Scientific Program

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    ISS11 - Symposium Supported by Pfizer: Future Options for ALK+ Metastatic NSCLC (Not IASLC CME Accredited)

    • Moderators:
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      Welcome and Introduction

      07:00 - 08:00  |  Presenting Author(s): Geoffrey Liu

      • Abstract

      Abstract not provided

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      Recent advances in treating ALK+ NSCLC: An evolving landscape

      08:00 - 08:00  |  Presenting Author(s): Ben J Solomon

      • Abstract

      Abstract not provided

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      Navigating the spectrum of resistance mutations in ALK+ NSCLC: How to identify and treat them

      08:00 - 08:00  |  Presenting Author(s): Alice T. Shaw

      • Abstract

      Abstract not provided

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      Panel Q&A

      08:00 - 08:00  |  Presenting Author(s): Geoffrey Liu, Ben J Solomon, Alice T. Shaw

      • Abstract

      Abstract not provided

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    ISS12 - Symposium Supported by Roche: Selecting the Right Cancer Immunotherapy Regimen for the Right Patient in First-line Lung Cancer (Not IASLC CME Accredited)

    • Moderators:
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      Spotlight on cancer immunotherapy: scientific advances and evolving clinical practice in first-line lung cancer

      07:00 - 07:00  |  Author(s): Suresh S. Ramalingam

      • Abstract

      Abstract not provided

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      Optimising treatment for first-line NSCLC

      07:00 - 07:00  |  Presenting Author(s): Vassiliki A Papadimitrakopoulou  |  Author(s): Ross Soo

      • Abstract

      Abstract not provided

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      Putting it all into perspective: what does this mean for our patients?

      07:00 - 07:00  |  Presenting Author(s): Suresh S. Ramalingam, Vassiliki A Papadimitrakopoulou, Ross Soo

      • Abstract

      Abstract not provided

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    ISS13 - Symposium Supported by Medscape: Progress of the NSCLC Revolution: Questioning the Experts (Not IASLC CME Accredited)

    • Moderators:
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      Welcome and Introductions

      07:00 - 07:05  |  Presenting Author(s): Tony S. Mok

      • Abstract

      Abstract not provided

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      Molecular Testing in NSCLC: Where Are We Going?

      07:05 - 07:20  |  Presenting Author(s): Fabrice Barlesi

      • Abstract

      Abstract not provided

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      Treating New Molecular Targets in NSCLC: How Are We Progressing?

      07:20 - 07:35  |  Presenting Author(s): Sanjay Popat

      • Abstract

      Abstract not provided

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      Immunotherapy in NSCLC: Where Have We Got to?

      07:35 - 07:45  |  Presenting Author(s): Edward B Garon

      • Abstract

      Abstract not provided

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      How Are We Doing in the Delivery of the NSCLC Revolution?

      07:45 - 07:57  |  Presenting Author(s): Tony S. Mok, Fabrice Barlesi, Edward B Garon, Sanjay Popat

      • Abstract

      Abstract not provided

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    MTE11 - Biology of Small Cell Lung Cancer (Ticketed Session)

    • Type: Meet the Expert Session
    • Track: Biology
    • Moderators:
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      MTE11.01 - Novel Therapeutic Targets in SCLC

      07:00 - 07:30  |  Presenting Author(s): Julien Sage

      • Abstract

      Abstract

      Small cell lung cancer (SCLC) remains the most lethal form of lung cancer, in part because of its rapid growth and dissemination, and also because of its ability to evade therapy. In the last few years, however, a number of studies have taken advantage of improved pre-clinical mouse models of SCLC as well as increased access to primary human samples to identify novel candidate therapeutic targets against SCLC. Some of these new therapeutic targets include activation of the immune system (T cells, NK cells, or macrophages), as well as cell-intrinsic signaling pathways that often act in autocrine or paracrine manners (e.g. Hedgehog or Notch signaling). This presentation will put these different approaches in context and discuss signaling pathways that may not be mutated in SCLC but can still significantly contribute to the proliferation and the survival of SCLC cells during SCLC progression and metastasis.

