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R. Booton



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    ED 04 - How to Set up a Multidisciplinary Lung Cancer Program Within a Community Care Environment and Provide Everyone with the Best Care for Lung Cancer (ID 4)

    • Event: WCLC 2015
    • Type: Education Session
    • Track: Community Practice
    • Presentations: 1
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      ED04.06 - Evaluating Quality of Care Outcomes from Screening to Treatment in Community Based Settings (ID 1787)

      14:15 - 15:45  |  Author(s): R. Booton

      • Abstract
      • Presentation

      Abstract not provided

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    MINI 19 - Surgical Topics in Localized NSCLC (ID 138)

    • Event: WCLC 2015
    • Type: Mini Oral
    • Track: Treatment of Localized Disease - NSCLC
    • Presentations: 1
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      MINI19.04 - Relationship Between Adequacy of Intra-Operative Lymph Node Sampling During Surgical Resection of NSCLC and Survival (ID 1239)

      16:45 - 18:15  |  Author(s): R. Booton

      • Abstract
      • Presentation
      • Slides

      Background:
      Intra-operative lymph node sampling during lung cancer resection is a key surgical performance measure. It informs prognosis, treatment selection for adjuvant chemotherapy and surveillance programs following treatment. This study aimed to analyse the relationship between adequacy of intra-operative lymph node sampling and survival at a large thoracic oncology centre in the United Kingdom.

      Methods:
      A retrospective review of pathological reports for all patients undergoing lung cancer resections at the University Hospital South Manchester from 01/01/2011 to 31/12/2013 was undertaken. Intra-operative lymph node sampling was assessed for adequacy against standards set out by the IASLC Staging Manual in Thoracic Oncology. Survival data was obtained through national death registry data and provided a minimum of twelve months follow-up for all patients at the time of analysis in January 2015.

      Results:
      A total of 987 patients underwent surgical resection for NSCLC in the study period. Overall, there was no significant difference in survival between patients with adequate intra-operative lymph nodal sampling and those with inadequate sampling (log rank p=0.66). Median survival times were not estimable for pN0 and pN1 patients as only a small proportion died. However there was a significant difference in the median survival time of pN2 patients according to whether the intra-operative lymph node sampling was adequate or inadequate (Figure 1). Figure 1Figure 2





      Conclusion:
      Few patients have died in the pN0 and pN1 categories limiting interpretation. As the data matures we expect to see a survival difference according to adequacy of intra-operative nodal sampling that is supported by the differential median survival data of pN2 patients according to nodal adequacy. The data supports that the survival difference is due to inaccurate staging, inadequate resection (R1) and inappropriate omission of adjuvant.

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    MINI 20 - Surgery (ID 137)

    • Event: WCLC 2015
    • Type: Mini Oral
    • Track: Treatment of Locoregional Disease – NSCLC
    • Presentations: 1
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      MINI20.08 - Survival in Unexpected Multi-Station pN2 Following Surgical Resection of NSCLC (ID 1246)

      16:45 - 18:15  |  Author(s): R. Booton

      • Abstract
      • Presentation
      • Slides

      Background:
      In our cancer network, single station N2 NSCLC may be managed with surgical resection followed by adjuvant chemotherapy as meaningful survival has been shown in such circumstances. Multi-station N2 disease diagnosed pre-operatively is not considered a surgical entity. However, sometimes occult multi-station pN2 may only be identified during intra-operative nodal sampling. This study aimed to analyse the survival of such patients at a large thoracic surgical centre in the United Kingdom.

      Methods:
      A retrospective review of all pathological reports from NSCLC resections at the University Hospital South Manchester from 01/01/2011 to 31/12/2013. Based on the histological results from intra-operative nodal sampling, patients were stratified into nodal categories pN0, pN1, pN2 single station and pN2 multi-station. Survival data was obtained through national death registry data allowing a minimum of twelve months follow-up for all patients at the time of analysis in January 2015.

