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E. Beddow



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    O11 - Symptom Management (ID 137)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Supportive Care
    • Presentations: 2
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      O11.07 - Tracheobronchial Stent Insertion in the Management of Primary Lung Cancer: 5 Year Experience (ID 818)

      16:15 - 17:45  |  Author(s): E. Beddow

      • Abstract
      • Presentation
      • Slides

      Background
      Central airway obstruction is seen in around 30% of patients with primary lung cancer. This is often a life-threatening presentation of the disease due to imminent airway loss and therefore requires urgent intervention. Direct bronchoscopic techniques including airway stenting can offer an immediate improvement in symptoms and quality of life, in addition to providing time for further treatment modalities. Here we report outcomes from a large single centre five year experience of tracheobronchial stent insertion for palliation of advanced primary lung cancer.

      Methods
      A retrospective review of all patients undergoing tracheobronchial stent insertion between January 2007 and January 2012 was performed. Patients undergoing stent insertion for benign or secondary malignant disease were excluded. A total of 70 patients underwent 80 stenting procedures with an average age of 66 years. Patient notes were used to collect patient demographic, disease and stenting data. Outcomes included post-procedure length of stay, complications, need for further intervention and overall survival.

      Results
      Disease was identified within the trachea in 18 cases, bilaterally within the bronchi in 10 cases and in the left or right bronchus in 23 and 28 cases respectively. Expandable, nitinol stents were used for all patients with either a proximal or distal release system. Uncovered stents (57), covered stents (20) or a mixture of the two (3) were placed. The average length of stay was 2.5 days (range 0-17); however, 69% of patients were discharged on the same day or on day one following the procedure. There were no cases of stent migration identified. The most common complication was retained secretions requiring repeat bronchoscopy which occurred in 5 cases. One patient required telescopic insertion of a second stent due to malposition of the first. Median survival was 2.6 months with a 20% one-year survival. There were 4 in hospital deaths.

      Conclusion
      Central airway obstruction secondary to primary lung cancer can cause disabling dyspnoea and impending suffocation. Interventional bronchoscopic techniques, in particular airway stenting, can provide immediate relief of these symptoms. The survival data here reflects the advanced stage of disease in this patient group and, although unlikely to improve survival, airway stenting can offer the opportunity for further adjuvant treatment in some cases. More importantly perhaps, 91% of patients were discharged home following the procedure allowing an improved in quality of life. In our experience, tracheobronchial stent insertion can be used effectively to achieve these outcomes with minimal complications and a short hospital admission. Figure 1

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      O11.08 - A Comparison of Tracheobronchial Stent Insertion With and Without Radiological Guidance in Patients with Advanced Primary Lung Carcinoma (ID 819)

      16:15 - 17:45  |  Author(s): E. Beddow

      • Abstract
      • Slides

      Background
      Tracheobronchial stent insertion is safe and effective in managing central airway obstruction in advanced lung carcinoma. Airway stenting offers both immediate relief of severe dyspnoea and time for adjuvant therapy. It is commonly used in specialist thoracic centres with a variety of stent models employed. A large number of centres still use fluoroscopic guidance for stent positioning, leading to increased radiation exposure for both patients and staff. The aim of this study was to compare outcomes in patients undergoing stent insertion with or without radiological guidance.

      Methods
      70 patients were identified who underwent a total of 79 stent procedures. The cohort was divided into two groups based on whether stents were inserted under radiological guidance or direct vision at bronchoscopy. Retrospective analysis of notes was performed to collect data with regards to stenting strategy and post-operative course. The primary outcomes were length of stay, complications, repeat procedure and survival.

      Results
      Of the 79 stent procedures, 41 were with radiological guidance (group 1) and 38 were under direct vision only (group 2). There was an equal distribution with regards to the position of the stents (Table 1). Both techniques were well tolerated with minimal complications and no stent migration. Post-procedure length of stay was 2.73 days in group 1 and 2.26 days in group 2, with no significant statistical difference seen (p=0.93). There was also no difference in need for further stent intervention. A comparison of survival is shown in Figure 1. Figure 1 Figure 2

      Conclusion
      Airway stenting is a vital technique in the management of impending central airways obstruction. Although traditionally carried out under radiological guidance, we found no differences in complications, need for repeat procedure or survival when using direct vision. This not only saves radiation exposure to patients and staff, but also improves the cost-effectiveness and logistics of planning these urgent cases.

