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O. Pikin
Moderator of
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SC24 - Management of Indeterminate Pulmonary Nodules (ID 348)
- Event: WCLC 2016
- Type: Science Session
- Track: Pulmonology
- Presentations: 5
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SC24.01 - Risk Assessment in the Management of Pulmonary Nodules (ID 6700)
11:00 - 11:20 | Author(s): S. Shiono, N. Yanagawa
- Abstract
- Presentation
Abstract:
Background Solitary pulmonary nodules are seen on approximately 0.1% of all chest X-ray films.[1] High-resolution computed tomography (HRCT), which is used in lung cancer screening programs, can detect pulmonary nodules that are smaller than those detected by conventional radiography. The radiological diagnosis and treatment of these small pulmonary nodules are now the focus of lung cancer research. The timely detection of lung cancers is essential for successful treatment. The guidelines and recommendations for the management of pulmonary nodules include follow up, nonsurgical biopsy, or surgery; and are based on the size of the nodule, and ground glass opacity (GGO) ratio or size of the solid component.[2-4] Diagnosis The diagnosis of a pulmonary nodule is frequently problematic. The management of pulmonary nodules is based on their characteristics. When a pulmonary nodule is monitored by CT, the important features include not only its size but also its density. According to the guidelines of the American College of Chest Physicians, solid nodules measuring > 8 mm in diameter need further examination.[3] The Fleischner Society for Thoracic Imaging and Diagnosis uses a cutoff diameter of 5 mm for decision making for subsolid nodules.[2] It should be kept in mind that solid nodules that are suspicious for lung cancer are frequently invasive. A subsolid nodule can be classified as a pure ground glass nodule (GGN) or part-solid nodule. Subsolid nodules grow slowly and may develop a solid component. The HRCT findings of early lung adenocarcinomas were significantly correlated with the histopathologic findings of the resected specimens.[5] In the evaluation of subsolid nodules, the features indicating noninvasive lung adenocarcinoma include tumor disappearance rate, diameter of consolidation, and GGO ratio.[6] However, even HRCT cannot accurately assess the areas of solid opacities or GGO, and results might vary between investigators. In the upcoming 8[th] TNM classification, the Lung Cancer Staging Project of the International Association for the Study of Lung Cancer showed that the solid part of a nodule on HRCT represents the clinical T factor, and that measurement of the solid part is essential for lung cancer staging.[5] Positron emission tomography (PET)-CT has a clearly established role in lung cancer clinical practice. Based on the pretest probability, PET-CT should be used for patients with a solid, indeterminate nodule > 8 mm in size.[3,4] For adenocarcinomas in situ (AIS) and minimally invasive adenocarcinomas (MIA) of the lung that show solid opacities on HRCT, the preoperative PET-CT and thin-section CT findings together can provide information on the aggressiveness of the tumor. Our study group found that these modalities used together could detect aggressive lung cancers in clinical stage IA (Fig. 1).[7] However, since PET-CT can show false-negative results for slow-growing and low-grade lung malignancies, we think that HRCT is the best modality for identifying indolent lung cancers. Transthoracic biopsy, bronchoscopy, or surgery is used for obtaining specimens for histopathological diagnosis. The definitive diagnosis of small pulmonary nodules, especially GGO-dominant nodules, is challenging. The diagnostic yields of percutaneous CT-guided fine needle aspiration biopsy for GGO-dominant and solid-dominant lesions were 51.2% and 75.6%, respectively (p = 0.018).[9] The diagnostic yield of GGO-dominant lesions < 10 mm was 35.2%. Since invasive biopsy is not without risk, a histopathological diagnosis should be limited to nonsurgical candidates. For cases with high likelihood of lung cancer, a surgical biopsy followed by lung resection might be warranted. Although surgery might be performed on patients with benign nodules, it does provide the definitive diagnosis. If surgery is performed after careful preoperative assessment, the surgical mortality is very low, and the surgical risk may be acceptable. Treatment While lobectomy is the standard procedure for lung cancers, sublobar resection, meaning segmentectomy or wedge resection, might be justified for patients with noninvasive small lung cancers. However, to date, which procedure, sublobar resection or lobectomy, provides a better outcome remains unclear in these cases, since prospective randomized control trials are ongoing (JCOG0802/WJOG4607L[8] and CALGB140503). One of the concerns in sublobar resection is recurrence at the surgical margin (Fig. 2). Recurrence at the surgical margin might be accounted for by tumor cells spreading via air spaces.