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ES 01 - New TNM and WHO Classification (ID 510)
- Event: WCLC 2017
- Type: Educational Session
- Track: Radiology/Staging/Screening
- Presentations: 4
- Moderators:M. Noguchi, Peter Goldstraw
- Coordinates: 10/16/2017, 11:00 - 12:30, Room 301 + 302
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ES 01.01 - New TNM Classification (ID 7583)
11:00 - 12:30 | Presenting Author(s): Ramon Rami-Porta
- Abstract
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Abstract:
Introduction The new tumor, node and metastasis (TNM) classification of lung cancer –the 8[th] edition– has already been discussed in the two previous World Conferences of Lung Cancer. (J Thorac Oncol 2015; 10 (Supp 2): s69; J Thorac Oncol 2017; 12 (Supp 1): s2-s3.) The purpose of this educational session is to revise the innovations of the 8[th] edition, to point out its lights and shadows, and to highlight how they can affect our clinical practice. The innovations introduced in the 8[th] edition were based on sound statistical analyses of 70,189 patients with non-small cell lung cancer and 6,189 with small cell lung cancer diagnosed from 1999 to 2010. (1) Although a large number of patients was registered in the International Association for the Study of Lung Cancer database, data originated mainly from Asia and Europe and the other geographic regions of the world were scarcely represented. The innovations are applicable to both types of carcinomas (2) and also to bronchopulmonary carcinoids. (3) Rules to classify lung cancers with multiple lesions were provided based on data where data were available or on multidisciplinary consensus. (4) Primary tumor (T component) New T categories were introduced based on tumor size: T1a 1-2cm, T1c >2-3cm, T2a >3-4cm, T2b >4-5cm, T3 >5-7cm and T4 >7cm. In addition, endobronchial location less than 2 cm from the carina and total atelectasis /pneumonitis were reclassified as T2, while invasion of the diaphragm was reclassified as T4 and invasion of the mediastinal pleural was deleted as a T descriptor. The definition of visceral pleural invasion proposed for the 7[th] edition, i.e., the invasion of its elastic layer, was confirmed for the 8[th] edition and the recommendation to use elastic stains was reinforced. (5, 6) Codes for adenocarcinoma in situ –Tis(AIS) – and minimally invasive adenocarcinoma –T1mi– were defined, too. (7) Because tumor size has more prognostic relevance, its measurement must be as accurate as possible. The recommendation is to measure it on computed tomography with the lung window, because the mediastinal window may underestimate it. The registered size should be the greatest dimension in any of the available projections: axial, coronal or saggital. For part-solid non-mucinous adenocarcinomas, only does the size of the solid part on computed tomography at clinical staging or the size of the invasive part at pathologic examination count to assign a T category based on tumor size. (7) Nodal involvement (N component) The present N categories (NX, N0, N1, N2 and N3) and their descriptors remain unchanged. An important confirmation in the analyses of survival was that quantification of nodal disease at pathologic staging impacts prognosis: the more involved nodal stations, the worse the prognosis. (8) Therefore, identifying the number of involved nodal stations is important both at clinical and pathologic staging, although it is difficult to determine them accurately at clinical staging unless a lymphadenectomy is performed at the time of mediastinoscopy. The proposed subclassification of the N categories for prospective testing are: N1a – involvement of a single N1 station; N1b – involvement of multiple N1 stations; N2a1 – involvement of a single N2 station without N1; N2a2 – involvement of a single N2 station with N1; and N2b – involvement of multiple N2 stations. N1b and N2a1 have similar prognosis. Metastatic disease (M component) Intrathoracic metastases (M1a: malignant pleural and pericardial effusions and/or nodules, and contralateral separate tumor nodules) remain the same. Extrathoracic metastases were divided into single extrathoracic metastasis (the redefined M1b category) and multiple extrathoracic metastases in one or in several organs (the new M1c category). (9) These innovations imply that counting the number of metastases is important, at least from the prognostic point of view, but also from the therapeutic, because single extrathoracic metastasis can be the base to define oligometastatic disease, the treatment of which is aimed to be radical, with whatever therapeutic means are available, instead of palliative, as it usually is the case with polymetastatic disease. Stage grouping More stages have been created to accommodate the new T1 (T1a N0 M0 is stage IA1, T1b N0 M0 is stage IA2 and T1c N0 M0 is stage IA3) categories; to isolate locally advanced tumors (T3-T4 N3 M0 are now stage IIIC); or to separate metastatic disease (M1a and M1b are stage IVA and M1c is stage IVB). (10) Some tumors have shifted their positions. Tumors that are stage shifters should be treated according to evidence and not according to the treatment for those stages in which they now are based on prognosis, because a mere change in taxonomy does not imply a change in treatment. Clinical judgment in the multidisciplinary team discussions should led to the best therapeutic option for these patients whose tumors have moved from one stage to another. Conclusion The 8[th] edition facilitates the indication of prognosis and the stratification of tumors in future clinical trial, but requires more discipline from us when measuring tumor size, quantifying nodal disease and determining the number of extrathoracic metastasis. References 1. Rami-Porta R, Bolejack V, Giroux DJ et al. J Thorac Oncol 2014; 9: 1618-1624. 2. Nicholson AG, Chansky K, Crowley J et al. J Thorac Oncol 2016; 11: 300-311. 3. Travis WD, Giroux DJ, Chansky K, et al. J Thorac Oncol 2008; 3: 1213-1223. 4. Detterbeck FC, Nicholson AG, Franklin WA et al. J Thorac Oncol 2016; 11: 539-650. 5.Travis WD, Brombilla E, Rami-Porta R et al. J Thorac Oncol 2008; 3: 1384-1390. 6. Rami-Porta R, Bolejack V, Crowley J et al. J Thorac Oncol 2015; 10: 990-1003. 7. Travis WD, Asamura H, Bankier A et al. J Thorac Oncol 2016; 11: 1204-1223. 8. Asamura H, Chansky K, Crowley J et al. J Thorac Oncol 2015; 10: 1675-1684. 9. Eberhardt WEE, Mitchell A, Crowley J et al. J Thorac Oncol 2015; 10: 1515-1522. 10. Goldstraw P, Chansky K, Crowley J et al. J Thorac Oncol 2016; 11: 39-51.