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      MTE11.02 - Biological Subsets of SCLC

      07:30 - 08:00  |  Presenting Author(s): Charles M. Rudin

      • Abstract

      Abstract

      Small cell lung cancer (SCLC) is an exceptionally lethal cancer for which new therapeutic approaches are needed. Over the past few years several research teams have applied global profiling approaches to characterize the SCLC genome, epigenome, transcriptome, and proteome. Despite the seemingly homogeneous microscopic appearance of SCLC, these studies have consistently suggested the presence of biologically distinct subsets of disease. Parallel studies across libraries of patient-derived xenografts and in a diversity of genetically engineered mouse models of SCLC have validated these subset distinctions. Some models suggest that these subsets reflect parallel programs of oncogenesis, perhaps emerging from distinct cells of origin. Conversely, other data imply a temporal hierarchy among disease subsets, or at least that transition from one phenotypic subset to another is possible. Most exciting from a treatment perspective, several research groups have reported unique therapeutic vulnerabilities among these subsets. Several of these therapeutic strategies are being actively tested in SCLC patients, and emerging correlative data further confirm the predicted differential sensitivities among SCLC subsets. Together, these studies advocate for a very different approach to clinical translation in SCLC than that taken to date. Rather than treating all SCLC the same, a more successful approach may be to consider focused trials among biomarker-selected subsets of disease, exploiting the distinct dependencies and vulnerabilities of biologically relevant subsets. This presentation will highlight some of the recent preclinical studies that have defined determinants of these subsets, together with recent clinical work emphasizing their importance to the field, and to our patients.

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    MTE12 - IO in the Real World - High Risk Populations And Patient Support (Ticketed Session)

    • Type: Meet the Expert Session
    • Track: Immunooncology
    • Moderators:
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      MTE12.01 - Is IO an Option for Patients with Contraindications (Auto-immune Disease, Pulmonary Fibrosis, HIV, Hepatitis, Transplant etc)

      07:00 - 07:40  |  Presenting Author(s): Andrew G Robinson

      • Abstract

      Abstract

      This session will focus on an approach to making informed decisions for patients largely excluded from the pivotal clinical trials of immunotherapy. The non-comprehensive presentation will focus on some distinct clinical entities (HIV, Hepatitis B&C, Tuberculosis), select auto-immune diseases (AID’S), and organ transplant patients, and illustrate an approach to use clinically.

      Information from reports of similar patients treated with immunotherapy is informative[1, 2], however caution is required in interpreting these reports as both selection and reporting bias may occur.

      There are six key questions that need to be considered prior to starting therapy – accepting that many of these answers have a high degree of uncertainty. Decisions are based on close collaboration with disease experts; evidence from published and presented studies and reports; and biologic plausibility/pathogenesis.

      1: What is the benefit and toxicity of this therapy compared to it’s alternatives in the absence of contraindications?

      2: How may the underlying condition impact the benefit and toxicity?

      An understanding of the condition and co-management with other specialists is desirable. Is there a potential for benefit or harm from activating T-cells? The potential impact is estimated from: critically reading cohort studies/case series/case reports; discussions with specialist colleagues for understanding disease pathogenesis; and understanding where the patient is in the spectrum of their comorbid disease. Consider possible effects on the organ at risk, but also other organs (i.e. extra-colonic manifestations of ulcerative colitis; extra-articular manifestations of rheumatic disease etc.), and whether there is any impact on toxicities unrelated to underlying condition.

      For auto-immune disease, the cohort studies of Leonardi et al and meta-analysis of Abdel-Wahab are informative. Leonardi et al included 56 patients with NSCLC and a history of auto-immune disease treated at several large treatment institutions over 3 years. Most patients were asymptomatic from their AID at baseline. Abdel-Wahab et al included 123 patients, but did not restrict to lung cancer, and included patients treated with both CTLA-4 and PD-1 inhibitors. For Leonardi et al, 5 of 10 patients who were symptomatic had a disease flare or worsening, while 8/46 who were not symptomatic at baseline had a flare. The vast majority of these patients were treated in second or above line (84%). The Abdel-Wahab paper revealed 75% of patients had a disease exacerbation or immune related adverse even or both, however 46% of patients were symptomatic from their AID at baseline. Case reports and small series are available for solid organ transplant, while prospective cohorts and retrospective cohorts are available for some chronic infections.

      Given the significant biases inherent in these case series and reviews, a prudent approach to most auto-immune diseases is to assume that disease may worsen/recur, and to monitor and intervene early. Also assume that there are some patients who will not worsen, either because of a lack of functioning remaining immune system/burning out of initial disease/or other reasons. Disease specific recommendations and considerations (Multiple Sclerosis, Guillian-Barre, Crohn’s/UC, and inflammatory arthritises) will be discussed in the session.

      3: How may concomitant medications impact the benefit and toxicity, what are the alternatives (if any) to these medications?

      This impact is estimated from cohort studies, case reports, biological rationale, and discussion with specialist colleagues regarding alternative therapies with potentially less impact on T-cell function.

      While cohort studies have been varied in showing an impact of immuno-suppressive medications on immune therapy response, the data remain extremely sparse and biologic rationale is used for decision making. A general approach would be to use the lowest dose feasible with the most targeted approach feasible for the underlying disease. It is plausible that gut-specific therapy for IBD (i.e. vedolizumab), will have less effect on Tumor T cells than systemic steroids, anti-TNF agents, etc. There is very little collective published experience in this area.

