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D. Fielding
Moderator of
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E08 - Early Endobronchial Tumours (ID 8)
- Event: WCLC 2013
- Type: Educational Session
- Track: Pulmonology + Endoscopy/Pulmonary
- Presentations: 4
- Moderators:N. Kurimoto, D. Fielding
- Coordinates: 10/29/2013, 14:00 - 15:30, Bayside Gallery A, Level 1
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E08.1 - Screening / Early Detection of Central Malignancy (ID 408)
14:05 - 14:25 | Author(s): A. McWilliams
- Abstract
- Presentation
Abstract
Introduction: Excellent cure rates for central lung cancer can be achieved with local endobronchial therapy if lesions can be detected at a pre-invasive stage. Flexible white light bronchoscopy is the most commonly used imaging tool to evaluate the central airways but it has a limited ability to detect small pre-invasive central lung cancers. Screening with low dose thoracic CT (LDCT) has been shown to be useful in the early detection of lung cancer, but it largely detects peripheral lesions. Despite advances in CT technology, LDCT cannot detect early pre-invasive central lung cancers due to limitation of resolution. Method: Optical imaging modalities that are both established and in development will be reviewed and discussed. These include techniques such as autofluorescence bronchoscopy, narrow band imaging, optical coherence tomography, confocal microendoscopy, endocystoscopy and raman spectroscopy. Results: Autofluoresence imaging is the most well proven imaging tool to be used in conjunction with white light bronchoscopy to rapidly detect small preinvasive lesions. Narrow band imaging may also be useful but further comparative studies are needed. Optical coherence tomography and raman spectroscopy are promising techniques that can be easily applied via small probes during flexible bronchoscopy to further evaluate abnormal lesions. Further development of in-vivo microscopic evaluation of abnormal lesions is ongoing using confocal microendoscopy and endocystoscopy although tissue staining and direct contact is currently required. Conclusion: The detection of early central lung cancers requires more sophisticated tools than conventional white light bronchoscopy. The future utilisation of other imaging tools as part of a minimally invasive flexible bronchoscopic procedure appears promising. A multimodality approach will enable the rapid detection and diagnosis of early curable central lung cancers in selected high-risk populations.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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E08.2 - Defining the Pathology - Dysplasia / Ca Insitu / Invasive Malignancy (ID 409)
14:25 - 14:45 | Author(s): E. Thunnissen
- Abstract
- Presentation
Abstract not provided
Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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E08.3 - Endobronchial Interventions (PDT/Cryo/Surgery) (ID 410)
14:45 - 15:05 | Author(s): D. Gompelmann
- Abstract
- Presentation
Abstract not provided
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E08.4 - RT Approaches for Early Stage Central Tumours (ID 411)
15:05 - 15:25 | Author(s): F. Lagerwaard, C.J. Haasbeek, S. Senan, M. Dahele, B. Slotman
- Abstract
- Presentation
Abstract
Stereotactic ablative radiotherapy (SABR) is an established treatment modality in the curative treatment of early stage peripheral non-small cell lung cancer (NSCLC). The local control rates of SABR in many publications have exceeded 90% when tumors of up to 5 cm were treated, with corresponding regional nodal failure rates of approximately 10%. SABR has been reported in many series to have only modest early and late toxicity, generally maintaining pulmonary function and preserving health-related quality of life. Following the publication of an phase II study, which showed an 11-fold increase in severe toxicity in the subgroup of patients with centrally located lung tumors that had been treated with a high dose per fraction, these central locations had been considered to be a ‘no fly zone’ for SABR [Timmerman 2006]. Although several subsequent single center studies have shown that SABR performed with an adapted fractionation scheme using daily fractions of 6.0–7.5 Gy to total doses of 48–60 Gy has been both effective and safe, the results of the ongoing Radiation Therapy Oncology Group (RTOG) phase II trial (0813) for SABR in central tumors, have to be awaited to determine the maximum tolerated dose which can be delivered in five fractions. A recently published systematic review of the literature identified a total of 20 studies reporting on the outcome of SABR in 315 patients with centrally located early stage NSCLC, including two phase II studies [Senthi 2013]. The overall survival