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ES 01.02 - New Histological Classification (ID 7584)
11:00 - 12:30 | Presenting Author(s): William D Travis
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The 2015 WHO Classification had a major impact on the new 8[th] Edition TNM Classification. Compared to the 2004 Classification, major changes include: 1) use of immunohistochemistry throughout; 2) New emphasis on genetic studies and personalized therapeutic strategies; 3) A new classification of lung cancer in small biopsy and cytology samples; 4) adoption of the 2011 IASLC/ATS/ERS lung adenocarcinoma classification; 5) reclassification of large cell carcinoma based upon immunohistochemistry and genetics. Since publication of the 2015 WHO Classification new advances include recognition of ciliated muconodular papillary tumors, SMARCA4 and SMARCB1 deficient neoplasms and digital image analysis as a novel way to assess lung cancer morphology. This presentation will primarily focus on the impact of the new WHO Classification on the 8[th] Edition TNM classification. First the new TNM classification incorporates the introduction of the concepts of adenocarcinoma in situ (AIS) which should be staged as Tis (AIS) and minimally invasive adenocarcinoma (MIA) which should be staged as T1mi. AIS is defined as a lung adenocarcinoma with pure lepidic growth measuring ≤3 cm. MIA is defined as a ≤3 cm lepidic predominant adenocarcinoma with an invasive component measuring 0.5 cm or less. Both AIS and MIA should lack stromal, vascular, or pleural invasion and spread through alveolar space invasion (STAS). Lepidic predominant adenocarcinomas are lung adenocarcinomas with a predominant lepidic component that measure > 3 cm in total size or that have an invasive component measuring >0.5 cm. It is recommended to use invasive size for T-descriptor size in nonmucinous adenocarcinomas with a lepidic component. This is in keeping with a recommendation made in three editions of the UICC TNM Supplement since 2003. It is also supported by a growing amount of evidence showing that invasive size is a better predictor of survival than total size in nonmucinous adenocarcinomas with a lepidic component. Both radiologists and pathologists should report the greatest dimension for tumor size for both clinical and pathologic staging. In addition for nonmucinous lung adenocarcinomas, both the total size and invasive size should be reported with invasive size used for T-factor size determination. By computed tomography (CT) in nonmucinous lung adenocarcinomas, the presence of ground glass versus solid opacities generally correspond to lepidic versus invasive patterns respectively seen pathologically. Since, this is not an absolute correlation, when CT features suggest nonmucinous AIS, MIA and LPA, reporting of the suspected diagnosis and clinical staging, should be made as a preliminary assessment that may need to be revised after evaluation of resected specimens pathologically. Since the mucinous variants of AIS, MIA and invasive mucinous adenocarcinomas usually present by CT as a solid or consolidated nodule, and due to the lack of proven correlation between ground glass/solid CT appearance with lepidic/invasive growth pathologically it is not recommended to apply the total vs solid size assessment by CT in suspected invasive mucinous adenocarcinomas. Furthermore there is insufficient data in invasive mucinous adenocarcinomas that invasive size is a better predictor of survival than total size. Pathologic assessment of total vs invasive tumor size in resected nonmucinous lung adenocarcinomas with a lepidic component can be improved by reviewing CT scans because the lepidic component is often poorly appreciated pathologically on gross exam and size is underestimated. In addition, tumor size can be more accurately assessed after radiologic pathologic correlation in the following settings: 1) Lepidic nonmucinous adenocarcinomas that do not fit onto a single slide, 2) Sausage or bilobed shaped tumors where the maximum single diameter may be better assessed using all three CT views (axial, coronal and sagittal) rather than just axial alone, 3) Tumors removed in multiple parts, 4) Intraoperative defects in tumors, 5) Marked non-neoplastic reactions, 6) Mistaken pathologic assessment. In neoadjuvant tumors, it can be difficult to measure tumor size because tumors that show considerable treatment effect often do not have a uniform response allowing a single focus of viable tumor to be measured. It has been shown that 90% or more treatment effect is the most important prognostic finding instead of tumor size in surgically resected nonsmall cell lung cancer patients following induction therapy. One way to estimate viable tumor size is to multiply the percent of viable tumor cells times the size of the total tumor bed. This can be utilized in the setting of a single focus or multiple foci of viable tumor. Recording the percentage of treatment effect is important in addition to estimating tumor size for T-factor determination. REFERENCES 1. Travis WD, et al The New IASLC/ATS/ERS international multidisciplinary lung adenocarcinoma classification. JThoracic Oncol 2011;6:244-85. 2. Travis WD, et al WHO Classification of Tumours of the Lung, Pleura, Thymus and Heart. Lyon: International Agency for Research on Cancer; 2015. 3. Travis WD, et al The IASLC Lung Cancer Staging Project: Proposals for Coding T Categories for Subsolid Nodules and Assessment of Tumor Size in Part-Solid Tumors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol 2016;11:1204-23. 4. Tsutani Y, et al Prognostic significance of using solid versus whole tumor size on high-resolution computed tomography for predicting pathologic malignant grade of tumors in clinical stage IA lung adenocarcinoma. JThoracCardiovascSurg 2012;143:607-12. 