Virtual Library

Background
It is known that in lung adenocarcinoma, ground glass nodule (GGN) tumors have a better prognosis than solid tumors. The aim of this study is to determine whether it is more useful to evaluate the whole tumor size or only the solid component size to predict the pathologic malignancy and the prognostic outcome in lung adenocarcinoma.

Methods
Using high-resolution computed tomography (HRCT) data of 232 patients with adenocarcinoma 7 cm or less who underwent curative resection, we retrospectively measured the whole tumor and solid component sizes with lung window setting (WTLW and SCLW) and whole tumor sizes with a mediastinal window setting (WTMW).

Results
There was significant correlation between the WTLW and the measurements of pathological specimens (r=0.792, P<0.0001). The SCLW and WTMW values significantly correlated with the area of pathologically confirmed invasion (r=0.762, P<0.0001 and r=0.771, P<0.0001, respectively). The receiver operating characteristics area under the curve for WTLW, SCLW and WTMW used to identify lymph node metastasis or lymphatic or vascular invasion were 0.693, 0.817 and 0.824, respectively. Kaplan-Meier curves of DFS and OS were better divided according to SCLW and WTMW, compared with WTLW. Multivariate analysis of DFS and OS revealed that WTMW was an independent prognostic factor (HR=0.72, 95%CI=0.58-0.90, P=0.004 and HR=0.74, 95%CI=0.57-0.96, P=0.022, respectively).

Conclusion
The predictive values of the solid tumor size visualized on HRCT especially in the mediastinal window for pathologic high-grade malignancy and prognosis in lung adenocarcinoma less than 7 cm were greater than those of whole tumor size.

Background
Asbestos is known for one of the risk factors of lung cancer (LC). The subjects with asbestos exposure are considered to have increased risk of LC especially if chest X-ray shows fibrotic changes of the lung. However, there are few reports about the association between the risk of LC and fibrotic changes detected by chest CT. The aim of this study was to define the specific CT findings of risk of LC among the subjects with asbestos exposure.

Methods
The low-dose chest CT(LD-CT) was taken as LC screening with written informed consent in subjects with former asbestos exposure in a prone position with the dose less than 30mAs. Each image was independently interpreted with more than two radiologists especially focused on fibrotic changes including subpleural curvilinear shadow/subpleural dots, reticular shadow, parenchymal band, traction bronchiectasis, and honeycombing. These findings were scored according to the extent. A chi square test was used to investigate the difference of categorical variables, and Mann-Whitney U test was applied as a non-parametric test.

Results
Between 2010 and 2012, chest LD-CT was taken in 2,126 subjects at 8 institutions in Japan. During the period, 38 (1.79%) LC was detected. We compared LC group and non-LC group, and there was no difference of duration of occupational asbestos exposure, or the prevalence of fibrotic changes on chest LD-CT. The extent of the fibrosis determined by scoring of the LD-CT findings, however, was more prominent in LC group than in non-LC group, though it was not statistically significant (p=0.067). On the other hand, LC developed more frequently in subjects with some fibrotic change (2.67%) than in those without any fibrotic change (1.44%, p=0.067).

Conclusion
The fibrotic changes of the lung detected on LD-chest CT might be the risk factor of LC development in subjects with former asbestos exposure. Further examination is planned with more subjects and longer period of observation.

Background
We previously reported the correlation among the thin-section computed tomography (TS-CT) findings, the pathological factors (Noguchi’s classification) and the prognosis of the patients. The purpose of this study was to examine the tumor shadow disappearance rate (TDR) on TS-CT findings, clinical course and pathological factors of small-sized adenocarcinomas of the lung according to the 2011 IASLC/ERS Classification.

Methods
We retrospectively analyzed 111 peripheral non-mucinous adenocarcinomas of the lung ≤ 10 mm in diameter that were surgically resected at our institute between January 1997 and February 2013. CT scans were obtained by commercially available scanners (X-Vigor/Real or Aquilion M/16 CT scanner; Toshiba Medical Systems; Tokyo, Japan). TS images were obtained with a 1 mm section thickness, pitch of 1, section spacing of 1 mm, 512 × 512 pixel resolution and 1 second scanning time. TDR was defined as the ratio of the maximum diameter of the tumor opacity of the mediastinal window to that of the lung window on TS-CT. We also examined the relationship among the TDR, the patient backgrounds, pathological findings (i.e., lymph node metastasis, pleural invasion, vascular invasion and lymphatic invasion) and clinical course. The histologic subtypes were analyzed according to the 2011 IASLC/ATS/ERS International Multidisciplinary Classification of Lung Adenocarcinoma.

Results
The median age of the patients was 64 (range, 23-83) years, and 66 patients (59.5%) were female. Sixty-four patients (57.7%) were never-smokers. The average tumor size was 8.7 mm (range, 5-10 mm). Regarding the histological subtypes, 70 cases were adenocarcinoma in situ (AIS) or minimally invasive adenocarcinoma (MIA), 19 were acinar predominant (AP), 13 were papillary predominant (PP) and seven were solid predominant (SP). Two cases could not be determined. Seventy cases diagnosed AIS or MIA were all stage IA, and none of these patients relapsed. Six cases relapsed after surgery; three cases of AP, two of PP and one of a SP tumor. In a comparison of the clinical course, the pathological differentiation and the TS-CT findings, all six cases relapsed after surgery showed ≤ 40% in TDR. Four cases diagnosed with lymph node metastasis (i.e., cases diagnosed in stage IIA or higher) showed ≤ 22% in TDR. Twelve cases with pleural invasion or vascular invasion or lymphatic invasion in the pathological factors of the resected lesions showed ≤ 28% in TDR. The TDR of AIS and MIA cases were all ≥ 50%.

Conclusion
There are sometimes pathologically invasive lesions even in small-sized adenocarcinomas of the lung. We found that the TDR is related to the clinical course and pathological factors in small-sized adenocarcinomas of the lung (10 mm or less in diameter). The lesions with a TDR ≤ 40% in the TS-CT images may be a group of highly malignant with an increased risk of relapse. The TDR may contribute to the determination of the optimal therapeutic strategy. We need a more robust prospective study to validate the efficacy of TDR.

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 1

Conclusion
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.

Background
Biological behavior of small lung adenocarcinoma differs in each patient. High intensity area of the tumor on single slice of chest CT has been reported as a prognostic factor in several studies. However, because single slice is obviously insufficient to utilize all of the information on CT images of a tumor, we applied 3- dimensional volumetric evaluation for whole tumor volume. Our study aims to predict lymph node metastasis and tumor invasiveness by means of preoperative quantitative CT for lung cancer patients.

Methods
From January 2011 to November 2012, 236 lesions of cT1N0M0 lung adenocarcinoma were surgically resected in our institute. Among them, total 211 lesions of 193 patients were included in this study (Age: 67.2±9.5 male/female: 94/99). We analyzed preoperative CT images of 211 lesions of resected cT1N0M0 lung adenocarcinoma retrospectively. All patients were subjected to helical scanning using sections 1mm or less thick during one breath hold. We applied threshold of -800 and -300 Hounsfield units (HU) within those CT data, calculated the tumor volume, and then, integrated them with clinico-pathological information. We defined the area -300HU and over as “solid tumor volume” and between -800 to-301 HU as “GGO tumor volume”. Spearman’s rank test was utilized for statistical analyses.

Results
We divided those lesions into 3 groups by solid tumor volume; less than 0.25cm[3] (n=61), 0.25 to 1.5cm[3] (n=72), and over 1.5cm[3] (n=78). Solid tumor volume correlated with histological tumor invasiveness; less than 0.25cm[3], p1to3 (0, 0%) ly1 (0, 0%) v1 (0, 0%); 0.25 to 1.5cm[3], p1to3 (6, 77%) ly1 (1, 1%) v1 (1, 1%); over 1.5cm[3], p1to3 (14, 19%) ly1 (4, 6%) v1 (14, 19%), (p<0.01, p=0.03, p<0.01, respectively). Pathological tumor differentiation was also investigated; less than 0.25cm[3], well (34, 56%) moderate (26, 43%) poor (1, 2%); 0.25 to 1.5cm[3], well (17, 22%) moderate (57, 73%) poor (4, 5%); over 1.5cm[3], well (8, 11%) moderate (51, 71%) poor (13, 18%) (p<0.01). Lymph node metastases were found in none (0%) of solid tumor volume less than 0.25cm[3], in 2 (3%) with 0.25 to 1.5cm[3], in 6 (8%) with over 1.5cm[3] (p=0.01). Moreover we calculated the proportion of solid tumor volume / (solid tumor volume + GGO tumor volume) as “solid tumor ratio”. We divided those lesions into 2 groups by solid tumor ratio; 0.3 or less (n=123), and over 0.3 (n=88). Solid tumor ratio also correlated with histological tumor invasiveness; 0.3 or less, p1to3 (0, 0%) ly1 (0, 0%) v1 (0, 0%); over 0.3, p1to3 (20, 23%) ly1 (5, 6%) v1 (15, 17%). (p<0.01, p<0.01, p<0.01, respectively) Strikingly, lymph node metastases were found in none (0%) of solid tumor ratio 0.3 or less, but in 8 (9%) with over 0.3. (p<0.01)

Conclusion
Both tumor volume -300HU and over “solid tumor volume” and “solid tumor ratio” significantly correlated with tumor invasiveness. Preoperative quantitative CT is probably useful for predicting tumor invasiveness and lymph node metastases, and, as a result, effectively selecting operative procedure for cT1N0M0 lung cancer whether lobectomy or segmentectomy is applicable.

Background
Superior vena cava (SVC) obstruction can cause development of collateral vessels. During contrast-enhanced thoracic CT, contrast material may reflux into the collaterals such as paravertebral venous plexus. However, unusual pseudopathologic vertebral body enhancement on CT in the presence of SVC obstruction has not been studied previously. So, the aim of this study was to demonstrate clinical presentation and imaging findings of pseudopathologic vertebral body enhancement in patients with SVC obstruction.

Methods
From March 2009 to September 2012, a retrospective radiologic database review was performed to identify patients with obstruction of SVC causing contrast reflux into collateral vessels and presented with unusual vertebral body enhancement on thoracic CT. Thirteen patients (eleven men, mean age 51.4 years) with vertebral body enhancement were enrolled. The underlying diseases that caused SVC obstruction were adenocarcinoma of the lung in four, non-small cell lung cancer in two, large cell neuroendocrine carcinoma, small cell lung cancer, thymic carcinoma, sarcomatoid carcinoma, diffuse large B-cell lymphoma, Hodgkin’s lymphoma and metastatic lymphadenopathy from pancreatic cancer in one patient each. Enhancement patterns, locations and the presence of a connection between vertebral body enhancement and the paravertebral venous plexus were evaluated. Enhancement patterns of vertebral bodies were classified as nodular enhancement with round shape that occupying < 1/3 of vertebral body or polygonal enhancement that occupying ≥ 1/3 of vertebral body on axial image. The locations of enhanced areas within vertebral bodies were described using right lateral/central/left lateral, anterior/posterior, and upper/middle/lower in the x-, y-, or z-axis directions, respectively.

Results
A total of 39 vertebral body enhancements were found in the 13 patients, involving cervical (n = 12), thoracic (n = 25), or lumbar (n = 2) vertebrae. Vertebral body enhancements showed a nodular (n = 19) or a polygonal (n = 20) pattern. The central portions of vertebral bodies were more frequently involved. The connection to the paravertebral venous plexus was observed in 34 lesions (87.2%).

Conclusion
Patients with SVC obstruction with extensive collateral vessels might exhibit a pseudopathologic vertebral enhancement. They tended to involve the central portion of the vertebral body and most of them showed connection to the paravertebral venous plexus.

Background
Coronary artery calcification (CAC) is frequently detected on low-dose CT of the thorax (LDCT). Concurrent assessment of CAC and lung cancer screening using LDCT is beneficial in terms of cost and radiation dose reduction. The aim of our study was to evaluate the reliability of visual ranking of CAC on LDCT compared to Agatston score on ECG-gated calcium scoring CT.

Methods
The subjects were 576 patients who were consecutively registered for health screening and undergoing both LDCT and ECG-gated calcium scoring CT. We excluded subjects with a calcium score of zero. The final study cohort included 117 patients with CAC (97 men; mean age, 53.4±8.5). Agatston score on ECG-gated calcium scoring CT was used as the gold standard (mean score, 166.0; range, 0.4-3719.3). Two board-certified radiologists and two radiology residents participated in an observer performance study. Visual ranking of CAC was performed according to four categories (1-10, 11-100, 101-400, and 401 or higher) for coronary artery disease (CAD) risk stratification. Weighted kappa statistics was used to measure the degree of reliability on visual ranking of CAC on LDCT: kappa values between 0 and 0.40 were considered to indicate positive but poor agreement; between 0.40 and 0.75, good agreement; greater than 0.75, excellent agreement.

Results
The degree of reliability on visual ranking of CAC on LDCT compared to ECG-gated calcium scoring CT was excellent for board-certified radiologists and good for radiology residents. A high degree of association was observed with 71.6% of visual rankings in exactly the same category as the Agatston category and 98.9% varying by no more than one category.

Conclusion
Visual ranking of CAC on LDCT is reliable for prediction of categorization of Agatston score ranks. LDCT is useful for both CAD risk stratification and lung cancer screening.

Background
[18]F-fluoro-2-deoxy-glucose (FDG) uptake on Positron Emission Tomography (PET) is highly accurate in the detection of mediastinal lymph node metastasis and extrathoracic metastasis and plays an important role in the staging of lung cancer. Furthermore, recent studies suggest that PET-CT and Standardized Uptake Value (SUVmax) reflects tumor metabolism and proliferation capacity, and can be used as a prognostic factor as well as to predict response to therapy.

Methods
Our study aims to detect SUVmax differences between different lung cancer histologic sub-types. We conducted a retrospective single centre study. All lung cancers diagnosed in 2008-2009, with a PET-TC evaluation at diagnosis, and with follow-up at IPOLFG were included. Data regarding socio-demographic factors, smoking habits, histological diagnosis, staging, and performance status were obtained from clinical chart reviews. Statistical analysis was performed using STATA

Results
A total of 92 patients have been included in this study to date. 64 (69.6%) of our patients were male and 28 (30.4%) were female. Median age was 64.5 years, standard-deviation of 10.16 years, minimum of 36 and maximum of 82 years. 47 patients (51.65%) were current smokers, 31 (34.07%) were former smokers, and 11 (12.09%) were non-smokers. 54% presented ³ 40 Pack years. The most frequent histologic sub-type was Adenocarcinoma (ADC) (41.3%), followed by Squamous Cell Carcinoma (SCC) (30.4%). 42 patients had stage I or II lung cancer, 31 had stage III, and 19 with stage IV. The median size of the primary tumor lesion was 4.05cm (standard-deviation of 2.62cm), and the median SUVmax was 10.11 (standard deviation of 5.86). SUVmax by primary tumor histological sub-type revealed the following characteristics: median SUVmax in the SCC group was 12.12 (standard-deviation 6.3), ADC group 8.26 (standard-deviation 4.5), Non-small Cell Carcinoma group 12.65 (standard-deviation 7.5), Neuro-endocrine Carcinoma group 7.25 (standard-deviation 5.4) and Small Cell Carcinoma 10.67 (standard-deviation 3.6). The observed differences were statistically significant between the 5 considered groups (p=0.0233, One-way ANOVA) and specifically, we observed a highly significant difference in SUVmax between SCC and ADC groups (p=0.005, t-test). We also observed a positive correlation between tumor size and SUVmax.

Conclusion
Our preliminary results confirm the effect of tumor biology in PET-CT and SUVmax with observed differences between different histological sub-types, and suggest that PET-CT can be specifically important in the assessment of SCC and ADC subtypes. These results support further studies regarding the usefulness of PET-CT in tumor biology characterization in SCC and ADC subgroups.

Background
To describe HRCT findings of newly developed peripheral T1 lung cancer in idiopathic interstitial pneumonia (IIP) during IIP follow-up

Methods
Between November 2001 and October 2012, 66 consecutive patients (62men, 4 women; median age 64, range 40~85 years) who were diagnosed as IIP, fulfilled the American Thoracic Society diagnostic criteria and new cancer (including fourteen small cell) simultaneously, were included. Two radiologists independently reviewed 132 serial CT scans of 66 patients, determined the earliest scan showing lung cancer, and evaluated tumor size (mm), lobar location, axial location on transverse image, shape, and density of tumor. The median interval between null-IIP to new cancer-IIP was measured. Delay in diagnosis was measured from the time of the earliest scan showing lung cancer and the subsequent clinical diagnosis. Formal radiologic reports as ‘first choice’ before diagnosis of cancer were reviewed.

Results
The inter-observer agreement was good (Kappa value > 0.77). The median smallest tumor size on axial scan at presentation was 17mm (± 6.57, range, 5-30mm) with T1a/T1b (48/18). Tumor was most commonly located in right lower lobe (29/66, 43.9%), followed by left lower lobe (13, 19.7%). Thirty five tumors (53.0%) were in the interface between normal and fibrotic lung cysts such as honeycomb cysts, twenty two (33.3%) were in the midst of fibrotic lung cysts, and nine (13.6%) were in the normal lung. Fifty nine (83.3%) tumors had round or oval shape, seven (10.6%) tumors had a stellate shape, and two had a band-like shape. Most of the tumors (90.3%) presented as solid density rather than part solid, ground-glass opacity or consolidation. Lung cancers were found during the mean follow-up CT period of 513 days. The median delay in diagnosis was 440 days. Most of the lesions (70%) were interpreted as lung cancer, but nine were interpreted as pneumonia or fungal infection and seven were missed (10.6%) on HRCT.

Conclusion
About one third of the tumors were misdiagnosed including missed in ten percents. Over fifty percent of the cancers are located at the interface between normal lung and fibrotic cysts. New lung cancers usually show as tumor with a round or oval shape and solid density.

Background
Thin-section CT (TS-CT) provides us with a more precise image of small pulmonary carcinomas. Thin-slice sections with thicknesses of 0.5 mm-1mm reflect, with some accuracy, the histopathological findings; mixed ground-glass opacity (part-solid GGO) is one characteristic finding of pulmonary adenocarciomas. These findings are vary in appearance, for example; some contain mainly GGO components, and some contain mainly solid portions. CT findings of mixed GGO, pathological findings and prognoses have been reported. Presently, we do not fully understand the correlation between TS-CT findings of mixed GGO and the status of EGFR mutation.

Methods
We retrospectively reviewed the records and TS-CT scans of 115 patients with mixed GGO tumors. All patients had undergone surgical resection between 2002 and 2008. Tumor diameters measured 20mm or less in size. All TS-CT images were acquired by Aquillion CT scanner (Toshiba Medical System). TS-CT images of tumors were obtained at 135kVp at 250mAs with 0.5-1mm section thickness. All images were photographed using mediastinal (level, 40HU; width, 400HU) and lung (level, -600HU); width, 1600HU) window settings. All TS-CT images on lung window setting were classified as: (1) Predominant GGO type (pGGO; solid portion areas less than 50% of tumor), (2) Heterogeneous type (heterogenous increased density), (3) Predominat solid type (pSolid; Solid portion areas took up more than 50% of tumor). We analyzed EGFR and Kras mutations, and then studied the correlations between these TS-CT findings and the status of EGFR mutations.

Results
The tumors in all 115 cases were well-differentiated adenocarcinomas. GwS type; 24 cases, Heteogenous type; 30 cases, and SwG type 61 cases. The EGFR mutation ratio was 66.6% in pGGO type, 90% in Heterogenous type and 52.7% in pSolid type. The ratio of EGFR mutation was greater in Heterogenous types compared to pGGO and pSolid types. (pGGO/Hetero p=0.045, pSolid/Hetero p=0.00038).

Conclusion
There is a correlation between the thin-section findings of mixed GGO and the status of EGFR mutations.

Background
Pulmonary carcinoids are histologically classified into typical and atypical. It is important to identify these preoperatively for treatment planning and prognosis. Our purpose was to calculate the diagnostic sensibility of positron emission tomography/computed tomography (PET/CT) using two different tracers ([18]Fluorine-fluorodeoxyglucose [FDG], a glucose analogue and [68]Gallium-DOTANOC, a somatostatin analogue) in a series of patients with suspected bronchial carcinoids (BCs). Additionally, we have evaluated the combination of dual tracer PET/CT findings in differentiating typical and atypical pulmonary carcinoids.

Methods
Forty-four patients (16 male/28 female; mean age: 57.8 y.o.) with suspected BCs (based on radiological findings) underwent PET/CT with FDG and [68]Gallium-DOTANOC in 2 high-volume centers. Detection rates of BCs on a per patient-based analysis were calculated. Histology was used as reference standard. The Chi-square test was used to correlate histology and PET findings.

Results
After surgery, 23 typical carcinoids (TCs), 10 atypical carcinoids (ATCs) and 11 benign pulmonary lesions (amartomas) were found. Overall and histology-based sensibility rates of both PET-methods are shown in Table. In particular, no false positive results were found and the overall detection rate for BCs was 100% when combining both PET methods (one positive at least). DOTANOC-PET/CT is superior in detecting TCs (sensibility= 91.3%) while FDG-PET/CT seems to be more useful in ATCs (sensibility= 100%). A significant association between histological type and PET findings with the two tracers was found (p<0.05). Moreover, the ratio of SUVmax values (DOTANOC/FDG) was significantly higher in TC-group when compared with ATC-group (10.00 vs 0.90; p= 0.027) Figure 1

Conclusion
Overall diagnostic performance of PET-CT in detecting BCs is optimal when integrating dual tracer PET-CT findings (FDG and DOTANOC). The combination of dual tracer PET/TC findings and the ratio of SUVmax values (DOTANOC/FDG) may be useful in differentiating TCs and ATCs. Therefore, both PET/CT methods should be performed in suspected BCs or when the histological subtype of BCs is unknown.

Background
A solitary pulmonary nodule (SPN) is radiologically defined as an intraparenchymal lung lesion that is < 3 cm in diameter and is not associated with atelectasis or adenopathy. The diagnosis of SPN is challenging. A prediction model would facilitates this task. Until now, three SPN prediction models have been developed, which are Mayo model, VA model and Peking University (PU) model. We compared the accuracy of three models in Chinese patients with SPN.

Methods
From July 2003 to December 2011, 154 surgical patients with an SPN measuring 3-30mm from Guangdong Lung Cancer Institute were included in this study. Data on gender, age, cancer history, smoking, nodule size, spiculation, calcification, border and final pathological diagnosis were collected retrospectively . Each patient’s final diagnosis was compared with probability calculated by MAYO model, VA model and PU model. The accuracy of each model was assessed by area under the receiver operating characteristics (ROC) curve and calibration curve.

Results
The area under the ROC curve (AUC) of PU model(0.800; 95% CI 0.708 to 0.891) was larger than that of MAYO model(0.753; 95% CI 0.650 to 0.857) and VA model(0.728; 95% CI 0.623 to 0.833), but this difference was not statistically significant. Calibration curves showed that all the three models overestimated malignancy.Figure 1 Figure 1 Receiver operating characteristic curves of Mayo model, VA model and PU model. AUC(Mayo)= 0.753(95% CI 0.650 to 0.857). AUC(VA)= 0.728; 95% CI 0.623 to 0.833. AUC(PU)= 0.800; 95% CI 0.708 to 0.891.

Conclusion
Three prediction models are sufficiently accurate in SPN malignancy prediction in Chinese patients.

Background
A recent study revealed that maximum iodine-related attenuation (IRA~max~) of dual-energy CT (DECT) of primary tumor strongly correlates with maximum standardized uptake value (SUV~max~) of [18]FDG PET-CT in non-small cell lung cancer (NSCLC) (n = 27; r = 0.785; p = 0.001). It suggested that DECT could serve as a valuable functional imaging test in NSCLC. The aim of our study is to validate the previous results in our NSCLC cohort.

Methods
Twenty-seven patients with NSCLC who underwent both DECT and [18]FDG PET-CT were analyzed. The maximum and mean IRA as well as virtual non-contrast (VNC) images were calculated from DECT. Pearson correlation test was used to analyze the relationship between all measurements of DECT and the SUV~max~ of [18]FDG PET-CT in primary tumors and lymph nodes.

Results
Twenty-seven primary tumors and 51 thoracic lymph nodes with an SUV~max~ of >2.5 were included in analyses. In primary tumors, there was a moderate correlation between IRA~max~ and SUV~max~ (r = 0.565; p = 0.002) whereas no correlation was found between other DECT measurements and SUV~max.~ In lymph nodes, we observed no correlation between IRA~max~ and SUV~max~ (r = 0.197; p = 0.165) as well as between other DECT measurements and SUV~max.~

Conclusion
In patients with NSCLC, correlation between IRA~max~ and SUV~max ~was observed in primary tumors but not in lymph nodes. Because of relatively small population in our study and previous study, further large prospective studies are needed for validation.

Background
Genotype manifests itself as phenotype and that the one may inform the other. In terms of phenotype, imaging has the potential to assist in noninvasively characterizing the tumor, however, there are very few investigators who have pursued that potential connection between imaging features and the genetic characteristics of lung cancer. The purpose of this study was to retrospectively correlate the CT morphologic patterns of nodular lung adenocarcinomas (ADs) with pathological and molecular phenotypes in an East-Asian cohort of patients.

Methods
The institutional review board approved this retrospective study, and all patients provided informed consent. 600 primary lung ADs smaller than 3 cm in diameter that were surgically resected from 592 patients (M:F=257:335; mean age, 63) were included. CT morphologic pattern of ADs was evaluated by three board-certified thoracic radiologists and was classified into four patterns: pure GGN, GGO dominant part-solid nodule (PSN), solid dominant PSN, and pure solid nodule. EGFR mutation, ALK rearrangement, and KRAS mutation were evaluated using PCR-based direct DNA sequencing and FISH. Histologic subtype was classified according to IASLC/ATS/ERS classification of lung AD. The Fisher exact test and student t-test were used to assess statistical significance.

Results
Figure 1 In terms of CT morphologic patterns, 17.2%,15.2%, 31.8%, and 35.8% of tumors manifested as pure GGN, GGO dominant PSNs, solid dominant PSNs, and pure solid nodules, respectively. EGFR mutation was significantly more often found in ADs that manifested as subsolid nodules (69.9%, 269/385) than in ADs presented as pure solid nodules (46.7%, 100/214) (P<.0001). ALK rearrangement was more frequent in ADs that manifested as pure solid nodule (8.5%, 13/153) than in tumors presented as subsolid nodule (1.8%, 5/281) (P=.001). KRAS mutation showed no significant difference between subsolid nodules (6.6%, 8/121) and pure solid nodules (8.5%, 5/59) (P=.760). The ratio of subsolid nodule vs pure solid nodule was 72.7% vs 27.3% in ADs with EGFR mutation and was 27.8% vs 72.2% in ADs with ALK rearrangement. EGFR mutation was more frequent in minimally invasive ADs (P=.004) and lepidic predominant ADs (P=.018). ALK rearrangement was more frequent in solid predominant ADs (P=.002) and invasive mucinous ADs (P=.030). KRAS mutation was more frequent in invasive mucinous ADs (P=.001).

Conclusion
EGFR mutation was significantly more often found in ADs that manifested as subsolid nodules, and ALK rearrangement was more frequent in ADs that manifested as pure solid nodule.

Background
The distinction between SCLC and NSCLC has been recently replaced by a more detailed re-classification. As 70% of patients with LC are still not eligible for surgery, tumor characterization is often based on needle biopsy. For the management of lung masses (LM), the availability of adequate samples is critical not only for pathological diagnosis, but also for additional molecular studies. In this context, our aim was to evaluate the safety and accuracy of image-guided core biopsies (CB) in our last 4-year series.

Methods
480 consecutive patients (325 male; 33-87 y, mean 68; LM diameter 6-150 mm, m 37,4) underwent 439 CT-guided, 35 US-guided and 6 US+CT-guided lung biopsies. In 325/480 cases (68%) a CB was preferred due to the possible requirement of molecular studies. 275 CB were performed with >=18G tru-cut needle, 50 with <18G, both by a coaxial technique (inserted in a 1G larger styleted cannula). 1 to 6 sampling per patient (m 1.5) were performed. Adverse events (including major complications) were recorded and correlated with technical issues (namely, with needle size). To assess the accuracy of CB, surgical specimens, outcome of non-surgical therapy and follow-up imaging were considered as gold standards. Sensitivity, specificity, diagnostic accuracy and positive and negative predictive values of CB were calculated.

Results
81/325 (24.9%) adverse events occurred, but only 23 (7%) were major complications (MC) (22 pneumothorax and 1 hemothorax, requiring drainage and prolonged hospitalization). The incidence of MC wasn’t different between either CB and FNAB group (11/155, 7%), or larger and smaller CB needle size (20/275 vs. 3/50, p=n.s). Only the depth of the LM seemed to be significant as negative predictor for MC (p=.0061). Pathological diagnosis was of benign LM in 60 CB (18.4%), malignancy in 265 (81.5%). According to the above gold standard criteria, TP were 265, FN 13, TN 47, FP 0. Sensitivity, specificity and diagnostic accuracy were 95.3%, 100% and 96%, respectively. PPV was 100%, NPV 78.3%.

Conclusion
CB is as safe as FNAB in characterizing LM; particularly, needle size doesn’t impact on MC rate. CB is highly accurate in morphological characterization of LM, also providing additional tissue for molecular studies, when needed.

Background
Differential diagnosis of primary lung cancer and metastatic lung tumor before surgery is important. However, histological diagnosis using bronchofiberscopy is often difficult in these small peripheral lung nodules. It appears to be useful to diagnose pulmonary nodules using chest CT. As already known, primary lung cancer presents complicated appearance in chest CT. Contour of primary lung cancer is expressed using the words such as undulated, irregular, and spiculated. Contrary, metastatic lung tumor usually shows simple round shadow. These characteristics are used for the differential diagnosis of tumors. However, we often meet tumors with borderline complexity that we are not able to clearly classify. Chest CT finding is expressed by words at the diagnosis. Therefore, it is difficult to standardize or compare the diagnostic properties. Numerical evaluation of complexity of tumor outline results in the quantitative evaluation of tumor shape and may help the standardization of diagnosis of pulmonary nodules on chest CT. Malignant pulmonary tumors basically show round appearance. Therefore, complexity of tumor outline is to be expressed by the deviation from a circle. And the extent of deviation can be expressed numerically. The array data set of the deviation is to be regarded as the composition of various kinds of waves. Fast Fourier transform (FFT) analysis is suitable to evaluate these components of the wave data. In this study, we performed the quantitative analysis for the complexity of tumor outline of both primary lung cancer and metastatic lung tumor utilizing FFT analysis. And then we evaluated the usefulness and adequacy of our evaluation method.

