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• 10912

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  P1.17 - Poster Session 1 - Bronchoscopy, Endoscopy (ID 182)

  • Event: WCLC 2013
  • Type: Poster Session
  • Track: Pulmonology + Endoscopy/Pulmonary
  • Presentations: 2
  • Moderators:
  • Coordinates: 10/28/2013, 09:30 - 16:30, Exhibit Hall, Ground Level

  • 10919

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    P1.17-007 - A proposal for a new clinical strategy and follow-up in patients with bronchial carcinoids initially treated bronchoscopically. (ID 2468)

    09:30 - 09:30  |  Author(s): H.A.P. Brokx
    • Abstract

    Background
    Bronchial carcinoids (BC) belong to the wide spectrum of neuroendocrine tumors; ranging from tumorlets, typical carcinoid (TC), intermediate-grade atypical carcinoid (AC), to highly malignant large cell neuroendocrine and small cell carcinoma. The Travis classification (Am J SurgPathol 1998; 22:934) seems essential for choosing the best treatment strategy based on retrospective analyses of surgically resected specimens. We implemented an initial bronchoscopic treatment (IBT) strategy and its long term outcome have been reported with update of the final analysis (J Thorac Cardiovasc Surg. 2007 Apr;133(4):973; Abstract IASLC Sydney submitted). The long-term outcome seems to justify IBT and the histological differentiation between typical versus atypical seems to matter much less, while conservation of normal lung parenchyma is optimal. We question how optimal the close surveillance strategy of IBT protocol should be, i.e. in performing regular high resolution CT (HRCT) and/or bronchoscopy after the initial success of bronchoscopic treatment.

    Methods
    In the IBT protocol, HRCT and bronchoscopy were performed 6-monthly in the first two years and annually until the fifth year. Thereafter a yearly check-up was advised to the referring pulmonologists. We analyzed retrospectively the value of HRCT and/or bronchoscopy in this IBT cohort for early detection of local recurrences, that require surgical salvage.

    Results
    So far, IBT was successful in 57 of the 133 patients (43%). Sixty-seven patients (50%) could be immediately identified to be surgical candidates without further delay due to obvious extraluminal tumor growth. Four patients (3%) developed extraluminal tumor recurrence and surgical salvage was performed at 47, 104, 115, 192 months. In all four cases follow-up HRCT suggested local extraluminal tumor growth, which were confirmed by bronchoscopy. The surgical outcome was radical and did not lead to more extensive resections than initially anticipated. Detailed treatment results are shown in table 1. Table 1. Initial bronchoscopic treatment strategy in patients with bronchial carcinoids

    	BT	Completion Surgery	Remark
    Number of patients	62	71
    Histology TC AC	56 (90%) 6 (10%)	43 (61%) 28 (39%)
    Follow up (median) in months	87.5 (2-223)	87 (12-264)
    Completely resected	57 (92%)	64 (90%)
    Residual after CT/recurrences Additional treatment bronchoscopy Additional treatment surgery	3 4	0 0	Interval in months: 10,13,63 47,104,115,192
    Alive with disease	5	0	2 unfit for surgery 3 refused surgery
    Alive with metastatic disease	0	1	40 months
    Carcinoid related mortalities	0	2	Pulmonary metastases
    Treatment related mortalities	0	1
    Non-carcinoid related mortalities	8	3

    Conclusion
    Initial bronchoscopic treatment strategy in patients with bronchial carcinoids is justifiable. Local regrowth after successful bronchoscopic removal was infrequent (3%) and was timely detected by HRCT. HRCT can be performed much less frequent and regular bronchoscopy was redundant if IBT attempt was successful. The significance of an iceberg phenomenon is questionable.

  • 10920

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    P1.17-008 - Results of a close surveillance strategy for subjects with pre-invasive endobronchial squamous lesions (ID 2678)

    09:30 - 09:30  |  Author(s): H.A.P. Brokx
    • Abstract

    Background
    The dismal overall 5-year survival of non-small cell lung cancer (NSCLC) patients is mainly due to advanced stage of disease at time of initial diagnosis in most and the inability to cure metastatic disease in all patients. In contrast, the prognoses of in situ mucosal and small parenchymal lesions are excellent. Early detection strategies might result in the identification of early-stage, (pre-)invasive lesions that are still eligible for curative treatment. The present study was set out to characterize the risk of lung cancer development in a cohort of high-risk subjects harboring pre-invasive endobronchial lesions and to assess the results of surveillance using autofluorescence bronchoscopy (AFB) and computed tomography (CT) scan.

    Methods
    Between November 1995 and December 2012, one hundred and sixty-four at risk individuals with pre-invasive endobronchial lesions were monitored by repeated AFB and CT. During the course of surveillance, progression of lesions to cancer (in situ), recurrences and second primary cancers were treated with different modalities (e.g. endobronchial techniques, surgery, radiotherapy), depending on tumor stage and location. Log-rank tests were performed to examine the relation between baseline characteristics and progression-free and overall survival (PFS and OS, respectively). Cox regression was used for multivariate survival analysis.