5. Maeyashiki T, et al The size of consolidation on thin-section computed tomography is a better predictor of survival than the maximum tumour dimension in resectable lung cancer. Eur J Cardiothorac Surg 2013;43:915-8. 6. Yoshida A, et al Clinicopathological and molecular characterization of SMARCA4-deficient thoracic sarcomas with comparison to potentially related entities. Modern pathology : 2017;30:797-809. 7. Luo X, et al Comprehensive Computational Pathological Image Analysis Predicts Lung Cancer Prognosis. J Thorac Oncol 2016;12:501-9. 8. Kamata T, et al . Ciliated Muconodular Papillary Tumors of the Lung: A Clinicopathologic Analysis of 10 Cases. The American journal of surgical pathology 2015;39:753-60. 9. MacMahon H, et al Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 2017;284:228-43. 10. Kamata T, et al. Frequent BRAF or EGFR Mutations in Ciliated Muconodular Papillary Tumors of the Lung. J Thorac Oncol 2016;11:261-5.
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ES 01.03 - Immunohistochemistry, Chromosomal and DNA Analysis, and Molecular Testing (ID 7585)
11:00 - 12:30 | Presenting Author(s): Yasushi Yatabe
- Abstract
- Presentation
Abstract not provided
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ES 01.04 - Staging and Pathology of Multiple Nodules Presenting in the Lungs (ID 7586)
11:00 - 12:30 | Presenting Author(s): Andrew G Nicholson
- Abstract
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Multiple tumor nodules arising in the lungs can be due either to separate primary lung cancers (SPLCs) or intrapulmonary metastases (IPM) (separate tumor nodules). The recently revised Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) staging manuals (8th editions), based on proposals from work undertaken by the IASLC Staging and Prognostic Factors Committee (SPFC), include updates in T, N and M components, that reflect increased interest in staging of patients with multiple tumor nodules (1-4) due to increased frequency of presentation (1) and advances in classification of tumor subtypes (5). T categories for multiple tumor nodules are unchanged when compared to the 7[th] edition, with SPLCs continuing to be staged individually, with the recommendation that multiple lesions be grouped with the number of lesions in brackets (e.g. (2)), or (m) for multiple. Patients with IPM are staged as T3 (same lobe), T4 (different lobe in ipsilateral lung) and M1a (contralateral lung). However, although unchanged, these categories have been impacted by changes in the histologic classification of lung cancer (6), in particular adenocarcinomas (7). For the current edition, those tumors that present with multiple areas of pneumonic consolidation, these frequently corresponding to invasive mucinous adenocarcinomas, are viewed as a potential subgroup of IPM. There is also increased interest in those patients who present with multiple ground glass lesions, these typically corresponding to patients with non-mucinous adenocarcinomas with a lepidic component. These types of multiple tumor nodules are currently viewed as a potential subgroup of SPLCs. It is hoped that the next decade will see further research from within the lung cancer community that informs the 9[th] edition in relation to the staging of these types of tumor (3). In relation to pathologic staging, from 1975 until recently, distinction between SPLC and IPM was undertaken using criteria proposed by Martini and Melamed: tumors occurring in different lobes, having different major histologic types or being separated by a time interval of more than two years were to be classified as SPLCs (8). Recently, these criteria have been supplanted by the process of comprehensive histologic assessment (CHA) (9). CHA involves determination of major histologic type, assessment of predominant and minor histologic patterns according to histologic subtyping and evaluation of cytological features. CHA has been shown to significantly improve the pathologic distinction between SPLC and IPM to a level comparable to molecular analysis (9). Recent work undertaken by the IASLC Pathology Committee has also shown that usage of this methodology has good reproducibility amongst diagnostic pathologists. Furthermore, p staging status strongly correlated with nuclear pleomorphism, cell size, acinar formation, nucleolar size, and mitotic rate. In addition to the above, immunohistochemistry already has a role in refining the distinction between SPLC and IPM, and molecular techniques are also likely to be used increasingly in the situation. Studies have been published showing that comprehensive genotypic and morphological assessment is feasible, though they are not yet sufficient to establish clonal relationships between multiple tumour nodules (10). Ultimately, a multidisciplinary approach is likely to be the best methodology for distinction between SPLC and IPM, in particular the assessment of imaging data alongside histologic, immunohistochemical and molecular profiles, both in the context of biopsies and resections. 1. Detterbeck FC, Franklin WA, Nicholson AG, Girard N, Arenberg DA, Travis WD, et al. The IASLC Lung Cancer Staging Project: Background Data and Proposed Criteria to Distinguish Separate Primary Lung Cancers from Metastatic Foci in Patients with Two Lung Tumors in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2016. 2. Detterbeck FC, Bolejack V, Arenberg DA, Crowley J, Donington JS, Franklin WA, et al. The IASLC Lung Cancer Staging Project: Background Data and Proposals for the Classification of Lung Cancer with Separate Tumor Nodules in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2016. 