      Results:
      987 surgical resections for NSCLC were performed during the study period 2011 to 2013 at UHSM. A total of 132 patients had pN2 disease; 85 with single station pN2 and 47 with multi-station N2. The median survival time for those patients with multi-station pN2 was 798 days (95% CI 405-1191 days) and 762 days (95% CI 616-908 days) for those with single station pN2. Median survival times were not estimable for patients with pN0 and pN1 as only a small proportion of patients died. For pairwise comparisons between N categories, a Bonferroni adjustment for multiple comparisons used a critical value of 0.008 for significance. Patients with single station pN2 and multi station pN2 had significantly lower survival times than patients with N0, but there was no statistically significant difference in survival between patients with pN1, single station pN2 and multi-station pN2 (Figure 1).Figure 1



      Conclusion:
      Interestingly, patients with multi-station pN2 had a similar survival to those with single station pN2. This cohort of multistation pN2 patients is likely to represent those with microscopic nodal metastases and does not represent all multistation N2 disease. Although the numbers are small it does raise interesting questions about the exclusion of patients with radiologically-occult multi-station N2 disease, detected during the pre-operative systematic sampling of small mediastinal nodes through endoscopic or surgical techniques, being excluded from surgery as part of their multi-modality treatment in our network.

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    ORAL 14 - Biology 2 (ID 112)

    • Event: WCLC 2015
    • Type: Oral Session
    • Track: Thymoma, Mesothelioma and Other Thoracic Malignancies
    • Presentations: 1
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      ORAL14.06 - MesobanK - an International Mesothelioma Tissue Bioresource - Now Open for Tissue Requests (ID 988)

      16:45 - 18:15  |  Author(s): R. Booton

      • Abstract
      • Presentation
      • Slides

      Background:
      Availability of quality assured, fully annotated mesothelioma tissue collected to rigorous standard operating procedures (SOPs) to facilitate basic and translational research is very limited. MesobanK, funded by the British Lung Foundation and the Mick Knighton Mesothelioma Research Fund, is a UK based bioresource to collect fresh tissue, blood, pleural fluid and anonymised linked clinical data to strict SOPs from patients with malignant pleural mesothelioma.

      Methods:
      1) To construct a tissue microarray (TMA) from 1000 cases of formalin fixed paraffin embedded pleural mesothelioma tissue linked to a clinical data set. Each case will have several cores taken to allow for tumour heterogeneity. 2) To collect 300 cases of fresh pleural mesothelioma tissue (5 samples per case), blood (whole blood, serum, plasma and buffy coat) and pleural fluid (supernatant and cell pellet) linked to a clinical data set. Longer term follow up and survival data will be provided by the UK National Cancer Registration Service. 3) To develop at least 20 new fully characterised and annotated mesothelioma cell lines. Governance MesobanK abides by all relevant UK and EU legislation regarding the collection of tissue and data. Mesobank is a member of the UK Confederation of Cancer Biobanks. Prioritisation for access to samples will be based solely on scientific merit. The project is managed by a dedicated project manager and overseen by a Steering Committee; an independent Scientific Advisory Board reviews anonymised applications for samples.

      Results:
      All required ethical permissions have been obtained. A secure, web-based multi-user database has been constructed for data collection. As of April 2015, 730 of the 1000 cases for the TMA have been acquired from UK pathology departments and the first part of the TMA construction is underway at the Cancer Research UK Cambridge Institute. In the first year of operation, 100 prospective cases have been banked and quality control to assess tumour percentage and necrosis in each sample is underway. Figure 1 shows weight of sample versus tumour percentage from the QC of the first 144 samples. Twenty six new cell lines have been developed and are currently being characterised. Figure 1



      Conclusion:
      Procurement of formalin fixed tissue for the TMA and fresh biospecimens is progressing well and MesobanK is now open for investigators to apply for tissue samples. Enquiries about tissue availability should be directed to mesobankadmin@papworth.nhs.uk. An application form is available at www.mesobank.com. A cost contribution model has been developed to support on-going funding of MesobanK.

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    P1.02 - Poster Session/ Treatment of Localized Disease – NSCLC (ID 209)

    • Event: WCLC 2015
    • Type: Poster
    • Track: Treatment of Localized Disease - NSCLC
    • Presentations: 2
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      P1.02-015 - Pathological Variables in Resected NSCLC Tumours: Predictors of Survival? (ID 1249)

      09:30 - 17:00  |  Author(s): R. Booton

      • Abstract
      • Slides

      Background:
      Lung cancer recurrence following treatment with radical intent remains a significant problem for thoracic oncology specialists. Identifying novel predictors of recurrence may inform future management strategies including indications for adjuvant chemotherapy and the intensity of surveillance programs. This study used survival analysis, as a surrogate marker of disease recurrence, to assess if pathological variables in resected NSCLC could predict survival.

