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M.G. Mehta



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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pulmonology + Endoscopy/Pulmonary
    • Presentations: 1
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      P1.17-009 - What is the rate of surgical upstaging following negative EBUS-TBNA of mediastinal lymph nodes for NSCLC? (ID 2621)

      09:30 - 09:30  |  Author(s): M.G. Mehta

      • Abstract

      Background
      Mediastinal lymph node evaluation is a critical determinant of treatment strategy in NSCLC. Many staging modalities, both invasive and non-invasive, have been evaluated over the past few decades with varying degrees of accuracy. Despite the fact that CT imaging is the preliminary investigation for diagnosis of lung cancer, various studies have shown that CT scanning is less accurate (sensitivity of 41% to 63%, a specificity of 43% to 57%, and an accuracy of 39% to 59%) for the detection of mediastinal nodal metastasis. According to a meta analysis looking at nodal disease, the sensitivity for PET is 79% to 84% and its specificity is 89% to 91%.The ability of PET CT to provide morphologic and functional information enhances the diagnostic accuracy of mediastinal nodal staging in NSCLC . Most guidelines would however need tissue confirmation which can be obtained by EBUS- TBNA. This procedure has the advantage that it can be performed under sedation , however , the downside to this is the small samples without accurate anatomical definition. In our institute we perform PET-CT scan followed by EBUS TBNA for pre operative staging of the mediastinal lymph node {in selected cases}. However, in cases where EBUS-TBNA of mediastinal lymph nodes is negative for malignancy, there is still a possibility that metastases to these lymph nodes are found at surgery. This will result in an upstaging of the NSCLC following surgery. We aimed to determine the rate of surgical upstaging following negative EBUS-TBNA of mediastinal lymph nodes for NSCLC.

      Methods
      This is a retrospective study. From January 2009 till May 2013, we identified 304 patients who underwent surgery for NSCLC. All the patients who were planned for surgical resection underwent a staging CT scan thorax or a PET CT scan. Only those patients with suspicious lymph nodes on either of the imaging, were subjected to EBUS TBNA. These lymph nodes were then re-evaluated by histopathology following surgery. Of these 65 patients who had EBUS-TBNA prior to surgery , fifty-three patients had negative EBUS-TBNA and they formed the basis of this report.

      Results
      Out of the 53 patients with a negative EBUS-TBNA, nine of them (17%) demonstrated positive lymph nodes in surgery, giving a negative predictive value of 83% for EBUS-TBNA in this selected group. The negative predictive value of PET CT was around 77% whereas negative predictive value for EBUS TBNA was 83%.

      Conclusion
      Our study confirms a negative predictive value (83%) of EBUS-TBNA in excluding N2/3 disease in patients diagnosed with NSCLC which is higher than PET CT scan (77%). The slightly lower negative predictive value of EBUS TBNA may be attributed to the fact that not all the surgical candidates were staged with a pre operative histological confirmation of the mediastinal lymph nodes. However a combination of PET CT scan and EBUS TBNA is a reasonable pre operative staging for mediastinal lymph nodes with low complication rates.

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    P3.24 - Poster Session 3 - Supportive Care (ID 160)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P3.24-005 - The Role of Lesser Resection for Treatment of Early Stage Non-Small Cell Lung Cancer in Medicallly Compromised Patients (ID 198)

      09:30 - 09:30  |  Author(s): M.G. Mehta

      • Abstract

      Background
      Lobectomy is the standard of Surgical care for medically fit patients with primary Non-Small Cell Lung Cancer. It is a well known fact that those with small peripheral lesions and those unfit for surgery (impaired Performance Status or Poor Pulmonary Functional capacity) could be considered for Lesser Resections (Wedge Resection or Segmentectomy) albeit with increased risk of recurrence. We have attempted in this study to identify factors other than poor PFTs (FEV1/DLCO <45%) as an indication for performing Lesser Resections rather than stereotactic Radiotherapy or best supportive care.

      Methods
      70 patients underwent a Lesser Resection for primary Lung Cancer from 2002 to 2012. This was a retrospective study. Sixteen patients were excluded because the final histopathology was not consistent with primary lung cancer. Alternative diagnoses such as metastatic disease, benign disease and carcinoid tumours were made. Thus 54 patients were available for the final analysis of which only nine patients had poor PFTs. Therefore 45 patients with primary Lung cancer underwent a Wedge Resection or Segmentectomy although they were fit for Lobectomy as per their Pulmonary Function Test.

      Results
      Of the 54 patients who underwent a Lesser Resection, 31 were chronic smokers with greater than 20 pack years smoking history. All the tumours were Stage I (88% stage Ia and 12% stage Ib). The majority of the patients had Adenocarcinoma (61%) and 19% were Squamous Cell carcinomas with the remainder being Large Cell or Not Otherwise Specified Non-Small Cell Carcinomas. There were no Small Cell carcinomas in our study popultaion. The most important unfavourable factors other than decreased PFTs included Chronic Obstructive Airway Disease (53.7%), Coronary Artery Disease (20.3%) and other factors such as Hypertension, Diabetes and Obesity ranging from 7% to 11%. At least half the study population had three or more unfavourable medical comorbidities. Three patients had other advanced cancers in the past. Twenty one patients (39%) had metachronous primary Lung Cancers compared to only 7% having synchronous lung primary tumours. Three patients (5%) had local recurrence and three (5%) had regional recurrence. Five patients (9%) had distant metastasis. The median survival for the entire population was 21 months as compared to historical controls where best supportive care has an overall survival of only 13 months in stage 1 Lung Cancer.

      Conclusion
      From this study we conclude that chronic heavy smokers and patients with other unfavourable factors outlined above may still benefit from Lesser Resections. The theoretical advantages of a Lesser Resections include preservation of pulmonary function,and the ability of the patient to undergo further resections in the future if a second primary lung cancer should develop. Although the numbers are small and longer follow up periods are needed it may be one of the other indications for lesser resections besides poor PFTs. We have shown that the presence of a positive synchronous and/or metachronous Cancer history has significantly influenced our surgical strategy for stage 1 patients that my have otherwise been suitable for Lobectomy.