Methods
Sequential cases of 72 histologically proven primary lung cancers (Group PL) and 54 metastatic lung tumors (Group MT) were included. The diameters of tumors in groups PL and MT were 18.9±7.4 mm and 12.2±6.1 mm, respectively. The outline of each tumor on chest CT images was described using polar coordinates, and converted to rectangular coordinates, yielding wave data of the tumor outline. The FFT was then used to analyze the wave data. The complexity index (Cxi) was defined as the sum of the amplitude of all harmonics over a fundamental frequency.

Results
The Cxi was higher (P <0.0001) for group PL (10.3±6.7 mm) than for group MT (3.2±2.4 mm), and it was correlated with tumor diameter in both groups: PL (r =0.667, P <0.0001) and MT (r = 0.809, P <0.0001). The cut-off equation “Cxi = 0.127 DT + 2.23” provided the highest diagnostic accuracy for distinguishing Group PL from Group MT such as a sensitivity of 95.8%, a specificity of 81.5%, and an accuracy of 89.7%.

Conclusion
Complexity of outline of the pulmonary nodules can be evaluated quantitatively using FFT analysis. This analytical procedure was designed from the beginning as it can be equipped on the graphic workstation, and we are now starting to develop it. This analytical method will help the diagnosis of primary lung cancer. FFT analysis appears useful for quantification of complexity of the tumor outline.

Background
Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor with a complex growth pattern. Imaging plays a crucial role in diagnosis and management. The diagnosis of MPM is based on histology using essentially immunohistochemistry on pleural biopsies. Occasional long-term survival results are probably due to the biologic characteristics of the disease. 18F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET)-computed tomography (CT) (FDG PET-CT) has become an invaluable tool for the diagnosis, staging, and prognosis of this severe disease as it combines both anatomic and functional information in a single imaging procedure, allowing for improved management of this disease.

Methods
From April 20011 and May 2013, eight patients with histologically proven MPM underwent integrated FDG PET and computed tomography (CT) scanning. These were analyzed: mean age was 53.6 years (range: 40-66) and histologic MPM subtypes were epithelioid (7 patients) and biphasic (1 patients). We observed a significant correlation between high SUV(max) and high-grade disease. There were 75 % male patients and 25% female patients. PET-CT images showed intense abnormal FDG uptake (SUVmax>8.0) in the pleural lesions of all 8 MPM patients at delayed phase, while it showed abnormal FDG uptake in all (100%) patients at early phase. In all patients, the values of SUVmax at delayed phase were higher than those at the early phase. PET-CT also indicated metastasis in the lymph node in 4 patients (50%) and in the peritoneal lesions in one patient (12.5%) with MPM. The results showed that 18F-FDG PET-CT at delayed phase is very useful for the diagnosis of pleural diseases and high uptake of 18F-FDG PET-CT may be a predictive factor of prognosis in MPM patients.

Results
MPM has a limited response to conventional chemotherapy and radiotherapy, thus early diagnosis of MPM is extremely critical. In these group patients, PET-CT showed all lesions with high sensitivity (%100). CT scans have limited accuracy in the differentiation between benign and malignant pleural disease. Also CT tends to underestimate early chest wall invasion and peritoneal involvement and has well-known limitations in the evaluation of lymph node metastases. Several studies have reported that 18-fluorodeoxyglucose (FDG) PET-CT plays an important role in the assessment of thoracic malignancy such as lung cancer. With a small patients experience, we suggest that PET-CT is useful as an aid for diagnosis and prognosis of MPM. PET-CT provides useful information concerning the extension of the lesions to thoracic and abdominal walls not fully evaluated by the initial conventional cross-sectional imaging. PET/CT also allows an accurate therapeutic monitoring of the disease.

Conclusion
Our results showed (even with a limited group of patients experience), PET/CT seems to be superior to convantional imaging modalities in identifying more extensive disease involvement, and detecting unexpected occult distant metastases.

Background
Non-small cell lung carcinomas (NSCLCs) are sometimes detected incidentally on imaging for unrelated causes. We studied the rate of incidental detection and its impact on long-term survival in a nation-wide cohort of patients operated for NSCLC.

Methods
This population-based study included all patients who underwent pulmonary resection for NSCLC in Iceland between 1991 and 2010. Demographics and clinicopathological features were compared in patients diagnosed incidentally and those presenting due to symptoms. The data was devided into four 5-year periods to assess trends, and multivariate analysis used to evaluate prognostic factors of cancer-specific survival (CSS), focusing on incidental detection.

Results
From a total of 512 patients, 174 (34%) were diagnosed incidentally and this proportion remained unchanged during the study period. Most tumors were detected by chest X-ray (CXR) (26%) or CT (8%), but the proportion of CT diagnoses rose to 15% during the last 5-year period. The incidentally detected tumors were smaller (3.0 vs 4.3 cm, p<0.0001) and were diagnosed at earlier TNM-stages (64 vs. 40% on TNM-stage I, p<0.0001). Furthermore, a higher fraction of the incidentally detected tumors were adenocarcinomas. Five-year CSS for patients with symptoms was 40%, those incidentally detected on CXR 57% and on CT 80% (p<0.001). By multivariate analysis patients detected incidentally on CT had significantly better CSS compared to those diagnosed incidentally by CXR or for patients with symptoms related to NSCLC (HR 0.38, 95% CI 0.16-0.88, p=0.02).

Conclusion
A third of surgically treated NSCLC-patients are detected incidentally, and this fraction has not changed for two decades. However the proportion of CT-detected NSCLCs is increasing and these patients seem to have a more favorable survival than patients detected incidentally on CXR or those who present with symptoms.

Background
PET for early prediction of tumor response to Erlotinib in patients with advanced non small cell lung cancer NSCLC has been evaluated. The aim of this prospective study was to compare the early metabolic treatment response using European Organization for Research and Treatment of Cancer (EORTC) 1999 recommendations, PET Response Criteria in Solid Tumors (PERCIST), and the standard treatment response using Response Evaluation Criteria in Solid Tumors (RECIST).

Methods
PET was performed before treatment and after 45 days of receiving Erlotinib 150 mgrs daily in advanced NSCLC pts. The hottest lesion in each patient was evaluated according to the EORTC 1999 recommendations, PERCIST and RECIST to assess metabolic and anatomic response. Response classifications were compared statistically using Wilcoxon signed-rank test. Overall survival (OS) and Progression-Free Survival (PFS) time were calculated by the Kaplan-Meier test.

Results
14 patients (10 men and 4 women, mean age: 64.1±12.0 years, range 38 to 79 years) were evaluated. Anatomic responses according to RECIST were as follows: 4 Partial Response (PR) and 10 Progressive Disease (PD). Metabolic responses according to EORTC criteria were 5 Partial Metabolic Response (PMR), 5 Stable Metabolic Disease (SMD), and 4 Progressive Metabolic Comparisons of EORTC and RECIST assessment with PERCIST were as follows:

	PERCIST
RECIST	PMR	SMD	PMD	Total
PR	4	0	0	4
SD	0	0	0	0
PD	0	6	4	10
Total	4	6	4	14
EORTC
PMR	4	1	0	5
SMD	0	5	0	5
PMD	0	0	4	4
Total	4	6	4	14

There was a significant difference in the results of response classification between metabolic classifications and RECIST (p<0.04). RECIST and PERCIST (Responders vs. Non-responders) were significant factors associated with DFS ( HR =4.070; 95% CI, 1.383-11.972; p=0.002 for RECIST and HR =0.245; 95% CI, 0.0835-0.722; p=0.001 for PERCIST) and OS ( HR =2.620; 95% CI, 0.8806-7.795; p<0.046 for RECIST and HR =0.3817; 95% CI, 0.1283-1.1356; p=0.046 for PERCIST). EORTC criteria was a significant prognostic factor for predicting DFS ( HR = 0.319; 95% CI, 0.061-1.667; p=0.028) but not for OS (p=0.65).

Conclusion
Metabolic and anatomic response were different in NSCLC pts treated with Erlotinib. PERCIST can be considered an appropriate metabolic evaluation method of therapeutic efficacy to discriminate responders from non responders. Mature results will be presented.

Background
The epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor make very important role in chemotherapy for primary lung adenocarcinoma. It is necessary to examine EGFR mutation before medication, but it is difficult to examine for all patients. Our purpose is to determine EGFR mutation presence by HRCT findings of primary lung adenocarcinoma.

Methods
This study consists of 476 primary lung adenocarcinomas which were examined EGFR mutation (exon 18, 19 and 21) by a genetic analysis. EGFR mutation-positive group (EGFR-P) were 223 cases (resected =178, non-resected =45), and EGFR wild-type group (EGFR-W) were 253 cases (resected =161, non-resected =92). At first, presence of findings, such as much pleural effusion, atelectasis, or secondary pneumonia, that come to have difficulty in evaluation of size and the character of tumor, was determined. Then, all evaluable parameters were analyzed. The high resolution-CT (HRCT) findings that were analyzed independently by 2 radiologists with special attention were 21 parameters (tumor size, well-defined margin, irregular margin, spiculation, lobulation, pure ground-glass opacity (GGO), part-solid, solid, air bronchogram, cavity, calcification, broncho-vascular convergence, pleural indentation, pleural concave, pleural thickness, lymphangitis carcinomatosis, emphysema, interstitial pneumonia, pulmonary metastasis, pleural effusion, and lymph node enlargement). The age, gender and smoking history were additionally reviewed. These parameters were evaluated with Chi square test and multivariate analysis. A p-value less than 0.01 were considered to indicate a statistically significant difference.

Results
The cases that were hard to analyze a tumor into by such as atelectasis were two (EGFR-P) and 26 (EGFR-W), respectively. A statistical significant difference was present (p=3.4E-05). Chi square test showed a statistically significant difference about "part-solid (p=5.5E-06)", "air bronchogram (p=0.0036)" and "pleural indentation (p=0.0002)" more frequently in EGFR-P than in EGFR-W. Similarly “woman (p=1.3E-09)” and “non-smoker (p=2.7E-13)” were observed more frequently in EGFR-P than in EGFR-W. On the other hand, “solid (p=2.1E-07)”, “cavity (p=0.0004)”, “emphysema (p=5.1E-14)”, “interstitial pneumonia (p=3.1E-8)” and “lymph node enlargement (p=0.0008)” were observed more frequently in EGFR-W than in EGFR-P. And Multivariable analysis showed that “cavity (p=0.003)”, “emphysema (p=0.001)” and “interstitial pneumonia (p=0.001)” were observed more frequently in EGFR-W than in EGFR-P. On the other hand, there was no parameter that became statistically significantly more frequently in EGFR-P than EGFR-W. By the multivariable analysis, there was no significant statistical difference about gender and smoking history.

Conclusion
The cases that were hard to analyze a tumor into by such as atelectasis were significant in EGFR-W. Some HRCT findings (part-solid, solid, air bronchogram, cavity, pleural indentation, emphysema and interstitial pneumonia) indicated more statistically significant usefulness for a diagnosis of the EGFR mutation. Especially multivariable analysis showed that HRCT findings (cavity, emphysema and interstitial pneumonia) were more statistically significant about EGFR mutation than gender and smoking history.

Background
Lung cancer is a leading cause of the cancer-related death in the world, and frequently presents with an advanced disease at diagnosis. Thus, early detection of lung cancer is thought as an important opportunity for decreasing mortality. It is willingly expected that novel method of early detection of lung cancer using biomarkers, such as cancer-specific up-regulation of methylation levels on genomic DNA. We hereby report that 7 CpG sites were found to be highly methylated in Non-Small-Cell-Lung Cancer (NSCLC), those which are possible promising NSCLC-specific biomarkers.

Methods
Samples for genome-wide DNA methylation analysis consisted of 10 surgical specimens including 8 NSCLC (3 adenocarcinomas, 2 squamous cell carcinomas, 2 bronchioalveolar carcinomas and 1 large cell carcinoma) and 2 adjacent normal lung tissues. Genomic DNAs were isolated from frozen tissue sections by using QIAamp DNA mini kit (QIAGEN) followed by bisulfite conversion with Epitect bisulfite kit (QIAGEN) according to manufacturer’s protocol. Bisulfite converted DNAs were hybridized to the Illumina Infinium HumanMethylation 450 BeadChip, which screens methylation levels of more than 450,000 CpG sites within a single array. Evaluation of the array screening data revealed a series of candidate CpG sites that are preferentially methylated in cancer samples as compared to normal controls. To further validate cancer-specific up-regulation of methylation levels at candidate CpG sites, the QIAGEN Pyromark Q24 system was employed to conduct bisulfite pyrosequencing analysis. Pyromark CpG assay probes were designed with the aid of PyroMark Assay Design Software 2.0 to encompass up to 300 bases region around the CpG site of interest, and used to carry out PCR amplification and pyrosequencing on bisulfite-converted genomic DNA templates. The analyzed samples included 136 surgical specimens consisting of 68 pairs of NSCLC and adjacent non-cancerous matched tissue, which are collected by macrodissection from paraffin-embedded sections. The 68 NSCLC samples are classified in terms of histological types as follows: 54 adenocarcinomas, 10 squamous cell carcinomas, 2 adenosquamous cell carcinomas, 2 large cell carcinomas, and in terms of cancer staging as follows: 37 of stage I, 15 of stage II, 12 of stage III and 4 of stage IV.

Results
Seven CpG sites were found to be highly methylated in NSCLC samples compared to adjacent controls in a statistically significant manner (two-way ANOVA, p < 0.05). The Illumina CpG cluster numbers (cg#) of the 7 CpG sites and their genomic locations in GRCh37 coordinates are as follows: L3302 (cg26917140; chr1:91184770), L3303 (cg04654530; chr2:63282702), L3304 (cg27315333; chr2:63285950), L3305 (cg17080163; chr2:123418757),　L3310 (cg15347189; chr3:187387999), L3314 (cg03148184; chr4:111562513), L3316 (cg16509851; chr4:174430614). Among them, L3303 and L3310 are located within the genomic region corresponding to orthodenticle homeobox 1 (OTX1) gene and somatostatin (SST) 1st exon, respectively.

Conclusion
These 7 CpG sites are possible promising NSCLC-specific biomarkers for screening and early detection of lung cancer, and our goal is the development of the technology to detect these novel biomarkers from a blood sample. This technology may eventually lead to early detection of lung cancer, which is thought as an important opportunity for decreasing lung cancer mortality.

Background
To present results of the first four lung cancer (LC) screening programs based on low dose chest CT (LDCT) conducted in Poland.

Methods
Four LC screening programs were conducted in different Polish cities (Gdansk, Poznan, Szczecin, Warsaw) between 2008 and 2011. Algorithms used for patient`s selection for further diagnostics were based on IELCAP protocols with local modifications. The enrolled patients were ages 50-75, being either active smokers or with history of >20 pack years. The following data were analyzed: number of LC detected and resected in both protocols, and percentage of stage I cancers detected.

Results
34810 patients were screened in accordance with protocols. Results are presented in table I.

Parameter	G	P	W	Sz	All
N[o ]of patients	8693	9357	1740	15020	34810
LC detected	91	96	17	120	324
LC stage I	58	52	12	83	205

The overall detection rate was 1 cancer per 102 CTs and varied from 1/125 to 1/90 (1.05%, 1.03%, 1.0%, 0.86%, 0.98% respectively). The majority of cancers were diagnosed in stage I (64%, 55%, 70%, 69% 64.5% respectively), while this parameter does not exceed 30% in overall population treated by thoracic surgery in Poland. The differences between centers regarding both detection rate and stage I percentage were not significant (p=0.167 and p=0.599 respectively). However, if one compares the biggest center alone (Szczecin) vs all other ones together, the detection rate in Szczecin is significantly lower (p=0.0278).

Conclusion
The detection rate of all LC as well as stage I LC in the Polish LDCT screening programs is high and comparable in different centers.

Background
The National Lung Screening Trial (NLST) compared low dose CT (LDCT) with chest radiography (CXR) in high-risk populations and found a 20% reduction in lung cancer mortality at 6 years with LDCT after an initial scan and two annual rounds of screening. This is the first randomized controlled trial (RCT) to show a mortality benefit with lung cancer screening. LDCT screening is not yet part of the standard of care and no formal process currently exists in Ontario, Canada for lung cancer screening. Injudicious use of LDCT can potentially cause more harm than benefit, including exposure of healthy persons to ionizing radiation and subsequent invasive procedures for ultimately benign lesions. When used correctly, however, LDCT screening has the potential to save lives. A practice guideline was developed to guide clinicians and healthcare policy makers with evidence-based recommendations for screening high-risk populations for lung cancer.

Methods
The guideline was developed using the methods of Cancer Care Ontario’s Program in Evidence-Based Care (PEBC). The core methodology of the PEBC’s guideline development process is a systematic review. A systematic review had recently been completed by a collaboration of the American Cancer Society, the American College of Chest Physicians, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. The evidence from that systematic review formed the basis of the current recommendations, which were reviewed, and amended where necessary, by clinical experts in the fields of medical, radiation, and thoracic oncology; diagnostic radiology; pulmonary disease; and population health. The recommendations were reviewed by the Provincial Lung Cancer Disease Site Group and underwent both internal review by an expert panel and external review by clinicians with expertise in the topic to achieve consensus.

Results
The systematic review included three RCTs comparing LDCT screening with CXR (including the NLST), 5 RCTs comparing LDCT screening with usual care (no screening), and 13 single-arm studies of LDCT in patients at risk for lung cancer. One large RCT reported a statistically significant reduction in lung cancer mortality with low-dose computed tomography at six years compared with CXR. The practice guideline recommendations generally align with the parameters of the NLST. Deviations were described and justified by the guideline working group. The recommendations support screening persons at high-risk for lung cancer with advice for defining a positive result on LDCT, appropriate follow-up, and optimal screening interval.

Conclusion
The benefits of screening high-risk populations for lung cancer with LDCT outweigh the harms if screening is implemented in a strictly controlled manner targeting the high risk population. This practice guideline forms the basis for the rationale for a screening program. An economic impact analysis will need to be done to design an appropriate cost effective lung cancer screening program prior to implementation.

Background
Lung cancer is a leading cause of cancer death. The lack of symptoms in this disease and problems associated with screening programs for early detection means that patients present late with advanced disease. Studies using low-dose computed tomography proved to be beneficial, and the efficacy of computed tomography scanning as a screening tool for lung cancer is an important and contested topic. However, it has been reported that the increased incidence of cancer after computed tomography scan exposure was mostly due to irradiation. So, computed tomography scans should be limited to situations where there is a definite clinical indication. The search for non-invasive diagnostic methods of lung cancer has led to new avenues of research, including the exploration of the exhaled breath. Previous studies have shown that lung cancer can, in principle, be detected through exhaled-breath analysis. This study evaluated the potential of exhaled-breath analysis for the detection of lung cancer.

Methods
Breath samples were taken from patients with lung cancer and from healthy volunteers. The exhaled breath was collected in 1L Analytic- Barrier[TM] bag (OMI ODOR-AIR SERVICE Co. Ltd.). Profiles of volatile organic compounds were determined by gas chromatography/mass spectrometry (Shimadzu Co. Ltd.).

Results
We collected breath samples from 111 patients with lung cancer and 29 healthy volunteers using Analytic-Barrier[TM] bags. The volatile organic compounds were extracted with solid phase micro-extraction and analyzed by gas chromatography/mass spectrometry. The number of volatile organic compounds detected in breath samples was 68. Among the volatile organic compounds 10 compounds were found in only breath of the lung cancer patients. In addition, 11 compounds were found at significantly higher concentrations in breath of the lung cancer patients compared to the controls.

Conclusion
Our data suggest that compounds in breath could possibly be taken as useful breath biomarkers for discerning potential lung cancer patients and volatile organic compounds analysis could be used as a complementary test for the diagnosis of lung cancer. The vision of exhaled breath analysis is that of a broad use in clinical routine for personalized screening, diagnosis and treatment monitoring.

Background
Background: CT Coronary Angiography provides accurate non-invasive evaluation of coronary arteries but also images lung parenchyma and other mediastinal structures. Little is known about the range and incidence of non-cardiac findings in the Australian population and while CT screening has been shown to reduce mortality in high risk individuals the significance of identified pulmonary nodules in this mixed risk population is unknown. A lack of data regarding the malignant potential of these incidentally identified nodules makes evaluation of the relative risk/benefit of both initial imaging of the lung and subsequent surveillance scanning is difficult.

Methods
Methods: A retrospective analysis was performed on reports of all cardiac CT scans done in the calendar year 2012. Descriptive data was collected including baseline patient characteristics, type of nodule and smoking history, as well as whether a full field or restricted field view was performed. Surveillance radiological data and pathology was collected on a sub-group of the population.

Results
Results: 2500 Cardiac CT scans analysed with 48% females. Reports analysed for presence of lung nodules and type of nodule with most common nodule granuloma. Total lung nodules 14% (355) with follow up recommended by specialist radiologists; significant variation from recommendation in practice was noted. 39% of population positive for smoking exposure placing them in high risk population. No episodes of malignancy within follow up CT scans with the majority of nodules being stable over the follow up period. Majority of nodules were <4mm making up 60% of the total nodules described, 4-8mm 20% nodules of described nodules, >8mm making up 12% of nodules. Pulmonary Cysts represented 4% of nodules. Subpleural nodules described separately and making up a minority of nodules.

Conclusion
Conclusion: Cardiac CTs are an increasingly common modality used to evaluate coronary artery disease. Pulmonary nodules are a common finding with a prevalence in this study of 14%; this contributes significantly to a economic burden as well as exposure of the community to ionising radiation which there is growing community and professional concern around. The findings of this audit are in line with published data of a low risk of de novo malignancy in pulmonary nodules as well as a high prevalence of pulmonary nodules across the cohort.

Background
A small percentage of at-risk individuals ultimately develop lung cancer. This warrants a search for a strategy to identify individuals who will be developing lung cancer. The bronchial epithelium represents the field of carcinogenesis and may serve as surrogate tissue for biomarker of risk. Therefore we hypothesized that proteomic alterations in the histologically normal airway epithelium from risk stratified individuals allow us to derive a signature of risk of developing lung cancer.

Methods
We have collected bronchial brushings specimens from risk stratified individuals (Bach PB et al. 2003) and categorized them as Control (group 1), low (group 2) and high (group 3) risk groups. We collected three bronchial brushings specimens from each individual in a single session for acquiring shotgun proteomics (n=30). We also collected brushings from cancer patients whose risk criteria are similar to low (group 5) and high (group 6) risk groups as well as a group of never smoker lung cancer patients (group 4). Shotgun proteomics data were acquired from 3 technical replicates of pooled specimens from 5 individuals. Candidate biomarkers were selected based on group comparison and trend analysis.

Results
We have acquired shotgun proteomics data from bronchial brushings specimen from individuals at-risk for lung cancer development. A total of 4973 proteins have been identified. Jonchere-Terpestra trend test was performed among control, low risk and high risk groups (Groups 1, 2, and 3). Expression level of 316 proteins were altered (trend p <0.05) with 238 proteins demonstrating upward and 78 proteins downward trends. DNA repair and oxidative stress and the galactose metabolic enzyme pathway were enriched in the upward trend analysis.

Conclusion
We identified a proteomic candidate signature of risk of developing lung cancer from histologically normal bronchial epithelial cells. Integration of these results with those upcoming from two other molecular platforms will allow us to narrow down the molecular aberrations most predictive of risk. This signature will be validated in an independent cohort. Such signature of risk for lung cancer may serve as a powerful tool for lung cancer risk assessment and may provide the basis of patient selection for surveillance programs and chemoprevention. This work is funded by RO1 CA102353to PPM.

Background
CXR-screening has long been considered ineffective because RPTs have failed to demonstrate significant mortality reductions in populations randomized to CXR-screening. While these studies demonstrate significant survival advantages associated with CXR-screening, these advantages are widely believed to be spurious, due to the interpretation that CXR-screening leads to substantial overdiagnosis. Indeed, the overdiagnosis hypothesis is the only alternative to the conclusion that CXR-screening saved lives in these trials. The objective of this analysis is to assess the magnitude of overdiagnosis in the context of CXR-screening, and to determine whether survival or mortality provides the best measure of efficacy in existing RPTs.

Methods
The Memorial-Sloan-Kettering and Johns-Hopkins Lung Projects were designed to assess the effectiveness of sputum cytology, since participants were randomized to annual CXR-screening and sputum cytology every four-months or to annual CXR alone. In Mayo-Lung-Project (MLP), following a normal prevalence CXR, 9,192 smokers were randomized to an experimental group (EG) undergoing CXR and cytology every 4-months for 6-years followed by 3-years of observation, or to a control group (CG) observed for 9-years. Controls were advised to obtain annual CXR.

Results
In MSKLP and JHLP, there were no differences between EG and CG regarding mortality, survival, or stage distribution. However, 5-year survival in both trials was about three-fold superior to contemporary national statistics. This suggests a beneficial effect of CXR, assuming that overdiagnosis did not confound survival in EG and CG in both studies. In MLP, lung cancer mortality was 6% higher in EG (p=0.62), although 5-year survival was significantly superior in EG (34% vs. 13%; p=0.0021). The fact that lung cancer incidence was 30% higher in EG (p=0.013) led to the hypothesis that overdiagnosis was responsible for the mortality/survival discrepancy. However, MLP data are inconsistent with overdiagnosis. Long-term survival was achieved only among those undergoing resection. Half of resected cancers were apparently cured, while no unresected patient was cured (7-year survival: 50% vs. 0%: p<0.0001). Indeed, follow-up extended to >20 years in MLP continues to show higher incidence and mortality in EG. While interpreted as supporting overdiagnosis, long-term follow-up results are primarily informative as to randomization adequacy. Mathematical modeling studies indicate that in MLP-EG higher lung cancer incidence and mortality was due to population heterogeneity, due to problems with randomization, not to overdiagnosis.

Conclusion
Abundant evidence supports that the magnitude of overdiagnosis is minimal in the context of CXR-screening. Moreover, evidence from RPTs indicates that CXR-screening is superior to no screening. The survival endpoint is not meaningless in RPTs if one can exclude or adjust for confounding due to overdiagnosis and with sufficiently long follow-up. Because overdiagnosis was not a confounder of survival in MLP, survival most accurately reflected CXR effectiveness. Indeed, long-term survival provided an unbiased surrogate for cure. While the National Lung Screening Trial demonstrates that CT-screening is superior to CXR-screening, CXR is more widely accessible and relatively inexpensive. CXR-screening has the potential to substantially reduce the global burden of lung cancer mortality.

Background
Lung cancer is the leading cause of cancer death for both males and females in New South Wales (NSW), Australia. Similar to other countries, the five-year relative survival rate for lung cancer in NSW is low, reported at 17.6% (2005-07). The poor relative survival rate suggests that in most cases, diagnosis occurs late, predominantly in stage III or IV. A multi-channel public education campaign was implemented in NSW to increase awareness of three symptoms consistent with lung cancer (persistent cough, change in cough and blood in cough) and prompt people experiencing these symptoms to see their General Practitioner (GP) immediately. If people experiencing these symptoms seek a doctor as soon as symptoms are experienced, it has the potential to reduce diagnostic delay and hence, an improvement in the five-year relative survival of lung cancer.

Methods
The public education campaign, comprised mass media television advertising implemented over 5 weeks (March/April 2013) at 100 TARPs per week in conjunction with public relations activity and a direct mail communication to GPs across NSW. Quantitative telephone surveys were conducted in July 2012 (pre-campaign) and April 2013 (post-campaign) with adults over 45 years of age residing in NSW (both; n=1000). Unprompted and prompted recall of the campaign were measured and levels of unprompted awareness of symptoms consistent with lung cancer and confidence in recognising symptoms consistent with lung cancer were compared between the two surveys.

Results
Overall, 28.7% of the targeted population recalled the campaign unprompted, increasing to 60.5% when prompted. Pre- and post-campaign results demonstrate an increase in unprompted awareness of key lung cancer symptoms emphasised by the campaign; ‘coughing up blood’ (from 39.1% to 45.4% (p = 0.004)), ‘cough that does not go away for two or three weeks’ (from 17.0% to 40.7% (p = <0.001)) but no significant different in awareness of ‘worsening or change in cough’ (6.3% to 4.6% (p = 0.096)). Post-campaign awareness of these symptoms was higher amongst non-smokers than smokers, particularly for persistent cough. Encouragingly, confidence to recognise a symptom increased from 58.8% to 67.4% (p = <0.001).

Conclusion
These findings suggest that a mass media public education campaign can be an effective approach to increase awareness of symptoms consistent with lung cancer and confidence in recognising these symptoms. Increased awareness and recognition of symptoms can lead to earlier diagnosis and treatment.

Background
The ability to capture and characterise peripheral blood circulating tumour cells (CTCs) has the potential for the development of a blood test for cancer. A number of technological platforms are available to obtain CTCs including filtration-based devices utilising advances of antibody independent capture of cells. This technique shows promising results in experimental conditions; however, its performance has not yet been well evaluated in a clinical setting. We have evaluated diagnostic performance of filtration-based technology using cytomorphologic criteria in patients undergoing surgery for lung cancer.

Methods
From 06/03/2012 to 24/01/2013 we obtained and processed blood from 74 patients undergoing surgery for known or suspected lung cancer using ScreenCell[TM] Cyto devices. Captured cells were stained using H&E and independently assessed by two pathologists (AGN, AR) for the presence of atypical cells suspicious for cancer. Results were reported as confirmed cancer, suspicious or no evidence for cancer. Diagnostic performance was evaluated against the reference of cancer identified within surgically obtained specimens reported by a principal pathologist. Sensitivity and specificity analyses were undertaken. Inter-observer agreement was established by kappa-statistics.

Results
According to histopathology assessment, 42 patients (56.7%) had primary lung cancer, 18 patients (24.3%) had metastatic cancer (predominantly of colorectal origin), and 14 patients (18.9%) had benign lung diseases. The proportion of patients in which cells suspicious for cancer were identified was 39 (52.7%) and 42 (56.7%) as reported by two pathologists. Among those cases, 6 (15.4%) and 14 (33.3%) were reported as confirmatory. The agreement between the pathologists was 77% corresponding to a kappa-statistics of 53.7% indicating moderate agreement. In metastatic cancer patients, suspicious cells were discovered in 10 (55.6%) and 9 (50%) cases by two pathologists. In non-cancer patients, suspicious cell were found in 6 (42.8%) and 5 (35.7%) cases by two pathologists, respectively. The test performance for the diagnosis of cancer using cytomorphological criteria yielded poor-to-moderate sensitivity and specificity values, high positive predictive values and low negative predictive values (Table).

