Virtual Library

 x 
My Library Virtual Library FAQ

Start Your Search

P.N. Antippa



Author of

  • +

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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pulmonology + Endoscopy/Pulmonary
    • Presentations: 1
    • +

      P1.17-009 - What is the rate of surgical upstaging following negative EBUS-TBNA of mediastinal lymph nodes for NSCLC? (ID 2621)

      09:30 - 16:30  |  Author(s): P.N. Antippa

      • Abstract

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

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

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

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

  • +

    P2.12 - Poster Session 2 - NSCLC Early Stage (ID 205)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 2
    • +

      P2.12-013 - Patterns of recurrence following surgical resection of stage I-III non-small cell lung cancer (NSCLC) (ID 1968)

      09:30 - 16:30  |  Author(s): P.N. Antippa

      • Abstract

      Background
      Despite receiving curative treatment, a significant proportion of patients with locoregional non-small cell lung cancer (NSCLC) will develop recurrent disease. The role of routine surveillance imaging following curative treatment remains controversial, as there is no definitive evidence that early detection and treatment of asymptomatic metastases improves survival. The aim of this study was to explore the patterns of recurrence in stage I-III NSCLC patients treated in routine clinical care.

      Methods
      Retrospective analysis of 218 patients across two tertiary centres in Melbourne, Australia, who underwent surgical resection of stage I-III NSCLC over a 5-year period. Patients who died within 30 days of surgery or with no follow-up data were excluded. Clinicopathologic, treatment and outcome data were collected.

      Results
      Between July 2006 and June 2012, 206 patients underwent surgical resection, with a median follow-up of 30 months. Median age was 69 years (range 46–84), with a male:female ratio of 65 vs 35%. There were 113 (55%), 52 (25%) and 39 (19%) stage I, II and III tumours respectively. One patient had a pathologic complete response to neoadjuvant chemoradiotherapy. Adjuvant chemotherapy was delivered to three (3%), 20 (39%) and 28 (72%) patients with stage I, II and III disease respectively. Nine of 39 (23%) stage III patients received adjuvant radiotherapy. 73 of 206 (35%) patients relapsed at a median of 10.5 months from surgery (range 0.7–46.4). A further 15 (7%) patients were diagnosed with new primary lung cancers and four (2%) with second, non-pulmonary malignancies. Relapses were more frequent in patients with higher stage tumours (Table 1). Of the patients receiving adjuvant or neoadjuvant chemotherapy, 55% developed recurrent disease. Among patients who recurred, 46 (63%) were symptomatic, with 32 of these (70%) requiring emergency or early clinical reviews. In contrast, new primary tumours were significantly more likely to be detected on routine surveillance imaging (87% vs 29% of recurrences, p=0.0001). One-year post-relapse survival was 40% for disease recurrences vs 53% for new primary lung cancers.

      Table 1 – Clinicopathologic features and patterns of relapse in 206 patients with resected stage I-III NSCLC[1]
      Total N Disease-free n (%) Relapsed NSCLC n (%) New primary lung cancer n (%)
      TOTAL 206 104 (51%) 73 (35%) 15 (7%)
      Stage 0 I II III 1 113 52 39 1 (100%) 70 (62%) 21 (40%) 10 (26%) 0 25 (22%) 21 (40%) 25 (64%) 0 10 (9%) 2 (4%) 3 (8%)
      Chemotherapy receipt Yes No 53 145 17 (32%) 84 (58%) 29 (55%) 42 (29%) 3 (6%) 12 (8%)
      Histology Adenocarcinoma Squamous cell Large cell Other 112 57 15 21 53 (47%) 32 (56%) 6 (40%) 13 (62%) 41 (37%) 18 (32%) 8 (53%) 6 (29%) 9 (8%) 5 (9%) 1 (7%) 0
      Method of relapse detection[2] Routine imaging Symptomatic 34 51 N/A N/A 21 (62%) 46 (90%) 13 (38%) 2 (4%)
      [1]Data for second non-pulmonary malignancies not shown [2]Method of relapse detection not documented in six patients

      Conclusion
      The goals of routine surveillance imaging following curative treatment of NSCLC are two-fold; early detection of: 1) asymptomatic disease recurrence and, 2) new primary lung cancers. Our data demonstrate that the majority of disease recurrences are symptomatic at the time of diagnosis, thus negating the value of routine imaging. In contrast, the high proportion of asymptomatic new primary cancers detected on surveillance imaging supports this approach for patients fit for curative-intent treatment.