3. Detterbeck FC, Nicholson AG, Franklin WA, Marom EM, Travis WD, Girard N, et al. The IASLC Lung Cancer Staging Project: Summary of Proposals for Revisions of the Classification of Lung Cancers with Multiple Pulmonary Sites of Involvement in the Forthcoming Eighth Edition of the TNM Classification. J Thorac Oncol. 2016. 4. Detterbeck FC, Marom EM, Arenberg DA, Franklin WA, Nicholson AG, Travis WD, et al. The IASLC Lung Cancer Staging Project: Background Data and Proposals for the Application of TNM Staging Rules to Lung Cancer Presenting as Multiple Nodules with Ground Glass or Lepidic Features or a Pneumonic-Type of Involvement in the Forthcoming Eighth Edition of the TNM Classification. J Thorac Oncol. 2016. 5. Travis WD, Asamura H, Bankier AA, Beasley MB, Detterbeck F, Flieder DB, et al. The IASLC Lung Cancer Staging Project: Proposals for Coding T Categories for Subsolid Nodules and Assessment of Tumor Size in Part-Solid Tumors in the Forthcoming Eighth Edition of the TNM Classification of Lung Cancer. J Thorac Oncol. 2016;11(8):1204-23. 6. Travis WD, Brambilla E, Burke AP, Marx A, Nicholson, AG WHO Classification of Tumours of the Lung, Pleura, Thymus and Heart. IARC Press, 2015. 7. Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, et al. International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011;6(2):244-85. 8. Martini N, Melamed MR. Multiple primary lung cancers. J Thorac Cardiovasc Surg. 1975;60:606-12. 9. Girard N, Deshpande C, Lau C, Finley D, Rusch V, Pao W, et al. Comprehensive histologic assessment helps to differentiate multiple lung primary nonsmall cell carcinomas from metastases. Am J Surg Pathol. 2009;33(12):1752-64. 10. Schneider F, Derrick V, Davison JM, Strollo D, Incharoen P, Dacic S. Morphological and molecular approach to synchronous non-small cell lung carcinomas: impact on staging. Mod Pathol. 2016;29(7):735-42.
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YI 01 - Young Investigator and First Time Attendee Session (ID 588)
- Event: WCLC 2017
- Type: Young Investigator
- Track: Education/Publication/Career Development
- Presentations: 12
- Moderators:Peter Goldstraw, Giorgio Vittorio Scagliotti
- Coordinates: 10/15/2017, 08:00 - 11:30, F201 + F202 (Annex Hall)
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YI 01.01 - Introduction to IASLC: What It Can Do For You (ID 7845)
08:00 - 11:30 | Presenting Author(s): Silvia Novello
- Abstract
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Abstract not provided
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YI 01.02 - Planning an Academic Career in Lung Cancer (ID 7846)
08:00 - 11:30 | Presenting Author(s): Navneet Singh
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Decision making in life is not always easy. This is applicable not just for patient care but also for matters related to our own-self and is particularly true in the context of career options in medicine. Over the past few decades, the level of expertise provided by health-care providers has enhanced considerably from having comprehensive ‘all-in-one’ doctors to specialists to super-specialists and currently focused super-specialists. This has been associated with the practice of medicine having changed from ‘evidence-based-medicine’ to ‘personalized medicine’ and currently of ‘precision medicine’ and ‘tailor-made’ therapies. This has largely been based on an increase in the quantity and quality of research being conducted worldwide. A majority of this research occurs in academic medical centers/university hospitals wherein faculty/attending consultants are not just involved in patient care but have to devote a substantial percentage of their time in planning and conducting research as well as teaching undergraduate/postgraduate residents and fellows. So the natural questions that crop up for someone in training are: 1) ‘How do I decide whether I am inclined to be working in an academic institute?’ [Will I be able to ‘gel-in’ or be a complete misfit?] ‘2) What is the time-point during my training/post-training period when I need to take the decision of pursuing an academic career?’ 3) ‘What are the essential and desirable qualities/traits that are conducive to working in an academic set-up?’ There are no straightforward answers to any of these. However, generally during the final year of fellowship, most individuals are able to decide whether they would like to continue working in an academic centre or not. This is often possible with guidance from course faculty. The chief-guide under whom the individual has been pursuing research (thesis/dissertation) may be able to identify if the latter has an ‘academic bent of mind’ and provide mentorship and help the transition from ‘fellow’ (in-training) to full-time faculty [‘attending’ consultant]. It is important for anyone intending to pursue an academic career to realize that conducting and participating in research is an integral part as opposed to working in non-academic centers where patient care is the primary focus. Inclination towards research may sometimes manifest as being able to identify ‘grey’ areas in practice of medicine (clinical situations for which there are no clear-cut answers). The best researchers are and often have been those who are able to identify these areas of uncertainty related to diagnosis and treatment of a particular condition or disease and carry out research directed to answer the queries that they had in their minds when picking up these uncertainties. Keeping abreast of the latest developments in one's focus area (by regularly accessing and reading the latest publications in peer reviewed journals) as well as publishing one's own experience/research in such journals is thus part and parcel of one's job profile while working in an academic center. For lung cancer – a disease that carries the highest cancer-related mortality amongst both gender combined and the commonest cancer in males, there have been very encouraging developments in the last couple of decades and especially the last five years. We now have five pillars for treatment – targeted therapy and more lately immunotherapy coming in as very useful additions to traditional modalities (surgery, chemotherapy and radiotherapy). And these are truly exciting times for carrying out research in lung cancer in several ways: 1) Number of investigational molecules (targeted therapy and immunotherapy) being developed/tested in preclinical/clinical trials is increasing at an unparalleled rate 2) Conventional pathway followed for testing [preclinical, phase-1, phase-2, phase-3 clinical trials] is being modified to reduce time to clinical approval for successful drugs by having combined phase 1/2 or phase 2/3 trials. 