The performance of the diagnosis of cancer using filter-based antibody-independent technique of CTCs trapping

Statistic	Pathologist 1	Pathologist 2
Sensitivity (95% CI), %	55.0 (41.6-67.9)	61.7 (48.2-73.9)
Specificity (95% CI), %	57.1 (28.9-82.3)	64.3 (35.1-87.2)
Positive Predictive Value (95% CI), %	84.6 (69.5-94.1)	88.1 (74.4-96.0)
Negative Predictive Value (95% CI), %	22.9 (10.4-40.1)	28.1 (13.7-46.7)

Conclusion
The results of our study highlight the potential of filter-based antibody-independent technology to develop an accurate blood test for the diagnosis of cancer in the peripheral blood. However, conventional cytomorphological criteria used for the diagnosis provide inadequate sensitivity and specificity. Improved performance with immunocytochemistry is still required prior to further clinical validation.

Background
Thailand is among the countries with a high burden of tuberculosis (TB) with 137 new cases per 100,000 persons per year reported. The radiographic findings of TB can mimic lung cancer even after a complete anti-TB treatment. Currently, no clear evidence of benefits from lung cancer screening has been established in a high-risk population residing in an endemic area of TB.

Methods
A prospective study was started in July 2012 to determine the role of low-dose computerized tomography (LDCT) as a lung cancer screening tool in Thai heavy smokers (>30 pack-years) without a history of active TB within a recent year. Abnormal LDCT findings were categorized into 3 groups: negative, indeterminate, and suspicious for malignancy according to the baseline nodular volume and volume doubling time in a follow-up LDCT.

Results
As of April 2013, 580 subjects were enrolled. At baseline, 406 cases (70%) had abnormal LDCT findings including 16 cases (2.8%) suspicious for primary lung cancer. Two hundred and forty-five cases (42%) had benign characteristic nodules, 78 cases (13.4%) had inflammation or infection patterns, and 67 cases (11.6%) were indeterminate for malignancy. Of the suspicious primary lung cancer group, 3 cases had a previous lung nodule without any evidence of nodule progression, 13 cases underwent tissue biopsy with resulting lung cancers in 7 cases, caseous granuloma in 2 cases, and negative results in 4 cases. Two cases with the inflammation/infection pattern had asymptomatic progressive lesions in a 2-month follow-up LDCT and underwent bronchoscopy. One case was proven pulmonary TB while the other was culture-negative TB; both of them responded well to anti-TB drugs. Two additional primary lung cancer cases were detected at a 3-month follow-up LDCT yielding a total of 9 positive lung cancer cases (1.5% of total subjects) which consisted of 4 - stage I cancer, 1 - stage II cancer, 1 - stage III cancer, and 3 - stage IV cancers. Early-stage cases (5/9) received potentially curative surgery. Notably, 7 and 2 lung cancer cases were detected from suspicious and indeterminate group, respectively. Three other malignancies were also detected including 1 mediastinal lymphoma, 1 small cell of unknown primary and 1 cholangiocarcinoma.

Conclusion
Our preliminary result revealed that despite a high burden of TB in Thailand, LDCT screening in heavy smokers could yield a high rate of primary lung cancer in this population at risk.

Background
The association between chronic obstructive pulmonary disease (COPD) and lung cancer has been previously reported. However, the mechanism whereby emphysema (a destructive process) promotes lung carcinogenesis (a proliferative process) has not been adequately explained. Emphysema is associated with lower lung density while lung inflammation is associated with increase in lung density. We hypothesized that lung density and emphysema are independent predictors of malignancy risk of lung nodules found on screening low dose spiral CT (LDCT).

Methods
Image analysis was performed on a subset of LDCT scans (120 kVp, 40 mAs) from the Pan Canadian Early Detection of Lung Cancer Study and the BCCA Lung Health Study using the VIDA Diagnostics CT image analysis software Pulmonary Workstation 2. The lobe with the pulmonary nodule was first segmented. The average lung density surrounding the nodule was measured. Emphysema severity was defined as percentage of the lobe with -950 Hounsfield Units (HU). Multivariate logistic regression analysis was performed to determine if lung density and degree of emphysema were independently associated with malignant lung nodules.

Results
A total of 161 subjects with lung nodules ≤20 mm were studied. The clinical and CT characteristics are shown in the Table 1. Table 1. Study variables by lung cancer status

	No Cancer	Cancer	P-value
N=	95	66
Age	64±5	63±6	0.52
Gender : Men: Women	53% : 47%	38% : 62%	0.078
Current: Former smoker	61% : 39%	45% : 55%	0.051
Family history %	21%	38%	0.022
Nodule diameter	10.5 ± 3.0	12.9 ± 4.1	<0.001
Nodule Type – solid	53%	50%
- part solid	11%	29%	0.003
- Non-solid	37%	20%
Nodule location (upper versus middle or lower)	45%	65%	0.016
Spiculation (%)	18%	39%	0.017
Emphysema (visual score) % present	67%	78%	0.152
Density of lobe with nodule	-848±32	-837±32	0.024
% emphysema in lobe with nodule	9.3%±9.7	7.1%±6.9	0.09

While the presence of emphysema of any grade in both lungs by visual score was higher in the lung cancer group (78% versus 67%), the difference was not statistically significant in the univariate or multivariate analysis. Quantitative measurement of emphysema severity (area with -950 HU) in the same lobe where the lung nodule located showed that the degree of emphysema was less in patients with lung cancer (7.1% versus 9.3 %, P = 0.041 in the final multivariable logistic regression model consisting of family history, nodule size, type and spiculation). Lung density surrounding the lung nodule was significantly higher in the lung cancer group compared to the benign nodule group in univariate analysis (P = 0.024) but not in multivariable analysis.

Conclusion
Our results suggest lung inflammation as reflected by increase in lung density may be a more important factor in lung carcinogenesis while emphysema may be more of a dosimeter for lung damage by tobacco smoke exposure. Further studies in a larger dataset are being performed to determine the incremental value of lung density in predicting the malignancy risk of lung nodules ≤ 2cm detected by screening LDCT.

Background
For patients with advanced non-small cell lung cancer (NSCLC), it is unclear whether the anatomical location of their metastases has a different impact on survival. In this project, we sought to describe these metastatic sites using the 7th edition of the TNM classification and analyse their prognostic implications. A special emphasis was placed on brain metastases, as these patients are commonly excluded from participating in clinical trials, based on perceptions of inferior outcomes.

Methods
Consecutive patients diagnosed with NSCLC, between 2005 and 2009 at Hôpital du Sacré-Coeur de Montréal were included in this retrospective analysis. They were re-classified, from the TNM 6[th] edition, in use at the time, to the TNM 7. The following metastatic locations were considered: brain, pleura, contra lateral lung, extra-thoracic lymph nodes, soft tissues, pericardium, adrenal glands and skeleton. The treatments received were classified in one of these three groups: standard, non-standard and palliative care. Cox proportional hazards analysis was used to identify predictive factors for survival among the following parameters: age, body mass index, gender, histology, smoking history, type of treatment, number and location of metastatic sites.

Results
Five hundred thirty seven patients with stage IV NSCLC were identified. Their metastatic sites were, in decreasing order of frequency: skeleton (41%), pleura (32%), contra lateral lung (28%), brain (26%), liver (18%), extra-thoracic lymph nodes (16%), soft tissues (14%), adrenal glands (14%) and pericardium (6%). Forty-five percent of patients had metastases to 1 organ, 33% had 2 and 22% had 3 to 6 organs involved. In univariable analyses, metastases to the liver, adrenal glands or skeleton were associated with worse prognosis (HR=1,37; 1,38 and 1.34, respectively; p < 0.05). The patients with liver or adrenal metastases were more likely to have at least another metastatic site (90%). In multivariable analyses, not surprisingly, better survival was found in patients who could receive standard treatment, those having adenocarcinoma histology and less metastatic sites. Having contra lateral lung metastases conferred a better prognosis (HR=0.74, p=0.0037). Remarkably, brain metastases were not a prognostic factor in uni or multivariable analyses. This group of patients was more likely to have at least one of three better-risk factors: age < 65 (68%), brain as a unique metastatic site (37%), and more frequent in patients with adenocarcinoma than squamous cell cancer (27 vs. 13%). Conversely, they were less likely to be treated with palliative care compared to patients with extra-cerebral metastases (8 vs. 35%).

Conclusion
A history of brain metastases did not have a prognostic influence in our NSCLC patient cohort. This finding could be explained by the presence of better-risk factors in that group of patients. Brain metastases should not be considered by itself an exclusion criterion from clinical trials.

Background
Lung cancer is a major cause of mortality in Russia: 51,364 deaths in 2008, 18.0% of all cancer-related deaths (GLOBOCAN). Mutations in the EGFR gene are known to predict for sensitivity to EGFR tyrosine kinase inhibitors in patients with advanced non-small-cell lung cancer (NSCLC). Clinico-pathological characteristics associated with a higher prevalence of EGFR mutations are: adenocarcinoma histology, East Asian origin, non-smoking history, and female gender. This study aimed to document the characteristics, clinical management and outcomes of Russian patients with NSCLC, and to investigate associations between EGFR mutations and clinico-pathological parameters.

Methods
A non-interventional, prospective cohort study (ClinTrials ID: NCT01069835) carried out in a representative selection of hospitals in order to assess lung cancer management in countries throughout European and Asian parts of Russia. Patients with confirmed NSCLC attending participating centres for the first time between 1 February 2010 and 31 March 2011 were enrolled and followed-up according to routine practice for a minimum of 12 months or until death.

Results
A total of 838 patients were enrolled at 33 sites across the Russian Federation. Baseline characteristics were: mean age, 58.7 (SD ±8.5) years; male, 78.4%; European, 98.0%; Russian, 79.6%; Tatar, 3.8%; Ukrainian, 3.1%; Byelorussian, 1.3%; current smokers, 49.4%; never-smokers, 26.5%; ECOG performance status (PS) 1, 65.6%; disease stage IV, 25.4%; stage III, 37.8%; stage I/II, 36.7%. Metastases were found in 38.1% of patients; the most common metastatic sites included: respiratory system, 70.2%; pleura, 17.2%; bone, 11.9%; liver, 10.3%. EGFR mutations were detected in 85/838 (10.1%) patients (84/821 [10.2%] European patients and 1/15 [6.7%] Asian patients), who were mostly women, 69.4%; <70 years old, 85.9%; never smokers, 71.8%; PS 1, 59.3%; adenocarcinoma, 58.8%. EGFR mutation rates by histological type were: squamous-cell carcinoma (SCC), 18/455 (4.0%); adenocarcinoma, 50/260 (19.2%); adenocarcinoma bronchioloalveolar, 11/54 (20.4%); large-cell carcinoma, 2/24 (8.3%); adenosquamous carcinoma, 2/19 (10.5%); other histology, 2/26 (7.7%). Logistic regression analysis of EGFR mutations; statistically significant odds ratios: male vs female, 0.086 (p<0.0001); any smoking history vs no smoking history, 0.110 (p<0.0001); non-SCC vs SCC, 5.365 (p<0.0001); increase in age (10 years), 1.391 (p=0.0227). Platinum-containing doublets were the most commonly used chemotherapy at first (83.5%) and second line (51.0%). In patients who received first- and second-line chemotherapy, objective response rate, disease progression rate and median progression-free survival (PFS) were, respectively, 16.1% and 3.6%, 63.8% and 76.8%, 35.0 weeks and 19.4 weeks. Median PFS (weeks) after first-line chemotherapy by histology and EGFR mutation status was: SCC, 36.3; non-SCC, 34.0; EGFR mutation positive, 36.9; EGFR mutation negative, 34.3.

Conclusion
In this cohort, the proportion of patients with EGFR mutation-positive NSCLC was similar to other studies of NSCLC in Caucasian populations. EGFR mutation status was significantly associated with female gender and non-smoking history, in-line with previous studies of Asian and Caucasian patients with advanced NSCLC. This study contributes to a better understanding of prognostic and predictive factors of NSCLC, which will enable optimal treatment selection in future clinical practice.

Background
The LungPath study is a national multi-centre survey of lung cancer diagnosis and staging practice in England. As part of the project, we looked for variation in access to key investigations such as EBUS and PET-CT scanning and linked this to how likely these studies were used to be in different centres and the impact these differences may have on patient care.

Methods
Twenty willing English lung cancer centres were randomly selected to participate in the LungPath study. Participating centres agreed to submit data on each new lung cancer patient seen during the study period of six months from January to June 2012. Data collected included clinical information such as age, gender and performance status, the dates of all radiological investigations performed and anonymised pathology reports from all other investigations performed. The data collected was used to map each individual patient’s diagnostic pathway. In addition, we collected information about typical waiting times for key investigations and whether these investigations were available on-site or at other institutions. We analysed the patient data to see if the availability of investigations such as EBUS and PET-CT impacted the patient pathways in each centre.

Results
There were significant differences between centres in the availability of EBUS and PET-scanning. Approximately half of the units surveyed reported waiting times for EBUS and PET-scanning of one week or less while the other half reported longer waits, typically two weeks and sometimes longer. There were large differences in the proportions of patients that underwent EBUS or PET-scanning from centre to centre with patients up to six times more likely to receive an EBUS and four times more likely to receive a PET-scan in some centres than others. There was a clear relationship between the use of the investiagtion and the waiting time. We also found that the point in the diagnostic pathways that these investigations were used varied and in many cases differed from best practice guidelines; several centres routinely performed EBUS as a separate procedure after a bronchoscopy had already been performed.

Conclusion
There are marked differences in the availability and use of EBUS and PET-scanning within different lung cancer units involved in diagnosing and staging lung cancer in England. There is a need for commissioners to ensure fairer service provision across England and opportunities for education of clinicians to make best use of the available resources.

Background
The treatment of patients (pts) with advanced non–small-cell lung cancer (NSCLC) is based on clinical trials experience and molecular characteristics. Although molecular testing has become more mainstream, knowledge gaps need to be addressed to optimize treatment decision. Delay to treatment may compromise palliative efficacy. To evaluate therapeutic delays, procedures for 71 biopsies from pts with stage IV NSCLC newly diagnosed submitted to molecular testing were retrospectively analysed.

Methods
Demographic data, site of biopsy, type of first systemic treatment, EGFR mutations in exons 18, 19 and 21 using a dual technical approach (direct sequencing of polymerase chain reaction (PCR) products followed by bidirectional sequencing by Sanger method), EML-4-ALK rearrangements by fluorescence in-situ hybridization (both done in a single central laboratory sponsored by pharmaceutical companies), year of diagnosis, time from first consultation to molecular testing results (diagnostic delay, DD), and time from first consultation to treatment initiation (therapeutic delay, TD) were obtained from 71consecutive pts with stage IV NSCLC newly diagnosed seen from 8/2010 to 5/2013 in two general oncologic institutions located on Patagonia, Argentina.

Results
Median age was 59 years (range 22-82), 38 % were women. 86% were adenocarcinoma. 62% of specimens were derived from primary tumors, 38% from metastatic sites. EGFR analyses was done in all 71 specimens, 13 have insufficient material for testing (18%) (group ND) (27% of ND in biopsies obtained during 2010-2011 versus 10% of those seen during 2012-2013, p: 0.04). 8 evaluable pts (14%) presented any EGFR mutation, whereas 50 (86%) were negative. 11 pts were evaluated for ALK translocation in 2013. Only 1 pt was positive. As a consequence, 9 pts from the entire cohort were able to be treated with molecular directed treatments as first line (13%, group POS) Median DD for EGFR analyses was 18 days (range 8-32). It was 13 days during 2013 probably due to a better multidisciplinary approach. Median DD for ALK analyses was 18 days (range 14-32). Median TD was 24 days (13-77) for the entire cohort. It was 23 days (13-36) for Non-POS pts and 39 days (21-77) for POS pts (p:0.0001) Despite positivity only 4/9 POS pts were treated with TKI as first line treatment. Main reasons for no treatment were excessive delay for drug accessibility (5) and performance status deterioration (1). DD represent 75 % of TD in non-POS pts, and 48 % in POS pts

Conclusion
1- Molecular testing permit to indicate first line TKI treatments in 13% of pts 2- DD may compromise treatment in all pts, but specially in the numerous non-POS pts who otherwise would have been starting therapy after first consultation. 3- With a multidisciplinary approach, it is possible to have better testing results and to reduce DD. 4- Drug accessibility is an important cause of TD in POS pts 5- TD for any preventable reasons should be promptly reduced as survival or quality of life may be compromised.

Background
EGFR mutations are highly associated with pulmonary adenocarcinoma in East Asian never-smoker population. The aim of this study is to evaluate the clinical characteristics of non-small cell lung cancer (NSCLC) with EGFR mutations in never smokers.

Methods
From June 2011 to Dec 2012, consecutive NSCLC patients who admitted for initial diagnosis of lung cancer without smoking habit were recruited in Seoul National University Hospital.

Results
Among 979 of lung cancer patients, 342 never smokers with NSCLC (38.6%) were analyzed. Mean age was 62.7 ± 10.6 years old and mean BMI was 23.8 ± 3.0 kg/m[2]. Adenocarcinoma (307, 89.8%) was the major pathologic diagnosis. The most common clinical stage was IV (134, 39.2%), followed by stage Ia (115, 33.6%). Among 303 patients who underwent EGFR mutation test, 180 (59.4%) patients had EGFR mutations. The never smokers with NSCLC-EGFR (+) showed better performance status (P=0.006), lower uptake of SUV in main mass (8.9 ± 5.9 vs. 11.4 ± 6.8, P=0.003), early clinical stage (≤ II, P=0.009), and higher proportion of curative lung resection (63.3% vs. 41.2%, P=0.005) compared to the patients with NSCLC-EGFR (-).

Conclusion
EGFR mutations are associated with early stage of non-small cell lung cancer in never smokers.

Background
In many cancers, the N-classification of current TNM stage is categorized by the number of positive lymph nodes. However, for non-small cell lung cancer (NSCLC), it is classified by the involvement of specific regional node groups. The aim of this study is to make a new N-classification grouping (nN stage) based upon the number of metastatic lymph nodes and to evaluate its prognostic significance in predicting outcome after resection of NSCLC.

Methods
Between January 2000 and April 2011, 2319 patients underwent surgery for NSCLC in our hospital. A total of 1982 patients was selected by excluding patients who received preoperative induction therapy or did not get curative resection and those with pN3 metastatic lymph nodes. Prospectively collected clinical information as well as pathologic variables were retrospectively analyzed. The recursive partitioning analysis was applied to define the most significant cut-off number of metastatic lymph nodes. We then analyzed overall and disease-free survival using the new nN stage grouping to test if it can provide more accurate classification compared to the conventional N stage grouping.

Results
Recursive partitioning analysis identified patients could be divided into three distinct groups according to the number of metastatic lymph nodes: nN0 (none), nN1 (1-7), nN2 (>7). Among 1982 patients, 1371 patients were nN0, 538 were nN1, and 73 were nN2. The 5-year overall survival rates were 79.8%, 62.1% and 36.1% for nN0, nN1, and nN2, respectively, and they were statistically different (p < 0.001, log-rank test). For conventional N stage, 1371 patients were pN0, 284 were pN1, and 327 were pN2. The 5-year survival rates were 79.8%, 63.8%, and 54.8% for pN0, pN1, and pN2 stages, respectively (p < 0.001, log-rank test). The chi-square value of nN stage was superior to that of pN stage (141.02 vs. 117.16). When we further analyzed those with pN2 patients, the nN1/pN2 group showed a significantly better survival rate than nN2/pN2 group (p < 0.001, log-rank test). Moreover, the overall survival of nN1/pN2 patients was not different from that of nN1/pN1 patients. (p = 0.074, log-rank test) Figure 1

Conclusion
The nN-classification seemed to predict long-term survival more accurately compared to conventional N stage grouping. Our result suggested the new N stage grouping based on the number of metastatic lymph node should be considered for the next revision of the TNM classification system for NSCLC.

Background
Mutations in the epidermal growth factor receptor (EGFR) gene have been identified in lung adenocarcinomas and are associated with a high response to EGFR tyrosine kinase inhibitors. EGFR mutations can be detected in tumour tissue, cytology specimens and blood from lung cancer patients. Thus far, EGFR mutation analysis has not been systematically demonstrated for sputum samples. The aim of the present study was to determine whether EGFR mutation analysis is feasible on sputum samples, employing different assays in a multicenter study.

Methods
Sputum samples were collected from 10 lung cancer patients with confirmed EGFR mutation in their tumour tissue, 10 lung cancer patients without evidence of an EGFR mutation, and 10 patients with chronic obstructive pulmonary disease (COPD). DNA was isolated from the sputum and used for mutation analysis by Cycleave PCR, COLD-PCR, PangaeaBiotech SL technology (PST), and High Resolution Melting, respectively. Targeted resequencing (TruSeq Amplicon Cancer Panel) and droplet digital PCR were additionally performed on the 10 samples with EGFR mutation.

Results
Dependent on the assay, EGFR mutations could be detected in 30-50% of the sputum samples of patients with EGFR mutations (Table). The different techniques revealed consistent results, with slightly higher sensitivity for PST. Neither the lung cancer patients without EGFR mutation nor the COPD controls tested positive for EGFR mutations in their sputum samples, indicating high clinical specificity of all assays.

Subject	Gender	Age (years)	Tumour stage	EGFR mutation status of tumour tissue[1]	EGFR mutation analysis on sputum specimens[2]
					Cycleave PCR	COLD-PCR	PST[3]	HRM-sequencing	Cytology[4]
A	F	72	IV	Del E746-A750	0	0	0	0	0
B	M	66	I	Del E746-A750	0	2	0	0	0
C[6]	F	78	IV	Del E746-A750	1	1	1	1	2
D	F	46	III	Del E746-A750	0	0	1	0	0
E[6]	M	54	IV	Del E746-A750	1	1	1	1	0
F	F	49	III	Del E746-A750 & c.2369C>T [p.T790M]	0	0	0	0	0
G	F	54	IV	Del E746-A750 & c.2369C>T [p.T790M]	0	0	1[5]	0	1
H	F	73	IV	c.2753T>G [p.L858R]	0	0	0	0	0
I	F	61	IV	c.2753T>G [p.L858R]	0	0	0	0	0
J[6]	M	60	IV	Del E746-A750	1	1	1	1	2

[1 ]del E746-A750= deletion exon 19 [2] mutation identified: 0=no, 1=yes, 2=dubious [3] exclusively del19 and L858R were assessed [4] tumour cells: 0=no, 1=yes, 2=in related sample of same patient [5 ]only del19 detected [6 ]TSACP and ddPCR both tested EGFR mutation (del19) positive.

Conclusion
EGFR mutations can be detected in sputum samples from patients with EGFR-mutated non-small cell lung cancer, which may replace biopsy procedure for some patients.

Background
Diagnosis of postoperative recurrence of lung cancer usually depends on radiologic examinations. However, the diagnostic yield of radiological examination is limited and it often times show false-positive result. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is well accepted modality for the pre-operative lymph node staging in patients with lung cancer; however, the efficacy of diagnosis for post-operative recurrence still remains unclear. In this study, usefulness of EBUS-TBNA pathologic confirmation of regional node metastasis was investigated in comparison with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET).

Methods
The patients who were suspected to have lymph node recurrence by routine chest CT follow-up after radical surgery for lung cancer were retrospectively investigated, and diagnostic yields of FDG-PET and EBUS-TBNA for the recurrence were compared. The cut-off value for positive results by PET was standard uptake value (SUV max) more than 2.5. Rapid on-site cytological evaluation was performed during the procedure of EBUS-TBNA for convenience and pathological diagnosis was employed by independent pathologist. A dedicated 22-gauge needle was used for TBNA. Final decision of presence of nodal recurrence was made based on pathological findings of cancer recurrence for EBUS-TBNA sample, and that of absence of the recurrence was made based on radiologic follow-up for more than 6 month.

Results
A total of 40 patients were eligible for this study. The mean duration between thoracotomy and EBUS-TBNA was 23.5 months, and the median follow-up period after EBUS-TBNA was 21.8 months. Diagnostic sensitivity, specificity and accuracy of EBUS-TBNA was 100% for each whereas those of FDG-PET were 95.8%, 12.5%, and 62.5%, respectively. 24 patients with metastatic lymph node confirmed by EBUS-TBNA showed significantly unfavorable prognosis than 16 patients with negative result by EBUS-TBNA (p=0.024). 22 out of the 24 patients who diagnosed as recurrence received anti-cancer treatments properly. 14 patients with positive results by FDG-PET but negative by EBUS-TBNA were determined as negative (false positive) since no deterioration of the nodal status was confirmed by radiological follow-up. Pathological findings of these false-positive lymph nodes showed 12 anthracosis and 2 non-specific granuloma.

Conclusion
Minimally-invasive diagnosis by EBUS-TBNA should be indicated when regional lymph node recurrence is suspected since radiologic modalities frequently recognize benign lesions as positive. The accurate diagnosis by EBUS-TBNA reduces fertile cancer treatment and improves patient management. Figure 1

Background
Patients which are treated due to various malignant tumours, should be investigated by pneumologists because of having intrathoracic lympadenopathy and/or pulmonary infiltrates. We should consider either progression of first malignant tumour, secondary and tertiary malignancies, adverse reactions on therapy, infectious diseases, or, last but not least, systemic diseases, e.g. sarcoidosis. However in sarcoidosis patients, increased risk of hematologic and lung malignancies were reported. The occurrence of intrathoracic lymphadenopathy with or without pulmonary infiltrates is subject to frequent diagnostic difficulties in patients with cancer history. Accumulation of pulmonary infiltrates and lymphadenopathy may be mistakenly interpreted as metastases. We present 41 patients with malignancies, who contracted sarcoidosis simultaneously, subsequently or before the diagnosis of malignancy. The coincidence of both diseases hasn't been published in the Czech Republic yet. In these patients, according to a number of studies, increased prevalence of malignant diseases was found. Sarcoidosis is a non-tumor, chronic, systemic granulomatous disease of unknown etiology and characterized by T-cell dysfunction. It affects mainly the lungs and lymphatic system, but also other parenchymal organs, the skin, the eyes, the heart. The generally accepted hypothesis is some environmental factors may promote the development of sarcoidosis in genetically susceptible individuals. Characteristic lesions are noncaseating granulomas, which consist of epithelioid cells and T-lymphocytes.

Methods
During the course of 28 years we have examined around 500 patients with sarcoidosis. We selected patients with sarcoidosis and also malignant diseases from these.Using the method of retrospective study, we evaluated the frequency of the coincidence of the period since 1996.

Results
Of all the investigated we follow a group of 41 patients with malignancy and sarcoidosis. In 33 patients there was the primary tumor, in 7 patients primary sarcoidosis, 1 patient had two diagnoses simultaneously. These are 18 men and 22 women with the mean age of 62,3 years. The spectrum of malignancies covers hematological malignancy (6), lung (3), breast (13), head and neck (4), intestine (3), melanoma (4), seminoma (3) and other (5). All patients had sarcoidosis diagnosed by biopsy (23) by CT or PET / CT and the bronchioalveolar lavages (18). Mediastinal lymphadenopathy was presented by 37 patients, pulmonary infiltrates and nodules were detected in 31 patients, infiltrates only 3 patients, extrapulmonary disease in 9 patients. The interval between sarcoidosis and the primary cancer was 0-552 months with a median of 36.Treatment with corticosteroids (or in combination with immunosuppressive agents) had to be initiated in 28 patients, 12 patients were left without treatment. 31 patients showed regression or disappearance of lesions, 8 patients were stable and disease didn't progress, the development of 2 patient is still unknown.

Conclusion
Differential diagnosis of pulmonary lesions is a common problem in patients with primary malignant disease in history. Not every pulmonary lesion must be just a manifestation of the disease, but as we argue in this presentation, it may be a manifestation of sarcoidosis. Therefore, we stress the need of histological verification of each newly formed pathological finding. The exclusion of generalized malignancy should have a significant influence on the treatment and survival.

Background
A fusion gene between the anaplastic lymphoma kinase (ALK) gene and echinoderm microtubule-associated protein-like 4 (EML4) occurs in nearly 5% of cases of non-small cell lung cancer (NSCLC). This fusion gene leads to the production of the EML4-ALK tyrosine kinase, which is considered as one of the oncogene driver mutations in NSCLC. The ALK inhibitor, crizotinib, showed remarkable antitumor activity in patients with advanced ALK-positive NSCLC, and was approved in Japan in 2011. Although the break apart FISH is considered as the gold standard to identify ALK rearrangement, pre-screening by immunohistochemistry (IHC) have been proposed in Japan because diagnosable number of cases is limited. However, disagreement of IHC and FISH are indicated. Therefore, the ALK rearrangements of NSCLC in our institute were screened by the IHC, FISH and RT-PCR, and that compatibility was examined.

Methods
EML4-ALK rearrangements of 176 examples were screened by IHC(5A4), FISH, and RT-PCR among 179 patients diagnosed as NSCLC in Kansai Medical University Hirakata Hospital from June 2012 to December 2012.

Results
Ten patients (5.7%) were diagnosed as ALK positive NSCLC. Five were male, and median age was 63 (46-81). The results by each technique of ten cases are shown in Table.

patient	IHC	FISH	RT-PCR
1	positive	positive	positive
2	positive	positive	negative
3	positive	positive	negative
4	positive	positive	negative
5	positive	positive	negative
6	negative	positive	negative
7	negative	positive	negative
8	negative	positive	negative
9	negative	negative	positive
10	negative	negative	positive

Conclusion
Although IHC is useful as a large-scale screening test, many false negative do exist. According to our results, there are few cases in agreement between IHC, FISH and RT-PCR. Various laboratory tests for ALK rearrangement detection are required for effective medication.

Background
The prediction of prognosis has been essential for programing cancer treatment strategies. In NSCLC, the TNM staging system is a worldwide standard form and there have been considerate improvements in its accuracy. However, the TNM staging system still has many limitations. It cannot reflect all the detailed pronostic parameters. In the AJCC system, prognostic factors are used to make a mutually exclusive partitioning of patients and ordering of patients assumes that all the patients receive surgery only. Therefore, treatment-specific prognosis cannot be predicted in the AJCC system. The prognoses of TNM stages may be different between institutes, however the same hazard ratio represents the same prognosis. So we propose a hazard ratio scoring system as an alternative prognosis predition method which can be used for specific clinical purposes.

Methods
A nomogram was developed and validated using clinical data of 2,115 patients who received surgery for NSCLC. Patients were randomly divided into the training set (n=1,060) and validation set (n=1,055). Nomogram predictions for 3- and 5-year overall survival were calculated for each patient in training set by using Cox proportional hazard model and compared with actual survival. Validation set was used for evaluating nomogram and AJCC staging.