[10] Accurate intraoperative cytology and adequate surgical margins have been reported to be important for preventing recurrence at the surgical margin. Another concern is lymph node metastasis. In a prospective radiological study for clinical stage IA lung cancer, 47 of 545 (8.6%) patients had lymph node metastasis.[6] Sublobar resection, especially wedge resection, dose not allow evaluation of lymph nodes for metastatic disease. Conclusion HRCT findings play an important role in discriminating the biological behaviors of pulmonary nodules. The definitive diagnosis by HRCT can be difficult, and the combination of HRCT and PET-CT might be beneficial. Randomized control trials should clarify the role of sublobar resection in treating patients with noninvasive lung cancer. Figure 1. Figure 1 Figure 2. Figure 2 References 1. Ost D, Fein AM, Feinsilver SH. The solitary pulmonary nodule. N Engl J Med 2003;348:2535-42. 2. Naidich D, Bankier AA, MacMahon H, Schaefer-Prokop CM, Pistolesi M, Goo JM, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT: A statement from the Fleischner Society. Radiology 2013;266:304-17. 3. Gould MK, Donington J, Lunch WR, Mazzone PJ, Midthun DE, Naidich DP, et al. Evaluation of individuals with pulmonary nodules: when is it lung cancer? Diagnosis and management of lung cancer 3[rd] ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e93s-120s. 4. National Comprehensive Cancer Network. Guidelines for surveillance following therapy for non-small cell lung cancer Ver 4.2016. Available at: www.nccn.com. 5. Travis WD, Asamura H, Bankier AA, Beaseley MB, Detterbeck F, Flieder DB, et al. The IASLC Lung Cancer Staging Project: Proposals for coding T categories for subsolid nodules and assessment of tumor size in part-solid tumors in the forthcoming eighth edition of the TNM classification of lung cancer. J Thorac Oncol 2016;11:1204-23. 6. Suzuki K, Koike T, Asakawa T, Kusumot M, Asamura H, Nagai K, et al. A prospective radiological study of thin-section computed tomography to predict pathological noninvasiveness in peripheral clinical IA lung cancer (Japan Clinical Oncology Group 0201). J Thorac Oncol 2011;6:751-6. 7. Shiono S, Yanagawa N, Abiko M, Sato T. Detection of non-aggressive stage IA lung cancer using chest computed tomography and positron emission tomography/computed tomography. Interact Cardiovasc Thorac Surg. 2014;21:637-43. 8. Nakamura K, Saji H, Nakajima R, Okada M, Asamura H, Shibata T et al. A phase III randomized trial of lobectomy versus limited resection for smallsized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol 2010;40:271–4. 9. Shimizu K, Ikeda N, Tsuboi M, Hirano T, Kato H. Percutaneous CT-guided fine needle aspiration for lung cancer smaller than 2 cm and revealed by ground-glass opacity at CT. Lung Cancer 2006;51:173-9. 10. Shiono S, Yanagawa N. Spread through air spaces is a predictive factor of recurrence and a prognostic factor in stage I lung adenocarcinoma. Interact Cardiovasc Thorac Surg. 2016 Jun 26. pii: ivw211.
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SC24.02 - Radiological Techniques for the Evaluation of Pulmonary Nodules (ID 6701)
11:20 - 11:35 | Author(s): R. Munden
- Abstract
- Presentation
Abstract:
Radiologic Techniques for the Evaluation of Pulmonary Nodules The incidental detection of pulmonary nodules has increased with improved CT technology and thin section imaging techniques[1][,][2]. Adding to this increased detection of nodules is the heightened interest in the purposeful search for nodules such as in oncology patients and lung cancer screening programs. The management of CT detected nodules is a subject of much debate and dependent upon the clinical setting. For instance, in a lung cancer screening setting, there has been a large volume of investigation of solid, semi-solid and ground glass nodules that is the foundation of management recommendations such as LungRads[3]. In patients with a known malignancy, there is minimal literature on management recommendations and thus more influenced by pulmonary metastatic potential of the malignancy and clinician experience[4]. Finally incidentally detected nodule management is greatly influenced by cancer risk factors and nodule texture; for these situations, the Fleischner criteria have been the most