3) Intense efforts are being made to expand indications for already approved/available drugs e.g. assessing utility of targeted agents in early stage/resectable NSCLC and of combination regimens (EGFR-TKIs/ALK inhibitors+ chemotherapy, PD-1/PD-L1 immune check-point inhibitors+ chemotherapy). Several unaddressed issues exist in lung cancer currently which require concerted efforts and inputs from researchers worldwide including: 1) Improving the screening algorithm for early detection such that false positive results and need for/number of invasive procedures required is reduced. Development of blood, sputum or exhaled-breath based screening tests could find greater acceptability and applicability worldwide. 2) Improving the genomic understanding of SCLC – a histological subtype without significant advances in the past leading treatment to be essentially with two modalities (chemotherapy and radiation). Identifying ‘targetable’ molecular aberrations can revolutionize management of this aggressive histological type while ongoing efforts to establish the role of immune check-point inhibitors continue. 3) Detection of EGFR sensitizing mutations and acquired T790M resistance-conferring mutation (for initiating 1[st]/2[nd] generation EGFR-TKIs and osimertinib respectively) in circulating tumor DNA (ctDNA; sometimes called circulating free tumor DNA - cfDNA) is already applicable in clinical practice and potentially can be used for monitoring treatment responses also. Next-generation-sequencing(NGS) platforms appear promising in detecting both somatic point-mutations and rearrangements/fusions with minimal tissue and/or ctDNA. Development and validation of methods for non-invasive biological monitoring of responses to chemotherapy, radiation, immunotherapy and non-EGFR targeted therapies in the complete spectrum of histological types (SCLC, squamous and non-squamous NSCLC) and disease stage distribution (neoadjuvant treatment preceding surgery, post surgery – adjuvant setting, locally advanced NSCLC following induction concurrent chemo-radiation and metastatic setting) will make it more convenient for patients and treating oncologists alike. The advantages of working in an academic setup in lung cancer are apparent both for the clinician and his/her colleagues in other clinical departments/basic sciences. Current research and clinical practice requires collaboration of different disciplines [pulmonology, diagnostic and interventional radiology (including nuclear imaging), pathology (histopathology, cytopathology, molecular pathology), thoracic surgery/surgical oncology, radiation oncology and medical oncology]. Based upon the academic institute’s geographical location, the number/work profile of departments that exist for a given discipline may vary considerably. These variations notwithstanding, the bottom-line is that reaching out to and working together with colleagues from other departments and disciplines [multidisciplinary team approach] is mandatory for attempting conduct of high-quality research and delivery of high-quality patient care in thoracic oncology. This potential advantage and benefit also comes with several challenges. One is required to carefully balance and utilize working hours for patient care, research and training while attempting to do the best in all three fields. This invariably, if not mandatorily, leads to spill-over of work into ‘off-work’ hours and impinges on ‘family-hours’ or ‘personal-time.’ The support of one's spouse, parents and children in such settings cannot be undermined or understated. One needs to keep a balance between ‘All-work-and-no-play makes Jack a frustrated man’ versus ‘Jack-of-all-trades and master-of-none’. Neither is desirable and the ultimate aim is to have a satisfying career in thoracic oncology while working in an academic setting wherein one is able to: 1) provide patients (often under-privileged and belonging to poor socio-economic strata) the best diagnostic and treatment facilities (despite presence of resource constraints) – Patient Care 2) be involved in clinically relevant basic and translational research that has the potential to improve patient care in one’s own geographical location – Research 3) share one’s experience with residents/fellows and colleagues within the institute and outside – Medical Education Navneet Singh MD DM Email: [The author is a thoracic medical oncologist-cum-pulmonologist currently working as an Associate Professor of Pulmonary Medicine at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. He is a member of IASLC’s Staging & Prognostic Factors Committee; Publications Committee and is IASLC’s Regent for the Indian Subcontinent. Additionally, he is Chair-Elect of the American Society of Clinical Oncology’s (ASCO) International Development and Education Award (IDEA) Working Group and a member of its Multidisciplinary Cancer Management Course Working Group and Thoracic Cancer Guideline Advisory Group. His detailed profile is accessible at http://www.linkedin.com/in/navneet-singh-160012.]