Results
The median overall survival was 55.6 months for the training set and 58.1 months for validation set. In the prediction of 5-year survival, the nomogram showed an area under the receiver operating characteristic curve of 0.78 (95% CI, 0.76-0.79) in the training set. The validation set showed a good discrimination with an AUC of 0.85 (95% CI, 0.82-0.89). AJCC TNM staging system showed an AUC of 0.74 (95% CI, 0.70-0.79) with a training set.

Conclusion
The nomogram represented the survival results of a single institute more accurately than AJCC TNM staging system. The hazard scoring system cannot replace the position of the AJCC TNM system, however it can be used for programing treatment strategies concerning new or site-specific treatment methods, biomarkers and future clinical parameters.

Background
Lung cancer is one of the most common cancers worldwide. It is the leading cause of cancer death in both men and women in the West countries and in Latin America too. In Argentina, 15% of cancer deaths are because of lung cancer (9000 patients per year). The histology and the analysis of EGFR and ALK must be done in all NSCLC. To obtain the tissue, the histological diagnosis and the biological studies is particularly difficult in many centers in our country because we have to send the tissue to other cities. We want to know if we meet the world’s standard in our Institutions. Objetive:The primary objective is to assess whether the material obtained by different methods is enough for correct histopathological diagnosis and molecular biology analysis. We also evaluated the prevalence of different histological subtypes, the prevalence of EGFR mutations in patients with adenocarcinoma, the methodology for obtaining tumor tissue, and the delay in evaluation of EGFR mutation status, and currently in ALK translocations.

Methods
A retrospective study analyzed 229 consecutive patients with diagnosed NSCLC in Instituto Oncológico de Cordoba. The diagnostic method used for obtaining tissue was FNA CT-guided in 120 patients (52%), bronchoscopy in 69 (30%), surgery in 29 (13%) and pleural effusion cytology in 11 (5%). EGFR mutations were performed by PCR.

Results
A subtype was determined in 218(95%) out of the 229 patients studied; 11(5%) were classified as NOS. 147 patients(64%) were adenocarcinoma, 59(26%) squamous cell carcinoma, 12(5%) large cell carcinoma and 11 carcinoma NOS (5%). In the last period, 66 patients’ tissues with adenocarcinoma were sent for EGFR mutations analysis: In 38 patients (58%), tumor sample was optimal and in 28 (42%) patients, it was suboptimal or inappropriate for analysis. Of patient with optimal sample, 22(34%) presented different mutations and 16 (24%) patients were Wild Type. The time to obtain the result was 1.86 weeks in those with adequate sample (2.1 weeks vs 1.6 weeks for those with insufficient or inadequate sample).

Conclusion
In 95% of cases, we could determine the histological subtype and only 5% were NOS. Out of the 66 patients in whom we can evaluate the EGFR, 42% of the samples could not be analyzed due to insufficient material or inadequate fixation and processing techniques. These results are higher but it is not easy to compare them with local and Latin American statistics as they are not enough. The percentage of TKIs sensitivity was 21%, similar to national statistics published (19.3%) and western countries. Latin American average is 33.2% in one study. The time to obtain the results of EGFR mutation is consistent with recent guidelines proposed by the International Association for the Study of Lung Cancer. In our region, we have to work hard in multidisciplinary issues to obtain appropriate tissues in NSCLC.

Background
The incidence of lung cancer in the Czech Republic is high. It has reached 91/100 000 in men and 31/100 000 in women. The TNM stages I and II are diagnosed in less than 20% of all patients. Patients with COPD are at higher risk of lung cancer. How exactly emphysema affects the development of malignancy and how many patients with/without emphysema will suffer from lung cancer is unknown. Likewise, we do not know how many patients with existing lung cancer are diagnosed post-mortem and we have been interested in whether this group of patients shares any common features. Therefore, we decided to carry out an autopsy study which would provide answers to our questions.

Methods
We compared clinical data with autopsy findings in patients, both adults and children, from the largest hospital in the Czech Republic. During two studied years (2011-2013) we obtained complete sets of data on 708 patients.

Results
The studied group included 398 men and 310 women, with a median age of 71 years. Autopsies found a total of 55 lung cancer cases (7.8% of the set). Out of these, 24 (44%) tumours were diagnosed only by autopsy. In 40% of autopsy cases emphysema was proved along with a pulmonary malignancy. In the group of 24 patients with newly diagnosed lung cancer, emphysema was more common than in patients with a previously known tumour (50% vs. 32%).Patients with lung cancer discovered during autopsy died due to CHF in 8 cases, pneumonia in 6 cases, exacerbation of COPD in 2 cases, stroke in 2 cases, other tumours in 3 cases, and abdominal conditions in 3 cases. Emphysema during lifetime has been described less often than post-mortem (84 vs. 197 patients). The prevalence of autopsy proven emphysema was therefore 27.8%, the prevalence determined by clinical data was 11.8%. Lung cancer was diagnosed in one of every 10 patients with emphysema (20/197) and one in every 15 patients without emphysema (35/511).

Conclusion
The number of patients undiagnosed with lung cancer during their lifetime (44%) was higher than both literature data and our expectations. Studies carried out in the past accounted for 1 newly diagnosed lung cancer case per 80 autopsies, whereas in our group the ratio was 1:30 (Ošťádal, Studia pneumologica, 1994). On the other hand 27.8% cases with emphysema confirmed by autopsy corresponded with data in literature (15-65%; Thurlbeck, W. et Wright, J. L.: Chronic Airflow Obstruction) and results of similar previous studies which proved emphysema in 53% of autopsies on cases around the age of 70 years (Dalquen, P.: Incidence of Pulmonary Emphysema, and Study of 467 randomised autopsy cases 1, Beiträge zur Pathologie, 153, 4, 330-381). Our further results confirmed our clinical experience about the more frequent occurrence of lung cancer in patients with emphysema (1 in 10) compared with those without emphysema (1 in 15). "Supported by Projects (Ministry of Health) of conceptual development of research organization 00064203 (FN Motol, Prague, Czech Republic)."

Background
Lung cancer is the leading cause of cancer related death worldwide when considering both genders. The great effort to reduce smoking and introduce of cigarette has changed lung cancer epidemiology. In developed countries the increasing incidence of adenocarcinoma and decrease of squamous cell carcinoma are well known. Other characteristic reported is the rising number of women with the disease. Better understanding of current lung cancer epidemiology is necessary for the appropriate design of public health strategies for prevention, diagnosis and treatment.

Methods
Retrospective analysis of all patients with non-small cell lung cancer (NSCLC) treated with lung resection between 1986 and 2010 in a University Hospital of South Brazil. Analysis was divided in three periods 1986-1990, 1991-2000 and 2001-2010. Histological diagnosis was performed by the same pathology group and all staging was updated according to the new IASLC 7th edition. All analyses were performed using the SAS program version 13.

Results
We studied 817 patients who underwent lung resection for NSCLC from 1986 to 2010. 70.0% were males, average age 61.4 years, 44.2% squamous cell carcinoma and 40.0% adenocarcinoma, 26.7% stage IIIA. The female proportion increased from 22.0% in the first period to 36.0% in the last decade. Mean age at surgery treatment was 52.7 years for women and 57.3 for men in the first period, and 60.1 for woman and 63.9 for men in the last period (p<0.001). The proportion of squamous cell changed from 49.1% initially to 38.7% on the last period (p=0.017). In comparison, the adenocarcinoma prevalence increased from 35.4%, 39.6% and most recently 41.21%. Of the total NSCLC patients, females with adenocarcinoma represented 9.4% in the first period, 12.5% in the second and 16.8% in last period. Patients with stage IIIA represented 27.9% in the last decade. Type of surgery was predominantly lobectomy. Pneumonectomy was the surgical procedure in 21.9%, 18.8% and 16.8% of cases in each period respectively (p<0.03).

Conclusion
In this cohort of patients in south Brazil, gender analysis shows that rates of lung cancer in females is raising over the last three decades but has not surpassed men rates. The proportion of adenocarcinoma in females has increased. The significant decrease of pneumonectomy rates probably reflects changes on surgical management techniques and indication. The mean average age for patients undergoing surgical treatment has increased for both men and women. These findings are in accordance with the data of developed countries.

Background
EGFR activating mutations in pulmonary adenocarcinoma does confer better prognosis and are also predictive of higher response rates to both chemotherapy and EGFR-tyrosine kinase inhibitors. Therefore, EGFR genotyping in these patients (pts) is a very helpful biomarker for treatment selection. Here we aimed to report the results of consecutive EGFR genotyping in our Institution in Sao Paulo - Brazil.

Methods
It is a prospective, observational study on all consecutively tested samples from pts diagnosed with pulmonary adenocarcinoma and treated at ICESP. All samples were formalin-fixed and paraffin-embedded. Tumor areas were selected and macrodissected, followed by whole DNA extraction and amplification by PCR. EGFR genotyping was performed through DNA sequencing (exons 18, 19, 20 and 21) by Sanger´s methodology.

Results
191 pts had tumor samples genotyped between Aug/2011 and Apr/2013. Median age was 64 y (17-90), 106 (56%) female. According to ethnicity, 154 pts were Caucasian (81%), 26 African-American (14%) and 11 Asian (6%). Seventy pts were classified as never-smokers (37%), 23 (12%) as light-smokers (≤ 10 p.y.) and 95 as current smokers (51%). EGFR activating mutations could be identified in 54 out of 191 samples (28%): 35 were exon 19 deletions (65%), 15 were L858R mutation in exon 21 (30%), and three were rare mutations (G719S and G719A in exon 18, and V774M in exon 20). These mutations were found to be more frequent in females than in males (56% vs. 45%, p=0.035), and in never-smokers and light-smokers than in current smokers (77% vs. 20%, p<0.0001). It is noteworthy to mention that 11 mutations were detected in current smokers. All tumors harboring EGFR activating mutations presented TTF-1 expression by immunohistochemistry, and among those seven TTF-1-negative adenocarcinomas, no mutation was detected (p=0.0969). In a mean follow-up of 12 months, 77 pts were dead. Median overall survival was not reached in those pts whose tumors harboring EGFR-activating mutations, versus 19 months in pts with wild-type EGFR tumors (HR 0.40; 95%CI 0.29-0.78, p=0.003).

Conclusion
In this group of pts, the frequency of EGFR activating mutations was 28%, being more frequent in females, and never-smokers or light smokers, as previously described. Indeed, the presence of EGFR activating mutations was a favorable prognostic factor. The data here presented does reinforce the importance of testing EGFR activating mutations in all pts with TTF-1-positive, pulmonary adenocarcinoma.

Background
Cancer and tuberculosis are two conditions that can coexist, and their association is more common in areas of high prevalence of tuberculosis like developing countries.

Methods
To report the clinical characteristics of patients with cancer and tuberculosis association treated at a chest hospital. In this restrospective study, we reviewed the records of 970 patients treated for tuberculosis during the period 1998-2010.

Results
There were 16 patients with cancer and tuberculosis association. The average age was 55.25 years, 11 males and 5 females. Cancer was diagnosed before tuberculosis in 12 patients. The median time to onset of infection was 24 months. Tuberculosis preceded the cancer diagnosis in 3 patients and was obtained simultaneously by surgical biopsy in 2 cases. The most frequent association was with pulmonary cancer and hematological malignancies, 3 patients each. Pulmonary tuberculosis was present in 11 patients, 4 were extrapulmonary and 1 patient had both pulmonary and extrapulmonary disease. Bacteriological confirmation was obtained in 49% of patients and histopathology in 31.3%. Regarding to the evolution of tuberculosis, 50% completed treatment, 25% were derived, lost to follow up in 12.5% and 6.3% died during treatment of infection .

Conclusion
The probability of association of cancer and tuberculosis in the same patient should be taken into account in countries with high prevalence of tuberculosis. The coexistence of these two diseases frequently poses diagnostic difficulties and delay in treatment of both diseases. In countries with high rates of latent TB the oncologist should consider the possibility of reactivation of TB secondary to alterations of immunity produced by tumor and chemo or radiation treatments.

Background
No clear consensus has been reached on the XPA gene A23G (rs1800975) polymorphism and lung cancer risk. We performed a meta-analysis in an effort to systematically explore the possible association.

Methods
Case-control studies in English and Chinese publications performed with human subjects were identified by searching MEDLINE, EMBASE, Wanfang and CNKI databases prior to June 2013. References of retrieved articles were also screened. According to the inclusion criteria, 10 articles (12 studies) were finally included. The fixed-effects model and the random-effects model were applied for dichotomous outcomes to combine the results of the individual studies.

Results
Overall, statistical association could be found between A23G polymorphism and lung cancer risk in recessive genetic model (AA vs. (AG+GG)) (P=0.001, OR=1.21, 95%CI [1.08–1.35], P~heterogeneity~=0.11, fixed-effects model) and in the homozygote comparison (AA vs. GG) (P=0.03, OR=1.15, 95%CI [1.01–1.31], P~heterogeneity~=0.14, fixed-effects model). In East Asians, significant association was found in allele comparison model (A vs. G) (P=0.03, OR=1.13, 95%CI [1.01–1.26], P~heterogeneity~=0.39, fixed-effects model), in recessive genetic model (AA vs. (AG+GG)) (P=0.005, OR=1.30, 95%CI [1.08–1.56], P~heterogeneity~=0.58, fixed-effects model) and in the homozygote comparison (AA vs. GG) (P=0.02, OR=1.30, 95%CI[1.04–1.63], P~heterogeneity~=0.39, fixed-effects model). No evidence suggested that A23G polymorphism might associate with lung cancer risk in the Caucasians or African-Americans. Stratification analysis was performed by histologic types and indicated that AA genotype might represent a risk factor for squamous cell carcinoma (AA vs. (AG+GG)) (P=0.01, OR=1.42, 95%CI [1.08–1.86], P~heterogeneity~=0.27, fixed-effects model); (AA vs. GG) (P=0.03, OR=1.43, 95%CI[1.04–1.96], P~heterogeneity~=0.21, fixed-effects model). No association was observed in adenocarcinoma subgroup. Stratification analysis performed by gender shown that A allele might increase the lung cancer risk in male (A vs. G) (P=0.02, OR=1.18, 95%CI [1.02–1.37], P~heterogeneity~=0.48, fixed-effects model), but did not found association in female subgroup. Figure 1 Figure – Meta-analysis for the association between XPA gene rs1800975 polymorphism and lung cancer risk in the contrast of AA vs. (AG+GG) in overall. “Events” indicates the number of the AA genotype; “Total” indicates the total number of the AG+GG genotype plus the AA genotype.

Conclusion
XPA gene A23G polymorphism might associate with lung cancer risk in Overall and East Asians. This polymorphism might also associate with lung cancer risk in male and in the squamous cell carcinoma subgroup.

Background
Lung cancer is the fourth most common invasive cancer in Australia and was the leading cause of cancer death for both males and females in 2007. Five-year relative survival for lung cancer in Australia, which compares the risk of death for that cancer with age- and sex- matched population controls and overestimates absolute survival, is 13%. Gender based disparities have been noted, with men having worse outcomes. In this study, we publish for the first time an analysis of long-term (5 year) survival for lung cancer in Queensland, a northern state of Australia, where cancer is a notifiable disease. Differential outcomes for different tumour histologies, age groups, sex and estimated socio-economic status are compared, across 25 years spanning 1982-2006.

Methods
Cancer incidence and survival data on all Queensland residents diagnosed with non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) between 1982 and 2009 were derived from the Oncology Analysis System, Queensland Cancer Control Analysis Team. Incidence and overall all-cause survival at five years from diagnosis were aggregated over four time periods to 2006 and stratified by histological subtype, age, gender, and estimated socioeconomic status derived from postcode information. Survival at 5 years from diagnosis was calculated using Kaplan-Meier estimates.

Results
The absolute incidence of lung cancer diagnoses in Queensland has increased between 1982 and 2009, from 820 cases per year (in the time period 1982-1990) to 1,632 cases per year (time period 2006-2009). The increased incidence of non-squamous NSCLC accounts for the majority of this and has increased significantly from 322/year to 1,083/year. Approximately one out of eight cases of lung cancer are SCLC. Five year survival for those diagnosed 2002-06 was 14% for all lung cancer, with a significantly worse outcome for SCLC (6%) compared with NSCLC (15%). Survival from squamous NSCLC was marginally better than non-squamous histologies (17% vs 15%). Significant discrepancies are seen in outcome related to gender (16% for women vs 13% for men) (p<0.05) and based on age (17% for those aged less than 65, and 13% for those 65 and older) (p<0.05). The outcomes are favourable compared with the five years 1982-86, where overall 5-year survival from lung cancer was 12% (4% for SCLC and 13% for NSCLC). No significant relationship was seen with outcome based on estimated socio-economic status across the entire time period, although this was not recorded for 34% of patients. For those classed as affluent or middle class, 5-year survival was 14% compared with 12% in disadvantaged areas.

Conclusion
Five year survival for lung cancer in Queensland, Australia compares favourably with national and international norms, and has increased over the last 25 years. There is a significantly worse outcome for men seen across all tumour subtypes, which has been noted in other tumour streams. Of note, there is no significant differential in survival based on socioeconomic status, where this could be estimated.

Background
The Victorian Lung Cancer Registry (VLCR) pilot project was established in January 2011 and aims to recruit all newly diagnosed lung cancer cases across participating sites in Victoria. Case ascertainment for the registry is derived from institutional ICD-10 coding with subsequent assessment against inclusion criteria. Incomplete case ascertainment threatens data validity and several methods have been proposed for estimating this in cancer registries.

Methods
A quantitative, case finding audit was employed to evaluate the VLCR’s case ascertainment methodology at a major metropolitan hospital between 01/07/2011 and 30/06/2012. ICD-codes determined that 125 new cases were registered at the hospital. Lists of patients recorded or suspected to have a diagnosis of lung cancer were requested from the following institutional and external departments: Radiotherapy, Day Procedure Unit, Oncology Lung Multidisciplinary Team Meeting (MDM), Cardiothoracic Surgery (CTS), Victorian Cancer Registry (VCR) and Pathology. Comparisons were made between patients included in the registry and departmental lists provided. Medical records were then assessed to check eligibility of outstanding patients for inclusion in the registry.

Results
Six patient lists were compared with the VLCR. Excluding duplications and exclusions a total of 10 eligible patients had not been recruited by the registry. Investigations indicated that the underreporting of these cases was largely attributed to the use of the ICD10 R91 Code. This code is not a primary lung malignancy code and is assigned by clinical coders for abnormal findings on diagnostic imaging of the lung where lung cancer is suspected but not confirmed. Of the 10 patients eligible for inclusion in the registry, 7 were discharged with the R91 code and pending clinical confirmation were later included in the registry. The remaining 3 patients were not included in hospital data extracts as they were non admitted day patients and therefore not coded. A capture – recapture methodology is used to evaluate ascertainment completeness.

Conclusion
The completeness of cancer registry data – the extent to which all of the incident cancers occurring in the population are included in the registry database – is an extremely important attribute of a cancer registry. Only a high degree of completeness in case-finding procedures will ensure cancer incidence rates and survival proportions are close to their true value.[i] It was identified that a possible 7.5% of total lung cancer patients were not being captured by the VLCR recruitment method. The inclusion of the R Code in hospital ICD code extracts will increase the VLCR ascertainment rate. [i] Parkin, D. M. and F. Bray (2009). "Evaluation of data quality in the cancer registry: Principles and methods Part II. Completeness." European Journal of Cancer 45(5): 756-764.

Background
Previous studies demonstrate disparities in the incidence of lung cancer. Specifically, in the United States, in comparison to non-Hispanic Whites, African Americans have a higher incidence rate of lung cancer while a lower incidence rate is seen among Hispanics. Recent studies demonstrate significant progress in smoking-cessation programs for non-Hispanic Whites; however, there are still a lower number of smoking cessation programs directed towards African Americans and trends of increased smoking behavior among Hispanics. No studies have evaluated recent histologic-specific incidence trends of lung cancer that may reflect these changing smoking behavioral patterns.

Methods
Using the Surveillance, Epidemiology and End Results data from years 1992-2010, lung cancer incidence rates and average annual percentage change (APC) were computed overall and by histology for African Americans, Hispanics, and non-Hispanic Whites.

Results
Incidence rates of lung cancer steadily decreased for non-Hispanic Whites, African-Americans, and Hispanics males (APC = -2.0, -2.6, and -1.9, respectively) from 1992 to 2010. This was true for all histological subtypes. Overall incidence rates of lung cancer among females have been relatively stable, with evidence of recent declines since 2005 among African Americans and non-Hispanic Whites. These trends were seen for all histological subtypes among females, except for the notable exceptions of increases in adenocarcinoma among African Americans (APC = 2.9 from 2003-2010) and Hispanics (APC = 1.2 from 1992-2010).

Conclusion
For men, overall and histologic-specific incidence rates of lung cancer have decreased among Non-Hispanics Whites, African Americans, and Hispanics. For women, in recent years, non-Hispanic Whites demonstrate a similar pattern of decline in lung cancer incidence rates. However, the overall incidence rate of lung cancer among African American and Hispanic women while decreasing or remaining slightly stable, an increased incidence of adenocarcinoma has been observed that warrants further exploration.

Background
There is scientific evidence of increasing lung cancer incidence in women. and lung cancer pattern and risk factors in women are not the same as with men due to genetic and hormonal differences

Methods
In this study we reviewed the clinical and pathologic features in our female lung cancer patients diagnosed and followed at our clinic between 2005 and 2009.

Results
In this period, we followed 360 lung cancer patientsl. Of them, 30(8.3%) were women.Their mean age was 62.83 +/- 12.43 (range 33-83). 93.4% (n:28) were housewives, 80% (n:24) were nonsmoker, 13.3%(n:4) were exsmoker, 6.7% (n:2) were current smokers. 93.7'% were postmenapausal women. They had no history of cancer, COPD, asthma, or tuberculosis. Hypertension, coronary arterial disease, and DM were present in 20% (n:6), 10% (n:3), and 6.6% (n:2) of them respectively. Only one patient (3.3%) was aymptomatic. Most common symptoms were cough, dyspnea, chest pain and hemoptysis in order. At the time of diagnosis, 63.3%(n:19) were ECOG 0, 23.3% (n:7) were ECOG 1, 13.3% (n:4) were ECOG 2. Histopathologic diagnosis were adenocarcinoma in 53.3%, squamous cell carcinoma in 13.3%, NSCLC (not otherwise specified) in 16.7% and SCLC in 16.7%. Of NSCLC patients only 8.6% were early stage, remaining 91.4% were locally advanced or metastatic disease. 20% of SCLC patients were at limited stage, remaining 80% had extensive disease. Most common sites of metastasis were lung/pleura (40%), brain (36.7%) and bone(30%). Three patients rejected any form of therapy. Surgery +/- adjuvant therapy were applied to 2 patients, chemotherapy +/- radiotherapy were given to 22 patients.

Conclusion
In conclusion, majority of our women lung cancer patients were nonsmokers, with adenocarcinoma histology, postmenapausal and in good performance status.

Background
The incidence of NSCLC in young patients increases annually. Our objective is to characterize this specific population

Methods
Retrospective study of 61 consecutive NSCLC-AD cases in patients under 50 years old, diagnosed between 2001 and 2011. Clinical data, histology, Performance Status (PS), therapy and overall survival (OS) were evaluated.

Results
Of all the patients 70.5% were men, mean age 44.7 ± 4.12 years, most of them smokers (55.7%) with a Performance Status (PS) of 1 (83.6%), 2 (9.8%) or 3 (6.6%). Comorbidities were found in 42.6% of patients. The most frequent histology was adenocarcinoma (55.7%) followed by squamous cell (39.4%) and large cell (4.9%). Metastasis in 1, 2 or 3 organs were found in 49.2%, 27.9% and 22.9% respectively. Excluding two patients that are still alive (49.5 and 65.3 months after initial diagnosis), the global OS was 12.4 months. All patients with PS 3 were smokers with comorbidities, had more than 2 sites of metastization and underwent best supportive care only. Mean OS of this group was 0.7 months. Only 1 patient with PS 2 showed comorbidities and they were all submitted to 1[st] line chemotherapy with "platinum-based doublets". No 2[nd] line therapy was initiated and mean OS of this group was 4.7 months. In the PS 1 group (51 patients), 43.1% showed at least 1 comorbidity and 56.9% had >1 metastasized organ. The mean OS of this group was 10.8 months. All patients underwent 1[st] line chemotherapy – options were "platinum-based doublets" (50 patients) and Erlotinib (1 patient). Second line therapy was done in 60.8% (31) of these patients (Pemetrexed in 14 patients, Docetaxel in 11 patients and Erlotinib in 6 patients), and 3[rd] line in 35.5% (11) – options were Erlotinib (9 patients), Pemetrexed and Carboplantin+Vinorelbine (1 patient each). Two patients started 4[th] line therapy (3.9%) with Pemetrexed. OS for different therapeutic lines in this group (patients that underwent only one line of therapy, 2 lines or 3 lines) were respectively 5.8 months, 11.45 months and 29.2 months.

Conclusion
In our study, young patients with NSCLC present in advanced stages with important comorbidities and have an overall prognosis similar to the literature. Stronger physical reserve may allow several therapeutic lines to be completed in a significant number of cases.

Background
Despite the established causal relationship between tobacco smoking and cancer many cancer patients continue to smoke after diagnosis. This partly reflects the ignorance of the beneficial effects of smoking cessation even after diagnosis. The aim of the study is to demonstrate the effect of continuing or quitting smoking in patients with diagnosed cancer.

Methods
This study is based on a review of medical databases (Pub Med CENTRAL, MEDLINE, Cochrane Library) of the last thirty years. All articles included in the present analysis were in English.

Results
In patients with early stage lung cancer, continued smoking after diagnosis is associated with an increased risk of all cause mortality and decreased survival. Research has demonstrated significant difference in actuarial overall survival favoring the non-smoking group among patients with lung cancer. In patients with oral cancer smoking cessation or reduction leads to a significant reduction in mortality. There is also evidence that tobacco smoking exacerbates and prolongs radiotherapy induced complications.Of particular importance is the evidence that continued smoking is associated with adverse effects during anticancer treatment. Smoking increases tumor progression and resistance to chemotherapy due to nicotine-induced resistance to apoptosis by modulating mitochondrial signaling. Continuing smoking is also related with inferior outcomes during treatment with novel targeted therapies such as erlotinib. Continuing smoking in gastric and lung cancer patients is also associated with an increased risk of developing second primary tumors. Quitting smoking after lung cancer diagnosis is associated with better performance status while persistent smokers have worse overall quality of life. Patients who continued to smoke despite being diagnosed with cancer report more severe pain than never smokers and a greater interference from pain.

Conclusion
Continuing smoking after cancer diagnosis is related with reduced treatment efficacy and reduced survival, risk for more secondary malignancies and deterioration in quality of life.

Background
According to the World Health Organization, tobacco use is a major cause of illness and death worldwide, especially lung cancer. Currently in Portugal, tobacco use among young people has increased. It has been observed that adolescents’ smokers have a high probability of becoming adult smokers. Objective: To assess tobacco use in high school students and the associated social and family factors.

Methods
Based on all students aged between 15 and 19 years old, 100 adolescents were recruited from each of three high schools. The smoking habits of adolescents were evaluated according to a protocol adapted from the Global Youth Survey (GYTS), Center of Disease Control and Prevention (2001). The questionnaire consisted of 34 questions related to tobacco use, knowledge and attitudes towards smoking, smoking cessation, school regulation and the family role in preventing smoking. Participants were classified as: 1 - never having tried smoking; 2 - have just tried smoking (not smoked in the previous month); 3 - occasional smokers (smoked at least 1 day during the previous month); 4 - current smokers (smoked at least 20 days in the previous month). The protocol was approved by the School Direction and statistical analysis was performed with SPSS ® for the entire sample and by gender.

Results
Of the total sample (n=285), 46% were males and 54% females whose average age was 16.6 ± 1.2 years (min:15; max:19). About 59.6% of adolescents have experienced smoking at least once, 54% of who were female. Although the average age of tobacco onset was between 12-15 years (64%), we found that 21% of subjects experienced smoking before 11 years of age. Over 90% admitted smoking with friends and public spaces were the place preferred (38%) followed by social events (21%). Regarding the harmful effects of tobacco on health, school revealed a reducer role as a trainer, since 51.6% of adolescents admitted that the issue of smoking was never raised during the present school year. There is a statistically significant association regarding the initiation of smoking and parents educational level (mother: p=0.001; father: p=0.05). The same occurred when the mother is a smoker (p = 0.002).

Conclusion
There is an early initiation of smoking in this population and a high percentage of adolescents do it regularly. We emphasize the enormous importance of an effective intervention strategy in relation to the harmful effects of tobacco, with strong involvement of the school and family, in order to reduce tobacco consumption and prevent its health consequences with regard to morbidity and mortality.

Background
Many patients in a multidiscipinary thoracic oncology surgery clinic smoke, and are treated for diseases related to smoking. While some patients may be former smokers, many are actively smoking and unable to quit. In the short term, perioperative complications such as impaired wound healing, and increased respiratory complications are linked to continued tobacco use whereas long term survival may be impacted by smoking causing increased cardiovascular risk, worsening emphysema and future development of metachronous primary tumors. Although quitting smoking has proven health benefits, nicotine addiction is one of the most challenging to overcome leading to a nihilistic view of tobacco cessation in this setting by some patients and clinicians. Unaided cessation has a poor success rate (<5%), while a combination of physician recommendation, face to face counseling by certified tobacco treatment specialists (TTS), individualized pharmacotherapy and ongoing follow up can improve quit rates and tobacco abstinence.

Methods
A multidisciplinary team from thoracic surgery, the college of nursing and the college of health professions was assembled with the goal of providing multifaceted, evidence-based tobacco treatment as an integrated part of our thoracic oncology surgery clinic. Three team members obtained TTS training. After institutional board review approval, all clinic patients were queried for tobacco use, and any patient actively smoking underwent brief intervention by the thoracic surgeon (who is a TTS) and was referred for more in depth counseling to another member of the team who is also a TTS. For patient convenience, and increased compliance with referral to cessation services, the counseling took place in clinic, in a private conference room adjacent to the exam rooms. Demographic data, tobacco use data, other drug/alcohol use and medication use data were recorded prospectively in a database. Follow up visits were conducted in the inpatient setting, upon return to clinic and/or contact via phone. Exhaled breath carbon monoxide monitoring was used during the visits to confirm initial active use and also used to confirm successful cessation.