      4: If this patient requires immune suppression for toxicity, are there special considerations or risks?

      Information from clinical trials and population studies help determine the likelihood of immune suppression. Expertise from specialist colleagues may be required to understand how to mitigate the effect of immunosuppression before or during immunosuppression.

      This is particularly true for infectious diseases that may have exacerbations with prolonged courses of immunosuppression (hepatitis B, TB etc). Suppressive or eradicative anti-infectious medications may improve safety of subsequent immunosuppression and may be considered.

      5: Does the patient have the reserve to tolerate the expected or possible toxicities of the immunotherapy?

      Physician judgement/experience and a knowledge of how clinical trials toxicities translate to the ‘real’ world are needed.

      Patients with certain immune or non-immune underlying conditions that result in a decreased patient/organ reserve may be less likely to tolerate toxicities. For instance, an asymptomatic pneumonitis (Grade 1 toxicity) in a relatively fit patient may translate to a grade 4/5 toxicity in a patient who at baseline is oxygen dependent with near end-stage pulmonary disease.

      6: If I proceed with IO therapy, how do I monitor to intervene early if complications arise?

      Other than ‘routine’ monitoring; How do I monitor for the infectious disease; transplant rejection; or auto-immune flare? Most of the published experience with toxicity suggests that reversibility of toxicity may occur with early intervention. Thus, monitoring is required and will be disease specific. Ideally, a monitoring plan agreed upon by both the oncologist and the disease specialist will be explicit. Patient education is crucial, as many of these diseases will present clinically and not through testing.

      REFERENCES

      1. Ostios-Garcia, L., et al., Safety and Efficacy of PD-1 Inhibitors Among HIV-Positive Patients With Non-Small Cell Lung Cancer. J Thorac Oncol, 2018.

      2. Abdel-Wahab, N., et al., Use of Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Autoimmune Disease: A Systematic Review. Ann Intern Med, 2018. 168(2): p. 121-130.

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      MTE12.02 - How can we Minimize Toxicity for our High Risk Patients?

      07:40 - 08:00  |  Presenting Author(s): Massey Nematollahi

      • Abstract

      Abstract

      This session will focus on strategies and innovative approaches to minimize cancer immuno-therapy toxicities.

      Immune checkpoint inhibitors (ICI) are a new class of anti-neoplastic agents termed immuno-therapy and are now standard of practice for lung cancer population including elderly with comorbidities. These agents have significantly impacted patient outcomes by offering durable responses. However, the effective and safe delivery of these agents require expertise in understanding the unique characteristics of the ICI (Immune Checkpoint Inhibitors) that differ from cytotoxic chemotherapy. Certain immunotherapy protocols may have up to 50% rate of developing severe irAEs. The number of indications of ICI treatment is rapidly evolving and broadening thus being proactive in developing a specialized clinic for these patients would not only centralize care and optimize efficacy but minimize toxicities in high risk population.

      Currently there is a large unmet need for an education class for patients prior to starting immunotherapy. Many centers have “chemotherapy teaching class” which are attended by all patients prior to starting chemotherapy, however the information regarding toxicities does not apply to ICI and could lead to under reporting of IrAEs particularly in high risk population with comorbidities and elderly.

      At William Osler Health Center, under supervision of Dr. Parneet Cheema an immune-oncology clinic has been established.

      Objective:

      The objective of this initiative is to generate a standardized, reproducible, and safe implementation immunotherapy program that could be easily recreated at any community cancer center.

      This presentation will discuss the clinic design, immunotherapy teaching class, logistics and standardized ICI delivery, care monitoring, and follow-up.

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    MTE13 - Clonal Evolution and Targeted Therapy (Ticketed Session)

    • Type: Meet the Expert Session
    • Track: Targeted Therapy
    • Moderators:
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      MTE13.01 - Clonal Evolution and Targeted Therapy

      07:00 - 07:30  |  Presenting Author(s): Ramaswamy Govindan

      • Abstract

      Abstract not provided

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      MTE13.02 - Clonal Evolution and Targeted Therapy

      07:30 - 08:00  |  Presenting Author(s): Janessa Laskin

      • Abstract

      Abstract not provided

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    MTE14 - Nodule Management (Pro Con Debate and Case Presentations) (Ticketed Session)

    • Type: Meet the Expert Session
    • Track: Screening and Early Detection
    • Moderators:
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      MTE14.01 - Nodule Management (Pro Con Debate and Case Presentations)

