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L.B. Irving



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    MA 20 - Recent Advances in Pulmonology/Endoscopy (ID 685)

    • Event: WCLC 2017
    • Type: Mini Oral
    • Track: Pulmonology/Endoscopy
    • Presentations: 1
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      MA 20.09 - Accuracy & Utility of Systematic Mediastinal LN Staging via EBUS-TBNA in cN0/N1 NSCLC: Systematic Review & Meta-Analysis (ID 9154)

      14:30 - 16:15  |  Author(s): L.B. Irving

      • Abstract
      • Presentation
      • Slides

      Background:
      Accurate mediastinal staging is crucial in potentially operable lung cancer to avoid non-therapeutic resection. Performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging of the radiologically normal mediastinum has been reported with inconsistent findings. We assessed the value of pre-operative systematic staging using EBUS-TBNA in cN0/N1 lung cancer.

      Method:
      For this systematic review and meta-analysis, we searched MEDLINE, PubMed, EMBASE, Cochrane databases from inception to October 2016. We included studies evaluating EBUS-TBNA for systematic mediastinal staging in cN0/N1 lung cancer. For each study, we extracted data on participant age and sex, radiological stage, EBUS-TBNA protocol, number and size of lymph nodes sampled, EBUS-TBNA stage, reference standard stage, and 2x2 tables. We evaluated the diagnostic accuracy of EBUS-TBNA for detection of occult mediastinal metastases. PROSPERO registration number CRD42017057020

      Result:
      We identified 1,173 articles, of which nine (1,146 patients) were included in meta-analysis. Mean prevalence of N2/N3 disease was 15% (6-24%). EBUS-TBNA had a pooled sensitivity 49% (95%CI 41-57%) (see figure 1), pooled specificity 100% (95%CI 99-100%), and mean negative predictive value 91% (82-100%) for detection of unsuspected N2/N3 disease. Number Needed to Test to detect occult N2/N3 disease was 14 (95%CI 10.8-16.3), NNT was reduced to 7 for studies which added endoscopic ultrasound to EBUS-TBNA. Moderate inter-study heterogeneitywas observed (I[2] 40.6%). Figure 1



      Conclusion:
      Pre-operative systematic staging by EBUS-TBNA of early lung cancer can reduce rates of non-therapeutic resection and decrease incidence of post-operative upstaging. Sensitivity for detection of radiologically occult mediastinal metastases appears lower than for targeted sampling of pathologic lymph nodes. Verification of negative results by mediastinoscopy in selected cases remains of value.

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    P1.14 - Radiotherapy (ID 700)

    • Event: WCLC 2017
    • Type: Poster Session with Presenters Present
    • Track: Radiotherapy
    • Presentations: 1
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      P1.14-017 - Impact of Systematic EBUS-TBNA Mediastinal Staging on Radical Radiotherapy Planning in NSCLC (ID 8497)

      09:30 - 16:00  |  Author(s): L.B. Irving

      • Abstract
      • Slides

      Background:
      Radical radiotherapy often relies solely on radiological imaging to determine treatment volumes. Systematic mediastinal staging with endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) may identify PET-occult sites of mediastinal disease, or demonstrate benign causes for PET-positive LN. This study evaluated 1) Involved nodal coverage 2) Doses to organs-at-risk when planned based on PET-CT and EBUS-TBNA and 3) Incident dose to mediastinal nodes between 3D-CRT and Intensity-Modulated-Radiotherapy (IMRT).

      Method:
      Radical radiotherapy plans (60Gy/30 fractions) were created for patients with stage change following EBUS-TBNA from a prospective clinical trial. We compared lung Normal-Tissue-Complication-Probability (NTCP, pneumonitis), oesophageal and heart dose for planning to targets based on PET-CT versus PET-CT+EBUS-TBNA. The incidental dose to PET-negative/EBUS-TBNA-positive nodes from 3DCRT and IMRT was evaluated using volume receiving 35Gy as a surrogate for control of sub-clinical disease (Kepka, IJROBP, 73(5) 2009).