Results
Over the initial seven months, 60 patients were identified as active smokers. All received brief intervention by the surgeon and referral to the quitline and in-clinic TTS counselor. Despite physician recommendation, the free of charge service, and the convenience of the service in clinic, 23/60 patients refused to meet the TTS counselor. Of the patients (24/60) who agreed to meet with the TTS, consented to enroll in the program, and agreed to follow up contact, 17/24 (70.8%) quit and remained abstinent at last contact (between 1-6 month follow up). Some patients did not meet inclusion criteria yet still met with the TTS counselor for referral to the quitline, or to talk about continued abstinence after quitting.

Conclusion
Integrating TTS in the multidisciplinary thoracic oncology surgery clinic can be accomplished. For those that enroll and consent to follow up, this pilot data demonstrates excellent short-term quit rates in this setting. Ongoing enrollment, further follow up, and planned expansion to involve other clinics (pulmonary and medical oncology) will allow better understanding of the efficacy of tobacco cessation services integrated into clinical settings.

Background
Background: Tobacco use increases toxicity, recurrence, second primary cancers, and mortality in cancer patients. However, oncologists do not routinely provide assistance with tobacco cessation and little is known about potential barriers that could be addressed to improve cessation practices among oncologists.

Methods
Methods: An online survey was sent to IASLC members querying demographics, tobacco assessment and cessation practices, perceptions of tobacco use by cancer patients, and barriers to tobacco cessation intervention. Results are reported and multivariate analyses were performed to identify likely barriers to tobacco assessment and cessation.

Results
Results: A total of 1,507 IASLC members responded to the survey representing a 40.5% response rate. Most respondents reported that tobacco use affected cancer outcome (92%) and that tobacco cessation should be a standard part of cancer care (90%). However, whereas 90% indicated that they regularly asked about tobacco use, only about 40% regularly discussed medications or provided cessation assistance. A lower likelihood of assessing tobacco use was associated with the following demographic variables: a) location outside of the United States (USA), b) practice non-academic centers, c) fewer years of service as a medical provider, d) less time spent on clinical activities, or e) current smoking. Variables associated with a decreased likelihood of giving advice to stop smoking were a) location outside of the USA and b) less time spent in clinic. A lower likelihood of providing cessation assistance was associated with providers outside of the USA. After adjustment for demographic variables, variables associated with increased likelihood of assessing tobacco use were a) providers who felt cessation affected outcome and b) providers who reported more training on cessation is needed. An increased likelihood to advise patients to stop smoking was observed in respondents who reported that additional cessation training is needed whereas a lack of time was reported as a variable that decreased likelihood to provide patient advice. Variables associated with a decreased likelihood to provide tobacco cessation assistance included: a) lack of time, b) lack of training, c) lack of available resources, and d) perception that tobacco cessation was a waste of time. However, variables associated with an increased likelihood to discuss medications or provide cessation assistance included respondents who a) reported having had adequate training in tobacco cessation or b) who reported that additional training is needed for clinicians.

Conclusion
Conclusions: Most IASLC member oncologists who responded to the survey asked about tobacco use, but few routinely provided tobacco cessation assistance to their patients. Cancer patients need increased access to tobacco cessation support. Differences in the measurements of perceived barriers suggest that efforts are needed to increase cessation resources and clinician education in order to improve tobacco cessation support for cancer patients.

Background
Smoking-related stigma may increase psychological distress and result in isolation and lack of communication, complicating attempts to mitigate stigma’s harmful effects felt by individuals dealing with lung cancer. However, monitored on-line communities ensure anonymity, foster positive coping through mutual support and negate feelings of being alone, allowing stigmatized individuals to reach out to ‘trusted others’ without fear of reprisal. This study explored the content and tenor of ‘naturally’ occurring communication in a monitored on-line lung cancer support community in the United States, as well as who uses the on-line support community and their issues and concerns.

Methods
This qualitative study comprised a convenience sample of archived on-line threaded messages posted in a monitored on-line lung cancer support community. A three phased content analysis approach was employed to analyze a sample of 688 pages (from a total of 4,916 pages) that contained threaded messages across two time periods: August to September 2008 and January to February 2009. Sixty-eight main posts and 586 replies in 344 pages for period one (262 users) and 55 main posts and 697 replies in 344 pages for period two (307 users) were analyzed. Themes capturing the issues, concerns, and emotions raised by community users were identified.

Results
Most of the 569 users were female, half were individuals diagnosed with lung cancer. Information requests and replies were often embedded within narratives of personal experiences with lung cancer and emotional support. Message tenor tended to be respectful, carefully crafted and even caveat-laden concerning personal experiences. An overarching sense of solidarity was evident in reflections of feelings, goals, responsibilities and interests in living with lung cancer. Nine major themes were captured from main posts and replies: Disease-related information, Diagnostic-related information, Treatment-related information, Symptoms and their meaning, Deterioration of health status, Advocacy, Experiences with health care providers/health care system, Survivorship issues, and Psychosocial concerns and feelings.

Conclusion
Individuals living with lung cancer freely shared their unmet needs consistent with those dealing with other types of cancer who receive on-line empathic support and guidance. A number of users expressed dissatisfaction and mistrust of health care providers due to their disengagement in providing timely support and practical information about diagnosis, prognosis, treatment effects and their lack of positive attitudes. Health care providers cannot address all information and emotional needs of diagnosed individuals and families due to the demands put on their time. But they can be encouraged by this study’s findings that suggest monitored on-line support communities serve as a complement to, not a replacement for, formal health care. Monitored on-line support communities can help individuals overcome frustrations and fears by serving as an added resource that helps them to communicate and ask questions of others who are in similar situations that, in turn, foster their control as partners with physicians in making decisions about their care.

Background
Malignant pleural effusion s occur in up to 15% of patients with advance malignancies. However, the incidence of lung entrapment in patients with malignant pleural effusions has never been reported. This may have an impact in the management of patients with malignant pleural effusions, as pleurodesis is unlikely to suceed. A two year review of patients with malignant pleural effusions who underwent medical pleuroscopy was perform, looking at the incidence of lung entrapment. Medical pleuroscopy has been performed in our hospital since January 2011.

Methods
A review of the records of patient who underwent medical pleuroscopy from 1 January 2011 to 31 December 2012 was performed. Patients with histology proven malignant effusions were included in our analysis. The incidence of lung entrapment was recorded based on the procedure report entered by the performing physician.

Results
Over a two year period, seventy-three medical pleuroscopies were performed. All patients underwent pleuroscopy guided parietal pleura biopsies. Out of 73 cases, thirty six (49.3%) were confirmed malignant on histology. Of the cases with histology proven malignant effusion, there were twenty five cases of primary lung cancer (69.4%), 10 cases of primary breast cancer (27.8%) and one case of primary cervical cancer (2.8%). Adenocarcinoma was the histology in 96% of patients with metastatic lung cancer (twenty four out of 25 patients) . The remaining patient patient with metastatic lung cancer was found to have squamous cell carcinoma. The incidence of lung entrapment among patients with histology proven malignant pleural effusion who had undergone pleuroscopy in our study was 94.4% (thirtyy four of 36 patients). Entrapment was not seen in two cases of metastatic lung adenocarcinoma.

Conclusion
Our study shows a 94.4% incidence of lung entrapment in patients with malignant pleural effusion who had undergone medical pleuroscopy. However, more studies are needed to look at the incidence of lung entrapment, as not all patients are fit to undergo medical pleuroscopy. Furthermore, pleuroscopy is not readily available in most hospitals world wide. If the overall incidence is indeed high, the long term management of malignant plerual effusions will require a review, in particular, the use of talc in pleurodesis.

Background
New Zealand’s National Lung Cancer Working Group (NLCWG) has established a number of standards for the management of patients with lung cancer as part of the Standards of Service Provision for Lung Cancer Patients in New Zealand. Standard One, relating to timely access to services, is that patients requiring active treatment should start treatment within 62 days of secondary care receiving a referral. The Ministry of Health has subsequently introduced Faster Cancer Treatment (FCT) Indicators for all cancer streams. • Indicator one (62 day target): time between referral with a high-suspicion of cancer and start of first cancer treatment • Indicator two (14 day target): time between referral and first specialist assessment (FSA) •Indicator three (31 day target): time between decision to treat and start of first cancer treatment Compliance targets around these indicators have not yet been set. A retrospective comparative audit performed by the Southern Cancer Network showed that only 28.3% of patients from the Upper South Island (incorporating the Nelson-Marlborough, West Coast, Canterbury and South Canterbury District health Boards) referred for curative intent treatment in 2010 met NLCWG Standard One. We performed a 3 month prospective audit to Determine if performance in the region around NLCWG Standard One had improved Identify barriers to compliance with the above targets

Methods
Data was collected prospectively for all patients presented at the regional lung cancer multidisciplinary meeting (MDM) from 1 August to 31 October 2012. Patients were included in the final audit if the recommendation of the decision MDM was that they should be offered curative intent treatment.

Results
A total of 73 patients were discussed at MDM during the audit period. 27 (37%) were recommended to undergo curative intent treatment. For these patients the median time between referral and FSA (Indicator 2) and between treatment FSA and start of definitive treatment (Indicator 3) were within target, with compliance of 88% and 78% respectively. However the median time between referral and start of first cancer treatment at 67.5 days did not meet Standard 1/ Indicator 1, with only 39.1% compliance with the 62 day target

FCT Indicator Median Interval (days) Ref - FSA 7 (0-33) Tx FSA to Tx 18 (3-55) Ref - Tx 67.5 (14-118)

Factors identified as barriers to achieving targets included diagnostic modality (bronchoscopy versus CT), number of staging investigations required and referral processes between services.

Conclusion
Performance against the 62 day target for patients in our region had improved but remained below the national recommended standard. A dedicated lung Cancer Clinic is to be established and referral processes between services streamlined to achieve acceptable performance against standards.

Background
The echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) is a recently identified fusion-type oncoprotein that occurs in about 4-5% of non small cell lung cancer (NSCLC). Important features associated with ALK-positive lung cancers include younger age, adenocarcinoma histology, and never or light smoking habit.

Methods
Review of medical record and of pathology slides.

Results
A 20 year old no-smoker girl presented in August 2012 with weight loss (8 kg over 6 months), intermittent fever, cough and thrombosis of the popliteal and subclavian veins. A total body Computed Tomography (tbCT) scan showed lymphadenopathy in the mediastinum, in the supraclavear and laterocervical areas, a lung mass in the right inferior lobe with omolateral pleural effusion, a nodule in the controlateral lung and an ovarian teratoma. A supraclavear node biopsy demonstrated a lung adenocarcinoma (cytokeratin (CK) 7 and thyroid transcription factor-1 (TTF-1) positive). Molecular analysis showed translocation of ALK and absence of mutations of the epidermal growth factor receptor (EGFR). Because of worsening of symptoms, a first line chemotherapy with cisplatin and docetaxel was started, while waiting for the molecular analysis. After three cycles, in Dicember 2012, the tbCT scan showed a substantial stable disease. By cause of the worsening of symptoms and of the chemotherapy toxicity (G4 neutropenia, G2 anemia), an oral treatment with Crizotinib was started. It was well tolerated. After 13 weeks of treatment the CT scan showed a partial response (40% according to Recist criteria); the ovarian teratoma and the thrombosis were stable.

Conclusion
Patients with EML4-ALK mutant NSCLC are reportedly significantly younger than patients with wild-type, however, to our knowledge, only a younger case of our patient was until today reported (14-year old[1]). This case confirms that Crizotinib is effective and well tollerated in very young patients. [1] Kim SJ, J Clin Oncol. 2012 Jun 1;30(16):e147-50. Realized with the support of: "Associazione Genitori "Per un sorriso in piu'".

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.

Background
Endobronchial ultrasonography (EBUS) have reached an important position in diagnosis of tumors and enlarged lymph nodes involving mostly mediastinum. The puncture of pathological mediastinal masses under EBUS control is perfomed with thin needle and the obtained samples are mainly evaluated by means of cytology, which in case of malignant tumors does not give definite diagnosis including subtyping of tumor. Thus we aimed to evaluate the EBUS puncture samples also by means of histopathology including immunohistochemistry.

Methods
During one year we investigated 94 patients (53 males, 41 females, mean age 52 years) with enalrged lymph nodes or tumor spread involving mediastinum by EBUS puncture with sampling for cytology, histopathology and immunohistochemistry. 42 patients had suspicion of sarcoidosis, 32 lung cancer with diastinal involvement, 7 metastates of extrapulmonary tumor to mediastinal lymph nodes, 3 lymphoma and 10 pulmonary infiltrates with mediastinal lymphadenopathy probably of inflammatory origin. The investigation was performed under general anesthesy and the other samples from the invoved sites of lungs (aspirates, brushes, excisions, transbronchial biopsies (TBB), bronchoalveolar lavage (BAL)) were taken ad the same time.

Results
In the sarcoidosis group we obtained histopathologically evaluable samples from EBUS puncture of lymph nodes in 19 patients (45%) and in 8 of them (19%) the sarcoid granulomas were described. In lung cancer group we had valid samples in 23 patients (72%) and in 17 of them (53%) we diagnosed the carcinoma histopathologically including immunohistochemical analysis, and in 6 patients (19%) we confirmed normal lymph nodes. In the group of patients with extrapulmonary malignancy we defined histopathologically the metastases in mediastinal lymph nodes in 2 of 7 patients and in 1 sarcoidosis. In the patients with suspect lymhopma histopathological evaluation of lymph nodes did not support the diagnosis. In the group of pulmonary infiltrates with mediastinal lymhadenopathy we proved by histopathology normal or inflammatory lymph nodes in 5 of 10 patients.

Conclusion
Histopathological evaluation including immunohistochemical analysis of samples from EBUS puncture of tumors involving mediastinum and mediastinal lymh nodes is of important value mainly in lung cancer and metastatic cancer involvement. This approach enables the patients to avoid surgical bioptic procedures in non-resectable cases and thus helps to start the targetted tratment of lung cancer as early as possible. In case of sarcoidosis the histopathological evaluation of lymph node puncture samples rises the propability of stating definite diagnosis in combination with other prcedures (BAL, TBB).Figure 1 Fig.1 Small cell cancer, sample from EBUS puncture, EMA staining

Background
Many clinical practice guidelines recommend that all lung cancer patients should be discussed at a multidisciplinary team meeting (MDM) to determine a management plan. Previous studies have shown that lung cancer MDM recommendations are largely concordant with guidelines. There are limited data on whether these recommendations are translated into actual treatment received. The aim of this study was to evaluate whether patients discussed at a lung cancer MDM actually received guideline-recommended treatment (GRT) and determine reasons for not receiving GRT.

Methods
The Liverpool/Macarthur lung cancer MDM prospectively collects data on new lung cancer patients including patient and tumour characteristics, staging investigations, referrals and treatment recommendations. All new lung cancer patients discussed at the MDM between 1/12/05 – 31/12/2010 were identified. Details of patient demographics, tumour characteristics and treatment were obtained from the MDM database and the Area Clinical Cancer Registry. GRT was assigned to each patient according to pathology, stage and ECOG performance status as per the 2004 Australian Lung Cancer Guidelines. This was compared to actual treatment received to determine adherence to GRT. For those who did not receive GRT, the medical record was reviewed to determine the reason why. Survival was compared between patients who did and did not receive GRT.

Results
808 patients were discussed at the MDM. 64% were male and the median age was 68 years. Pathology was NSCLC in 657 (81%), SCLC in 119 (15%) and not confirmed in 32 (4%). 128 (16%) had Stage I or II NSCLC, 306 (38%) Stage III NSCLC or limited stage SCLC and 372 (46%) metastatic disease. GRT could be assigned in 98% of patients who had both stage and ECOG performance status documented. Overall 411 (51%) of patients received GRT, and 380 (47%) did not receive GRT. The main reasons for not receiving GRT were decline in performance status (24%), large tumour volume precluding radical RT (17%), co-morbidities (14%) and patient preference (13%). On multivariate analysis, ECOG performance status, stage and age were significantly associated with receipt of GRT. GRT, ECOG performance status and stage were significant predictors of survival.

Conclusion
Despite discussion at an MDM, a significant proportion of patients were unable to receive GRT due to legitimate reasons. This may reflect the characteristics of the underlying lung cancer population who are older and have coexisting comorbidities. Alternative treatment strategies are needed for patients who are not suitable for GRT.

Background
Primary epithelial-myoepithelial carcinoma of the lung is a rare entity with fewer than 30 cases reported in the literature. These tumours are thought to arise from bronchial submucosal glands and have histological features similar to their salivary gland counterparts. In view of the infrequent nature of the disease, biological behaviour and clinical course have yet to be fully defined. Although considered a low-grade malignancy, there is a potential for invasion and metastasis; for this reason the majority of case reports have advocated complete surgical resection as the treatment of choice. Here we present a case of tracheal epithelial-myoepithelial carcinoma treated with recurrent bronchoscopy and cryotherapy as surgical resection was not possible.

Methods
A 46 year old lady presented with acute shortness of breath and wheeze. Given her past history of asthma she was initially treated for an exacerbation with steroids, antibiotics and nebulisers. The patient had no other history of note and had been a life-long non-smoker. Following a further deterioration leading to type I respiratory failure and episodes of haemoptysis she required intubation. CTPA demonstrated a tracheal mass. At bronchoscopy this well-circumscribed, vascular lesion was clearly identified 2cm above the carina (Figure 1). Multiple biopsies were taken confirming a primary epithelial-myoepithelial carcinoma of the lung. Figure 1 Figure 1: Tracheal tumour at bronchoscopy

Results
Following multidisciplinary discussion the patient was admitted for surgical excision. However, at the time of surgery it was not possible to achieve adequate single lung ventilation and the procedure was therefore abandoned. As an alternative management option the patient has undergone regular bronchoscopy and cryotherapy. There has been no evidence of local recurrence or metastasis in the 14 months since diagnosis.

Conclusion
Histologically these tumours are characterised by variable proportions of two cell types, with epithelial and myoepithelial cells forming duct-like structures. In the majority of cases a polypoid endobronchial mass is present and patients therefore present with symptoms associated with airways obstruction. Although considered a low-grade malignancy there has been one case report of extensive local and lymph node involvement. In addition, follow-up time has been too short to conclusively elucidate clinical behaviour. Here we have demonstrated the use of cryotherapy in the management of inoperable epithelial-myoepithelial carcinoma of the lung. The patient remains disease free at 14 months but will require on-going surveillance. We would agree that surgical excision remains the gold-standard in this patient group, but have provided a possible alternative strategy for inoperable cases.

Background
This is a clinical case of an EGFR-mutant Non-Small Cell Lung Cancer (NSCLC) with adenocarcinoma (ADC) histology: a subsequent diagnosis of high grade neuroendocrine small-cell lung cancer (SCLC) carrying an EGFR mutation was done at the first re-biopsy and further, a sarcomatous cancer was finally diagnosed. Recent publications were focused on drug-resistance mechanisms in patients with a specific biomolecular alteration re-biopsed after receiving the targeted therapy: in some cases morphologic and immunophenotypic changes were described. This finding suggests the possibility of "clonal resistance" with a selective pressure of some groups of cells, even if the histopathological features of these mechanisms have not yet been completely elucidated.

Methods
A 62-year-old caucasian man, with past smoking habit, presented with a 2-week history of cough and dyspnea. After a diagnosis of stage IV lung ADC, he received, on March 2010, 1st line treatment with cisplatin 75 mg/m2 plus pemetrexed 500 mg/m2 on Day 1 every 21 days, for 6 cycles. He achieved a partial response on computed tomography (CT) and a marked regression of his symptoms. On August 2011, a CT scan revealed a progressive disease (PD); he started treatment with Erlotinib plus ARQ-197/placebo within a clinical trial. As deemed by protocol, molecular analyses were performed on biopsy specimen at time of diagnosis, evidencing exon 21 – point mutation, p.Leu858Arg at EGFR mutational assessment. After 4 cycles, a local progressive disease was described by CT scan and a fibrobronchoscopic re-biopsy was performed in order to define the novel biomolecular profile at that time of the history of the disease. The histological evaluation highlighted a SCLC and molecular analyses confirmed the p.Leu858Arg mutation. Based on new histological diagnosis, he underwent chemotherapy with AUC6 carboplatin on Day 1 every 21 days plus etoposide 100 mg/m2 on Day 1,2,3 every 21 days, for a total of 6 cycles, until May 2012, achieving partial response at CT scan. On August 2012, because of radiological evidence of disease progression, he underwent chemotherapy with Cyclophosphamide 800 mg/m2, Doxorubicine 40mg/m2 and Vincristine 1mg/m2 on Day 1 every 21 days. After 3 cycles, he reported intense swelling in the supraclavicular right fossa and a fine needle aspiration of supraclavicular right lymphadenopathy was performed. The final pathological diagnosis was undifferentiated sarcoma cells (CK-,TTF1-, VIM+) . Patient died, on January 2013, because of worsening of clinical conditions.

Results
Not applicable

Conclusion
Many studies hypothesize that SCLC either evolved from the previously diagnosed NSCLC or that both arose from a common precursor. Further comparative molecular analysis of these histologically distinct tumors would be of value to better understand the potential role of EGFR in the evolution of lung cancer and the role of selection for an EGFR-mutant SCLC cell subclone as an unusual mechanism of acquired resistance to EGFR inhibitors in NSCLC.

Background
Cancer has a great impact on psychological functioning of patients and relatives and can be associated with various psychological disorders and symptoms. Mindfulness Based Intervention (MBI) is a relatively brief and cost-effective program that has been studied in patients with several diseases. Recent analyses have shown the efficacy of MBI in improving psychological symptoms related with physical illnesses like cancer, chronic fatigue syndrome, fibromyalgia, chronic pain, arthritis, diabetes, heart disease, stroke, and traumatic brain injury. MBI is based on the assumption that a non-judgmental awareness and acceptance of one’s moment-to-moment experience have an effect on the distressing tendencies to escape from or to over-engage with one’s disturbing feelings, emotions and thoughts. MBI can positively impact on coping strategies and on the adaptation to the disease, by encouraging patients to relate differently to their physical and psychological symptoms, resulting in a reduction of the psychological burden and improving patients’ Quality of Life (QoL). MB-BAI integrates MBI basic practices with increased attention to somatic resources and application of mindfulness in relationships.

Methods
We aim to evaluate whether a group-based Mindfulness Based Body and Affective Intervention can reduce psychological symptoms like anxiety, depression, perceived stress and improve the QoL of patients with cancer. Furthermore, our study involve patients’ caregivers/relatives in order to decrease the load of stress and difficulties related to the management of a disabling diseases like cancer. This project is designed as an observational study. The subjects currently involved in all are 36, including patients with advanced malignant disease (mostly lung cancer), their caregivers/relatives and the control group. Participants were enrolled at the Oncology Unit of San Luigi University Hospital of Orbassano, Italy, in collaboration with WALCE (Women Against Lung Cancer in Europe). The experimental group underwent a 8 weekly sessions of 3 hours each (plus an all day session) with a group based MB-BAI. The control group hasn’t receive any psychological intervention. The psychological assessment was performed at pre-intervention and after treatment for both groups. The evaluation encompasses the administration of the self-reportquestionnaires: Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS), Five Facet Mindfulness Questionnaire (FFMQ), Posttraumatic Growth Inventory (PTGI) and WHOQoL-Brief, patients qualitative reports.

Results
not applicable

Conclusion
The study is currently ongoing. As far as we know this is the first MBI applicationinadvanced lung cancer. Specific attention to somatic resources and relationships may increase its effectiveness. Preliminary results from patients’ reports suggest that the MB-BAI both reduces symptoms of anxiety and depression and improves resources. Results will be presented after the complete achievement of the after-treatment assessment; we hope they will confirm that MBI favor positively impact on the adaptation to the disease, resulting in a reduction of the psychological burden and improving patients’ Quality of Life (QoL).

Background
Since Billroth s report, in 1889, of a patient with multiple synchronous tumors, multiple primary malignances (MPM) have been recognized as a growing problem. The increase in incidence of MPM has been ascribe to several factors, such as increase in the incidence of many forms of cancer, the increase in longevity and cancer survival and better cancer follow-up.

Methods
Case report

Results
Here we present 65-year old ex-smoker with history of recent surgery for vocal cord squamous cell cancer who was seen in pulmonary out-patient clinic due to nodular lesion in the left lung seen on chest x-ray. Subsequent chest CT scan revealed focal lesion 18 mm in diameter with spicular margins located in the right upper lobe, another lesion with septa and cavitation, 62 x 58 mm in the right lower lobe and calcified nodule in the left lung, no enlarged lymph nodes or pleural effusion was seen. He underwent upper right lobe resection and sleeve resection of the lower right lobe. Histopathological examination revealed adenocarcinoma in the right upper lobe with lymph node metastasis. Tumor emboli in tumor lymphatic and pleural vessels were reported along with infiltration of visceral pleura. Examination of the right lower lobe showed squamous cell carcinoma with tumor emboli in tumor blood vessels. Subsequently, the patient was treated with adjuvant chemotherapy.He subsequently was treated with adiuvant chemotherapy (cisplatin+vinerolabine). During seven months of follow up he remained in good health with no signs of disease progression. MPM are defined as malignant tumors based on histology criteria with distinct location, which do not represent skip lesions, metastatic disease or recurrence of a primary pulmonary malignancy. According to time category they can divided as synchronous or metachornous. Retrospective date show an increased risk of developing a second lung cancer following the diagnosis of a first lung neoplasm, in patients who survive more than three years as many as 10 to 25% will develop a second primary lung cancer. The male to female ratio of individuals developing pulmonary MPMs is approximately 3:1 with the median age at presentation in the sixth decade. Patients who present with pulmonary MPM have a greater cigarette smoke exposure than those who developed a single lung cancer. 50 to 70% of patients have similar tumor histology in both primaries and identical genetic changes are find in 77% of tumors, supporting monoclonal origin in majority of MPMs. Diagnosis of multiple synchronous primary cancers must be distinguished from a primary tumor with one or more pulmonary metastases and from an extrapulmonary primary tumor with multiple lung metastases. Moreover, a second synchronous primary cancer must be distinguished from a coexisting benign pulmonary nodule detected on preoperative imagining.

Conclusion
Patients with synchronous multiple primary lung malignances have significantly worse prognosis than those with single primary lung malignancy, although it can be considerably improved with an aggressive surgical approach.

Background
Study in tertiary hospital in the thoracic surgery service by a group of surgeons, during which corroborate the usefulness of thoracoscopy in the diagnosis and management of different chest tumors that were presented in the thoracic surgery service for a period of one year: 2011 – 2012. During the procedure was used in all patients selective lung intubation, was performed intraoperative intercostal block for pain control, postoperative management was all endopleural tube, pain control with morphine and radiographic control to assess each 24hr endopleural catheter in 2 patients (15.3%) underwent incision of 2 and 4 cm to remove the tumor.

Methods
In one year 23 patients was admited to the Pachuca General Hospital with the diagnosis of lung tumors, all patients complete preoperative protocol wich include chest CT, lung or tumor biopsy, assesment by anesthesiology, internal medicine, pulmonomogist an medical oncology, the procedures include no anatomic segmentectomy with tumor free margin, exceresis tumor, lung and pleural biopsy, VATS lobectomy, lymph node dissection was performed mainly from stations 4, 5 and 7. Pathology reports were branchial cyst, mesothelioma sarcomatoid, bonchogenic cyst with ulcerated necrotic pneumonia, chondroid hamartoma with congestion and sclerosis, moderately differentiated adenocarcinoma and small cell carcinoma. In patients who had pleural effusions was performed on the basis of lung expansion chemical pleurodesis with 20ml yodopovidona more 10ml xylocaine 1% dilute to 100cc with saline.

Results
Radiological and histopathological diagnosis was corroborated in 95% of cases, the procedures include no anatomic segmentectomy, exceresis tumor, lung and pleural biopsy, VATS lobectomy, lymph node dissection. Pathology reports were branchial cyst, mesothelioma sarcomatoid, bonchogenic cyst with ulcerated necrotic pneumonia, chondroid hamartoma with congestion and sclerosis, moderately differentiated adenocarcinoma and small cell carcinoma. All patients continue managemnent with a multidiciplinary team getting support with other institutions in cancer management. In patients who had pleural effusions was performed on the basis of lung expansion chemical pleurodesis with 20ml yodopovidona more 10ml xylocaine 1% dilute to 100cc with saline was done and chest drain mainteined for 3 to 4 days. In cases of recurrence of pleural effusion a tunelized thoracic catheter was put on and in cases of persistent pneumothorax a Heimlich valve was colocated.

Conclusion
Pleuropulmonary tumors in patients with, sensitivity and specificity for the diagnosis and treatment by thoracoscopy is over 90% to reliably be able to obtain sufficient tissue for histopathological examination or final intraoperative complete resections and procedures, achieving an aesthetic addition.

Background
Some lung cancer patients experience unnecessary delays in their care in the US; these delays are not currently well-documented outside the Veterans Administration Hospital system. We evaluated the accuracy of patient interviews as a method of documenting timeliness of care. Our results will be used to implement a larger study that will inform the development of targeted interventions to reduce time to treatment for lung cancer patients.

Methods
Oncologists referred 36 patients with lung cancer. The initial 20 patients were interviewed to collect 11 dates pertinent to their cancer care (Figure 1). The next 16 patients completed the interview and their charts were reviewed in order to analyze the correspondence of patient-reported data with chart-reported data. We conducted quantitative and qualitative analysis of the interview data to document time intervals and examine delays. Figure 1

Results
Results: For the 16 patients whose charts were reviewed: patient-reported and chart-reported median time from the first visit to the first treatment was the same (41.5 days) median time difference between patient-reported and chart-reported dates varied from 0 to 8 days Lin’s correlation coefficient indicated almost perfect agreement (ρ >0.99) for five dates; and poor agreement (ρ <0.90) for six dates 2.25% of total dates were lacking from charts For the entire cohort (36 patients), based on the interview data: time to treatment varied (Table 1) 22 of 36 (61%) patients experienced one or more delays that could possibly be avoided 5.28% of total dates were not recalled by patients Figure 1

Conclusion
Interviewing patients has limitations but is an appropriate method of collecting dates regarding lung cancer care. There are multiple opportunities to reduce time to treatment for patients with lung cancer. More research is needed to understand delays in lung cancer care.

Background
Bone is the most frequent site of metastasis for lung cancer, and metastatic bone disease causes pain. Furthermore, bone metastasis may produce skeletal-related events (SREs) that greatly reduce quality of life and may even lead to death. Several guidelines have recommended use of bone-modifying agents (BMA) such as zoledronic acid (ZA) at the first diagnosis of bone metastases in patients with solid tumors, continued every 3-4 weeks as long as the patient is able to tolerate therapy or until evidence of a substantial decline in performance status. However, due to the risk of osteonecrosis of the jaw (ONJ) and a perceived lack of evidence for reduced SRE in lung cancer, some physicians have hesitated to administer ZA in lung cancer patients with bone metastasis. Therefore, the main objective of the present study was both to describe real world data of ZA and to compare SREs among previous reports.