      07:00 - 08:00  |  Presenting Author(s): Stephen Lam, Matthijs Oudkerk

      • Abstract

      Abstract

      A recent observation study on the management of lung nodules 8 mm to 20 mm by community pulmonologists in the US showed a high benign biopsy rate of 62% and benign surgical resection rate of 35%. Furthermore, the surgical resection rates were similar irrespective of the pre-test probability of malignancy risk.1 The study suggested there is a lack of adherence to nodule management guidelines. However, there are a number of lung nodule management guidelines and lung nodule malignancy risk prediction tools.2-6 Some are based on 2D diameter size measurement while others used volumetric measurement or a combination of both. New nodules with a prior negative CT have a higher probability of malignancy even at a smaller size. 7-9 Compares to baseline screen, the malignancy risk of new nodules is higher for nodules <8mm.9 Computer assisted diagnostic (CAD) tools facilitates volume measurement and reduce inter-observer variability but they may not be generally available. Volumetric measurement is particularly useful for comparison of serial scans for evidence of growth. Growth independent nodule characteristics such as right upper lung and central distribution may further improve volume based new nodule malignancy prediction. Nodule size and growth are the most important parameters for malignancy.

      To measure size accurately especially to determine changes in volume, it is necessary to address standardization of technical requirements related to the scanners and image acquisition protocols.10 The action thresholds for early recall CT imaging study, PET/CT or biopsy vary in different guidelines with major differences for non-solid nodules making it difficult for clinicians to remember or apply. Therefore, a lack of adherence to guideline recommendations could be related to a lack of clarity of guidelines. To facilitate implementation, there is a need to have an integrated nodule malignancy risk tool that takes into account prior LDCT history when there is more than a baseline LDCT.

      In this session, the important issues regarding which risk model should be applied and which nodule management approach should be used (e.g. diameter or volume) for baseline and new nodules will be discussed through case presentations.

      References:

      1. Tanner NT, Aggarwal J, Gould MK, Kearney P, Diette G, Anil Vachani A, Fang KC, Silvestri GA. Management of Pulmonary Nodules by Community Pulmonologists. A Multicenter Observational Study. Chest 2015:148(6):1405-1414.

      2. MacMahon H, Naidich DP, Goo JM, et al (2017). Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology; 284; 228-243.

      3. American College of Radiology. Lung CT Screening Reporting and Data System (Lung-RADS). Accessed 23rd June 2017 from www.acr.og/quality-saftey/resources/lungRADS.

      4. Callister MEJ, Baldwin DR, Akram AR et al (2015). BTS guidelines for investigation and management of pulmonary nodules. Thorax; 70:ii1-ii54. Doi: 10.1136/thoraxjnl-2015-207168.

      5. Horeweg N, van der Aalst CM, Vliegenthart R, et al. Volumetric computed tomography screening for lung cancer: three rounds of the NELSON trial. Eur Respir J 2013;42:1659-67.

      6. McWilliams AM, Tammemägi MC, Mayo JR, et al (2013). Probability of cancer in pulmonary nodules detected on first screening CT. N Eng J Med; 369: 910-919.

      7. Walter JE, Heuvelmans MA, Bock GH, Yousaf-Khan U, Groen HJM, Aalst CMV, Nackaerts K, Ooijen PMAV, Koning HJ, Vliegenthart R, Oudkerk M. Characteristics of new solid nodules detected in incidence screening rounds of low-dose CT lung cancer screening: the NELSON study.Thorax. 2018 Apr 16. pii: thoraxjnl-2017-211376. doi: 10.1136/thoraxjnl-2017-211376. [Epub ahead of print]

      8. Walter JE, Heuvelmans MA, de Jong PA, Vliegenthart R, van Ooijen PMA, Peters RB, Ten Haaf K, Yousaf-Khan U, van der Aalst CM, de Bock GH, Mali W, Groen HJM, de Koning HJ, Oudkerk M. Occurrence and lung cancer probability of new solid nodules at incidence screening with low-dose CT: analysis of data from the randomised, controlled NELSON trial. Lancet Oncol. 2016 Jul;17(7):907-916.

      9. Paul F. Pinsky PF, Gierada DF, Nath PH, Munden R. Lung Cancer Risk Associated With New Solid Nodules in the National Lung Screening Trial. AJR 2017; 209:1009–1014.

      10. Alexander A. Bankier AA, MacMahon H, Goo JM, Rubin GD, Schaefer-Prokop CM, Naidich DP. Recommendations for measuring pulmonary nodules at CT: A Statement from the Fleischner Society. Radiology 2017 Nov;285(2):584-600.

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    MTE15 - Who is Too High Risk for a VATS Resection? (Ticketed Session)

    • Type: Meet the Expert Session
    • Track: Treatment of Early Stage/Localized Disease
    • Moderators:
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      MTE15.01 - Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides?