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YI 01.03 - Community versus Academic Oncology (ID 7847)
08:00 - 11:30 | Presenting Author(s): Philip Bonomi
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Relatively little information is available for hematology oncology fellows to inform their choice for an academic oncology(AO) vs a community oncology(CO) career. In 2006, Desch and Blayney(1) described practical differences between AO and CO careers which are still pertinent today. A more recent report from Vanderbilt(2) describes factors which appear to influence oncology fellows’ career decisions. Once a career path has been selected, does this choice affect career and work-life balance satisfaction? Shanafelt and his colleagues have described the impact of career choice and related factors on job satisfaction(3,4). This review will summarize the results of these reports and share a perspective regarding possible changes in oncology practices which could impact career choice. Desch and Blayney(1) describe mission, governance, patient care, financial considerations, referral bases, career flexibility, and determinants of success. The mission for community oncologists(COs) consists of delivering excellent patient care and running a successful business. In contrast, the mission for academic oncologists(AOs) encompasses patient care, research and teaching. CO governance offers more autonomy and usually consists of a doctor owned corporation with equal ownership. AOs work in a hierarchical system with multiple levels between the physician and senior leadership. There are significant differences in delivering patient care. Desch and Blayney point out that “ COs are intern, resident, fellow, and attending all rolled into one. ” COs have more weekend and night call. In addition, COs provide care for multiple types of cancer patients , while AOs’ practice is usually limited to one or two types of malignancy. Patient referrals for COs depend upon building relationships with primary care physicians and surgeons in their community. AOs also get patient referrals from primary care physicians and surgeons, but they rely heavily on institutional reputation, the reputation of disease specific experts, and a robust clinical trial program. Publishing and giving presentations at local and national meetings establishes AOs as disease specific experts which results in physician referrals and in patient initiated consultations. Revenue for COs depends upon fees for physician services, for administration of intravenous treatment , for laboratory tests, for imaging, and revenue from chemotherapy/immunotherapy treatments. For AOs, revenue comes from fees for physician services, grants, clinical trial revenue, and philanthropy. In some academic institutions, revenue may also come from the ancillary sources, similar to private practice. Starting and subsequent compensation is higher for COs who receive significant salary increases when they become full partners in the corporation, 2-5 years after joining the practice. Salary for AOs increases with increasing academic rank and may be supplemented with bonuses and honorariums for lectures and participation in advisory boards. Desch and Blayney(1) suggest that there are critical success factors for COs and AOs. . Building a reputation as a local expert and being readily available to referring MD’s and partners is essential for COs. . They also point out that it is essential for COs to invest time to understand bonuses and to show that they value and support the practice staff. AOs must focus on area of expertise, choose a good mentor, publish results of research, and apply for grants. It is not realistic to expect AOs with a large clinical practice to be the principal investigator on a grant. However, these clinicians can learn the concepts of basic science and partner with laboratory investigators in translational research grant proposals. Horn and her collegues(2) studiedfactors associated with selecting an AO or CO career. They invited program directors at 56 NCI designated and National Comprehensive Cancer Network cancer centers. Fellows at these institutions were asked to complete a questionnaire regarding their interest in AO vs CO careers. . Fellows with a high interest in AO were more likely to be women, have an additional graduate degree, and to have participated in basic research. Also fellows who were more interested in AO gave more presentations at scientific meetings and had more publications. Having an influential mentor and a desire to teach were also related to pursuing a career in AO. . Fellows who were more interested in CO were motivated by work-life balance and autonomy. This study suggest that fellows who are primarily motivated by being involved in identifying new information and teaching are more likely to pursue AO , while fellows who are motivated by favorable work-life balance and having more autonomy are more likely to pursue a CO career. How do practicing oncologists feel about their careers? Shanafelt and colleagues(3,4) have published two reports describing results of a survey which evaluated burnout, career satisfaction, life – work balance satisfaction and retirement. They(3) found that COs spent more time in clinic and saw more patients.. Younger age and more hours in clinic were associated with increased risk of burnout, which was defined as a combination of emotional exhaustion and depersonalization (loss of concern for patients),. There was a trend for higher rate of emotional exhaustion and a significantly higher rate of depersonalization in community oncologists. Although the majority of oncologists would choose a career in oncology, there was a higher number of COs who stated they would not choose an oncology career. In the second report(4), they did not compare AOs and COs. They saw that although most oncologists find meaning in their work, 52% were dissatisfied with work-life balance. “They like their work but want to do less of it.” Work-life balance was affected by more night and weekend call, while method of compensation salary +/- bonuses (most AOs) versus incentive (most COs) was not related work-life balance. For oncologists who planned to reduce work hours, the most common reason was to spend more time with family. In summary, when making a career choice, oncology fellows should identify what motivates them. I suspect that the majority of oncologists will continue to be happy with their career choice and that the current differences between AO and CO careers may decrease because more COs will be employed by hospital systems. References 1.Desch CE, Blayney DW. Making the Choice Between Academic Oncology and Community Practice: The Big Picture and Details About Each Career. Oncol Pract 2:132-138, 2006 2.Horn L, Koehler E, Gilbert J, et al. Factors Associated with the Career Choices of Hematology and Medical Oncology Fellow Trained ar Academic Insitutions in the United States. J Clin Oncol 29: 3932 - 3938, 2011 3.Shanafelt TD, Gradishar WJ, Kosty M, et al.Burnout and Career Satisfaction Among US Oncologists. J Clin Oncol 32: 678-686, 2016 4.Shanafelt TD, Raymond M, Kosty M, et al.Satisfaction with Work-Life Balance and the Career and Retirement Plans of US Oncologists.J Clin Oncol 32:1127-1135, 2014
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YI 01.04 - Clinical Trials 101 (ID 7848)
08:00 - 11:30 | Presenting Author(s): Julie R Brahmer
- Abstract
- Presentation
Abstract not provided
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YI 01.05 - Investigator Initiated Trials (ID 7849)