Methods
All patients with non-small cell lung cancer (NSCLC) accompanied by metastatic bone disease (MBD) who were administered ZA at least twice from 12 hospitals in the TORG in Japan between January 2008 and December 2009 were eligible for inclusion in the study.

Results
A total of 198 consecutive patients (126 men, 72 women; median age, 64 years; range, 44-89 years) were identified. Histological type was as follows: adenocarcinoma (n=131, 66%); squamous cell carcinoma (n=30, 15%); and others (n=37, 19%). About two-thirds of patients experienced SRE before starting anti-cancer therapy. Median duration of ZA administration was 106 days (range, 28-1126 days), and median number of ZA administrations was four (range, 2-41). Median time to first SRE in patients who experienced SRE after treatment was 202 days (range, 156-264 days). No ONJ was reported from the 198 patients.

Conclusion
We found that ZA was not used sufficiently in clinical practice in Japan. Our data suggest that ONJ during the treatment of lung cancer patients is very rare, and ZA is potentially useful in lung patients with bone metastasis.

Background
Hermansky-Pudlak Syndrome (HPS) is a rarely seen autosomal recessive disease characterized by oculocutaneous albinism, bleeding tendency from platelet storage pool deficiency, and lysosomal occumulation of ceroid in the reticuloendothelial system. Ceroid occumulation in alveolary macrophages causes pulmonary inflammation and interstitial pneumonia. Pulmonary fibrosis is the most serious complication and main reason of mortality. Pulmonary fibrosis is also a well known etiology for the onset of lung carcinoma.

Methods
N/A

Results
A 64-year-old albino patient admitted with dyspnea, back pain, and weakness. He had a smoking history of 40 pack-years. In his past medical history, he has recurrent nasal bleeding, and he was given inhaler bronchodilators for dyspnea on exertion last year. Rutin laboratory analysis was normal. There was a mild hypoxemia (PaO2: 63 mmHg). There was a restirictive pulmonary functional deficit with a reduced diffusion capacity (%56). A thorax CT demonstrated pulmonary fibrosis, left pleural effusion, and irregularly marginated collapse and consolidation areas adjacent to pleural effusion. On PET/CT a mass lesion 6 cm in largest diameter (SUVmax: 15.6) is distiguised in left lower lobe superior segment. There was also a nodular pleural thickening (SUVmax: 13.5) on the left hemitorax and multiple mediastinal lymph nodes with high SUVmax levels. The presence of albinism, the history of bleeding diathesis, and the presence of pulmonary fibrosis suggested the diagnosis of HPS. The patient referred to ophthalmology consultation. There were hypopigmentation on coroid layer and iris. Hematology clinic comfirmed the presence of platelet dysfunction. After all the patient was diagnosed as HPS. After transfusion of platelets, a transtoracic needle biopsy was performed and the pathology was compatible with adenocarcinoma (Stage 4, pleural involvement). The patient refused any therapy and discharged from hospital with home oxygen therapy.

Conclusion
Herein we present a rare case with pulmonary fibrosis diagnosed simultaneously as HPS and pulmonary adenocarcinoma.

Background
Myoepithelial tumors commonly occur in the salivary glands, the sweat glands or the mammary glands, but extremely rare in the lung. We present a case of primary myoepithelial carcinoma of the lung with reports of previous cases.

Methods
A 67-year-old man presented with a nodular lesion in the lower lobe of the left lung. The patient had a surgical history of stenosis of the small intestine, and his serum carcinoembryonic antigen (CEA) level was slightly elevated. Histopathological examination revealed that the cause of intestinal stenosis was the ischemic enteritis. Computed tomography (CT) was carried out as screening for elevated CEA, and a small nodule was detected at the posterior basal segment (S[10]) of the left lung. The pulmonary nodule developed a tendency to increase during progress observation of half a year. Because of the clinical suspicion of malignancy, he underwent a wedge resection of the left lower lobe by video-assisted thoracic surgery (VATS).

Results
Macroscopically, the tumor was a whitish, well-circumscribed, irregular shaped, and solid mass measuring 10×8×6 mm in size. Microscopically, the tumor was mainly located outside the bronchial mucosa with focal invasion into the lamina propria of the mucosa, and composed of atypical cells arranged in trabecular or alveolar pattern and basement membrane-like eosinophilic hyaline stroma. The tumor cells had ovoid pleomorphic nuclei varying in size and clear cytoplasm. Small necrotic foci were scattered in the tumor. Mitotic figures were frequently seen (> 14/10 HPF) and abnormal mitoses were occasionally encountered. No ductal structures were found throughout the tumor. Immunohistochemical staining showed the tumor cells were positive for 34βE12, P-63, S-100, α-SMA, but negative for CK7, TTF-1, chromogranin A, synaptophysin, CD56. On the basis of the above features, the tumor was diagnosed as primary myoepithelial carcinoma of the lung (pT1aN0M0, Stage IA). The patient is doing well without recurrence for 22 months after the operation.

Conclusion
We present a rare case of primary myoepithelial carcinoma of the lung. To our knowledge, only nine cases of pulmonary myoepithelial carcinoma have been reported in the literature so far. Because the clinical course of those cases was poor, further studies will be necessary in order to clarify their histological features, biological behavior, effects of chemotherapy or radiotherapy, and clinical outcome.

Background
The prognosis of patients with non-small cell lung cancer and distant metastasis is poor. The aim of this study was to evaluate the value of local treatment to the primary site for patients with stage IV non-small cell lung cancer and oligometastatic disease at diagnosis, particularly the influence of local treatment to the primary site on prognosis.

Methods
From January 2004 to December 2011, 69 consecutive patients with stage IV non-small cell lung cancer treated with local palliative radiotherapy to the primary site were enrolled in this retrospective study. The prognosis factors including the patients’ general condition, disease characteristics and treatment factors were analysed. Patients were divided into two groups based on the number of distant metastases (Oligometastasis, OMT, 1-4 metastases; Polymetastasis, PMT, > 5 metastases). The relationship between the prognosis and treatment factors was explored. Overall survival was estimated using the Kaplan-Meier method, and prognostic factors were identified by univariate and multivariate analyses.

Results
The median overall survival was 14.1 (95%CI:7.3-20.8) months and the 1, 3-year overall survival rates were 53.0% and 9.0% , respectively. Gender, smoking index and performance status of Zubrod-ECOG-WHO were significantly associated with prognosis under univariate analysis. There was marginally significant associated with prognosis for those patients who received chemotherapy(P = 0.054) and received a sufficient dose of local palliative radiation to the primary site (at least 60Gy) (P = 0.063). On multiplicity analysis, chemotherapy and performance status retained significance. In the hierarchical analysis, patients who received at least 60 Gy of local radiotherapy to the primary site(P=0.048)(Fig 1.) and received chemotherapy (P= 0.041) achieved better overall survival in the OMT group.Figure 1

Conclusion
For non-small cell lung cancer with OMT, local aggressive treatment to the primary site may improve overall survival. Our results suggest that the selected non-small cell lung cancer patients with distant metastasis may benefit from aggressive local therapy.

Background
Desmiod tumor (aggressive fibromatosis) is an aggressive fibroblastic proliferation of well-circumscribed, locally invasive, differentiated fibrous tissue. Chest wall desmoids account for approximately 20% of all desmoids tumors. The etiology of this tumors is unknown. Local inflammatory changes involved in the healing response after trauma have often been postulated as stimulating the development of desmiod tumors. Although distant spread has not been documented in long-term follow-up studies, these tumors have a strong propensity to recur locally after resection. Several authors have emphasized the use of external radiotherapy as an adjunct to surgery to improve local control.

Methods
A 62-year-old male underwent left upper lobectomy using an anterolateral approach. The postoperative diagnosis was pulmonary adenocarcinoma (pT1N0M0 stage1A). Two years after operation, a computed tomography showed the 65x45x25mm diameter mass on the left chest wall around the previous operative scar. Three months later, the mass rapidly enlarged 110x100x55mm in size. A desmoid tumor was suspected from the specimen of an incisional biopsy.Figure 1

Results
A Resection of the tumor with the chest wall (from the 2nd rib to the 4th rib) was performed. And thoracoplasty using a myocutaneous flap made of latissimus dorsi muscle with the 10th rib and a titanium plates and Composix Mesh was performed for a defect in the chest wall. Histopathological examination revealed a desmoid tumor. The specimen showed proliferation of spindle shape cells with collagen fibers. No mitoses were present. Tumor cells invaded to ribs and intercostals muscles but surgical margin was negative. Adjuvant radiation therapy with a total dose of 50.4Gy was administered to prevent local recurrence.

Conclusion
He is doing well without recurrence at 37months after surgery and radiation. Wide local excision with negative pathological margins is the treatment of choice for most desmoid tumors. Postoperative radiation may be a treatment of choice to prevent local recurrence because the development of local recurrence would result in mutilating reopreration with disfigurement or even amputation.

Background
The treatment for non small cell lung cancer (NSCLC) with operable primary lesion and solitary brain metastasis has not formed but the combined local therapy with surgical pulmonary resection of primary lesion and curative neurosurgical intervention of solitary brain metastatic site is becoming a standard option for such patients. The purpose of this study is to assess the efficacy and safety of the combined local therapy for NSCLC with operable primary lesion and solitary brain metastasis.

Methods
Within 1781 NSCLC patients underwent surgical resection from December 1993 to December 2010 at Osaka City General Hospital, 11 cases with synchronous (within 1 month of the primary NSCLC diagnosis) solitary brain metastasis and treated with curative neurosurgical intervention were identified. We retrospectively reviewed these cases and analyzed the treatment, pathology, prognosis and prognostic characteristics. Overall survival was recorded from the date of lung surgery until the last follow-up observation.

Results
The study group consisted of 7 male and 4 female. The median age at the time of pulmonary resection was 57 years (range, 39-76 years). The histological subgroup was adenocarcinoma in 10 cases and large cell carcinoma in 1 case. Neurological symptoms as the initial symptom were recognized in 3 cases. Type of pulmonary resection for primary lesion were lobectomy in 10 patients and sleeve lobectomy in 1 patient, and lymphatic extension was pN0 in 7 patients and N1-2 in 4 patients. All patients received gamma knife stereotactic radiosurgery (GKSRS) for management of the solitary brain metastasis and curative neurosurgical resection was performed in 1 patient before GKSRS. Both pulmonary resection and neurological intervention caused no serious adverse events. Of 11 patients, 7 patients had died of disease and 4 patients (3 with pN0 and 1 with pN1) were alive and with disease. The median overall survival time was 14 months and the 3-year overall survival rate was 36.4%.

Conclusion
The aggressive combined local therapy with pulmonary resection and neurological intervention for NSCLC patients with operable primary lesion and synchronous solitary brain metastasis should be considered effective and safe for selected patients. The multicentre prospective randomized studies are required to clarify the effectiveness and optimal method of this local treatment for such patients.

Background
The World Health Organization (WHO) currently classifies Large Cell Neuroendocrine Lung Carcinoma (LCNEC) as a distinct subtype of pulmonary large cell carcinoma, however, the survival after surgical-resection of LCNEC appears to be substantially worse than for other Non-small cell carcinoma (NSCLC), resembling more the survival of small cell carcinoma. The question remains whether LCNEC is best treated the same as other NSCLC. The purpose of this study is to analyze the feasibility of the multidisciplinary treatment for LCNEC.

Methods
The records of 6 LCNEC (2.9%) out of 210 patients, who underwent an intended curative resection for lung cancer in our institute during a 10-year period beginning in 2002, were reviewed. The patients consisted of 6 male current smokers, with a median age of 68 years (63 – 82). The clinical stages were 2 in stage IB, 2 in stage IIA, 1 stage IIB and 1 stage IIIA. 5 patients underwent an anatomical resection. The rest of them underwent tumorectomy. 3 patients underwent not only pulmonary resection but also adjuvant chemotherapy for primary cancer. Median follow-up time was 37.5 months (15-81).

Results
The two patients with clinical stage IIA were upgraded to pathological stage IIIA after operation. Two of them, who were pathological stage IB and IIIA, died of pneumonia and secondary cancer without LCNEC recurrence 11 and 15 months after the operation. Recurrence of disease was observed in three patients with pathological stage IIB and IIIA. One of the patients died in 55 postoperative months after receiving adrenalectomy, chemotherapy and radiation therapy for 25 months for recurrent cancer. Two of the patients are still alive after receiving either surgery pus chemotherapy or radiation therapy for 32 months and 43months since undergoing initial treatment.

Conclusion
Multidisciplinary treatment should be considered as complementary technique to surgery for LCNEC and examined in larger trial.

Background
Since the validation of CT screening for lung cancer in 2010 in the United States by the National Cancer Institute’s National Lung Screening Trial, several well-respected professional societies have endorsed lung cancer screening and developed guidelines using low dose CT (LDCT). Despite this progress, adoption of lung cancer screening has been slow to advance. In 2011, in recognition of the importance of screening for lung cancer in a responsible way, Lung Cancer Alliance (LCA) convened a panel to review current evidence and develop a framework document to educate the public about their risk and guide healthcare professionals developing screening programs. This began a multi-year strategy to ensure responsible screening through a process of outreach, education and data collection with the goals of raising public awareness about the risks and benefits of screening and contributing to the refinement of screening guidelines and risk definitions. The focus of this abstract is the process of outreach and education as development of a data collection system is still in progress.

Methods
The National Framework for Excellence in Lung Cancer Screening and Continuum of Care was developed to educate consumers about rights, guide responsible screening center development and lay the groundwork for a data collection strategy. A list of screening Centers of Excellence was developed based on commitment to the National Framework guiding principles. Outreach to additional centers continues. A multi-pronged approach was adopted. A national media campaign focused on understanding lung cancer risks and the value of early detection. Educational materials were developed to educate those at risk about various aspects of screening. Center coordinators received regular communication about educational opportunities related to screening, journal articles and other information of interest. A needs assessment of existing centers was carried out to understand implementation challenges and identify what role LCA can play in addressing them. A network of center coordinators willing to talk with other coordinators about specific programmatic challenges was developed.

Results
At the time of submission, there were 90 centers on the LCA Screening Centers of Excellence list with an additional 50 centers identified for outreach. Regular communication occurs between LCA and the coordinators. Based on needs assessment results, tools have been developed to help coordinators learn from each other. Future goals include developing webinars and other ways to address challenging issues faced by centers and evaluation of these approaches.

Conclusion
Charities can play an important role in supporting the development of responsible lung cancer screening, as is evidenced by the actions of LCA in the United States. Because charities are well-connected to those at risk for lung cancer and to lung cancer treatment programs, they are ideal parties to be involved in furthering adoption of programs and behaviors. By identifying the barriers to adoption of responsible lung cancer screening and helping develop strategies to address them, lung cancer advocacy charities are a valuable partner in the effort to raise awareness of the risk for lung cancer and ensure that screening is done responsibly.

Background
Background: Expenditures in the United States on health care have reached and estimated $2.5 trillion and cost control measures have become major features of the current health care reform debate in this country. An approach to reducing ballooning health care costs has been to focus on quality and uniformity of standards of care using health informatic technologies. We have designed and implemented a web- based clinician-to-clinician communication and collaboration platform that is mobile device enabled. The system permits asynchronous communication among clinicians in conjunction with robust sharing of the content of the Electronic Medical Record (EMR) including X-rays, digital histopathologic images and molecular diagnostics. Principle aims of the project incluided (1) documenting accurate diagnoses (2) appropriate consultation and input from specialty services (3) treatment plan optimization spanning disciplines and (4) archiving the results of multidisciplinary decision making in a virtual environment.

Methods
Methods: Using Extensible Markup Language (XML) based system; a federal patient privacy regulation (HIPAA) compliant secure platform for communication was built according to specifications designated by clinicians in the Thoracic Oncology Section of UCSF Medical Center. The web based platform was approved by a committed on human research. The system was designed with integration of a Picture Archives Viewing System (PACS) and digitized pathology images to permit specific file upload, and annotation in a scalable manner allowing collaborations between two clinicians or among a group as large as 35. User group questionnaires and focus groups were performed to refine the computer-human interface and customize user experience. Members of the Thoracic Oncology Program (N=35) at the University of California at San Francisco were invited to participate in pilot study of the efficiency and ease of use of a novel web-based collaborative system for the purposes of an asynchronous “Virtual Tumor Board”.

Results
Results: A Trial of 50 patients had care plans coordinated via the virtual tumor board with input of the multi-disciplinary focus groups used in the development of the computer - human interface. 20% of clinicians related concerns over ease of use. 10% related concerns regarding excessive electronic messaging as a disruption of work flow. 15% voiced a main concern regarding clinician reimbursement for web based consultation. Of the cases presented on the virtual tumor board platform 100% achieved clinician consensus opinion with 5 days (mean 2.5 days). Patient Satisfaction assays suggested patient comfort with protected health information transfer on a secure platform. No adverse events were directly referable to system use.

Conclusion
Conclusion: A novel web based system for collaboration among clinicians holds the promise for reducing delays in optimized treatment planning and is regarded by clinicians as worthy approach to error reduction and reduction in delay to definitive treatment plan determination. Consensus opinions were rapidly obtained and archived records of discussion facilitates outcome reviews. Clinician concern included reimbursement patterns and efficiency but patient opinion was favorable toward this approach to collaborative decision making in oncology.

Background
Pneumonectomies are usually considered contraindicated for advanced NSCLC.

Methods
A 49 year old female patient was admitted for acute severe respiratory distress requiring intubation and mechanical ventilation shortly after admittance. The patient was cachectic (BMI 16) with a hetero-anamnesis of Graves disease, 30 pack-years smoking and progressive dyspnea over weeks for which the patient did not seek medical advice prior to admission. Chest X-ray on admission showed a "white" left hemi-thorax and mediastinal shift to the right. Bronchoscopy showed tumor occlusion of the left main bronchus where biopsies revealed non-small cell lung cancer. CT-scan showed a huge tumor mass almost completely filling the left hemi-thorax and displacing the mediastinum to the right, a >3 cm subcarinal adenopathy, a small left pleural effusion and a likely invasion of the left axillary chest wall. Cerebral CT-scan was normal. In this hopeless seeming situation, the next of kin expressed their wish for an attempt at palliative surgery, given the chance that relieve from compression and circulatory shunt might bring the patient to a possible extubation and ability to communicate with their children, even if only for a short time.Figure 1

Results
Via median sternotomy and left hemi-clamshell incision an intra-pericardic, extrapleural pneumonectomy extended to ribs 3-5, pericardium and thymus was performed. Pathologic examination, showed G3 "non-small cell" lung cancer, TTF-1 positive, Ki67 index 90%, involvement of pericardium and positive pericardial fluid. Subcarinal and all other 20 lymph nodes were negative. pT3N0M1a (pleural cytology), R1. Postoperatively, the patient's state improved quickly to extubation but she later required a temporary tracheostomy (day 7) because of exhaustion and overall muscle weakness. She could be revalidated and discharged at post-operative day 74. At 9 months follow-up she is fully ambulatory and CT-scan shows no sign of recurrence. Figure 1

Conclusion
In exceptional circumstances, palliative resections up to extended extrapleural pneumonectomy may be justifiable.

Background
Lymphangioma usually occurs in the head and neck area. We present a very rare case of cystic lymphangioma that originated from the diaphragm. Few cases were reported in the literature.

Methods
A 69-year-old woman was referred to our hospital for macrocytic anemia and weight loss. Pernicious anemia was diagnosed by the presence of the atrophic gastritis, the decreased serum vitamin B12 level, and the anti-parietal cell antibodies and anti-intrinsic factor antibodies in blood serum. In addition, on chest computed tomography (CT) she was found to have a multicystic mass, measuring 50 mm in diameter, which seemed located in the anterior mediastinum and abdominal cavity, across the diaphragm. The cranial part of the mass consisted of solid structure including fat components but no calcification, and the caudal part consisted of multicystic structure, of which septal wall was slightly enhanced. The mass did not appear to invade the liver but to compress. Fluorine-18-fluorodeoxyglucose positron emission tomography (PET) scan showed no abnormal uptake. The mass was suspected a cystic teratoma, a bronchial cyst, a lipoma, a thymoma, or Morgagni hernia. It was resected through right diagonal thoraco-laparotomy with short upper midline incision.

Results
Seen from intrathoracic side the mass did not invade the pericardium and seemed to have firm adhesion to the diaphragm, and from intraabdominal side did not perforate the peritoneum or invade the liver, and no hernia canal was seen. The mass was not able to apart from the diaphragm, and combined resection of the diaphragm was performed. Pathologically it was diagnosed as a lymphangioma.

Conclusion
Lymphangioma arising from diaphragm is a very rare tumor. It should be considered in the differential diagnosis of diaphragm tumor.

Background
NHS Scotland is committed to improving the quality of healthcare services and patient-centered care is at the heart of Better Cancer Care (2008). The importance of experiences of patients in the planning and delivery of cancer services is a priority in improving cancer services across Scotland and increasingly emphasis is being put on how services are being delivered at a local level.

Methods
A questionnaire developed by Gloucestershire Health Authority to elicit the views of patients with lung cancer was identified. This had been adapted by South-east Scotland Cancer Network (SCAN) in 2010 to survey their patient population. Permission was sought and granted from NHS Gloucester and NHS Lothian to further adapt the questionnaire and use it in the wider Scottish population. All three networks were involved adjusting the questionnaire to explore areas of care at the time of diagnosis, during treatment and in the follow-up period. The survey has a mixture of qualitative and quantitative components with room for free text for clarification after many of the questions. All patients with lung cancer and Mesothelioma attending Oncology follow-up were asked to completed the survey. New patients, patients on surgical follow-up and those currently receiving chemotherapy or radiotherapy were excluded. The questionnaire was handed out to all patients with lung cancer and mesothelioma attending oncology clinics during June 2013 in Scotland. The questionnaires were distributed by the receptionists or clinic staff to be completed prior to seeing their oncologist. All questionnaires were anonymous and once completed were collected and returned to the researchers. Assistance with the quantitative analysis will be obtained from the Clinical Effectiveness Team in NHS Lanarkshire. The questionnaires will be analysed using SPSS and Excel. Bar graphs will be provided for each question. Data will be cross tabulated against each region where the diagnosis of lung cancer was made. Free text will be collated into themes and assistance with this analysis obtained from the University of Dundee.

Results
'Not applicable as yet, awaiting results'

Conclusion
Not applicable as yet, awaiting results

Background
Solitary fibrous tumor of the pleura (SFT) is an infrequent diagnosis and presents with a spectrum of radiographic and clinical findings. SFT can follow indolent or agressive clinical courses. This report describes clinical, radiologic and pathologic findings from four patients with this diagnosis. Surgical management options and the role of surveillance are reviewed.

Methods
The medical records and pathology reports of these patients were abstracted. The pathology slides were reviewed and interpreted by a single pathologist.

Results
Each patient had unique presentation and clinical course. Two patients did not have cardiopulmonary symptoms; two had progressive dyspnea, cardiac arrythmia, or pleuritic pain. Surgical approaches included robotic-assisted surgery (2), limited thoracotomy (1), and posterolateral thoracotomy with median sternotomy (1). All patients did well in the short term and there were no mortalities. All tumors showed typical spindle cell morphology with hemagiopericytoma like vasculature. Two patients showed significant necrosis. One patient developed bilateral pulmonary and subcutaneous metastasis one year after R0 resection; this tumor showed increased mitotic activity and necrosis on original pathology. FIGURE 1: CT chest of a large fibrous tumor of the pleura Figure 1 FIGURE 2: CT Chest of pulmonary metastasis Figure 2

Conclusion
Our experience with management of solitary fibrous tumor of the pleura emphasizes the variety of radiographic and clinical presentations for this entity. In our series, one patient had disease progression despite original pathology interpretation indicating typical morphology. Interestingly, this patient had the greatest number of mitotic figures in the tumor. Surgical resection remains the standard of care. Because these tumors have malignant potential, ongoing radiographic surveillance is appropriate management in patients with this diagnosis.

Background
Lung cancer patients have been shown to have some of the highest level of unmet psychological, physical and daily living needs. Despite this, patients have limited access to the interdisciplinary team in the outpatient setting. Current best practice indicates that an interdisciplinary team can better meet the needs of patients through a collaborative approach to treatment, planning, supportive care and preserving current function Specifically at Sir Charles Gairdner Hospital, patients have limited access to interdisciplinary team members in an outpatient setting. This has resulted in the concept of the Lung INterdisciplinary Clinic (LINC) where patients will be routinely assessed and provided with appropriate interventions aimed at reducing their distress and increasing or maintaining their function. Health professionals included in the LINC clinic include a nurse, social worker, occupational therapist, physiotherapist & dietician.

Methods
This is a prospective cross sectional study of lung cancer and mesothelioma patients carried out between April 2013 and September 2013. Participants will be recruited to the study via the Lung multi-disciplinary team meeting (MDT), those referred directly from any outpatient clinic or self-referred. Participants under 18, have a cognitive impairment or NESB will be exluded. Initial Screen: Participants will complete the Distress Thermometer (DT), rating their overall distress on a scale of 0 to 10 and identifying items on a list that cause them distress. Referral pathway and intervention delivery: Based on the problem items selected by the patient, a referral will be made to the appropriate health professional to receive intervention to address the problem. The timeframe for when the intervention will be provided is dictated by the distress the problem causes the patient –see belowFigure 1 Evaluation of service: Following intervention by the required health professional(s), the patient will be contacted by phone and the DT will again be administered. A qualitative questionnaire will also be administered at this time.

Results
not available at this point

Conclusion
This project has significant benefits to the patient, the health service and the wider community. The study plans to provide a new and improved method of interdisciplinary service delivery to an underserviced population. At present there is no literature related to the significance of interventions completed in an outpatient setting aimed at reducing distress and concerns in lung cancer/mesothelioma patients. Therefore this research will aim to expand the current body of literature related to this population.

Background
Incidence of Lung cancer is on the rise, especially among women in India. NSCLC constitutes the vast majority and there is tendency of rise in adenocarcinomas especially in smokers. Recent advances suggest that NSCLC is not a single entity but a cohort of different types based on molecular markers. IHC is a simple method to detect these changes. Recent trend is the use of IHC markers for molecular sub typing. A retrospective analysis of 35 patients who were diagnosed to have NSCLC and received at least 3 cycles of chemotherapy was included in this study. The objectives of the study: (1) To explore IHC pattern (Ki67, EGFR, Her2neu & ALK) (2) To correlate the IHC pattern to clinical presentation and response to chemotherapy.

Methods
Paraffin blocks of 35 cases of NSCLC were retrieved and analyzed. Histopathology sub-typing was done based on WHO classification. IHC markers (Biogenics) EGFR, Her2 neu, ALK & Ki67 were done & interpreted by using intensity of staining and percentage of positive cells. H-score was calculated for EGFR and allocated into low EGFR (< 200) & high (≥200-Positive). Her2neu analysis was graded from 0 to 3+, ALKs scoring was done using 0 to 3+scale and Ki67 was scored low (≤10% cells) and high (> 10% of nuclear positivity).

Results
Out of 35 cases studied, 7 cases were <50 years. Male 26, Female 9. 21 cases were smokers. 7 patients had significant weight loss. Morphological classification revealed adenocarcinoma 26 (76%) & squamous 8 (24%). EGFR was positive in 28 cases out of which 21 (80%) were adenocarcinoma and 7 (87%) squamous cell carcinoma. The positivity of Her2 and ALK was seen in one case each. High Ki67 was seen in 21 cases out of which 50% adenocarcinoma & 100% squamous cell carcinoma. EGFR Positivity was observed in 6 (85%) <50 years of age. There was no difference in sex distribution. Loss of weight did not correlate with high Ki67. Among EGFR positive cases high Ki67 was found in 17 cases (58%). The EGFR positivity did not differ between smokers and non smokers. Response (Partial Response & Stable Disease) to either Taxane / Gemcitabine based combination therapy was observed in 90% of low Ki67 group. In EGFR positive, 75% of chemotherapy group had good response (PR+SD) compared to upfront targeted therapy (Erlotinib). All the patients who received upfront targeted therapy were in low performance status.

Conclusion
This study has shown some interesting data. The EGFR status did not differ between smokers and non smokers. The observation of percentage positivity of ALK and Her2 was very low in this study. Low Ki67 patients responded well to chemotherapy. The response to treatment in EGFR positive NSCLC with Gemcitabine / Taxane with Platinum based combination chemotherapy was much better than those patients who received upfront EGFR targeted therapy, but needs more patients for statistical significance.

Background
Sorafenib is an orally available multikinase inhibitor with antiproliferative and anti-angiogenic activity. Reported oral adverse events of any grade are stomatitis/mucositis (11-38%, mostly ≤ CTC-AE grade 2), oral mucosal pain and dysphagia in the absence of clinical lesions. Sorafenib is under investigation in NSCLC. We report a patient who developed symptomatic progression of an esophageal stenosis during sorafenib treatment.

Methods
not appicable

Results
Case: A 67-year old male presented at the outpatient clinic with dysphagia CTC-AE grade 3. He was diagnosed with a cT3N3M1a (oligometastatic adenocarcinoma, KRAS mutated) NSCLC in January 2011 for which he was treated with concurrent chemoradiotherapy. Treatment was complicated with grade 3 radiation esophagitis (confirmed with duodenogastroscopy) for which he was treated with a feeding tube and proton pump inhibition. Because of remaining grade 1 dysphagia, duodenogastroscopies were performed in August 2011 and February 2012. A stable relative stenosis of the upper esophagus was found, easy to pass with the duodenogastroscope. Because of progressive disease he was subsequently treated with erlotinib/ pemetrexed (September 2011, study) and docetaxel monotherapy (August 2012). February 2013 he progressed again with subsequent participation in a phase II study with sorafenib 400 mg BID and metformin 1000 mg BID. Within three weeks he developed dysphagia for solid foods. A chest computed tomography showed no external compression of the esophagus and no tumor progression. Duodenogastroscopy revealed a stenosis with ulceration in the upper part of the esophagus, passing the stenosis was only possible with a baby-duodenogastroscope. Because of swallowing problems, sorafenib was temporarily stopped and placement of a percutaneous feeding tube was planned. However, two days after stopping sorafenib, his dysphagia completely resolved and food passage was normal. So, ten days later sorafenib was restarted with dose reduction (200 mg BID). After restarting sorafenib his dysphagia returned with grade 3 within six weeks. Again, sorafenib was temporarily stopped and in a couple of days his dysphagia resolved. After another restart of sorafenib at the latter dose he again developed dysphagia, but this time manageable.