      Methods:
      We retrospectively reviewed all pathological reports for patients undergoing surgical resection for NSCLC at the University Hospital South Manchester from 01/01/2011 to 31/12/2013. The following variables were analysed in univariate and multivariate (cox regression) analysis: extra-capsular nodal disease, lymphovascular invasion, pleural invasion (PL0-3), residual disease (R0 vs R1), grade of differentiation, pT-stage and pN-stage. Survival was provided by national death registry data.

      Results:
      Extra-capsular nodal disease (p=<0.001, Figure 1), Lymphovascular invasion (p=<0.001), pleural invasion (PL3, p=<0.001), residual disease (R1, p=<0.001), pT-stage (pT4, pT3, pT2b, p=<0.001) and pN-stage (pN2, p<0.001) were all associated with significantly lower survival on univariate analysis. A multivariate cox regrerssion model was run with all significant univariate variables. The least significant variable was removed and this was repeated until only those significant at the 0.05 level remained (Table 1). Figure 1 Table 1

      Variables Hazard ratio (95% CI) p-value
      Extracapsular spread Yes vs no 1.47 (1.00, 2.17) 0.049
      Pleural invasion PL1 vs PL0 1.37 (0.97, 1.93) 0.002
      PL2 vs PL0 1.08 (0.63, 1.85)
      PL3 vs PL0 2.42 (1.53, 3.83)
      T stage 1b vs 1a 1.04 (0.61, 1.79) 0.006
      2a vs 1a 1.30 (0.81, 2.08)
      2b vs 1a 1.63 (0.95, 2.81)
      3 vs 1a 2.17 (1.28, 3.66)
      4 vs 1a 2.99 (1.46, 6.11)
      N stage N1 vs N0 1.30 (0.91, 1.87) 0.005
      N2 vs N0 1.80 (1.26, 2.58)




      Conclusion:
      Pathological T-stage and N-stage are well established predictors of prognosis and inform decisions around adjuvant chemotherapy. Extra-capsular nodal disease and pleural invasion (PL3) are additional independent predictors of survival. The presence of these pathological findings in resected NSCLC may help in the decision making around adjuvant therapy, the appropriate intensity of surveillance programs and the design or stratification of adjuvant therapy trials.

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      P1.02-020 - Physiological Assessment in Thoracic Surgery for High Risk Patients with Lung Cancer; How Do International Guidelines Compare? (ID 1461)

      09:30 - 17:00  |  Author(s): R. Booton

      • Abstract
      • Slides

      Background:
      Surgical resection is the best curative option in patients with appropriately staged lung cancer. Physiological assessment is vital in selecting patients for surgical resection with particular attention to risk of mortality and morbidity with the planned surgery. This is most crucial in patients deemed high-risk. Physiological parameters employed include spirometry (FEV1%), diffusion (DLCO%), Shuttle walks, Cardiopulmonary Exercise Testing (VO2Max absolute value and %) as well as post-operative predicted values for all of these tests using segment counting to discriminate depending on the planned surgery. However, three major international guidelines exist which advocate different approaches to assessing this patient group (BTS, ERS, ACCP). We aim to assess how these guidelines compare to one another and our local practice in informing decision-making.

      Methods:
      Patients with operable thoracic malignancy who were candidates for surgery and had CPET were eligible for inclusion. We retrospectively analysed all patients who underwent CPET at the University Hospital of South Manchester, a tertiary Thoracic Oncology Centre, between 01/01/2013 and 31/12/2013. Physiology reports, clinical correspondence and survival databases were analysed.