      07:00 - 07:30  |  Presenting Author(s): Hisao Asamura

      • Abstract

      Abstract

      Thoracoscope is, by its original meaning, defined as an endoscope to observe intrathoracic space, just like a bronchoscope for bronchial lumen. But today this endoscope has been widely accepted as a surgical instrument to perform various kinds of intrathoracic procedures which had been otherwise done with open thoracotomy. Video-assisted thoracic surgery (VATS) has been expected to reduce the surgical burden, and already applied for the complex surgeries such as those for lung cancer. It is now a part of our routine procedures. However, despite the minimally invasiveness of the procedure, VATS may become a risky surgery in several special situations. Not only the surgeons, but also pulmonologist, medical oncologist, or radiation oncologist should know the nature of the surgery, and the situations in which VATS should be rather avoided. In this MTE sessions, I would like to present the special situations in which the VATS procedures are at too high risk, and therefore, and are not considered to be performed.

      HIGH-RISK SURGERY

      When dose the surgery become at high risk? In what situation, we should think the surgery is at high risk? Generally, there must be two kinds of situations each alone or both combined, which make the surgery at high risk. One is the patients at high risk for surgery even for a routine lobectomy, with a limited pulmonary reserve. The other is the difficult, complex surgery such as the extended pulmonary resection. Technical limitations of a VATS procedure are generally related to several different situations, which are described below. In this MTE session, I would like to focus upon the surgical, technical risks for the VATS procedures.

      VATS LUNG RESECTRIONS AT TECHNICALLY HIGH RISK

      2-1. DIFFICULT ONE-LUNG VENTILATION. One-lung ventilation, collapsing the one entire lung of the operative side, is an indispensable part of the stable VATS procedure. Thoracic cavity is usually filled with expanded lung, and only very limited space is left when the lungs are airated. To make VATS procedures possible, deflation (collapse) of the lung on affected side is indispensable, which provides the space for observation and working of surgical instruments. Therefore, for patients who do not tolerate to the one-lung ventilation because of the limited pulmonary reserve or previous history of lung resection, VATS is generally not indicated. For these patients, we consider routine open thoracotomy with intermittent collapse of the operative side of the lung.

      2-2. TIGHT ADHESIONS. Tight adhesions might exist within the thoracic cavity, especially for patients with the history of pleurisy or surgery. As seen previously, the working pleural space is an indispensable element of a VATS procedure. Surgeons are concerned about such history in case VATS resection is indicated. There are several types of adhesions which make VATS procedure difficult. Examples for these conditions are as follows:

      1) Previous pleurisy. If intrathoracic adhesion, mostly due to the previous pleurisy, is extensive, it is impossible to have an enough working space. In fact, lysis under thoracoscopy can be done, but it is usually time-consuming with significant amount of blood loss. There might be even a higher risk of damaging the visceral pleura and lung parenchyma, which may cause prolonged air leakage especially in the elderly with bullous lung. Therefore, except for a localized one, the extensive symphysis of pleura should be respected as a contraindication and a case which should be converted to the open thoracotomy.

      2) Adhesions at pulmonary hilum (“Frozen hilum”). In some cases with past history of infection such as tuberculosis, the hilar nodes are tightly adhesive to the bronchovascular structures. This is extremely difficult situation even for routine lobectomy. VATS resection for such cases are hardly considered.

      3) Previous thoracotomy. Major lung resection after previous lung resection involving the hilum (for example, a completion right lower lobectomy after middle lobectomy) is one of the most challenging surgery even by open thoracotomy. Also, for these operations, VATS resection is rarely indicated.

      2-3. COMPLEX PROCEDURES. Among various procedures in thoracic surgery, complex procedures are thought to be done safely by open thoracotomy, and not by VATS. These might include the following: such as bronchovascular plasty, combined resection with neighboring structures, pneumonectomy, and pleuropneumonectomy.

      2-4. OTHER SITUATIONS WHICH MAKE VATS PROCEDURE AT HIGH RISK

      1) Complex anatomical variation. When complex anatomical variations are found during the surgery, the procedure should be converted to open thoracotomy without hesitation.

      2) Large lesions. Any large intrathoracic mass, wherever it is located, have a trouble in being retrieved from the thoracic cavity. Not only they inevitably require enough extension of the trocar port or access thoracotomy, but also, they might be crushed during being extracted, which may result in tumor dissemination.

      3) Special locations. In the intrapulmonary and mediastinal lesions, there are special locations where the thoracoscopic instrumentation is quite difficult: Lesions located at mediastinal aspect of the lung, and those close to hilum. Mediastinal mass (swollen lymph nodes) adjacent to the vital structures such as great vessels is also least suitable for this technique because of danger of massive bleeding.

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      MTE15.02 - Who is Too High Risk for a VATS Resection?