Conclusion
We present a patient who developed a grade 3 stenosis of the esophagus during treatment with sorafenib which clinically resolved shortly after stopping sorafenib but reoccurred after rechallenge with sorafenib at a lower dose. Dysphagia resolved again after stopping the sorafenib with again complaints after restarting. No other explanation was found (e.g. progression of malignancy, external compression). 1.5 year before, after concurrent chemoradiotherapy, he was diagnosed with a relative stenosis of the upper esophagus, but this remained stable until sorafenib treatment was started. He scored 8/13 points on the Naranjo score, making sorafenib a probable cause of the stenosis. The underlying mechanism is unknown. A possible explanation is sorafenib inhibition of the VEGF and MAP-kinase pathway. These pathways are both involved in the process of mucosal defense and repair, and it could be that blocking this pathway combined with sensitization by previous irradiation caused progression of the stenosis. This case stresses the importance of being aware of unusual side effects of medication and taking into account possible interactions with previous treatments.

Background
Despite the rising incidence of NSCLC in the elderly population in Thailand, a well defined chemotherapy regimen for these patients has not been reported. This study examines the toxicity and activity of doublet carboplatin and gemcitabine in Thai patients with advanced NSCLC.

Methods
Chemotherapy-naive patients with histological/cytological proven advanced NSCLC, aged > 65 years, ECOG 0-1 and adequate organs function were treated with carboplatin (AUC5) and gemcitabine (1000 mg/m[2] in a 30-min infusion D1, 8) every 21 day for maximum 6 cycles. The primary endpoint was objective tumor response rate and tolerability to this regimen.

Results
From November 2011 to February 2013, 30 patients were evaluated. Median age was 73 years (range 65-83), 70% were male, 70% were smoker and all patients had PS 0 (30%) or PS 1 (70%). Stage IIIb disease in 13% patients and stage IV in 87% patients. Non-squamous cell carcinoma in 73% patients (adenocarcinoma 66%, large cell carcinoma 3.5%, other 3.5%) and squamous cell carcinoma in 27% patients. The median number of cycle was 4 (range 2-6). Among the 29 patients with measurable disease, there were 7 PR, 15 SD and 7 PD (response rate 24%). The most common hematologic toxicity was grade 3 anemia in 20% and grade 3 leukopenia in 10%. Febrile neutropenia occurred in 3%. No treatment related death was observed. Non-hematologic toxicity was generally mild and grade 1 fatigue occurred in 30%. The median progression free survival was 4.9 months (range 2-16).

Conclusion
The doublets carboplatin and gemcitabine could be a valuable treatment option in elderly Thai patients. The activity and safety observed in this report is within the range of data reported for doublet chemotherapy regimen in the elderly patient with NSCLC.

Methods
HT-ANAM-301 (NCT01387269) and HT-ANAM-302 (NCT01387282), also known as ROMANA 1 and ROMANA 2, are double-blind, placebo-controlled, randomized (2:1 anamorelin HCl vs. placebo) Phase III trials in patients with NSCLC cachexia, with a target enrollment of 477 patients per study. Eligible patients must have unresectable Stage III or IV NSCLC and cachexia (weight loss of ≥5% body weight within prior 6 months or BMI <20 kg/m[2]). Patients receive once daily oral doses of anamorelin HCl (100 mg) or placebo for 12 weeks. Co-primary endpoints are the change from baseline in LBM as measured by DXA scan and in muscle strength as measured by handgrip strength (HGS). Secondary endpoints include change in body weight, overall survival, and quality of life. For HT-ANAM-301 only, blood samples are collected at Week 6 for population pharmacokinetics. After 12 weeks of treatment, patients may continue in a separate 12-week safety extension study (HT-ANAM-303 [ROMANA 3] NCT01395914).

Results
As of June 2013, 448 patients (93.9%) have been enrolled in ROMANA 2, and key baseline characteristics based on preliminary data available to-date are presented in the Table.Figure 1

Background
Lung cancer patients increasingly seek a second opinion in order to make sure they are receiving an exact diagnosis and an optimal treatment. A second opinion is more likely to be comprehensive when performed in centers with high level of expertise and within a multidisciplinary team.

Methods
A dedicated second opinion outpatient clinic was started within the Thoracic Oncology Unit of Ghent University Hospital, in March 2012, aiming at a quick access and evaluating its impact on diagnosis and treatment decisions. Second opinion was defined as a review of the cancer diagnosis and/or the treatment recommendations by another independent oncologist and/or multidisciplinary team. Patients had to be referred by either their general practitioner or the treating specialist. Prior to the consultation relevant investigations (medical history, pathology and imaging) had to be provided.

Results
Between March 2012 and June 2013, 79 pts were referred: 31 women and 48 men with a median age of 64 years [17-81 yrs]. Of these, 17 (22%) were never smokers, 18 (23%) smokers and 40 (51%) ex-smokers. Median interval was 3 working days [0-15 days] after first referral. Eighteen percent of patients were referred by their GP’s versus 80% by their treating specialist. Medical information including imaging was available in all pts at the moment of the consultation. Diagnosis included: adenocarcinoma (n=43 - 54%), squamous cell carcinoma (n=8 - 10%), NSCLC, NOS (n=1 large cell neuroendocrine carcinoma (n=3 - 4%), small cell lung cancer (n=4 - 5%), mesothelioma (n=6 - 8%), thymoma (n=2 - 3%), carcinoid tumor (n= 4 - 5%). In 4 patients no diagnosis had been established. Eleven patients were referred for confirmation of diagnosis and treatment, 11 for staging and 57 for treatment advice. Median consultation duration was 35 minutes [15-60 min], median time of multidisciplinary counseling 15 minutes [5-60 min]. In 43% of the referrals, diagnosis and treatment was confirmed, in 21% other diagnostic examinations were advised and in 29% a substantial change in treatment was proposed. Six percent of patients entered into a clinical trial. Almost 50% of patients continued their treatment at our center (26% on request of the referring physician, 23% on patient's request). Patient's satisfaction on waiting time and quality of the advice was high.

Conclusion
This dedicated second opinion outpatient clinic confirms the need for an academic second medical advice and provided a quick access. In 50% of cases a substantial change in diagnostic procedure or treatment was proposed.

Background
Echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion genes occur in approximately 4-7% of patients with adenocarcinoma of the lung (ACL). These tend to occur in individuals with limited or no tobacco exposure and largely occur in exclusion of KRAS mutations. The presence of a KRAS mutation is associated with a worse prognosis and predicts lack of response to targeted therapeutics such as crizotinib. We believe this to be the first case reported of a concurrent KRAS mutation and EML4-ALK translocation with a subsequent response to crizotinib.

Methods
Not applicable

Results
A 56 yo White female smoker had a recent diagnosis of cirrhosis due to hepatitis B and C. Imaging for her liver revealed an incidental finding of bilateral lung opacities, both of which were suspicious for malignancy. A biopsy of the LLL lesion confirmed ACL. Resection of the superior segment of the LLL was performed and confirmed a well-differentiated ACL with BAC features (T1b, N0, M0). Analysis revealed a KRAS mutation (p.G13C (c.37G>T); EGFR and EML4-ALK analysis were not performed. The right-sided lesion was observed. One year later, disease progression was identified in the right hilum and mediastinum. EBUS confirmed the presence of ACL in levels 10R and 4R lymph nodes. Molecular analysis again confirmed the presence of a KRAS mutation, albeit a different mutation (p.G12A (c.35G>C) than was observed in the left lung. There was no ALK gene rearrangement. She was treated with concurrent chemoradiation with cisplatin as the radiosensitizer in light of her pre-existing grade 2-3 thrombocytopenia from her underlying liver disease. She received 38 out of a planned 60 Gy due to thrombocytopenia and subsequent interruptions in therapy. Nonetheless, she did respond to therapy, but she had a local recurrence less than 8 months after therapy was terminated. At the time of progression, the patient sought further surgical intervention and a pneumonectomy was offered; however, mediastinoscopy confirmed the presence of adenocarcinoma in a level 7 node and plans for further resection were aborted. Mutational analysis confirmed the presence of the activating KRAS mutation, (p.G12A (c.35G>C) and negativity for an EGFR mutation; however, an EML4-ALk translocation was identified in 20% of cells analyzed. The patient was treated with crizotinib. After 8 weeks of therapy, PET/CT demonstrated objective evidence of response to therapy with the maximum SUV decreasing from a baseline of 11.3 to 6.8, with the lesion remaining stable in size. Therapy was well-tolerated, although the patient had an unexpected finding of normalization of her platelet count while on therapy with crizotinib.

Conclusion
This unusual case of a female smoker with a co-existing EML4-ALK translocation and activating KRAS mutation highlights several important points: 1. EML4-ALK translocations are not mutually exclusive of KRAS mutations in all patients with ACL. 2. Discordance in EML4-ALK translocation status can occur in metastatic deposits. 3. Individuals harboring both an EML4-ALK translocation and a KRAS mutation can respond to crizotinib. 4. Commonly used algorithms for molecular testing in ACL do not identify all patients who may benefit from molecularly targeted therapies.

Background
Primary pulmonary lymphoma (PPL) is a rare disease. Half of the patients are asymptomatic and other patients can present nonspecific symptoms such as cough, mild dyspnea, chest pain, or hemoptysis. The diagnosis of disease is based on histological examination and we can obtain a tissue by surgical biopsy, transbronchial or transthoracic biopsy. We report a case that PPL mimicking lung abscess was confirmed by surgical biopsy.

Methods
68-year-old female presenting with continuous mild fever and cough for 2 weeks, and suspected as pneumonia or lung abscess at the initial evaluation. There was no clinical improvement after antibiotic therapy for 5 weeks. Chest computed tomography showed as organizing pneumonia with abscess formation right middle lobe RML). So, we performed right middle lobe lobectomy. In operative findings, there was large amount milkfish drainage with hard mass in RML. There was no culture positive in milkfish drainage. Post op 7th day, she discharge without any complication.

Results
Pathologic findings reveals the mass was malignant primary pulmonary lymphoma in (diffuse large cell type B-cell lymphoma).

Conclusion
PPL is a vary rare entity and the diagnosis based on radiological findings is limited so, we reports it.

Background
Major goals in advanced NSCLC include accurate evaluation of survival and quality of life. Few trials evaluate both of these major endpoints well. In many studies, only a minority of patients have quality of life and other patient reported outcomes (PROs) such as symptoms systematically followed over time, which decreases the value of the assessment of the treatment. Prior studies have identified barriers to measuring quality of life in clinical trials and in practice. To overcome these barriers, we used a computer-assisted version of the validated LCSS measure and tested this prospectively in a large study in patients with Stage IV and IIIB NSCLC. The eLCSS-QL requires only two minutes for completion of the patient version and proved to be highly acceptable in earlier studies (Hollen, Supp Care Cancer 2012).

Methods
This trial was conducted at 65 sites in 9 Asian countries. 622 patients received first-line treatment with docetaxel -based chemotherapy. Patient demographics included: 70% male; 65% adenocarcinoma; median: KPS = 90; ECOG = 1 (27% ECOG 0). Stages: IV (72%), IIIB (28%). 84% had two or more major symptoms. 80% received combination chemotherapy with cisplatin (52%) or carboplatin (28%). The eLCSS-QL was completed every 3 weeks at the clinic. We also surveyed 98 physicians and nurses treating these patients regarding their experiences concerning communication, usefulness and acceptability of the eLCSS-QL.

Results
Ninety-seven percent of patients completed the eLCSS-QL at baseline; 90% completed follow-up evaluations. Over 90% found the eLCSS-QL easy to use and acceptable to complete at each visit. More than 80% of patients reported increased awareness of symptoms and that the quality of life evaluation made it easier to speak with doctors and nurses. 1% refused eLCSS-QL completion. Of physicians and nurses, more than 90% found the eLCSS-QL easy to use and increased symptom awareness; 80% reported improved communication, enhanced satisfaction with the patient visit, and would recommend its use to others. Nearly 90% of physicians reported they could identify benefit from chemotherapy earlier; 76% would order fewer imaging tests and 80% said the eLCSS-QL could save time. Cross-cultural testing was performed in this 9 nation trial. Cronbach’s alpha scores were high for each country, and exceeded 0.85 overall, demonstrating good cross-cultural reliability. Treatment outcomes: major response rate 37%; median survivals: 13.9 months (docetaxel + cisplatin), 12.7 months (docetaxel + carboplatin).

Conclusion
Placing the well validated LCSS onto an electronic platform (eLCSS-QL) helped overcome barriers to evaluating QL in this large clinical trial, with 90% of patients completing baseline and repeated QL measures. Patients, physicians, and nurses all found the eLCSS-QL to be highly acceptable and easy to use. The good cross-cultural aspects of the eLCSS-QL indicate that the electronic platform is particularly suitable for multinational trials. This large prospective trial demonstrates that improved compliance with quality of life and PRO evaluation is feasible and can easily be accomplished in large clinical trials. Additionally, the electronic format enhances the potential for the use of PROs in decision making in clinical practice.

Background
The tradition of Lung Cancer Awareness Month (LCAM) started in Slovakia in November 2008 with the help of several organizations, including Slovak Oncological Society, Ministry of Health, Ministry of Education, Ministry of Agriculture, Roche Slovakia, leading lung cancer centers, and many others, including volunteers, with the main purpose to raise awareness about all aspects of lung cancer. Several interesting projects were realized as a part of LCAMs in 2008 – 2012. Among them were the press conferences with participation of patients, leading experts, well known persons from cultural and political life; lung function testing in the Parliament of the Slovak Republic; lung function testing and educational leaflets distribution in the largest shopping centers in the country; the moving exhibition of lung models colored by the VIPs from the Slovakian cultural and sport life, i.e. by well known writers, actors and actresses, and sport stars; teaching activities at the secondary schools; publishing of free educational materials for patients and their relatives. In addition, during the LCAM in 2011 the Second Breath (Druhy Dych) Citizens Organization was established to help patients with lung cancer, and successfully continues with their activities (www.druhydych.eu). We decided to assess the influence of LCAMs on public awareness of lung cancer.

Methods
1. Search for the Slovak web pages containing the term “rakovina pluc” (“lung cancer“) was done in Google.sk for the time periods: 01.NOV.2007 – 31.DEC.2007, 01.NOV.2008 – 31.DEC.2008, and 01.NOV.2012 – 31.DEC.2012. 2. Another search was done in a Newton Media Database, aimed at the major Slovak media, for the years 2007 and 2012 to find the entries with the term “rakovina pluc” (“lung cancer”).

Results
1. The number of the Slovak web pages with the term “rakovina pluc” (“lung cancer”) in the time periods 01.NOV. – 31.DEC.2007, 01.NOV. – 31.DEC.2008, and O1.NOV. – 31.DEC.2012 was 14, 58, and 130, respectively. 2. The number of entries with the term “rakovina pluc” (“lung cancer”) in the Newton Media Database was 16 in 2007, and 36 in 2012.

Conclusion
Our results confirm, that LCAMs in Slovakia attracted media and public attention and thus increased the awareness of lung cancer. We believe that this has a positive impact on lung cancer patients’ care, and encourages us to continue with the LCAMs tradition.

Background
The management of non-small cell lung cancer (NSCLC) has changed markedly over last decade with the discovery of distinct molecular and genetic changes within the lung cancer genome and the availability of new therapeutic agents to target these genetic aberrations. However, the clinical benefits observed are not without significant financial costs. These include diagnostic testing to identify molecular targets and an increasing cost of cancer treatment. Chromosomal rearrangements of the anaplastic lymphoma kinase gene (ALK) are predictive for clinical response to crizotinib, a first-in-class oral ALK inhibitor. In a recent phase 3 trial, crizotinib was associated with a higher response rate, improved progression-free survival and improved quality of life when compared with docetaxel or pemetrexed as second-line chemotherapy for advanced NSCLC following platinum-based chemotherapy. We performed an analysis to estimate the cost-effectiveness of ALK testing and crizotinib treatment in the second-line setting for patients with stage IV ALK-rearranged NSCLC in the province of Ontario, Canada.

Methods
We developed a Markov state-transition model to compare the costs and effectiveness of ALK testing and treatment with crizotinib in positive cases with the current standard of care (docetaxel or pemetrexed chemotherapy). Patients had stage IV NSCLC with non-squamous histology and were previously treated with a platinum-based regimen. The analysis was conducted from the Canadian public health perspective (Ontario) and a “lifetime” time horizon was used. Transition probabilities, mortality rates and costs were calculated from the Ontario Registry, Cancer Care Ontario New Drug Funding Program, Ontario Case Costing Initiative, University Health Network and published literature, including a recent second-line randomized trial of crizotinib versus chemotherapy (Shaw et al. New Engl J Med 2013). Population-based ALK testing included initial immunohistochemical (IHC) staining followed by fluorescent in-situ hybridization (FISH) for positive cases. The outcome of the analysis was incremental cost per quality-adjusted life-years (QALY). The survival impact of crizotinib in ALK-positive NSCLC was derived from a retrospective study (Shaw et al. J Clin Oncol 2012), as the second-line randomized trial of crizotinib versus chemotherapy permitted >80% crossover from the standard chemotherapy arm to crizotinib.

Results
The use of crizotinib compared to pemetrexed and docetaxel in ALK-rearranged NSCLC, based on our preliminary model, could yield as much as +0.309 QALY and +0.433 QALY respectively, assuming no crossover from chemotherapy to crizotinib. Incremental costs based on the preliminary model are estimated at CAD $88,446 for pemetrexed and $102,764 for docetaxel, with incremental cost-effectiveness ratios of $286,198/QALY ($162,814/life-year) and $237,575/QALY ($136,707/life-year) gained respectively. Major drivers of cost-effectiveness included the cost of drug therapy and incremental survival. Data on the impact of ALK testing on the overall cost-effectiveness ratio will be presented at the 2013 WCLC meeting, as will refined cost estimates after further model calibration.

Conclusion
While crizotinib therapy 2[nd] line for advanced ALK-rearranged NSCLC is clearly superior to chemotherapy, the cost-effectiveness ratio is higher than traditionally accepted thresholds, driven largely by drug cost. Payors and manufacturers should collaborate to ensure that highly effective NSCLC treatments are available and affordable to patients with NSCLC.

Background
After decades of very slow progresses, lung cancer management rapidly evolved in the past few years. One could anticipate a possible leap in perception of the disease between patients and physicians.

Methods
We conducted a prospective nationwide observational survey of 2200 healthy subjects selected within a representative permanent polling database according to the relevant national and European laws. We collected data in relation to aetiology, epidemiology, diagnostic, therapy and prognostic by using a specific questionnaire as well as perception of lung cancer by using a lexical approach. Among them, 1629 returned the questionnaire and 1469 were eligible for a full analysis.

Results
We observed that the population has an average high level of information regarding epidemiological changes of lung cancer (“same incidence” for 40%, “higher incidence” for 47%, “increase in women” for 75%), and main risk factors (tobacco 93%, occupational 81% and environmental exposure 56%). Two thirds (67%) are aware of the danger of passive smoking. Only 22% of the whole population believed to be at risk of lung cancer. Differences were seen according to smoking habits as 62% of current smokers, 21% of former smokers and 6% of never-smokers believed to be at risk (p < 0.05) and according to the age, as 15% of responders above 65 years old thought to be at risk in comparison of 26% of responders below 34 (p < 0.05). The population overestimated the overall survival of lung cancer (32%) and underestimated the potential cure of early stage disease (52%). The participants clearly identified lung cancer as a severe disease (82%) with a worse prognostic than other cancers (colorectal, breast, prostate, p < 0.05). Most of the population was aware of the main treatments of lung cancer (surgery, chemotherapy and radiotherapy) but only 45% cited targeted therapy. By using lexical tests we observed that corpus can be split in two main lexical repertoires: a) the major repertoire in which the significant units have encoded lung cancer identified as a tobacco-induced, life-threatening disease, imposing heavy treatment and b) the minor repertoire in which significant units belonged to the representation of lung cancer as an environmental-induced disease. In comparison with breast cancer, lung cancer is characterized by a greater feeling of guilt and a more frequent association with the way of life.

Conclusion
We deciphered some aspects of lung cancer perception in the general population and anticipated that it may improve psychological adjustment in patient-doctor communication, fill in the knowledge gap of the perception of the disease and eventually help in lung cancer management.

Background
Malignant pleural effusion (MPE) is a disabling condition in patients with metastatic disease. Pleurodesis is a well established treatment for recurrent MPE; however, the best sclerosing agent is still a matter of debate. Iodopovidone is described in the literature as a sclerosing agent easily obtained, easy to use, and inexpensive; nevertheless, its safety has not been systematically evaluated. The objective of this study was to analyze the occurrence of frequent (>5%) adverse events after pleurodesis using two different dosages of Iodopovidone in patients with MPE.

Methods
Randomized double blind clinical trial including patients with recurrent MPE eligible for pleurodesis. All patients were randomized into two groups; group 1 received 1% Iodopovidone and group 2 received 2% Iodopovidone. We sought adverse events systematically after pleurodesis through pain analog scale, dyspnea scale, oxygen saturation, heart frequency, arterial blood pressure, body temperature, visual acuity, EKG, chest x-ray and laboratory tests (CRP, hemogram, renal function, liver function and thyroid function). All adverse events were registered and classified according to the CTCAEV v3.0. We considered pleurodesis as failed when the patient underwent new pleural procedures. We compared groups as for adverse events, quality-of-life, and success using, chi-square or t-test, p<0.05 was considered significant.

Results
Fifty patients underwent pleurodesis over the study period, 45 females and 5 males with a mean age of 56,7 years. The etiology of MPE was breast cancer in 34 patients (68%), lung cancer in 6 patients (12%), and other neoplasms in 10 patients (20%). We found no difference in patient’s demographical data between groups. The most frequent adverse event was elevation of alkaline phosphatase, which occurred in 21 patients (42%), 6 in group 1 and 15 in group 2 (p = 0.03). Hyponatremia was the second most common adverse event, it occurred in 19 patients (38%), 5 in group 1 and 14 in group 2 (p= 0,02). In no patient did these laboratorial alterations require further care. The most frequent clinical adverse event was severe pain, it was observed in 5 patients (10%), 1 patients from group 1 and in 4 patients from group 2 (p=0.69). Hypotension occurred in one patient from each group (p=1). Two patients had postoperative empyema in group 2, and none in group 1 (p=0,35). Other adverse effects or complications commonly reported in the literature such as fever, renal or visual disorder were not found. Pleurodesis success rate was 92% in the Group 1 and 84% in Group 2 (p = 0.5).

Conclusion
Clinically relevant adverse events are not frequent after iodopovidone pleurodesis, being pain the most common. Apparently, the occurrence of laboratorial alterations is dose-dependent

Background
Malignant pleural mesothelioma (MPM) is the main primary malignant tumor of the pleura. It is extremely aggressive and associated with poor survival, despite multimodal treatment appropriate. Most series report the experience accumulated with the treatment of MPM in a few North American or European specialized centers. In literature, we found very little information on epidemiology and treatment of mesothelioma in Latin America. The aim of this study was to describe the experience with MPM in a tertiary university hospital in Brazil.

Methods
Retrospective study with patients diagnosed with MPM between December 1999 and December 2011. Diagnosis was established by histopathological analysis of the pleura. Tumor staging included CT scans of the head, thorax and abdomen. Pet Scan/PET-CT has been included since 2002. Mediastinoscopy is routinely performed since 2002. All patients were initially considered for multimodal therapy (extrapleural pleuropneumonectomy with chemotherapy and radiotherapy). The chemotherapy regimens used were cisplatin, doxorubicin, cyclophosphamide, and recently, Pemetrexed. Categorical variables were presented as percentage and continuous variables as mean and standard deviation. Kaplan-Meier estimate was used for survival analysis.

Results
Fifty-nine patients were included (45 M/ 14 F); mean age 49 years (13-79). Forty-five patients had epithelioid tumors (76%); 4 (7%) had sarcomathoid tumors; 8 had biphasic tumors (14%), and 2 (3%) had desmoplastic tumors. 36% of the patients had confirmed asbestos exposure. Clincal stage was Stage I, 18 patients; Stage II, 8 patients; Stage III, 21 patients: and, Stage IV, 12 patients. Therapeutic approaches were multimodal (pleuropneumonectomy extrapleural plus chemotherapy-radiotherapy) in 21 patients (36%), chemotherapy and radiotherapy in 8 (14%), radiotherapy alone in 4 (7%), chemotherapy alone in 25 (43%). Survival among patients operated was 16 + 2 months, and 15.9 + 5.7 months in the non-operated group. There was no statistical difference in survival between the groups operated and non-operated. Surgical mortality was 15%, with 40% morbidity.

Conclusion
The pattern of our demographic data is similar to other international series. Despite aggressive treatment, poor survival was observed in the present study.

Background
Crizotinib(Xalkori®) was developed as a medicine for anaplastic lymphoma kinase (ALK)-rearranged non-small cell lung cancer (NSCLC). Multi institutes studies established its efficacy and safety for advanced lung carcinoma. After crizotinib release in Japan, there has been no report about usage of crizotinib for postoperative recurrence of lung cancer. We have four patients with postoperative recurrence of ALK-rearranged NSCLC who were treated with crizotinib. We herein report the efficacy and safety of the treatment.

Methods
not applicable

Results
Case report ALK-rearrangements were confirmed by FISH examination from surgical specimen in　all four patients. Histological diagnoses were pulmonary adenocarcinoma in all cases. Case 1. A 62-year-old man underwent the right middle and lower lobectomy (pT3N2M0) followed by adjuvant chemotherapy with platinum doublet. He had a mediastinum lymph node relapse six months after the operation. Crizotinib was administered as the 2[nd] line. A long stable disease (SD, six months) was obtained in this patient. Case 2. A 62-year-old woman underwent the right upper and middle lobectomy (pT2aN2M1a) followed by adjuvant chemotherapy with platinum doublet. She had multiple lung metastases thirty-one months after the operation. Progressive disease (PD) was detected after four courses of platinum doublet. Crizotinib was administered as the 5[th] line and partial response (PR) was obtained over 5 months. Case 3. A 63-year-old man underwent preoperative chemotherapy followed by the right upper lobectomy (ypT3N2M0). He received an adjuvant chemotherapy with platinum doublet. He developed brain metastases five months after the operation. Crizotinib was administered one month as the 4[th] line, and PR was obtained. Case 4. An 83-year-old woman underwent the left lower lobe wedge resection. (pT2aNXM1a) followed by four regimens of chemotherapy, resulting in PD. Crizotinib was administered as the 5[th] line. The side effects with increase in body weight (+4kg, Grade1), leg edema (Grade 2) and liver dysfunction (Grade 1) deveroped on the 7[th] day. Her symptoms quickly disappeared after discontinue of crizotinib. Another regimen chemotherapy was administered because she rejected restart of the crizotinib treatment.

Conclusion
In the efficacies of the crizotinib treatment, two cases were PR, one case was SD and one case was drop out. The crizotinib was effective in two cases which were PD with other regimen treatments. Crizotinib has possibilities of giving dramatic clinical response in ALK-rearranged NSCLC patients. In safeties of the crizotinib treatment, no adverse event was occurred in three cases and Grade 2 adverse in one case. There have been no serious complications.　Crizotinib treatments in ALK-rearranged NSCLC patients have great possibilities of having a clinical benefit. Crizotinib can also be effective and safe in postoperative recurrence of ALK-rearranged NSCLC patients. We reacknowledge an importance of molecular targeted therapy that creates dramatic clinical effects within a short time period. Further observation and accumulation of cases will be necessary to evaluate the clinical effectiveness of this treatment in postoperative recurrence of ALK-rearranged NSCLC patients.

Background
Malignancy after organ transplantation is generally the result of de-novo occurrence or recurrence of prior malignancy. Donor-related malignancy, defined as direct transmission of tumor from the donor organ or tumor arising from cells of donor origin in a recipient of a solid organ or hematopoietic stem cell transplant, is less common (0.02-0.2% of solid organ transplants). When organs from donors with known malignancy are used, the rate of transmission is up to 45%, with a mortality of 33-42%. We present the first case of donor-transmitted lung cancer in 550 liver transplants at Mayo Clinic Arizona.

Methods
Case report and literature review.

Results
A 69 year-old Caucasian male, former smoker, underwent deceased-donor liver transplantation for alcoholic cirrhosis and hepatocellular carcinoma. He was seen for a routine 4 month follow-up visit, had no complaints and was compliant with immunosuppression. Physical exam and laboratory tests were unremarkable. Abdominal CT revealed 3 small, solid, indeterminate liver masses. Follow-up MRI 6 weeks later demonstrated an increase in number and size of liver lesions. US-guided biopsy revealed poorly differentiated carcinoma most consistent with non-small cell carcinoma of the lung, with a minor component of small cell carcinoma. On PET-CT, the abnormal uptake was limited solely to the liver. Suspicion of donor-transmitted malignancy arose. The donor was a 50 year-old man, with history of alcohol and nicotine dependence (>20 pack/year), without history of malignancy. Chest x-ray, bronchoscopy and surgical lung examination, performed as part of procurement protocol, were normal. No other organ from this donor was transplanted. A PCR-panel of markers that recognize highly variable regions of DNA was used to compare donor liver tissue to the tumor and recipient liver tissue. Results confirmed cancer cells were of donor origin. Cancer was confined to the donor organ, but the patient could not undergo graft removal and re-transplantation. Immunosuppression was reduced, and chemotherapy (etoposide & carboplatin) was begun with initial response. Progression of metastatic liver disease led to second-line therapy with erlotinib. Unfortunately, patient succumbed shortly thereafter.

Conclusion
Donor-derived bronchogenic carcinoma after solid organ transplantation is extremely rare. One series reported lung cancer in 9 of 3374 patients (0.3%) transplanted over a 15 year period. Of these 9 patients, 3 patients had a kidney transplant, 3 had liver transplant, 2 had heart transplant and 1 had lung transplant. Treatment includes reduction/discontinuation of immunosuppression, chemotherapy and/or radiation therapy as appropriate, as well as removal of the transplanted organ and re-transplantation when feasible. In the present case we hypothesize that the donor had an undiagnosed lung cancer with subclinical hepatic metastases transmitted to our patient at the time of liver transplantation. Donor-derived lung cancer is extremely rare and can lead to significant morbidity and mortality. Proper diagnosis of donor origin is critical since it has a significant impact on management of these patients.

Background
Emerging research suggests that LC may be associated with greater levels of stigma, shame and hopelessness compared to other cancers. This study measured explicit, conscious attitudes (EAs) and used the Implicit Association Test (IAT) to assess implicit, unconscious attitudes (IAs) and stereotypes (ISs) of LC relative to BC.