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    P1.19 - Poster Session 1 - Imaging (ID 179)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Imaging, Staging & Screening
    • Presentations: 1
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      P1.19-003 - Test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours (ID 854)

      09:30 - 16:30  |  Author(s): E. Beddow

      • Abstract

      Background
      PET-CT is a standard investigation to stage the mediastinum in non-small cell lung cancer when radical management is planned. The absence or presence of mediastinal lymph node involvement on PET-CT informs surgical selection (with or without further nodal sampling). The clinical utility of PET-CT in carcinoid tumours is uncertain as its test performance at identifying mediastinal lymph node disease in these tumours is as yet undefined with such tumours being rare and FDG avidity often considered to be variable or low. As such, it is argued whether PET-CT serves the same purpose in selecting patients for radical management in carcinoid tumours as it does with other non-small cell lung cancers. The aim of this study was to determine the test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours by collating a multicentre database.

      Methods
      We collated retrospective data from 7 institutions by performing a search on pathological databases for a consecutive series of patients who underwent thoracic surgery for a carcinoid tumour from Nov 1999 - Jan 2013. Preoperative PET-CT staging reports (prior to surgery with lymph node dissection) were obtained from patients’ records and compared against the reference standard of pathologic results obtained from lymph node dissection, and test performance reported using sensitivity and specificity.

      Results
      From Nov 1999 - Jan 2013, a total of 247 patients from 7 institutions underwent surgery for a carcinoid tumour with a corresponding preoperative PET-CT scan. The mean age of the patients was 61 (SD 15) and 84 were male (34%). The pathologic sub-type was typical carcinoid in 217 patients (88%) and atypical carcinoid in 30 patients (12%). The mean SUV uptake in the primary tumour was 4.8 (SD 4). Results from lymph node dissection were obtained in 213 patients. PET-CT reported uptake at mediastinal lymph nodes in 19 patients, of which only 3 were positive on subsequent pathology. Pathological results, from lymph node dissection carried out in 213 patients at the time of surgery, found 8 patients with mediastinal lymph node positive disease, of which only 3 had been picked up in preoperative PET-CT staging. The calculated sensitivity and specificity of PET-CT to identify mediastinal lymph node disease was 38% (95% CI 8-76%) and 93% (88-96%) respectively.

      Conclusion
      In non-small cell lung cancer, preoperative PET-CT is used for nodal and distant staging to assist in the selection of patients for radical treatment. British Thoracic Society guidelines for the radical management of patients with lung cancer recommend “radical treatment without further mediastinal lymph node sampling if there is no significant uptake in normal sized mediastinal lymph nodes on PET-CT scanning”. In carcinoid tumours, our results of the largest cohort to date suggest that PET-CT has a poor sensitivity but good specificity for the presence of mediastinal lymph node metastases in the staging of pulmonary carcinoid tumours. Therefore lymph node metastases cannot accurately be ruled out in carcinoid tumours with a negative PET-CT. If treatment decisions are based on the N2 status, invasive mediastinal staging should be undertaken in carcinoid tumours.

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    P2.14 - Poster Session 2 - Mesothelioma (ID 196)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Mesothelioma
    • Presentations: 1
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      P2.14-006 - Is Pleurectomy-Decortication a Viable Management Option in the Treatment of Malignant Pleural Mesothelioma? (ID 1672)

      09:30 - 16:30  |  Author(s): E. Beddow

      • Abstract

      Background
      Malignant pleural mesothelioma remains a significant cause of morbidity and mortality in individuals exposed to asbestos. At present, around 2000 deaths per year in Britain are attributed to malignant mesothelioma, with numbers predicted to continue to increase until at least 2020. There is currently no known curative treatment. A number of management strategies have been advocated including chemotherapy, radiotherapy and surgical resection. The optimal management however remains elusive. In light of the results from the recent Mesothelioma and Radical Surgery trial there has been a move away from extra-pleural pneumonectomy (EPP) in the UK, with the majority of centres advocating a less radical approach. Pleurectomy-decortication may provide a safer alternative to EPP in patients with early stage disease as part of multi-modality treatment. Some authors, however, remain concerned about the morbidity of this operation. The aim of this study was to review patients undergoing pleurectomy-decortication for pleural mesothelioma within our institution to assess the safety and efficacy of this surgical approach.