      07:30 - 08:00  |  Presenting Author(s): Pieter E. Postmus

      • Abstract

      Abstract not provided

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    MTE16 - What Is Changing in the Management of Pulmonary Neuroendocrine Tumours? (Ticketed Session)

    • Type: Meet the Expert Session
    • Track: Small Cell Lung Cancer/NET
    • Moderators:
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      MTE16.01 - Proper Treatment of LCNEC; Chemotherapy or Targeted Therapy

      07:00 - 07:30  |  Presenting Author(s): Sumitra Thongprasert

      • Abstract

      Abstract

      Neuroendocrine Tumors of the Lung consisted of two subtypes which is small cell lung cancer (SCLC) and large cell neuroendocrine carcinoma (LCNEC). Both subtypes represent around 15% of all Lung Cancer. The incidence of LCNEC was quite low as compare to SCLC. However both are aggressive and poor prognosis. The treatment of LCNEC was usually followed the SCLC. In early stages (I-II-III), surgery is recommended but does not seem to be sufficient. Platinum-based adjuvant chemotherapy may be useful while the role of neoadjuvant chemotherapy is still not well defined. In patients with advanced stage LCNEC, the chemotherapy regimens used in SCLC which is cisplatin plus etoposide remain the standard of treatment, but results are not satisfactory. Due to their peculiar clinical and biological features and the lack of literature data, there is an emerging need for a consensus on the best treatment strategy for LCNEC and for the identification of new therapeutic options. In this review, we will discuss the key aspects of LCNEC management and the possibility of using the gene sequencing to clarify the selection of chemotherapy regimen.

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      MTE16.02 - The Management of Small Cell Lung Cancer following First Line Treatment Failure

      07:30 - 08:00  |  Presenting Author(s): Glenwood Goss

      • Abstract

      Abstract

      SCLC remains a clinical challenge that has not benefited from the same medical advances in recent years as non-small cell lung cancer (NSCLC). Beyond first line chemotherapy, there are few approved therapies for recurrent small cell lung cancer (SCLC). A multitude of agents have been tested over the past decades, yet little improvement has been made in survival rates. This talk will review previous efforts in treating SCLC upon progression after first-line therapy, the current science that is changing our understanding of the biology of SCLC and will discuss the evidence for new agents in this indication, by reviewing recent and current clinical trials.

      The addition of platinum agents to first-line chemotherapy regimens in the 1980’s improved overall response (OR) and complete response (CR) rates, and thus platinum doublet chemotherapy, most commonly in combination with etoposide, is the current standard of care.1 SCLC is initially very chemosensitive, OR rates to platinum-etoposide chemotherapy in the first line setting for limited disease (LD) are between 60-90% with CR rates of 40-70%2, and one third of patients will survive 5 years and be considered cured. The prognosis is far less optimistic for the two thirds of patients with SCLC who are diagnosed with extensive-stage (ES) disease. OR rates for ES SCLC are 40-70%2, and CR rates are 10-20%.3,4 The median progression-free survival (PFS) in the first-line setting is in the order of 15 months for LD5 and 6 months for ES.6

      Unfortunately, the high response rate seen in the first line setting is not maintained when patients are retreated. Patients can be classified into three groups based on their response to initial chemotherapy: sensitive (tumor response ≥ 90 days), resistant (recurrence within 90 days of completing primary therapy) and refractory (non-responders and progression on treatment).2 Therapeutic options therefore include re-challenge for those patients with sensitive disease or a change of regimen. Topotecan has been approved by the FDA since 1996 for the second-line treatment of SCLC following first-line relapse.7 There are additionally several guideline-recommended therapies that are not FDA/EMA approved, such as cyclophosphamide/doxorubicin/vincristine (CAV), irinotecan (Japan), docetaxel, paclitaxel, gemcitabine, temozolomide and nivolumab with ipilimumab.8 Response rates to second line therapy are 27% at best and less than 15% in chemo-refractory cases9, with a median time to progression of only 13 weeks.10 Despite decades of testing with multiple agents, there have been no new drug approvals in over 20 years and improved therapy is urgently needed.

      With the advent of targeted therapies over the past decades, there has been no shortage of early phase clinical trials in SCLC. However, these agents have yet to demonstrate success in phase II-III evaluation. The lack of progress in improving survival rates for SCLC led to its inclusion in the U.S. Congress’ Recalcitrant Cancer Research Act in 2012. Subsequent comprehensive molecular characterization of the disease has led to a better understanding of known molecular vulnerabilities and has pointed to new areas requiring therapeutic interrogation. Examples include developmental regulatory pathway abnormalities, DNA damage repair aberrations, and the manipulation of the immune response. Fundamental to further therapeutic progress remains the challenge of understanding the mechanisms that underlie the rapid emergence of chemo-resistance in SCLC. Recent reports of early phase clinical trials with immune checkpoint inhibitors documenting important response and survival rates, provide tangible hope for the approval of new treatment options. However, immune strategies should exclude the empiric testing of new monotherapies and combinations in the absence of strong pre-clinical science. This will necessitate the development of next generation pre-clinical models, that are biologically representative of the human immune system and disease. Finally, improved translational research will inform more rational clinical trial design, and concentrate resources towards the most promising therapeutic avenues.