widely used and accepted management guidelines[5]. The radiologic evaluation of nodules most often utilizes conventional imaging techniques of chest radiographs, computed tomography (CT), PET/CT. Occasionally MRI and ultrasound may be employed. Most recent changes involve risk stratification, computer software applications to enhance nodule analysis such as nodule enhancement patterns, volumetric computations, and texture analysis[6-8]. Future directions include incorporation of genomics into imaging as well as radiomic analysis and machine learning[9][,][10]. This presentation will review the highlights of the radiologic methods for evaluating pulmonary nodules with a focus on current guidelines and future directions. Reference: 1. Frank L, Quint LE. Chest CT incidentalomas: thyroid lesions, enlarged mediastinal lymph nodes, and lung nodules. Cancer imaging : the official publication of the International Cancer Imaging Society 2012;12:41-8. 2. Jacobs PC, Mali WP, Grobbee DE, van der Graaf Y. Prevalence of incidental findings in computed tomographic screening of the chest: a systematic review. Journal of computer assisted tomography 2008;32:214-21. 3. Lung CT Screening Reporting and Data Systen (Lung-RADS). 2014. (Accessed March 27, 2015, at www.acr.org/Quality-Safety/Resources/LungRADS ) 4. Munden RF, Erasmus JJ, Wahba H, Fineberg NS. Follow-up of small (4 mm or less) incidentally detected nodules by computed tomography in oncology patients: a retrospective review. J Thorac Oncol 2010;5:1958-62. 5. McMahon PM, Meza R, Plevritis SK, et al. Comparing benefits from many possible computed tomography lung cancer screening programs: extrapolating from the National Lung Screening Trial using comparative modeling. PloS one 2014;9:e99978. 6. McWilliams A, Tammemagi MC, Mayo JR, et al. Probability of cancer in pulmonary nodules detected on first screening CT. N Engl J Med 2013;369:910-9. 7. Revel MP, Merlin A, Peyrard S, et al. Software volumetric evaluation of doubling times for differentiating benign versus malignant pulmonary nodules. AJR Am J Roentgenol 2006;187:135-42. 8. Talwar A, Gleeson FV, Rahman NM, Pickup L, Gooding M, Kadir T. A Review Of The Use Of Computer Aided Texture Analysis For Pulmonary Nodules Classification. American journal of respiratory and critical care medicine 2015;191. 9. El-Zein RA, Lopez MS, D'Amelio AM, Jr., et al. The cytokinesis-blocked micronucleus assay as a strong predictor of lung cancer: extension of a lung cancer risk prediction model. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 2014;23:2462-70. 10. Gillies RJ, Kinahan PE, Hricak H. Radiomics: Images Are More than Pictures, They Are Data. Radiology 2016;278:563-77.
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SC24.03 - The Role of the Pulmonologist in the Management of Pulmonary Nodules (ID 6702)
11:35 - 11:50 | Author(s): P. Lambin
- Abstract
- Presentation
Abstract not provided
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SC24.04 - The Role of the Pathologist in the Management of Indeterminate Pulmonary Nodules (ID 6703)
11:50 - 12:10 | Author(s): K. Kerr
- Abstract
- Presentation
Abstract not provided
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SC24.05 - Indication and Techniques of Surgery (ID 6704)
12:10 - 12:30 | Author(s): U. Pastorino
- Abstract
- Presentation
Abstract not provided
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MA03 - Epidemiology, Risk Factors and Screening (ID 374)
- Event: WCLC 2016
- Type: Mini Oral Session
- Track: Epidemiology/Tobacco Control and Cessation/Prevention
- Presentations: 1
- Moderators:N. Bilir, H. Olschewski
- Coordinates: 12/05/2016, 14:20 - 15:50, Lehar 3-4
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MA03.11 - Discussant for MA03.08, MA03.09, MA03.10 (ID 6960)
15:32 - 15:44 | Author(s): O. Pikin
- Abstract
- Presentation
Abstract not provided
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P1.08 - Poster Session with Presenters Present (ID 460)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Surgery
- Presentations: 1
- Moderators:
- Coordinates: 12/05/2016, 14:30 - 15:45, Hall B (Poster Area)
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P1.08-078 - Does Surgery Have Real Benefit in Resectable Oligometastatic NSCLC? (ID 4106)
14:30 - 14:30 | Author(s): O. Pikin
- Abstract
Background:
The prognosis in patients with distant metastases of NSCLC is generally poor. Surgical resection of isolated distant metastases in NSCLC patients is not widely accepted and chemotherapy is usually administered. The study was aimed to evaluate the long-term results and prognosis after surgical resection of oligometastases in NSCLC patients.