    Results
    Demographical and clinical variables of the cohort are shown (Table). At inclusion, 80 individuals were identified with one or more high-grade pre-invasive lesions (severe dysplasia or CIS; HGD), whereas 84 subjects were identified solely with lower grade pre-invasive lesions (LGD). During close surveillance (median follow-up (FU) of 30 months, range 4-152), sixty-one lung cancers were detected (26 CT-detected, 35 AFB-detected cancers) in 55 individuals within a median time to event of 16.5 months. Mean PFS was similar between individuals with radiographically occult lesions vs. FU after surgery for early-stage NSCLC/ENT ca (122.3 vs. 126.9 months, p=0.237) and COPD vs. non-COPD (118.8 vs. 136.8 months, p=0.162). There was a relatively large difference in PFS between LGD and HGD groups (142.6 vs. 93.7 months, p=0.057). Independent risk determinants for OS were indication for surveillance (FU after surgery for early-stage NSCLC/ENT ca vs. radiographically occult lesions, p=0.008) and COPD-status (COPD vs. non-COPD, p<0.001).

    		Referral for radiographically occult lesion	Follow-up after surgery for early-stage NSCLC / ENT ca
    	total
    individuals, n	164	92	72
    Gender
    male	134	72	62
    female	30	20	10
    Age at baseline
    years, mean (range)	64.2 (42-83)	64.8 (42-81)	64.0 (43-82)
    Smoking status
    current smoker	75	44	31
    former smoker	74	36	38
    unknown	15	12	3
    Smoking history
    Pack-years, mean (range)	45 (4-137)	45 (4-120)	40 (15-137)
    COPD-status
    COPD	100	56	44
    non-COPD	45	22	23
    unknown	19	14	5
    AF Bronchoscopies
    Number, mean (range)	7 (1-27)	5 (2-27)	6 (1-18)
    CT-scans
    Number, mean (range)	3 (0-20)	2 (0-20)	3 (0-18)
    No. of detected lung cancers
    During surveillance period	61	29	32
    Parenchymal cancer	21	12	9
    Site-specific lesion progression	24	13	11
    Interval cancer	10	4	6
    Recurrences previous primaries	6	0	6
    Patient outcome
    alive	80	56	24
    died of lung cancer	33	13	20
    died of other/unknown cause	51	23	28

    Conclusion
    Our findings demonstrate that individuals with pre-invasive endobronchial lesions are at high risk of developing (second primary) lung cancers. Combined surveillance using AFB in addition to CT screening facilitated early detection and early (endobronchial) intervention in most patients. Future clinical trials are warranted to determine whether the current approach improves patient outcome.

• 11856

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  P2.17 - Poster Session 2 - Bronchoscopy, Endoscopy (ID 183)

  • Event: WCLC 2013
  • Type: Poster Session
  • Track: Pulmonology + Endoscopy/Pulmonary
  • Presentations: 1
  • Moderators:
  • Coordinates: 10/29/2013, 09:30 - 16:30, Exhibit Hall, Ground Level

  • 11862

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    P2.17-006 - Long term outcome of initial bronchoscopic treatment strategy in patients with bronchial carcinoids (ID 2447)

    09:30 - 09:30  |  Author(s): H.A.P. Brokx
    • Abstract

    Background
    Bronchial carcinoids are considered low-grade malignancies and, traditionally, are treated surgically. Tumor biology and advances in diagnostic and therapeutic techniques, however, enable a less invasive approach such as surgical bronchoplasty can preserve normal lung parenchyma. We previously reported favourable outcome for initial bronchoscopic treatment (BT) strategy in patients with intraluminally located bronchial carcinoids. We now present our long term results.

    Methods
    In patients presenting with a bronchial carcinoid, an initial diagnostic therapeutic bronchoscopy is attempted for complete tumor eradication for sampling sufficient tissue for the proper differentiation between typical (TC) and atypical (AC) histologic type apart from to optimally improve pre-surgical condition. A high resolution computed tomography is performed six weeks later, to determine intra- versus extraluminal tumor growth. In case of intraluminal growth of TC bronchoscopic removal attempt can be repeated. We perform surgical resection in case of extraluminal disease, or failure to bronchoscopic radical resection (i.e. recurrence or persistent residual tumor). Complete bronchoscopic resection of AC histological type is currently not followed by surgical resection.

    Results
    So far, 133 patients have been treated; 76 females, 67 males, median age 46 (range 16 – 85 years). Median follow up was 87 (range 2 – 264) months. Ninety-nine patients (84%) had TC, and 34 (26%) had AC. Bronchoscopic eradication was successful in 57 (43%) patients (51 TC, 6 AC). Detailed treatment results are shown in table 1. Table 1. Initial bronchoscopic treatment strategy in patients with bronchial carcinoids

    	BT	Completion Surgery	Remark
    Number of patients	62	71
    Histology TC AC	56 (90%) 6 (10%)	43 (61%) 28 (39%)
    Follow up (median) in months	87.5 (2-223)	87 (12-264)
    Completely resected	57 (92%)	64 (90%)
    Residual after CT/recurrences Additional treatment bronchoscopy Additional treatment surgery	3 4	0 0	Interval in months: 10,13,63 47,104,115,192
    Alive with disease	5	0	2 unfit for surgery 3 refused surgery
    Alive with metastatic disease	0	1	40 months
    Carcinoid related mortalities	0	2	Pulmonary metastases
    Treatment related mortalities	0	1
    Non-carcinoid related mortalities	8	3

    Conclusion
    Initial bronchoscopic treatment strategy in patients with bronchial carcinoids is justifiable with excellent long term outcome. It should be implemented in the standard algorithm for patients with bronchial carcinoids.