      References:

      1. Sundstrøm S, Bremnes RM, Kaasa S, et al. Cisplatin and etoposide regimen is superior to cyclophosphamide, epirubicin, and vincristine regimen in small-cell lung cancer: Results from a randomized phase III trial with 5 years’ follow-up. J Clin Oncol. 2002;20(24):4665-4672. doi:10.1200/JCO.2002.12.111.

      2. Cheng S, Evans WK, Stys-Norman D, Shepherd FA. Chemotherapy for relapsed small cell lung cancer: A systematic review and practice guideline. J Thorac Oncol. 2007;2(4):348-354. doi:10.1097/01.JTO.0000263720.15062.51.

      3. Alvarado-Luna G, Morales-Espinosa D. Treatment for small cell lung cancer, where are we now?-a review. Transl lung cancer Res. 2016;5(1):26-38. doi:10.3978/j.issn.2218-6751.2016.01.13.

      4. Van Meerbeeck JP, Fennell DA, De Ruysscher DKM. Small-cell lung cancer. Lancet. 2011;378(9804):1741-1755. doi:10.1016/S0140-6736(11)60165-7.

      5. Faivre-Finn C, Snee M, Ashcroft L, et al. Concurrent once-daily versus twice-daily chemoradiotherapy in patients with limited-stage small-cell lung cancer (CONVERT): an open-label, phase 3, randomised, superiority trial. Lancet Oncol. 2017;18(8):1116-1125. doi:10.1016/S1470-2045(17)30318-2.

      6. Foster NR, Renfro LA, Schild SE, et al. Multitrial evaluation of progression-free survival as a surrogate end point for overall survival in first-line extensive-stage small-cell lung cancer. J Thorac Oncol. 2015;10(7):1099-1106. doi:10.1097/JTO.0000000000000548.

      7. Ardizzoni A, Hansen H, Dombernowsky P, et al. Topotecan, a new active drug in the second-line treatment of small-cell lung cancer: a phase II study in patients with refractory and sensitive disease. The European Organization for Research and Treatment of Cancer Early Clinical Studies Group and New Dr. J Clin Oncol. 1997;15(5):2090-2096. doi:10.1200/JCO.1997.15.5.2090.

      8. Sabari JK, Lok BH, Laird JH, Poirier JT, Rudin CM. Unravelling the biology of SCLC: implications for therapy. Nat Rev Clin Oncol. 2017. doi:10.1038/nrclinonc.2017.71.

      9. Owonikoko TK, Behera M, Chen Z, et al. A systematic analysis of efficacy of second-line chemotherapy in sensitive and refractory small-cell lung cancer. J Thorac Oncol. 2012;7(5):866-872. doi:10.1097/JTO.0b013e31824c7f4b.

      10. von Pawel J, Schiller JH, Shepherd FA, et al. Topotecan Versus Cyclophosphamide, Doxorubicin, and Vincristine for the Treatment of Recurrent Small-Cell Lung Cancer. J Clin Oncol. 1999;17(2):658-667.

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    MTE17 - Living with and Beyond Lung Cancer: An Education for Advocates (Ticketed Session)

    • Type: Meet the Expert Session
    • Track: Advocacy
    • Moderators:
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      MTE17.01 - Living with and Beyond Lung Cancer: An Education for Advocates

      07:00 - 08:00  |  Presenting Author(s): Winfield Boerckel, Maureen Rigney  |  Author(s): Aoife McNamara

      • Abstract

      Abstract

      Who is this session for?

      This session is aimed at lung cancer advocates, including members of healthcare teams and advocacy organisations. The session will be an interactive discussion on living with and beyond lung cancer. Key topics include an introduction to survivorship, issues for lung cancer survivors, interventions and a global discussion on how advocates can address the needs of lung cancer survivors in their country. The session will be jointly presented by both authors.

      Background:

      Lung cancer has been the most common cancer in the world for several decades with an estimated 1.8 million new cases in 2012 (IARC, 2018). Sadly lung cancer is the leading cause of cancer deaths worldwide. Every year, lung cancer causes more than 1.6 million deaths; more than breast, colon and prostate cancers combined (IASLC, 2015).