      Results:
      96 patients fulfilled the inclusion criteria. 3 were excluded due to no available pulmonary function data. A further 17 were excluded as they were denied surgery for non-physiology reasons (patient declined surgery, metastatic disease discovered before, small cell histology, adequate resection margin impossible, severe comorbidities). The remaining 74 patients were included in the final analysis. 62/74(84%) underwent surgery (12 pneumonectomy, 3 bilobectomy, 33 lobectomy, 4 segmentectomy, 6 wedge resection, 4 futile thoracotomy due to finding unexpected advanced disease) The overall breakdown of risk classification of patients using the 3 guidelines was as follows. BTS: low-risk 27/74 (36%), medium-risk 31/74 (42%), high-risk 16/74 (22%). ACCP: low-risk 19/74 (26%), medium-risk 52/74 (70%), high-risk 3/74 (4%). ERS: low-risk 47/74 (63%), medium-risk 16/74 (22%), high-risk 11/74 (15%). Of the patients BTS guidelines classed high-risk, we operated on 8/16 (1 pneumonectomy, 3 lobectomy, 1 segmentectomy, 2 wedge resection, 1 futile thoracotomy) with 100% survival at 90 days. We did not operate on any of the 3 patients classed high-risk by ACCP guidelines. Of the patients ERS guidelines classed high-risk, we operated on 5/11 (1 pneumonectomy, 1 bilobectomy, 2 lobectomy, 1 segmentectomy) with 100% survival at 90 days. Of those classed high-risk by ACCP 2/3 would be high-risk by BTS guidelines and of those classed high risk by BTS 2/16 would be high-risk by ACCP guidelines. Of those classed high-risk by ERS 8/11 would be high-risk by BTS guidelines and of those classed high-risk by BTS 2/16 would be high-risk by ERS guidelines.

      Conclusion:
      From our results a lack of concordance between the three guidelines in classification of high-risk is evident. Also, with the exception of the ACCP guidelines, our local practice has shown that patients deemed high-risk for surgery were operated on (upto and including pneumonectomy) with no cases of 90-day mortality. With this in mind an appraisal of current guidelines is indicated as well as a more consistent approach worldwide to ensure that no potentially fit patients are excluded from surgical resection of lung cancer.

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    P2.02 - Poster Session/ Treatment of Localized Disease – NSCLC (ID 210)

    • Event: WCLC 2015
    • Type: Poster
    • Track: Treatment of Localized Disease - NSCLC
    • Presentations: 1
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      P2.02-008 - Planning the Optimal Patient Pathway in the Diagnosis and Staging of Suspected Lung Cancer; What Infrastructure Is Needed? (ID 1256)

      09:30 - 17:00  |  Author(s): R. Booton

      • Abstract
      • Slides

      Background:
      Lung cancer is the commonest cause of cancer death in the world. Recent research has suggested reducing the length of the diagnostic and staging pathway from 30 to 14 days may improve survival. University Hospital of South Manchester (UHSM) is a regional cancer centre in Manchester Cancer, a large cancer network in the North of the United Kingdom. Manchester Cancer diagnoses over 2000 lung cancers every year and UHSM is responsible for the diagnostic and staging pathways for over 200 lung cancer patients per year locally. We anticipate that an efficient patient journey will involve an “investigation day” where patients undergo the majority of the necessary investigations in a single visit/overnight stay. The results of this work may assist in planning the infrastructure required.

      Methods:
      Prospective data was collected on all patients referred to the rapid access chest clinic (suspected lung cancer) at UHSM from November 2014 to February 2015. Specifically, the investigations each patient underwent in their pathway, both for diagnosis/staging and physiological tests to determine appropriate treatment were recorded.

      Results:
      Results are presented in table 1.

      n (%)
      Total number of patients 264
      Number with lung cancer 73 (28%)
      PET-CT 67 (25%)
      Bronchoscopy 45 (17%)
      Diagnostic EBUS 29 (15%)
      Staging EBUS 29 (15%)
      Mediastinoscopy 0 (0%)
      Percutaneous CT-guided lung biopsy 25 (9%)
      Neck USS & biopsy 6 (2%)
      Liver biopsy 1 (1%)
      MR (brain, spine, adrenal, liver) 10 (4%)
      Bone biopsy 1 (1%)
      Bone scan 2 (1%)
      Spirometry 109 (41%)
      Diffusion studies 69 (26%)
      Differential perfusion scan 6 (2%)
      Shuttle walk 41 (16%)
      CPET 17 (6%)
      Echocardiogram 29 ( 11%)


