exploratory analyses did show pronounced efficacy for the combination of antiangiogenic agents like nintedanib, ramucirumab and bevacizumab compared to chemotherapy alone supporting the hypothesis that fast progressing tumors are more dependant on neo angiogenesis. The translational exploration of these clinical findings is on the way in several programs and trials. The understanding of this correlation will be important for the optimal placement of antiangiogenic agents e.g. in the combination with immunotherapies. Folkman J, Merler E, Abernathy C et al. Isolation of a tumor factor responsible for angiogenesis. J Exp Med 1971; 133: 275-288 Soria JC, Mauguen A, Reck M et al. Systematic review and meta-analysis of randomised phase II/III trials adding bevacizumab to platinum based chemotherapy as first-line treatment in patients with advanced non-small-cell lung cancer. Ann Oncol 2013; 24: 20-30 Reck M, Kaiser R, Mellemgaard A et al. Docetaxel plus nintedanib versus docetaxel plus placebo in patients with previously treated non-small-cell lung cancer (LUME-Lung 1): a phase 3, double blind, randomised controlled trial. Lancet Oncol 2014; 15: 143-50 Garon E, Ciuleanu TE, Arrieta O et al. Ramucirumab plus docetaxel versus placebo plus docetaxel for second-line treatment of stage IV non-small-cell lung cancer after disease progression on platinum based therapy (REVEL): a multicentre, double-blind, randomised phase 3 trial. Lancet 2014; 384: 665-773 Mok T, Gorbunova V, Juhasz E et al. A correlative biomarker analysis of bevacizumab and carboplatin-based chemotherapy for advanced nonsquamous non-small cell lung cancer: results of the phase II randomized ABIGAIL study (BO21015). J Thorac Oncol 2014; 9: 848-55.

Abstract:
Lung cancer is still the leading cause of cancer-related death in both men and women with 80% to 85% of cases being non-small-cell lung cancer (NSCLC).[1]The past fifteen years have brought significant breakthroughs in the understanding of the molecular biology of lung cancer. Signalling pathways and genetic driver mutations that are vital for tumour growth have been identified and can be effectively targeted by novel pharmacologic agents, resulting in significantly improved survival of patients with lung cancer.[2]Parallel to the progress in lung cancer treatment, imaging techniques aiming at improving diagnosis, staging, response evaluation, and detection of tumour recurrence have also considerably advanced in recent years.[3]However, standard morphologic computed tomography (CT) and magnetic resonance imaging (MRI) as well as fluor-18-fluorodeoxyglucose ([18]F-FDG) positron emission tomography CT (PET-CT) are still the currently most frequently utilized imaging modalities in clinical practice and most clinical trials.[4,5]Novel state-of-the-art functional imaging techniques such as dual-energy CT (DECT), dynamic contrast enhanced CT (DCE-CT), diffusion weighted MRI (DW-MRI), perfusion MRI, and PET-CT with more specific tracers that visualize angiogenesis, tumour oxygenation or tumour cell proliferation have not yet been broadly implemented, neither in clinical practice nor in phase I–III clinical trials [6]. In this context, Nishino et al.[4] published an article on personalized tumour response assessment in the era of molecular treatment in oncology. The authors showed that the concept of personalized medicine with regard to cancer treatment has been well applied in therapeutic decision-making and patient management in clinical oncology. With regard to imaging techniques, however, it was criticized that the developments in tumour response assessment that should parallel the advances in cancer treatment are not sufficient to produce state-of-the-art functional information that directly reflect treatment targets. Functional information on tumour response is highly required because there is growing evidence that the current objective criteria for treatment response assessment may not reliably indicate treatment failure and do not adequately capture disease biology. Molecular-targeted therapies and novel immunotherapies induce effects that differ from those induced by classic cytotoxic treatment including intratumorale haemorrhage, changes in vascularity, and tumour cavitation. Thus, conventional approaches for therapy response assessment such as RECIST or WHO criteria that exclusively focus on the change in tumour size are of decreasing value for drug response assessment in clinical trials.[7,8] Parallel to the development of novel imaging techniques automated and more detailed analysis of standard images is currently highly investigated and has led to the introduction of the term Radiomics. Radiomics refers to the comprehensive quantification of tumour phenotypes by applying a large number of quantitative image features that are standardized collected with specific software algorithms. Radiomics features have the capability to further enhance imaging data regarding prognostic tumour signatures, detection of tumour heterogeneity as well as the detection of underlying gene expression patterns which is of special interest in patients with metastatic disease. The aim of of this presentation is to provide an overview on state-of-the-art imaging techniques for the initial staging, response evaluation as well as surveillance in patients with lung cancer. The various techniques will be discussed regarding their pros and cons to further provide functional information that best reflects specific targeted therapies including anti-angiogenetic treatment, immunotherapies and stereotactic body radiation therapy. Moreover, imaging techniques and optimal time points after local minimally invasive treatments with microwave ablation or novel irreversible electroporation will be discussed. The second part of the presentation will focus on Radiomics and its potential value in lung cancer imaging. Literature: 1. Rami-Porta R, Crowley JJ, Goldstraw P. The revised TNM staging system for lung cancer. Ann Thorac Cardiovasc Surg 2009;15:4-9. 2. Rengan R, Maity AM, Stevenson JP, Hahn SM. New strategies in non-small cell lung cancer: improving outcomes in chemoradiotherapy for locally advanced disease. Clin Cancer Res 2011;17:4192-9. 3. Miles K. Can imaging help improve the survival of cancer patients? Cancer Imaging 2011;11 Spec No A:S86-92. 4. Nishino M, Jackman DM, Hatabu H, Janne PA, Johnson BE, Van den Abbeele AD. Imaging of lung cancer in the era of molecular medicine. Acad Radiol 2011;18:424-36. 5. Nishino M, Jagannathan JP, Ramaiya NH, Van den Abbeele AD. Revised RECIST guideline version 1.1: What oncologists want to know and what radiologists need to know. AJR Am J Roentgenol 2010;195:281-9. 6. Henzler T, Goldstraw P, Wenz F, et al. Perspectives of novel imaging techniques for staging, therapy response assessment, and monitoring of surveillance in lung cancer: summary of the Dresden 2013 Post WCLC-IASLC State-of-the-Art Imaging Workshop. J Thorac Oncol 2015;10:237-49. 7. Oxnard GR, Morris MJ, Hodi FS, et al. When progressive disease does not mean treatment failure: reconsidering the criteria for progression. J Natl Cancer Inst 2012;104:1534-41. 8. Stacchiotti S, Collini P, Messina A, et al. High-grade soft-tissue sarcomas: tumor response assessment--pilot study to assess the correlation between radiologic and pathologic response by using RECIST and Choi criteria. Radiology 2009;251:447-56.