08:00 - 11:30 | Presenting Author(s): Daniel SW Tan
- Abstract
- Presentation
Abstract not provided
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YI 01.07 - How to Get Your Paper Published (ID 7850)
08:00 - 11:30 | Presenting Author(s): Alex Adjei
- Abstract
- Presentation
Abstract not provided
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YI 01.08 - Why Should I Publish? An Overview of the Manuscript Cycle: From Submission to Publication (ID 7851)
08:00 - 11:30 | Presenting Author(s): Jim Jett
- Abstract
- Presentation
Abstract not provided
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YI 01.09 - How to Prepare an Abstract for an International Conference and How to Prepare Your Presentation for the Conference (Tips and Tricks) (ID 7852)
08:00 - 11:30 | Presenting Author(s): Michael Boyer
- Abstract
- Presentation
Abstract not provided
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YI 01.10 - How to Write a Grant Application for Young Investigators (ID 7853)
08:00 - 11:30 | Presenting Author(s): Heather A Wakelee
- Abstract
- Presentation
Abstract:
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YI 01.11 - The Young Investigator Travel Award Experience - A Report from a Previous Award Winner (ID 7854)
08:00 - 11:30 | Presenting Author(s): Takahiro Karasaki
- Abstract
- Presentation
Abstract:
I received the WCLC 2016 Young Investigator Travel Award for my presentation entitled “Immunogram for cancer-immunity cycle towards personalized immunotherapy of lung cancer”. It was my great honor to receive the award, and I want to thank the conference committee and all the conference attendees. This was my first time to attend the WCLC, and I enjoyed the conference and my stay in Vienna. I was given the opportunity to join the Faculty Dinner held in Vienna City Hall. It was a fabulous experience, and I thoroughly enjoyed sitting at the same table as world-renowned surgeons and oncologists. During the conference, I mainly attended immunotherapy sessions where I learned about the results of the most recent clinical studies. Furthermore, while attending the biomarker session, I realized that biomarkers in this field are still inadequate and the development of useful biomarkers in immunotherapy is an urgent need. Receiving the young investigator scholarship has encouraged me to continue our efforts to unveil the tumor microenvironment in each patient using individual next-generation sequencing data in order to develop “next-generation biomarkers” and achieve optimal personalized immunotherapy. Last year, in a Perspectives article in Science, Blank et al. proposed the concept of the cancer immunogram, a framework to illustrate multiple parameters that influence the cancer-immunity interaction (1). In their article, the concept was applied theoretically to patients but not tested in practice. To accomplish this, we developed an immunogram reflecting the cancer immunity cycle using next-generation sequencing data, and applied it to real patients with lung cancer. An immunogram for the cancer immunity cycle is a radar chart that consists of eight molecular profiles relevant to the development of T-cell immunity to tumor cells. We sought to translate cumbersome omics data into easily comprehensible “report cards” for clinicians. Immunograms can be used as integrated biomarkers, and may become a valuable resource for optimal personalized immunotherapy. After the presentation at the WCLC 2016, our findings were published in the Journal of Thoracic Oncology in May (2). It was an honor that our article was chosen by the Editor to be a featured article and was introduced by an elegant review (3). We recently updated our method by normalizing the immunogram score using TCGA data. We are pleased to share the details of this improvement during the present conference. Although we are working in a challenging field and there is still a long way to go, we are encouraged by the award and will continue to struggle toward further breakthroughs. References (1) Blank CU, Haanen JB, Ribas A, Schumacher TN. Cancer immunology. The “cancer immunogram” Science. 2016;352:658-60. (2) Karasaki T, Nagayama K, Kuwano H, et al. An Immunogram for the Cancer-Immunity Cycle: Towards Personalized Immunotherapy of Lung Cancer. J Thorac Oncol.2017;12(5):791-803. (3) Botling J, Sandelin M. Immune Biomarkers on the Radar-Comprehensive "Immunograms" for Multimodal Treatment Prediction. J Thorac Oncol.2017;12(5):770-2.
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YI 01.12 - Making the Most of the WCLC: A Guide for First Time Attendee - From an Expert Perspective (ID 7855)
08:00 - 11:30 | Presenting Author(s): Suresh Senan
- Abstract
- Presentation
Abstract not provided
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YI 01.13 - Making the Most of the WCLC: A Guide for First Time Attendee - From a Second Time Attendee (ID 7856)
08:00 - 11:30 | Presenting Author(s): Deepali Jain
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- Presentation
Abstract:
The IASLC (International association for the study of lung cancer) WCLC (World Conference on Lung Cancer) is world’s largest academic platform dedicated for the study of lung cancer and other thoracic malignancies which not only caters to physicians but also includes active participation from each discipline of medicine involves in patient care. In addition health advocacy groups and patients will also join WCLC to obtain and exchange the information. The focus of the meeting is on the biology, diagnosis, pathogenesis, treatment and management of lung cancer so to begin from active prevention and accurate diagnosis to advanced care. Because of advancing science of lung cancer, IASLC decided to hold WCLC every year so people will be kept abreast with the current knowledge and updates in this field. There are many academic opportunities for the young investigators or first-time attendee to pursue their career in the field of thoracic oncology. They can meet the experts during the conference, attend various educational sessions and take guidance in the field of basic, translational and clinical research. There are many awards which help in not only enhancement of academic career but also in attending conference from resource poor countries. Travel awards given to developing nation investigators so that they can attend the conference and present their latest research in addition to make collaborations and academic networking. International mentorship program of IASLC is very useful professional development and education program for early-career doctors from economically-developing countries in which you get an opportunity to spend a week time in a well established hospital or laboratory under the mentorship of an international expert in that field. This year, the Core Program Committee has organized a scientific program that includes more than 450 presentations. The conference motto is “Synergy to Conquer Lung Cancer” which will be very overwhelming at both scientific and educational fronts. The education sessions include state-of-the-art talks by experts on academically challenging and evolving topics. The scientific program includes research presentations in the form of posters and platform formats. There are many events and platforms where first time attendees can interact and do networking for future collaborations. It is certain that the 18[th] WCLC will help young investigators and first time attendees to build and shape-up their career in thoracic oncology.