      Methods
      A review of the thoracic surgical database identified eighteen patients who had undergone pleurectomy-decortication in the management malignant pleural mesothelioma between May 2009 and May 2013. Patient notes were analysed retrospectively to collect patient demographics and histological data. All surgical procedures were carried out by a single surgeon. The outcomes included were post-operative length of stay, complications and overall survival.

      Results
      The average age within this cohort was 68.8 years (range 54-82) and there was a higher percentage of men (M:F = 14:4). The pre-operative diagnosis of malignant mesothelioma had been confirmed in all cases, with the majority having previously undergone VATS pleural biopsy with or without talc pleurodesis. In 4 patients cytology alone was used for diagnosis and 1 patient had undergone image guided biopsy. All patients underwent surgical resection via a postero-lateral thoracotomy. The mean length of stay was 8.1 days (range 5-17). 67% of patients had an uncomplicated recovery. Of those where complications did occur, 3 patients had a persistent airleak and 3 had renal impairment requiring conservative management only. There were no in hospital deaths and the mean survival at follow-up was 17.0 months (range 2.3 – 38.7).

      Conclusion
      The role of surgical resection in the management of malignant pleural mesothelioma remains controversial. Although encouraging results following EPP have been reported in some large case series, these have not been replicated in randomised trials. Some researchers have suggested that the high rates of morbidity and mortality following EPP, without significant survival benefit, make this an unacceptable approach in the majority of patients. In our experience, pleurectomy-decortication can provide an alternative in patients with early stage disease and good performance status. At follow-up, 67% of patients were still alive and mean survival was 17 months. In patients with epitheliod subtype the mean survival was 21.6 months. This data supports previous studies which have identified a survival benefit with pleurectomy-decortication, although numbers are too small to draw firm conclusions. The procedure was however well tolerated in all patients with no major post-operative complications and no in hospital deaths.

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    P2.24 - Poster Session 2 - Supportive Care (ID 157)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P2.24-020 - Uk Lung Cancer Survival: Where are we going wrong? (ID 1363)

      09:30 - 16:30  |  Author(s): E. Beddow

      • Abstract

      Background
      A number of recent studies have reported poor cancer survival in England when compared to other developed countries worldwide. In particular, lung cancer has been highlighted as amongst the worst, with only Scotland and Malta showing poorer survival rates in Europe. The aim of this study was look for an explanation for these findings by assessing our post-operative survival in patients undergoing surgery for lung cancer. Through this we hope to establish whether the management of patients with curative disease is inferior or whether other key factors, such as stage and timing of diagnosis, are to blame.

      Methods
      501 patients were identified who had undergone lobectomy, bilobectomy or pneumonectomy for non-small cell lung cancer between January 2003 and January 2011. Information regarding patient demographics and histological stage of disease was collected. NHS number tracing was used to obtain patient status at follow-up. Survival data was plotted using the Kaplan-Meier method with comparison of stage 1 and 2 disease. In addition, information was collected from the NHS lung cancer database to identify the percentage of patients diagnosed with non-small cell lung cancer who underwent surgical management during the research period.

      Results
      Of the 501 patients within this cohort, 263 had stage 1 disease, 147 stage 2 disease and 91 stage 3 or 4 disease. Average age at the time of surgery was comparable between the groups (mean 67 years) and there were considerably more men within the study than women (M:F = 303:198). 5 year survival in patients with stage 1 or 2 disease was 75% or 40% respectively (Figure 1). On average, 12.9% of patients diagnosed with NSCLC underwent surgical resection. Figure 1: Comparison of survival following lung resection in patients with stage 1 and 2 NSCLC Figure 1

      Conclusion
      Cancer survival is an important measure of the effectiveness of both management strategies and healthcare systems. These findings demonstrate that in patients with early, operable lung cancers we are achieving survival rates comparable, and in some cases superior, to other developed countries. Only a very small number, 12.9% of patients, are diagnosed early enough to undergo surgery. This would suggest that it is not the treatment provided in England that is inferior, but our ability to diagnose lung cancer at an early stage.

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

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Supportive Care
    • Presentations: 1
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      P3.24-008 - Epithelial-Myoepithelial Carcinoma of the Trachea: Alternative Management of Inoperable Disease. (ID 349)

      09:30 - 16:30  |  Author(s): E. Beddow

      • Abstract

      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.