      Conclusion:
      Approximately one-third of new referrals to this lung cancer clinic are subsequently diagnosed with lung cancer. Reliable and rapid access to PET-CT, specialist bronchoscopy services and cardiorespiratory physiology testing is paramount for streamlining patient pathways. To realise our aspirations of an “investigation day” we estimate a need for 4 PET-CT slots, 4 lung function slots (with capability of spirometry, diffusion studies and shuttle walk), 8 bronchoscopy / EBUS slots and 2 CT-guided biopsy slots per week to serve our lung cancer population.

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    P3.11 - Poster Session/ Palliative and Supportive Care (ID 231)

    • Event: WCLC 2015
    • Type: Poster
    • Track: Palliative and Supportive Care
    • Presentations: 1
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      P3.11-007 - How Fit Are Lung Cancer Patients? An Observational Study of Co-Morbidities and Physiology (ID 1259)

      09:30 - 17:00  |  Author(s): R. Booton

      • Abstract
      • Slides

      Background:
      Co-morbidity is a key factor in determining prognosis and defining treatment in lung cancer. In the face of an ageing population and increasing prevalence of chronic medical conditions, lung cancer physicians will need to develop robust systems and services to ensure appropriate optimisation of co-morbidities during the diagnosis and staging pathway. The aim of this study was to provide a detailed description of co-morbidities and physiology in a UK lung cancer population.

      Methods:
      Prospective data was collected on all newly diagnosed lung cancer patients at the University Hospital South Manchester from November 2014 and February 2015. UHSM is a regional lung cancer centre and diagnoses over 200 lung cancers per year. Co-morbidities were assessed using the Charlson co-morbidity index. Performance status, MRC Dyspnoea Scale, BMI and physiological parameters for the cardiorespiratory and renal systems were also measured.

      Results:
      73 patients were diagnosed with lung cancer in the study period. Mean age was 70 years and 35 (48%) were male. 37 (51%) had radiological evidence of emphysema on staging CT of the thorax. Co-morbidities and physiological parameters for the patient cohort are presented in tables 1 & 2. Table 1: Charlson Co-morbidity Index

      n = 73 n (%)
      0 9 (12%)
      1-2 26 (37%)
      3-4 16 (22%)
      5-6 12 (16%)
      ≥7 10 (14%)
      Chronic pulmonary disease 27 (37%)
      Myocardial Infarction 14 (19%)
      Cerebrovascular disease 13 (18%)
      Diabetes without end-organ damage 10 (14%)
      Congestive cardiac failure 7 (10%)
      Peripheral vascular disease 7 (10%)
      Moderate-severe CKD 5 (7%)
      Dementia 3 (4%)
      Diabetes with end-organ damage 3 (4%)
      Connective tissue disease 3 (4%)
      Chronic liver disease 2 (3%)
      Lymphoma 1 (1%)
      Table 2: Fitness and physiological parameters
      PS 0-1 45 (62%)
      PS 2-4 28 (38%)
      MRC Dyspnoea Scale 1-2 38 (52%)
      MRC Dyspnoea Scale 3-5 35 (48%)
      BMI <20 17 (23%)
      BMI 20-30 34 (47%)
      BMI >30 22 (30%)
      FEV1 % predicted, mean 77.1 ±26.7
      FEV1:FVC 62.1 ±14.6
      DLCO % predicted, mean 72.0 ±21.2
      Shuttle walk distance, metres, mean 366 ±154
      Lowest O2 sats during shuttle, %, mean 92 ±4.1
      Peak VO2 % predicted, mean 71.7 ±17.8
      Estimated glomerular filtration rate 75.4 ±18.9
      Revised cardiac index ≥3 9 (12%)


      Conclusion:
      Chronic respiratory disease and disability is a major component of co-morbidity and physiological impairment in lung cancer patients. Cardiovascular disease and abnormalities in BMI are also highly prevalent. These results inform the need for rapid and reliable access to prehabilitation and dietetic services, robust cardiorespiratory physiological testing and specialist cardiovascular teams for all lung cancer physicians.

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