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ES 06 - Communication Skills in the End of Life/ Symptom Management in Lung Cancer (ID 515)
- Event: WCLC 2017
- Type: Educational Session
- Track: Nursing/Palliative Care/Ethics
- Presentations: 1
- Moderators:K. Kubota, Jin -Ji Yang
- Coordinates: 10/17/2017, 15:45 - 17:30, F201 + F202 (Annex Hall)
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ES 06.05 - Approach to Malignant Pleural Effusions (ID 7867)
15:45 - 17:30 | Presenting Author(s): Peter Goldstraw
- Abstract
- Presentation
Abstract:
The onset of an MPE usually indicates a significant reduction in prognosis, with a median life expectancy of 3 to 12 months from onset. MPE associated with breast cancer is usually associated with a better than average prognosis whilst lung cancer has the worst prognosis. Confirmation of malignancy and determination of the cell type may be established by increasingly invasive techniques; pleural aspiration cytology, facilitated by ultrasound guidance if the effusion is small or loculated, pleural biopsy, blind or image guided, thoracoscopy (usually now video-assisted) under local or general anaesthesia. Whilst it is reasonable to start with the least invasive procedure suitable in the circumstances, in patients who are reasonably fit it is important to avoid an escalating cascade of failed procedures, each with the risk of causing pleural adhesions and clot formation, making effective palliation more difficult. There is much to commend early acceptance of an approach which combines the best chance of a tissue diagnosis with the best chance of effective palliation. This decision will be influenced by an assessment of prognosis. Prognosis once an MPE has been confirmed is dependent upon the extent of metastatic disease and associated co-morbidity. In a surgically palliated population in-hospital and 30-day mortality was statistically related to blood albumen levels, being 0% and 0.98% in those with normal albumen levels and 6.8% and 19% in those with hypoalbumenaemia (p=0.001) (1). In a series of 278 patients referred to the Department of Thoracic Surgery at the Royal Brompton Hospital over a 72 month period 195 underwent thoracoscopic talc pleurodesis, 39 had a pleuro-peritoneal shunt inserted, 38 had pleurodesis through an intercostal drain, 29 had pleural biopsy alone and 9 were treated with long-term pleural drainage, a total of 310 surgical procedures. Overall median survival was 211 days post operatively. Survival was not significantly different for tumour type or method of palliation but was related to leucocytosis (p<0.0001), hypoxaemia (p=0.014) and hypoalbumenaemia (p0.0001) (2). The summative effect of these factors is shown in the table below. Table 1
How might this information be used to personalise treatment options in patients for whom effective systemic therapy does not exist. Those whose prognosis is judged to be less than 2 months (having all 3 adverse prognostic factors) palliation may be achieved by repeated pleural aspiration. If prognosis is judged to be greater than 2 months, and especially if the patient is in a poor general condition, adequate palliation could be achieved by the insertion of an indwelling pleural catheter under local anaesthesia. In fitter patients with an estimated survival greater than 6 months VATS insufflation of talc or the insertion of a pleuro-peritoneal shunt should be considered. The choice of talc or shunt will be dictated by the adequacy of lung expansion during positive pressure ventilation. In many respects these 2 techniques are complementary but having both of these techniques available at thoracoscopy allows affective long-term palliation to be achieved in 95% of patients (3). However pleuro-peritoneal shunts can be complicated by occlusion within 4 months in 15% of cases but spontaneous pleurodesis has usually been achieved by this time (4). Pleurectomy is rarely indicated in the palliation of MPE. Reference List (1) Pilling JE, Dusmet M, Ladas G, Goldstraw P. Predictors of early mortality and morbidity follwoing surgical palliation of malignant pleural effusion. Journal of Thoracic Oncology 2[8], s430. 2007. (2) Pilling JE, Dusmet ME, Ladas G, Goldstraw P. Prognostic Factors for Survival after Surgical Palliation of malignant Pleural Effusion. J Thorac Oncol 5, 1544-1550. 2010. (3) Petrou M, Kaplan D, Goldstraw P. The management of recurrent malignant pleural effusions: The complementary role of talc pleurodesis and pleuroperitoneal shunting. Cancer 75, 801-805. 1995. (4) Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. European Journal of Cardio-thoracic Surgery 18, 143-146. 2000.No of factors n Median survival (days) 95% CI p None 39 702 473-931 .00001 One or two 74 200 111-289 Three 23 42 23-61
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