      Result:
      Of 30 patients enrolled, four were upstaged by EBUS-TBNA; these patients had a significant geographic miss of nodal GTV when planned to PET-positive nodes only (Figure 1). When planned based on PET-CT alone, the incidental dose to PET-negative/EBUS-TBNA-positive nodes was higher with IMRT for two patients (v35Gy increased by 17% & 6%; Figure 1a&b) and lower with IMRT (v35Gy reduced by 16% and 6%; Figure 1c&d) for two, dependent on nodal position relative to the primary. Six patients had negative pathology for PET avid nodal stations; Inclusion of EBUS-negative, PET-positive nodes resulted in an average increased lung NTCP of 5% (range 1%-13%), mean oesophagus dose of 13Gy (range 4-23Gy) and mean heart dose of 4Gy (range -0.1-11Gy) over plans based on EBUS-positive nodes alone. Figure 1



      Conclusion:
      Systematic EBUS-TBNA has the potential to improve loco-regional control and limit the probability of lung and heart toxicity. The incidental dose to adjacent tissue is inherently related to involved node/tumour position and not solely dictated by the radiation delivery technique.

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    P2.13 - Radiology/Staging/Screening (ID 714)

    • Event: WCLC 2017
    • Type: Poster Session with Presenters Present
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      P2.13-023 - Lung Cancer Risk and Eligibility for Lung Cancer Screening in Patients Undergoing Computed Tomography Coronary Angiography (ID 10465)

      09:30 - 16:00  |  Author(s): L.B. Irving

      • Abstract

      Background:
      Computed Tomography Coronary Angiography (CTCA) is frequently performed for non-invasive coronary artery assessment. Extracardiac findings are frequent, with indeterminate pulmonary nodules the commonest incidental finding. Given the established efficacy of lung cancer screening with low dose CT (LDCT), CTCA has been suggested to be an opportunity for “opportunistic” lung cancer screening. This rationale has been used to justify full field of view imaging, despite limited field of view significantly reducing prevalence of nodules detected and therefore reduce downstream healthcare costs. Distribution of lung cancer risk of patients undergoing Cardiac CT has not previously been reported. We performed a cross-sectional survey to determine the proportion of patients undergoing CTCA who would be eligible for lung cancer screening, and to determine the lung cancer risk profile of eligible patients.

      Method:
      Patients attending two tertiary hospitals in Melbourne, Australia, for clinically indicated out-patient CT coronary angiography were screened for inclusion in the study. Patients eligible for Lung Cancer screening according to the US Preventive Services Task Force (USPSTF) recommendations were invited to complete a questionnaire including smoking history and demographic details, to determine 6-year lung cancer risk, according to the PLCO~m2012~ risk prediction model. A threshold PLCOm2012 risk at least 1.5% was used to identify a sub-group in whom LDCT screening is most likely to be cost-effective and reduce lung cancer mortality.

      Result:
      In a four month period, 216 patients (60% male) were screened prior to CTCA across both sites. Only 57 patients (26%) were potentially eligible for lung cancer screening according to USPSTF guidelines: 126 (58.3%) were never-smokers, with a further 33 patients (15.3%) outside the reccomended 55-80 years age range. Of 57 eligible patients, 48 (84%) consented to the questionnaire. Thirty-four were male (71%), with mean age 65.6+/-6.0 years. Median (IQR) PLCOm2012 risk was 1.30% (0.45–2.19%). Only 22 patients (45.8% of patients completing the questionnaire, estimated 12% of total cohort)had a PLCO~m2012~ risk score >1.5%, and just 18 of 48 (37.5% of patients completing the questionnaire) had a PLCOm2012 risk > 2.0%

      Conclusion:
      A majority of patients undergoing CTCA were never-smokers. Only 26% would be eligible for screening according to USPSTF criteria. Therefore routine use of Cardiac CT for “opportunistic” lung cancer screening is likely to result in net harm and is not appropriate A small proportion of patients undergoing CTCA have high risk for lung cancer and may benefit from full thoracic imaging at the time of CTCA