rates reported for centrally located tumors appeared to be similar to those of peripheral tumors. Similar to what has been described for peripheral lesions, central tumors showed a dose–response relationship for local control, with four studies reporting improved outcomes with a biological effective dose of 100 Gy~10~ or higher compared to lower doses. In those studies where fractionation schedules with a biological effective dose of 100 Gy~10~ or higher were used, the local control rates exceeded 85%. Post-SABR grade 3 or 4 toxicity occurred in 8.6% of central tumors treated with SABR, and the risk of treatment-related mortality was less than 1% if the biological effective dose for late responding tissues (BED Gy~3~) remained below 210 Gy~3~. In conclusion, SABR for central tumors has been shown to be both effective and safe, provided that appropriate risk-adapted fractionation schemes are used and careful contouring of organs at risk with quality assurance of all aspects of treatment planning and delivery are taken into account. The results of the RTOG dose-finding phase II study 0813, in which already 120 patients are entered, will further strengthen the data on the use of SABR for centrally located tumors.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
Author of
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O28 - Endoscopy (ID 124)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Pulmonology + Endoscopy/Pulmonary
- Presentations: 1
- Moderators:F.J. Herth, N. Ikeda
- Coordinates: 10/30/2013, 10:30 - 12:00, Parkside Auditorium, Level 1
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O28.02 - Grey Scale Texture Analysis of Endobronchial Ultrasound Mini Probe Guide Sheath Images for Prediction of Benign or Malignant Aetiology. (ID 1059)
10:40 - 10:50 | Author(s): D. Fielding
- Abstract
- Presentation
Background
Expert analysis of endobronchial ultrasound (EBUS) images obtained with the mini probe (MP) has established certain subjective criteria for predicting benign or malignant disease. Minimal data is available for objective analysis of these images. The aim of this study was to determine if greyscale texture analysis of EBUS-MP images could differentiate between benign and malignant peripheral lung lesions.Methods
Digital EBUS-MP images with contrast set at 4 and gain set at 10 were included in this study. A region of interest (ROI) was mapped for each image and analysed in a prediction set. The ROIs were analysed for the following greyscale texture features in MATLAB (v7.8.0.347 (R2009a)); mean pixel value, difference between maximum and minimum pixel value, standard deviation of the mean pixel value, entropy, correlation, energy and homogeneity. Significant greyscale texture features were used to assess a validation set. Figure 1Results
Eighty-five peripheral lung lesions were in the prediction set (47 malignant and 38 benign). Benign lesions had larger differences between maximum and minimum pixel values, larger standard deviations of the mean pixel values and a higher entropy than malignant lesions (p<0.0001 for all values). Eighty two peripheral lesions were in the validation set; 63/82 (76.8%) were correctly classified. Of these 45/49(91.8%) malignant lesions and 18/33 (54.5%) benign lesions were correctly classified. The negative predictive value for malignancy was 82% and the positive predictive value was 75%. Figure 1Conclusion
Greyscale texture analysis of EBUS-MP images could assist in differentiating between benign and malignant peripheral lung lesions but tissue diagnosis is still important.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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P3.17 - Poster Session 3 - Bronchoscopy, Endoscopy (ID 185)
- Event: WCLC 2013
- Type: Poster Session
- Track:
- Presentations: 1
- Moderators:
- Coordinates: 10/30/2013, 09:30 - 16:30, Exhibit Hall, Ground Level
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P3.17-004 - Breath-hold low dose CT immediately following PET/CT enables good quality Virtual Bronchoscopy prior to EBUS guide sheath biopsy (ID 2109)
09:30 - 09:30 | Author(s): D. Fielding
- Abstract
Background
Virtual Bronchoscopy (VB) facilitates localization of small lesions at EBUS Guide sheath(GS). A good quality CT to create the VB can be problematic to obtain in a timely fashion. Most lung cancer patients require PET, hence we explored options of getting the VB CT at PET upon initial referral prior to EBUS GS.Methods