Methods:
139 patients with isolated distant metastases of NSCLC (M1a – 38, M1b – 101) operated on in our clinic from 1998 to 2011 were included in the retrospective trial from the prospective database. Solitary brain metastasis was diagnosed in 82, pleural metastases – in 21, contralateral lung – in 17, adrenal metastases – in 11, others – in 8 patients. Synchronous metastases were detected in 61 (43,9%), metachronous – in 78 (56,1%) patients. In patients with pleural dissemination lung resection with pleurectomy followed by PDT was carried out. The primary lung cancer was completely resected in all cases. Surgery included pneumonectomy – in 17, lobectomy/bilobectomy – in 112 and sublobar resection – in 10 patients. Median follow up is 52 month.
Results:
Postoperative complications were registered in 10 (7,2%) patients, mortality – 2,2%. Median survival after pulmonary resection and removal of brain metastasis was 23,0 months, contralateral lung resection – 12,0, after lung resection with pleurectomy – 11,0 and adrenalectomy – 9,0 months. 5-year survival after lung resection and brain metastasectomy was 20,6%, contralateral lung resection – 12,0%, lung resection and pleurectomy (limited pleural spread) – 10,7%. No one survived more than 2 years after adrenalectomy. Survival of patients in N0-1 cases was significantly better in all groups: after brain metastasectomy - 34,5% vs 0%, contralateral lung resection – 28,0% vs 0%, pleural dissemination – 4,7% vs 0% in N2 positive patients with median survival 19,0 and 8,0; 15,0 and 8,0; 23,0 and 10,0 months respectively. Overall survival was worse in synchronous group if compare with metachronous detection: after brain metastasectomy 10,0% and 19,8%; contralateral lung resection 0% and 32,0% with median survival 18,0 and 25,0; 11,0 and 21,0 months respectively. Multivariate analysis confirmed that positive N2 status (p<0.001) and synchronous detection of oligometastatic disease (p=0.002) were independent unfavorable prognostic factors.
Conclusion:
Aggressive surgery in patients with oligometastatic NSCLC is justified in selected patients with solitary brain, contralateral lung metastasis and limited pleural dissemination, especially in N0-1cases and metachronous disease. Surgical resection should be whenever avoided in patients with oligometastatic lung cancer and positive N2 status.
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P3.04 - Poster Session with Presenters Present (ID 474)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Surgery
- Presentations: 1
- Moderators:
- Coordinates: 12/07/2016, 14:30 - 15:45, Hall B (Poster Area)
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P3.04-020 - Segmentectomy in Patients with Pulmonary Malignancies Using 3D-CT Reconstruction and Bronchovascular Separation (ID 4107)
14:30 - 14:30 | Author(s): O. Pikin
- Abstract
Background:
Progress in diagnostics and surgery in thoracic oncology is associated with increasing number of patients-candidates for sublobar anatomic pulmonary resection. Vascular variability of pulmonary segments anatomy requires special tools for individual preoperative planning.
Methods:
84 patients who underwent segmentectomy due to low pulmonary function, severe comorbidity, previous history of lung resection and metastatic lesion were included at the retrospective trial from prospectively collected database. Inclusion criteria were clinical T1aN0M0 peripheral non-small cell lung cancer (NSCLC) measuring ≤2 cm (n=23) and resectable pulmonary metastases not suitable for wedge resection due to deep parenchymal location (n=61). Segmentectomies were divided into typical (where parenchymal division involves 2 planes) and atypical (more complex and technically demanding, when the segmental excision involves 3 planes). 19 patients underwent VATS segmentectomy. Three-dimensional computed tomography (3D-CT) with bronchovascular separation was used preoperatively in 32 patients from October 2014 to May 2016. Mortality, morbidity, proportion of typical versus atypical and VATS versus open segmentectomies in two groups: with or without 3D-CT bronchovascular reconstruction, were compared.
Results:
There was no mortality in whole group. Morbidity rate was 14% not exceeding grade 3a according thoracic mortality and morbidity (TMM) score. The difference in morbidity rate was not statistically significant between two groups (15,3% and 12,5%; p=0,64) The most common complication was prolonged air leak > 7 days (8%). 3D-CT powered by separation of arterial, venous and bronchial structures enabled surgeons to perform atypical segmentectomies and use VATS approach more often (37% vs 4% and 42% vs 16%, respectively). 7 atypical segmentectomies were performed by VATS due to 3D-CT reconstruction with bronchovascular separation.
Conclusion:
3D-CT reconstruction with bronchovascular separation provides precise preoperative planning of individual pulmonary segments anatomy and enables to increase the proportion of atypical and VATS sublobar anatomic pulmonary resections.