    • +

      P2.12-014 - Brain metastases following surgical resection of stage I-III non-small cell lung cancer (NSCLC) (ID 1974)

      09:30 - 16:30  |  Author(s): P.N. Antippa

      • Abstract

      Background
      The brain is a common site of relapse following curative treatment of stage I-III non-small cell lung cancer (NSCLC). Retrospective series estimate actuarial risk of brain recurrence at ~10% for stage I-II and ~30% for stage III tumours. Possible risk factors are young age, non-squamous histology and higher tumour/nodal stage, with survival typically dictated by the presence of extracranial disease. The aim of this study was to review patterns and treatment of brain metastases in patients with relapsed stage I-III NSCLC.

      Methods
      Retrospective analysis of 218 patients with surgically resected stage I-III NSCLC at two tertiary centres in Melbourne, Australia over a 5-year period. Patients who died within 30 days of surgery or with no follow-up data were excluded. Treatment and outcome data for patients who subsequently developed brain metastases are reported.

      Results
      206 eligible patients underwent surgical resection between July 2006 and June 2012. None received prophylactic cranial irradiation. At a median follow-up of 30 months, 73 (35%) patients had relapsed. Twenty-two (30%) had intracranial metastases, ten with brain-only metastases at the time of relapse. The other 12 had concurrent extracranial disease. Median time to brain relapse was 7.7 months (range 0.7-38.6). The incidence of brain relapse increased with higher stage: 6%, 13% and 21% of patients with stage I, II and III disease respectively (Table 1). Relapses occurred at a median of 10.9 (stage I), 8.8 (stage II) and 6.4 (stage III) months from surgery. Brain metastases were noted more frequently in patients with adenocarcinoma. Although 18/57 patients with squamous cell histology relapsed, none were noted to have intracranial metastases. In five patients, asymptomatic brain metastases were detected on routine surveillance imaging and treated with palliative whole-brain radiotherapy. Three of the five had coexistent extracranial disease and died within four months of relapse. The other two had brain-only metastases and remain alive at nine and 16 months from relapse. For all patients, one-year survival following diagnosis of brain metastasis was higher in those with brain-only disease (50%) compared to those with concurrent extracranial metastases (9%).

      Table 1 – Clinicopathologic features in total and brain relapse populations
      Total population N Brain relapse n (%)
      TOTAL 206 22 (11%)
      Median age (yrs) 69 (46-84) 69 (50-84)
      Sex M F 134 72 15 (11%) 7 (10%)
      Stage 0 I II III 1 113 52 39 0 7 (6%) 7 (13%) 8 (21%)
      Histology Adenocarcinoma Squamous cell Large cell Other 112 57 15 21 16 (14%) 0 3 (20%) 3 (14%)
      Chemotherapy Adjuvant Neoadjuvant None 50 3 145 6 (12%) 1 (33%) 14 (10%)
      Radiotherapy Adjuvant Neoadjuvant None 12 2 185 5 (42%) 0 16 (9%)

      Conclusion
      In this small retrospective series, the majority of patients who developed brain metastases after curative treatment for NSCLC were symptomatic at the time of relapse. Post-relapse survival was worse in patients with coexistent extracranial disease. None of the incidentally detected asymptomatic brain metastases could be treated curatively, suggesting a limited role for including brain imaging in routine surveillance for resected NSCLC.

  • +

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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
    • +

      P3.24-005 - The Role of Lesser Resection for Treatment of Early Stage Non-Small Cell Lung Cancer in Medicallly Compromised Patients (ID 198)

      09:30 - 16:30  |  Author(s): P.N. Antippa

      • Abstract

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

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

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

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