      However there are lung cancer survivors. According to the Concord study (2015) 5-year net survival from lung cancer is typically low, in the range of 10–20% for most geographical areas. This study is the most comprehensive international comparison of cancer survival to date, covering countries that are home to two-thirds of the world’s population and shows extremely wide differences in survival between countries.

      Anyone who has been diagnosed with cancer is a survivor – from the time of diagnosis to the end of life. Caregivers and family members are also cancer survivors (National Coalition for Cancer Survivorship, 1986). For the purpose of this session, we will focus on lung cancer patients who are post treatment.

      Unmet needs:

      The impact of a cancer diagnosis can evoke a range of emotions, anything from fear, anxiety, anger or denial. There is no right or wrong way to feel and patients often describe it as being on ‘an emotional rollercoaster.’ A study performed by Zabora et al. in 2001 examined the prevalence of psychological distress by cancer site and found considerable variation. Of the patients surveyed, 43% of lung cancer patients experienced elevated levels of distress in comparison to 32% of breast cancer patients, 31% of bowel cancer patients and 30% of prostate cancer patients. Numerous studies have since replicated these results. And being off treatment does not imply less distress for lung cancer survivors (Eichler, 2018).

      Lung cancer survivors' health related quality of life is generally low; therefore, management is crucial during the posttreatment period. The experience of having unmet supportive care needs is most strongly associated with intrusive cancer-related thoughts, limitations in physical functioning, distress associated with physical symptoms, and health-care satisfaction (Sanders et al., 2010).

      Issues for post treatment survivors:

      The concept of quality of life has become a core concern for many healthcare professionals (Brennan, 2004). Surviving cancer does not always result in a return to ‘normal life’. The impact of a diagnosis can affect the overall quality of life of a survivor, including physically, psychologically and socially (Ivers, M. et al., 2009). For the purpose of this presentation, we will focus on post-treatment survivors and outline concerns real lung cancer survivors have expressed, including:

      Expectations

      Avoiding Triggers

      Anxiety Volume

      Guilt

      The Meaning of My Lung Cancer Experience

      Who/What Am I

      Social Disconnections

      Vulnerability

      Interventions:

      Psychosocial interventions with cancer patients usually focus on adaption and adjustment to diagnosis and treatment, helping the patient to engage in behaviours that are more conducive to better health (Neuz & Neuz, 2007). We will outline a variety of interventions that are successfully used to support lung cancer patients, including:

      CBT

      Focusing on Current Facts

      Staying In the Moment

      Talk Therapy

      Managing and Creating New Expectations

      Lowering the Anxiety Volume

      Re/Building Self-Esteem

      Socialization Exercises

      Global variations:

      There are wide variations in survival rates globally and this in turn impacts the work priorities of advocates. Both authors will present on lung cancer survival in their own country, demonstrating different unmet needs and priorities. The audience will then be invited to discuss key survivorship concerns within their organisations and given an opportunity to share their own survivorship initiatives and projects.

      Conclusion:

      Following group discussion, the authors will present some top tips on advocating for lung cancer survivors and direct the audience to useful resources.

      References:

      IARC (2018) Globocan 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide. Available at: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx

      IASLC (2015) 2015 Lung Cancer Factsheet. Available at: https://www.iaslc.org/lung-cancer-fact-sheet-2015-europe

      Allemani, C. et al. (2015) Global surveillance of cancer survival 1995 – 2009: analysis of individual data for 25 676 887 patients from 279 population-based registries in 67 countries (CONCORD-2). The Lancet, 385, March 14, 2015. Available at: https://www.ncri.ie/sites/ncri/files/pubs/papers/Globalsurveillance_CONCORD2.pdf

      National Coalition for Cancer Survivorship (1986) NCCS Charter. Available at: https://www.canceradvocacy.org/news/defining-cancer-survivorship/

      Zabora et al. (2001) The prevalence of Psychological Distress by cancer site. Psycho-Oncology, 10, 19 – 28.

      Sanders, SL. Et al. (2010) Supportive care needs in patients with lung cancer. Psycho-Oncology 19 (5) 480‐489.

      Eichler, M. et al. (2018) Psychological distress in lung cancer survivors at least 1 year after diagnosis—Results of a German multi-center cross sectional study. Psycho‐Oncology. 1–7.

      Brennan, J. (2004). Cancer in Context: A practical guide to supportive care. Oxford: Oxford University Press.

      Ivers, M., Dooley, B. & Bates, U. (2009) Development, Implementation and Evaluation of a Multidisciplinary Cancer Rehabilitation Programme. The CANSURVIVOR Project: meeting post-treatment cancer survivors’ needs. Dublin: Health Service Executive.

      Nezu, A.M., & Nezu, C.M. (2007). Psychological distress, depression and anxiety. In M.Feuerstein (Ed.), Handbook of cancer survivorship (pp. 323-338). New York: Springer.