Methods
To assess EAs, participants (Ps), [people with cancer (n=243), caregivers (n=677), healthcare providers (HCPs, n=142), and the general public (n=864)] were asked to rate their agreement, on a six-point scale, with statements about how people with LC and BC “do feel” (descriptive attitudes) or “ought to feel” (normative attitudes) about their disease. Implicit attitudes were measured with three IATs that used LC or BC images with words representing good/bad; hope/despair; or suitable/shameful. Implicit stereotypes used images representing smoking cigarettes, drinking alcohol and eating unhealthy foods. An IAT D score indicated the strength of bias against LC relative to BC: >0.65 = strong bias; 0.35-0.65 = moderate bias; 0.15-0.35 = slight bias; -0.15 -+0.15 = no bias, and < -0.15 indicated bias against BC.

Results
EAs and IAs were substantially more negative towards LC. Most Ps provided more negative ratings for LC than BC for both descriptive (70%vs.8%) and normative statements (56% vs. 3%). Ps had strong negative IAs towards LC compared to BC (bad: 74% vs. 10%; despair: 75% vs. 9%; shame: 67% vs. 17%). In the stereotype IATs, Ps were far more likely to associate LC with smoking than with eating unhealthy foods or drinking alcohol. Conversely, Ps were far less likely to associate BC with smoking than with eating or drinking (smoking: 86% LC vs. 7% BC; eating: 86% LC vs. 7% BC; drinking: 67% LC vs. 18%BC). These trends were consistent across caregivers, patients, HCPs, and the public. EAs, IAs and ISs were uncorrelated.

	Caregivers	Patients	HCPs	General Public
EXPLICIT
Negative Descriptive	75%, 7%, 18%	81%, 7%, 12%	88%, 5%, 7%	74%, 8%, 18%
Negative Normative	59%, 3%, 38%	64%, 2%, 34%	65%, 3%, 32%	56%, 3%, 41%
IMPLICIT ATTITUDES
Bad	D=0.43 73%, 12%, 15%	D=0.33 72%, 13%, 15%	D=0.33 63%, 17%, 20.0%	D=0.44 74%, 9%, 17%
Despair	D=0.43 73%, 10%, 17%	D=0.54 76%, 5%, 19%	D=0.44 77%, 13%, 10%	D=0.47 77%, 8%, 15%
Shame	D=0.32 65%, 18%, 17%	D=0.52 82%, 9%, 9%	D=0.41 72%, 11%, 17%	D=0.35 66%, 17%, 17%
IMPLICIT STEREOTYPES
Smoking vs. Eating	D=0.69 89%, 5%, 6%	D=0.71 90%, 5%, 5%	D=0.79 94%, 3%, 3%	D=0.57 84%, 8%, 8%
Smoking vs. Drinking	D=0.34 65%, 18%, 17%	D=0.17 54%, 31%, 15%	D=0.54 81%, 5%, 14%	D=0.34 69%, 17%, 14%
Drinking vs. Eating	D=0.10 40%,33%,27%	D=0.22 54%, 23%, 23%	D=0.21 59%, 29%, 12%	D=0.16 50%, 27%, 23%

Percentage order: LC bias%, BC bias%, No bias%. D=mean IAT score. All D scores significantly > 0 with ps<0.001

Conclusion
Ps had greater explicit and implicit negative bias against LC compared to BC.

Background
Bronchial sleeve lobectomy concomitant with pulmonary artery reconstruction (double sleeve) is a reasonable alternative procedure for pneumonectomy in appropriately selected patients with non-small cell lung cancer. However, video-assisted thoracic surgery double sleeve lobectomy is technically more challenging than routine lobectomy, and has never been reported. We aimed to report the first attempt on video-assisted thoracic surgery double sleeve lobectomy for non-small cell lung cancer.

Methods
From May 2012 to February 2013, three patients with non-small cell lung cancer of the left hilum directly involving the pulmonary artery were selected for curative resection via the VATS approach. Surgical procedures were performed with four ports for the first patient and three ports for the next two patients. The bronchus and pulmonary artery were reconstructed by end-to-end anastomosis using running Prolene stitches. Low-molecular heparin was subcutaneously administered during the first week after surgery.

Results
Surgical duration ranged from 350 to 490 min with blood loss between 30 to 200 ml. The first two patients developed pneumonia after surgery with no mortalities. All the patients were discharged home within 9-14 days after surgery. A total of 17, 12 and 14 lymph nodes were removed, and pathological stage of these three patients were T~2b~N~1~M~0~, T~2a~N~0~M~0~ and T~2b~N~0~M~0~ respectively. The reconstructed bronchus and artery worked well during 3-12 months follow-up.

Conclusion
video-assisted thoracic surgery double sleeve lobectomy is technically difficult but feasible. The operation can be successfully finished by skilled thoracoscopic surgeons, but the surgical incisions, procedures, and specific instruments still require further improvement.

Background
Chemotherapy is the standard treatment for most (stage II and beyond) lung cancer patients and treatment duration can be long ranging from months to years. Rural lung cancer patients often have to travel long distances for such specialist treatment. Geographical isolation and remoteness is implicated as one of the factors leading to inferior outcomes in these patients. Since 2007 Townsville cancer centre has been providing chemotherapy services to Mount Isa at a distance of 1000 km via Teleoncology ( using video conferencing). This model has previously been shown to be effective, safe, cost saving and sustainable. This study evaluates the feasibility and safety of chemotherapy for lung cancer patients treated via Teleoncology.

Methods
All patients with a diagnosis of lung cancer from Townsville Teleoncology data resource (comprising all patients treated with chemotherapy at Mount Isa Base hospital using videoconferencing from Townsville cancer centre) between April 2007 and March 2012 were eligible. Patient and tumour characteristics were studied and feasibility was evaluated using number and type of cycles, dose intensity and completion rates for chemotherapy administration. Toxicity was graded as per common terminology criteria for adverse events (CTCAE) v 4.0.

Results
Out of total 170 patients treated using Teleoncology, 33 (22%) had lung cancer. Of these 3 (9%) were small cell (SCLC) and remaining non small cell lung carcinomas. A total of 287 chemotherapy cycles (148 in first line, 97 in second line and 42 in third line) were administered under distant supervision. Of these, 8 cycles were neoadjuvant, 15 cycles in adjuvant and 254 cycles in palliative setting. One patient of SCLC had emergency chemotherapy initiated via Teleoncology. Carboplatin(C) and Gemcitabine(G) was the commonest regimen (72 cycles 25%) followed by Pemetrexate (66 cycles 23%) and C and Paclitaxel (56 cycles 19%). Other types of regimen administered were Cisplatin (Cis) and G, C and Etoposide (Eto), Cis and Vinorelbine (Vnb), and single agent Docetaxel, Gem, Vnb, Eto, C and Erlotinib. Commonest toxicities were fatigue, neuropathy, thrombocytopenia and anaemia. Grade 3-4 toxicity requiring dose reduction was 4% in first line, 32% in second line and 58% in third line setting. Accounting for dose reductions based on toxicity, anticipated chemotherapy dose intensity could be maintained in 261 cycles (91%). There were 7 episodes of inpatient admission at Mount Isa (3 febrile neutropenia and 2 each pulmonary embolism and recurrent pleural effusion), all supervised via Teleoncology from Townsville. 29 of these 33 patients had all of their chemotherapy treatment at Mount Isa without travelling to Townsville. Only 3 patients needed to travel to Townsville during palliative treatment, two for brain radiotherapy and one for VATS pleurodesis.

Conclusion
Teleoncology is a novel model of care for rural lung cancer patients. Using this model, standard chemotherapy for lung cancer can be safely administered with expected dose intensity. The feasibility and safety results from this study are comparable to published literature in lung cancer. Use of teleoncology has the potential to overcome the barrier of travel time associated with long distances and possibly improve outcome for rural lung cancer patients.

Background
Pulmonary papillary adenoma is an extremely rare tumor and considered to be benign although its malignancy potentiality is not completely understood. It is usually asymptomatic and detected incidentally as peripheral lesions in chest radiography. It originates from type II pneumocytes. The largest mass of 20 cases which has been reported in English literature was 3 cm in diameter. The diameter of the tumor of our case was 4 cm. We present our postoperatively diagnosed papillary adenoma case due to its rarity and central location.

Methods
Twenty-one year old male patient was admitted with a round mass lesion with regular margins was observed on the right side of his chest radiography. This 4 cm diameter mass in the right upper lobe closed to bronchus has been observed in thorax computed tomography. Any endobronchial lesion could be detected with bronchoscopy.

Results
Right thoracotomy was performed. The solid mass was enucleated and capitonnage was performed. The patient being discharged on the 7th postoperative day is being followed for 8 months.

Conclusion
Our case is a centrally localized pulmonary papillary adenoma although most of the cases presented in the literature are peripheral. This case should be considered in the differential diagnosis of solid pulmonary masses. The recommended treatment for this mass is surgically removal of the mass because of its malignancy potentiality.

Background
Patients with advanced lung cancer have been reported to be at high risk for venous thromboembolism (VTE). In patients with cancer, a rate of unexpected pulmonary embolism (UPE) of about 1.5% has been reported.The aim of the study was to determine the prevalence of UPE in patients with stage IIIB or IV NSCLC or extensive SCLC who underwent CT scans for cancer staging.

Methods
We reviewed the contrast-enhanced CT scans of the chest performed for routine cancer staging in consecutive patients with advanced lung cancer (stage IIIB or IV NSCLC or extensive SCLC) referred to the Division of Medical Oncology at the hospital of Perugia between 2008 and 2012. All CT scans were reviewed by an ad hoc panel composed by 3 radiologists. PE was defined as unexpected when a filling defect in central, lobar, segmental or sub-segmental pulmonary arteries was observed in absence of clinical suspicion of PE.

Results
Overall, 223 patients were included in the analysis: 180 patients with stage IV-NSCLC, 24 patients with stage IIIB-NSCLC, and 19 patients with extensive SCLC. A total of 899 CT scans were reviewed. The prevalence of UPE was 19.7% (44/223): 34 (77.3%) in patients with stage IV-NSCLC, 7 (15.9%) in patients with stage IIIB-NSCLC, and 3 (6.8%) in patients with advanced SCLC. Patients with UPE were 26 males and 18 females and had a mean age of 58 years (range 24-78). UPE was monolateral in 30 patients and bilateral in 14 patients. UPE involved central pulmonary arteries in 6 patients, lobar arteries in 16 patients and segmental arteries in 19 patients. 3 patients had an isolated sub-segmental UPE. The mean time between cancer diagnosis and UPE was 11.8 months. 27% of cancer patients with UPE had the positive CT scan at diagnosis and 50% within 3 months. A recurrence of UPE was observed in one patient.

Conclusion
Patients with stage IIIB or IV NSCLC or extensive SCLC have a high rate of UPE at CT scan performed for cancer staging. UPE was bilateral in about one third of patients. A minority of UPE involved isolated sub-segmental arteries.

Background
The American Society of Clinical Oncology issued a Provisional Clinical Opinion on the integration of palliative care (PC) with anti-cancer care which states, “Based upon strong evidence from a phase III RCT, patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at time of initial diagnosis.” There is both a national shortage of PC providers, as well as a lack of guidelines on the best operational ways to integrate PC into oncologic care. Here we describe different models of palliative care integration into anti-cancer care models performed at the Stanford Cancer Institute.

Methods
Three methods of PC integration into oncology care at Stanford Hospital and Clinics, a tertiary medical center, are being tested. These include a low resource model using a social work (SW) only intervention for advance care planning and goals of care, as well as two high resource models using an MD, advance nurse practitioner, and social worker. The first high resource model is concurrent care with joint PC and oncology visits, and the second is a traditional model of separate PC and oncology visits. Observations around successes and barriers within these various models, as well as resources needed, will be described. Data evaluated include volume, referral patterns, advance care planning, symptom assessment, and resource utilization.

Results
The SW only intervention was run as a pilot in thoracic oncology. Resources required for appropriate implementation included information technology (IT) for appropriate cohort identification, operations support, data management support, and team cooperation from the physician and nursing team. Process outcomes measured included % of patients seen by SW within 3 visits, documentation of advance care planning within the medical record, and co-signature of advance care planning documentation by the physician. The joint visit model utilized a high resource team (physician, nurse practitioner, and social worker) which was present concurrently with the oncology visit for advance care planning and symptom management. In addition to the resources required for the SW only intervention, this model also included a care coordinator for visit coordination. Process outcomes measured included lead time to arrange for the joint visit and documentation of advance care planning. End outcomes included discharge to hospice, hospital utilization patterns, and effective symptom management. Other outcomes included volume and number of referring providers. Our third model was a traditional clinic visit with the PC team only, not coordinated with the oncology team. Resources and outcomes were the same as for the joint visit model. A total of 529 consults were seen in the first year. 61% were seen in a traditional clinic model and 39% were seen in the concurrent model. Volume of consults have increased over time. There were 10 consults per month in January of 2012. Currently over 100 consults are seen per month.

Conclusion
Appropriate integration of PC into oncology care for thoracic oncology patients is still under investigation. Here we describe the strengths and weaknesses of three separate models of integration of PC with oncology care at an academic medical center.

Background
Distant metastases of MPM to the skeletal muscle, endocardium and skin have not been reported previously.

Methods
A 75 year-old male admitted to our pulmonary diseases clinic with chest and lower limb pain. He was a heavy smoker and exposed to asbestos in his childhood. Respiratory system was normal in physical examination. The thigh muscles were observed to be thick and hard and palpation was painful. There were few nodular lesions on the scalp which he reported to appear 2 months ago as well as the accompanying femoral thickening.

Results
Chest X-ray showed upper mediastinal enlargement and a mass in left superior lobe. Thorax CT revealed a pleural mass in the left apical region, left hilar lymphadenopathy and pleural thickening. Pathological FDG uptakes were observed over the right paraspinal muscle (C6), posterior scalp, paratracheal and left hilar lymp nodes, left apical mass, left pleura in lower and middle zone, left diaphragma, anterior pericardium, interventricular septum, left axilla, right 4. costochondral region, liver segment 8, right paraspinal muscle in L3 level, right abdominal oblic muscles, bilateral gluteal muscles and bilateral muscles in femoral region. Tru-cut biopsy was performed from the left apical mass and the diagnose was epitheloid type malignant pleural mesothelioma. A second biopsy was performed from anterior thigh muscles. The morphologic pattern was the same with the biopsy taken from lungs

Conclusion
Metastases of a MPM are very rare. We are presenting this case for the skeletal muscle metastasis defined for the first time.

Background
Angiosarcomas (AS) are rare aggressive tumors that represent about 1-2% of all soft-tissue sarcomas; 9.5% of them arise in the thorax. We describe five patients diagnosed with thoracic AS who were treated at ICESP.

Methods
It is a case series descriptive study with review of the medical files from five consecutively registered patients with AS confirmed by immunohistochemistry at our institution between June 2010 and March 2013.

Results
Case 1: A 49-year-old woman was admitted with pulmonary AS presenting progressive dyspnea and a recent hemoptysis. Pneumonectomy was performed in April 2011 and she was treated with adjuvant doxorubicin (every 3 weeks, 4 cycles) and paclitaxel (12 weeks). After 7 months, she developed progressive disease (PD) in liver, bones and lymph nodes. Weekly paclitaxel was restarted, but she had hepatic PD. Since May 2013 she has been treated with liposomal doxorubicin. She is alive after 26 months of diagnosis. Case 2: A 62-year-old woman was diagnosed with metastatic paracardiac AS after cardiac tamponade. She was treated with weekly paclitaxel and developed PD in liver and lungs. She died 3 months after diagnosis. Case 3: A 32-year-old man, was diagnosed with a primary AS in the right ventricle, metastatic to lungs, was admitted with recurrent pericardial effusion for 6 months. The tumor was considered unresectable and he was treated with doxorubicin and ifosfamide (only one cycle), temporarily interrupted due to febrile neutropenia grade 4, but with a partial response. He is alive after 3 months of diagnosis. Case 4: A 31-year-old man was diagnosed with unresectable AS in the right atrium after developing a superior vena cava syndrome. Weekly paclitaxel was started, with initial clinical improvement, but PD was detected after 6 cycles (24 weeks). As a second-line treatment, doxorubicin and ifosfamide were administered, with PD in lungs after 5 cycles. He died 13 months after the beginning of chemotherapy. Case 5: A 58-year-old woman was diagnosed with a right infraclavicular unresectable AS with local pain and edema in the upper right arm for one year. No response was seen after two cycles of doxorubicin and ifosfamide. Palliative radiotherapy followed by weekly paclitaxel was attempted as a second-line therapy with no response. Best supportive care was started and she is alive 6 months after diagnosis.

Conclusion
We concluded that thoracic AS presents a very dismal prognosis, due to the primary location and the high incidence of metastatic disease. For those patients with resectable disease and curative intent, surgery must always be considered. Weekly paclitaxel and the combination of doxorubicin and ifosfamide are both active in thoracic AS, but responses usually were not long-lasting. Oral tyrosine kinase inhibitors with antiangiogenic properties may be an option to be better explored.

Background
not applicable

Methods
Figure 1 This patient is a 50-year-old Hispanic woman who had been diagnosed with idiopathic edema of the right upper extremity and chest wall which progressed gradually over the last 8 years. Over the last year and-a-half, she has developed dyspnea on exertion with occasional cough. She has occasional right chest wall discomfort, but no abdominal pain. She has arm and back pain from the massive swelling. She has no GI complaints with the exception of nausea after meals. She has no lower extremity edema, no fever, chills or sweats. During our evaluation she was found to have massive right-sided pleural effusion.

Results
Figure 1 Biopsies of the pleura , soft tissues, and skin showed a myxoid mesenchymal neoplasm. Brain MRI showed no intracranial or meningeal masses. Her pleural fluid was most consistent with exudate. Cultures and cytology was negative. Glucose in the pleural fluid was not decreased. Triglycerides in the pleural fluid were 21 mg/dL.

Conclusion
This is an unsual case of a soft tissue sarcoma with significant swelling of the entire arm and ipsilateral chest with metastasis to the pleura. She had previously been diagnosed with idiopathic lymphededma and treated for that for years. The swelling was likely not due to lymphatic obstruction but rather due to slow progressive growth of the myxoid mesenchymal neoplasm. Earlier definitive diagnosis could have led to potential surgical resection, but with the massive involvement of her entire right arm, and ispilateral hemithorax, supportive care and systemic chemotherapy are the only treatment options.

Background
Lung cancer is the main cause of cancer death in men and women in Australia. Cure can be achieved by identifying patients with early (i.e. stage I and II) disease, treating them with surgery or radical radiotherapy. Despite this, the 5 year survival for stage I and II patients is reported at 60%. We looked at the cause of death in patients treated with curative intent over a 2 year period.

Methods
Local clinical practice information was collected in a prospective database. Cases presented at a multidisciplinary lung cancer meeting over a 24 month period (April 2006 -March 2008) were analysed. Patients with early stage NSCLC (stage I and stage II) based on the 6[th] edition IASLC TNM classification were identified (n=62). Treatment data was obtained for all identified cases (n=62/62) via hospital records. Cause of Death was determined via the death certificate as submitted to the Registry of Births, Deaths and Marriages.

Results
Five year survival was 25% (16/62) for early stage NSCLC. Cause of death of obtained for all but 3 patients (43/46). 74% (46/62) of patients received treatment with curative intent, 37% (23/62) surgery and 20% (13/62) radical radiotherapy. Of all patients who underwent radical treatment, lung cancer was the primary cause of death in 16% (10/46). Respiratory conditions were the second most common cause of death with 13% (6/46) attributed. The main cause was reported as pneumonia in 7 patients, COPD, IPF and Respiratory failure being others. The loss of lung from surgery or radiotherapy could be hypothesised to be a factor in these deaths due to reduce lung volume. Cardiac disease was the cause of death in 5 patients and 3 patients died due to bladder cancer, both diseases strongly associated with smoking. 1 patient died due to colonic cancer and 1 due to vascular dementia. Patients who underwent surgical resection had lower mortality rates than those who underwent radiotherapy with a 5 year survival in the surgical cohort of 60% (14/23) vs 7% (1/13) in the radical radiotherapy cohort as well as lower rates of lung cancer related death 17% (4/23) vs 46% (6/13).

Conclusion
Mortality in early stage lung cancer remains high in our cohort with recurrence of the lung cancer being the main cause of death. All patients were staged with PETCT prior to treatment. Diseases strongly associated with smoking were a common cause of disease as may be expected. Patients with radical therapy presenting with pneumonia are at high risk of death.

Background
Lung cancer is the leading cause of cancer death despite the improvement of therapeutics.Most patients (pts) present with advanced disease when first diagnosed. Erlotinib is an inhibitor of the epidermal growth factor receptor (EGFR) that is standardtreatment for non-small cell lung cancer (NSCLC) after failure of previous chemotherapy and 1[st] line in EGFR mutated pts. There are few data on toxicity observed in clinical practice described in the literature.

Methods
Retrospective study of all consecutive patients with advanced NSCLC treated with erlotinib in our department from October 2005 to November 2012.Primaryendpoint was to evaluate thetoxicity, secondary endpoint was to evaluate time to progression and survival. Data were obtained from clinical files and namely:demographics, histology, performance status (ECOG), stage and toxicity according to common terminology criteria for adverse events (CTCAE) version 4.

Results
From the 194pts treated with erlotinib, 111 pts (57%) were male and 83(43%) female, with a median age of 62 years (range 28-92); 37(19%) pts were former smokers, 87(45%) smokers and 70(36%) non-smokers. Histology was adenocarcinoma in 146 (75%) pts, squamous-cell in 25 (13%) and NSCLC-NOS in 23 (12%). Mutation: 21(11%) pts were EGFR mutated. Staging at the diagnosis: III in 71(37%) pts and IV 123(63%) pts. Before erlotinib 93(48%) pts had one line-chemotherapy, 79(41%) two-lines and 3 more than two-lines. Most commons used regimens were platin-based. Skin toxicity was observed in 85 pts (20 pts G2/3 toxicity) and gastro-intestinal toxicity in 21pts, 9 pts with G2/3 toxicity; 4 stop treatment due to toxicity (2 pts due to gastro-intestinal, 2 due to cutaneous). There were no treatment-related deaths or hospitalization. Complete/partial response was observed in 19(9.8%) pts, stable disease in 51 pts. The median TTP and survival after erlotinib treatment were 2.6 months, range (0.2-61) and 5 months range (0.7-160), respectively (CI 95%) with a median follow-up 6 months, (1- 61). Mutated pts had a longer TTP 9,4 month (6.6-12.2) than non-mutated 2,5 months(2,1-2,9),p< 0,001. Pts with cutaneous toxicity had a better TTP 2 months vs 4.2 months (p< 0.001) and survival 3,9months vs 9.4 months (p<0.001).

Conclusion
Although in our data there were no death related-treatments, the toxicity observed was highercomparing tothe literature. The efficacy results were similar. Cutaneous toxicity was positively correlated with better outcomes namely TTP and survival.

Background
Increasingly, neoadjuvant therapy is being used for the treatment of NSCLC. While several randomized controlled trials have been performed to evaluate this approach in patients with N2 disease, limited data exists in patients less than N2 disease. We examined our experience with neoadjuvant therapy in our institution and compared it to patients receiving adjuvant therapy.

Methods
This retrospective analysis included patients with less than clinical N2 disease that underwent curative surgical resection and received either neoadjuvant or adjuvant chemotherapy with or without radiation therapy from 2005 to 2010. Patient characteristics, peri-operative outcomes and survival data were analyzed for patients receiving neoadjuvant vs. adjuvant therapy. Comparison of categorical, continuous and survival variables across groups were performed using chi-square, t-test and Kaplan-Meier methods respectively. Multivariate analyses were performed using Cox Regression analyses.

Results
130 patients fulfilled the inclusion criteria – 54 patients had neoadjuvant therapy and 76 patients had adjuvant therapy. Patient characteristics in both comparison groups are summarized in Table 1. No peri-operative deaths were seen in either group. There was no statistically significant difference between the comparison groups with respect to age, gender, race, histology and grade. Patients with neoadjuvant therapy had a higher clinical stage than those that had adjuvant therapy. At a median follow-up of 41.5 months, there was no difference in the overall survival and recurrence free survival of patients in both groups in univariate analyses and in multivariate analyses after adjusting for potentially confounding variables including stage. Patients treated with neoadjuvant therapy had a higher rate of empyema (11.1% vs. 0%; p=0.004) and a trend toward increased arrhythmia and pneumonia than those treated with adjuvant therapy.

Conclusion
For NSCLC less than N2 disease, neoadjuvant therapy increases peri-operative morbidity without an improvement in overall and recurrence free survival. For this patient population, the role of neo-adjuvant therapy is questionable. Figure 1Figure 2

Background
The National Lung Cancer Forum for Nurses (NLCFN) is a UK professional organization which has a membership of around 280 Lung Cancer Nurse Specialists (LCNS) who primarily with lung cancer patients. LCNSs are the multi-disciplinary team members who spend the most time with patients. Therefore they add a unique and valued contribution to the debate regarding research priorities in lung cancer. The NLCFN is committed to developing the evidence base to inform the effectiveness and quality of their clinical care. The NLCFN recognized a need to develop research skills and capacity amongst its membership and facilitate research collaborations between academics and practitioners. To this aim the NLCFN established a Research Interest Group (RIG) in 2009. This paper summarizes a research development project undertaken by the NLCFN to increase research utilisation and capacity in lung cancer nursing.

Methods
A structured approach was taken building on research into evidence utilisation in health. (Birdell et al, 2005, Tod et al 2004, Palfreyman et al 2003a/b). Research development activity focused on four key areas, roles and responsibilities, relevance, relationships and partnerships, and organisational culture.

Results
Over a four year period the NLCFN has successfully developed its research activity and the infrastructure to support subsequent growth. Roles: The RIG is chaired jointly by a Professor of Health Services Research and NLCFN Chair. All NLCFN members are encouraged to have a role by contributing to the critical discussion regarding evidence. However, a core group of research active members take responsibility to lead on research. The RIG has provided a mechanism for the NLCFN to liaise with key national lung cancer groups and committees regarding evidence for practice and new project development, for example a current national project exploring the contribution of lung nurse specialists to clinical trial recruitment. Research relevance is guided by an on-going research prioritisation exercise. Research partnerships have been developed through shared membership of the RIG between clinical and academic staff. The partnership has fostered five applications for research funding from a range of funding organisations, two of which have been successful, one is currently in review. Funded projects include an evaluation of the LCNS role in treatment access. Another is evaluating the use of support roles in lung multi-disciplinary teams. Current applications include an analysis of treatment and health outcomes using linked national data sources. In addition a new PhD studentship has been developed through a collaboration between the NLCFN and Sheffield Hallam University. Regular meetings, good communication, sharing of good practice and support provide a culture to allow research ideas to flourish.

Conclusion
In four years the NLCFN has made remarkable progress regarding research development and capacity building. By taking a structured and systematic approach the outcomes have been impressive. It has supported LCNSs to be a valued partner in research prioritisation and in generating evidence to support lung cancer practice at a local and National level. The foundations for research growth have been built and an infrastructure developed to enhance future nursing engagement in research at all levels from application to leadership.

Background
The development of molecular targeted therapies has provided many cancer patients with promising treatment options. Tyrosine kinase inhibitors (TKIs) are a group of biological molecules designed to block specific molecular targets within the cell. They are easily taken in tablet form but can have significant systemic side effects causing physical and psychological discomfort. The importance of preparing the patient before treatment starts, evaluating the toxicities carefully using various validated tools and implementing appropriate care is well recognised. This study aimed to examine the physical side effects and psychosocial experiences of patients with advanced lung cancer taking TKIs. By using the Medical Research Council (MRC) framework for developing and evaluating complex interventions, this study forms the first stage of data gathering to inform the design of subsequent research projects. The overall aim is to develop a more specific toxicity measurement tool. A grant was awarded from the National Lung Cancer Forum for Nurses Research Interest Group.

Methods
Clinical teams at 4 hospitals within the West Anglia Cancer Research Network approached patients with advanced lung cancer taking TKI therapy for 3 to 24 months. Written informed consent was taken prior to focus group meetings which were held in the comfort of a cancer support centre. Separate provision was made for carers. Conversation was captured using two digital recorders and transcribed verbatim. A topic guide shaped the conversation. Field notes were taken to describe the dynamics of the group. The transcripts were analysed using grounded theory techniques of constant comparison of the narrative, incorporating memos of the researchers thoughts during the recordings, and deviant case analysis. Data was analysed and coded independently by two researchers and the findings compared and discussed. The theories generated were validated by checking the findings against the original data demonstrating a systematic research process of rigour and transparency. Analysis was aided by the use of NVivo 10 software.

Results
Two focus groups including 3 and 4 patients respectively were conducted. Of the 7 participants 6 were female, average age 68 years (range 58 - 81 years). All were currently taking Gefitinib, average 13 months (range 5 - 23 months). Early analysis shows common themes emerging such as pragmatic acceptance about their situation, feelings of isolation, experiencing the inconsistency and variety of chronic physical toxicities, the necessity of self-management, the need for support and uncertainty about their future. Body image changes were a significant problem for females including hair and skin changes. It is clear from the data that there is an on-going and changing psychosocial and physical experience for the patient. The nature of this experience will be expanded upon with individual anonymous quotes.

Conclusion
The experience of taking TKI’s, over an indefinite period of time, for advanced lung cancer is complex. Using the MRC framework we aim to evaluate the themes identified, so assessing not only the quantitative physical toxicities of the treatment but also the qualitative issues, the provision of support and the patients’ understanding of the side effects and management of their treatment.

Background
Recently, early movement on bed was encouraged to promote gastrointestinal function recovery. However, due to old ages and weak physical strength, the effects remain limited.

Methods
We selected 40 old patients with lung tumors receiving surgeries between January 2009 and December 2010.The patient evenly randomly assigned them into regular nursing care group(RNC) and acupoint electric stimulation group(AES) group each with 20 cases. Patients in the RNC group received regular nursing care and patients in the AES group received regular nursing care plus electric stimulation on acupoints. We evaluated the serum concentration of gastrin(GAS), motilin(MOT), cholecystokinin(CCK) and electrogastrogram(EGG) on the first, third and fifth day after surgery. We also recorded the anal exhaust time and the number of cases with such gastrointestinal function disorders as abdominal pain, abdominal distention and diarrhea.

Results
Comparison between two groups in GAS, MOT, EGG, the anal exhaust time, abdominal pain, abdominal distention and diarrhea showed significant statistical difference(P<0.05).

Conclusion
Electric stimulation on acupoints could increase postoperative GAS, MOT levels, promote recovery of gastrointestinal functions and decrease complications among senile patients with lung tumors.