We compared VB results for consecutive CTs acquired in one of 3 ways. These were: Group1 :reconstructed CT from the PET/CT ( tidal breathing), Group 2: a dedicated low dose inspiratory breath-hold CT as part of PET/CT, and Group 3 conventional diagnostic CT. CTs had volumetric acquisition and 1 mm overlapping cuts were derived giving at least 600 DICOM images per scan. DICOM images were loaded onto a Lung Point® VB device and VB created. This device gives automated results for the number of bronchial divisions visible, and nearest distance to lesion in question after creation of the VB. Data for Dose Length Product (DLP) and CT Dose Index (CTDI) were obtained for each scan. DLP for Group 1 included whole body CT whereas DLP for Group 2 is stated just for the Thorax CT.Results
In Group 2 unexpected positive mediastinal nodes were seen on PET enabling staging and diagnostic EBUS TBNA confirming malignancy to be done instead of EBUS GS in 3 patients. Poor VB results with the reconstructed CT were due to underlying COPD with small airway closure and hence inability of the software to detect these small airways; (scans acquired in both inspiration and expiration).Group 1 Tidal breathing Group2 Breath hold Group3 Conventional CT n 18 17 20 Lesion size (mm) 21.1± 12.0 23.8±11.0 21.6±7.2 Bronchial divisions 3.25±0.9 4.49±1.1, p<0.01 4.55±0.5 p<0.01 proximity to target lesion (mm) 25.8±19.5 6.7±6.3, p<0.001 cf Gp1 13.3±9.2, p<0.02 cf Gp1 DLP 435 ± 31 173 ± 77 341 ±94, p<0.001 cf Gp 2 CTDI 3.9 ± 1.3 4.1 ± 1.9 8.9±2.9, p<0.001 cf Gp2 % lesions reached at EBUS GS 83 85 90 % positive pathology at EBUS GS 58 54 63 Conclusion
Low dose single breath-hold CT at the time of PET gives at least equivalent results to dedicated CT with far less radiation exposure, and is technically superior to reconstructed CT. Higher visualised bronchial number allows closer proximity to lesions by the directed path. Obtaining this CT prior to EBUS GS means no additional high dose CT is required and additional nodal staging results with the PET can make for better procedural decision making.
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P3.19 - Poster Session 3 - Imaging (ID 181)
- Event: WCLC 2013
- Type: Poster Session
- Track: Imaging, Staging & Screening
- Presentations: 1
- Moderators:
- Coordinates: 10/30/2013, 09:30 - 16:30, Exhibit Hall, Ground Level
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P3.19-004 - Comparison of objective criteria and expert visual interpretation to classify benign and malignant hilar and mediastinal nodes on 18-F FDG PET/CT. (ID 1398)
09:30 - 09:30 | Author(s): D. Fielding
- Abstract
Background
Despite the widespread adoption of FDG-PET/CT in staging of lung cancer, there are no universally accepted criteria for classifying thoracic nodes as malignant. Previous studies have generally shown high negative predictive values, but there are varying reporting criteria and positive predictive values for classifying malignant involvement. Using Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) histology as the gold standard, we evaluated objective 18-F FDG-PET/CT criteria for interpreting mediastinal and hilar nodes and compared this to expert visual interpretation (EVI).Methods
A retrospective review of all patients with proven/suspected primary lung cancer who had both FDG-PET/CT and EBUS-TBNA from 2008-2010 was performed. Scan interpretation was blinded to histology. Separate prediction and validation datasets were used. 104 patients from 2008/2009 formed the prediction set; 48 patients from 2010 formed the validation set. Objective FDG-PET/CT criteria were: - SUVmax lymph node (SUVmaxLN) - Ratio SUVmaxLN/SUVmax primary lung malignancy if evident (R-SUVmax primary) - Ratio SUVmaxLN/SUVaverage liver (R-SUVavg liver) - Ratio SUVmaxLN/SUVmax liver (R-SUVmax liver) - Ratio SUVmaxLN/SUVmax blood pool (R-SUVmaxBP) An experienced Nuclear Medicine Physician visually reviewed all scans and classified each thoracic nodal station as benign, malignant, or equivocal. For statistical analysis, ‘equivocal’ nodes were classified benign.Results
87 malignant lymph nodes from 75 patients and 41 benign nodes from 21 patients were in the prediction set. All objective 18-F FDG-PET/CT criteria analysed were significantly higher in the malignant group compared to the benign group (p<0.0001 all criteria). EVI had 95.3% accuracy, with 83/87(95.4%) malignant nodes and 39/41(95.1%) benign nodes correctly classified. 34 malignant nodes from 34 patients and 19 benign nodes from 14 patients were in the validation set. The new proposed cut-off values of the objective criteria from the prediction set correctly classified 44/53(83.0%) nodes, with 28/34(82.4%) malignant nodes and 16/19(84.2%) benign nodes correctly classified. EVI had 91% accuracy, with 33/34(97.1%) malignant nodes and 15/19 (79.0%) benign nodes correctly classified. Figure 1Conclusion
Objective analysis of 18-F FDG PET/CT can differentiate between malignant and benign nodes with high accuracy, but is not superior to EVI. For objective criteria to perform optimally, there may need to be different criteria devised for different patient populations.
