Virtual Library

Start Your Search

Kasia Czarnecka-Kujawa



Author of

  • +

    MS19 - Pulmonary Dilemmas with Immunotherapy (ID 798)

    • Event: WCLC 2018
    • Type: Mini Symposium
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 13:30 - 15:00, Room 201 BD
    • +

      MS19.03 - Diagnostic Approaches Suspected IO Progression/Pseudoprogression and What/When to Rebiospy for TT Progression (Now Available) (ID 11483)

      14:10 - 14:30  |  Presenting Author(s): Kasia Czarnecka-Kujawa

      • Abstract
      • Presentation
      • Slides

      Abstract

      The 2000’s marked the beginning of precision medicine era with treatment of NSCLC becoming increasingly personalized. This was driven by effective therapies in biomarker-defined populations, most notably treatments targeting the epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), programmed cell death-1 (PD-1), and programmed cell death ligand-1 (PD-L1) pathways (1) testing for which is now the standard of care for majority of patients with NSCLC, both, at the time of diagnosis and with recurrent disease (2-4). In addition, testing indications emerged for other proto-oncogenes, many of which are actively investigated as therapy targets (3, 5). In addition, given development of effective treatments for recurrent NSCLC in setting of acquired resistance (AR) to targeted therapies (TT), the minimally-invasive tumor sampling to identify resistance mutations has become increasingly attractive, given frailty of population with metastatic lung cancer (4, 6).

      Imaging and clinical patient status are used to diagnose cancer progression, pseudoprogression and recurrence. Conventional tumor response criteria serve as standardized measures for treatment response in NSCLC. However, given unique tumor behaviour upon exposure to immunotherapy, immune response criteria have been developed to assess treatment response in patients on immunotherapy (7).

      While preparing to obtain a diagnostic sample in setting of suspected disease recurrence/progression one should consider: 1) procedural safety and convenience; 2) size of tissue sample, 3) proportion of tumor cells in the sample; 4) fixative used to preserve tissue; 5) tumor heterogeneity; 6) difference in genetic make up of the primary and metastatic tumor(4).

      The choice of diagnostic procedure to confirm disease recurrence/progression must be guided by the procedure safety and diagnostic yield. Percutaneous or surgical lung biopsies, are often not possible for patients with advanced lung cancer. The minimally-invasive techniques have become an attractive alternative for tissue acquisition in this setting. The most common, minimally-invasive techniques utilized by interventional pulmonologists are: 1) transbronchial biopsy (TBBx) or transbronchial needle aspiration (TBNA); 2) Endoscopic techniques: Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) and Esophageal Ultrasound- guided Fine Needle Aspiration (EUS-FNA); 3) and pleural fluid sampling. Studies show that endoscopic techniques provide tissue of comparable quantity and quality material for molecular testing compared to surgical or conventional needle biopsy. Reported adequacy of EBUS-TBNA samples for molecular diagnosis ranges from 77% to 98% (8). EBUS samples have one of the lowest insufficiency rates (4%) for EGFR and KRAS mutational analysis (compared with CT-FNA – 7.5%; ultrasound guided/superficial FNA- 10%) and can provide sufficient tissue quantity for multigene testing (i.e. p53 mutation, BRAF and PIK3CA) (8). EBUS-TBNA samples have been shown to yield a higher number of viable cells with less crush artifact and better concordance with the primary tumor for expression of the PD-L1 than TBBx (9). TBNA has been shown to improve diagnostic yield in NSCLC when added to conventional TBBx.

      High concordance has been reported for detection of EGFR mutation and PD-L1 expression between primary and metastatic tumors. Some authors suggest that either of the two sites can be used for molecular testing. However, there is a significant heterogeneity in PD-L1 expression within tumors (10). Additionally, AR to Tyrosine Kinase Inhibitors (TKI) develops almost invariably within 8–16 months on TKI use, resulting in disease progression. The T790M mutation is the most common mechanism of AR with TT available for patients baring this EGFR aberration. During workup of recurrence, some of the patients will be diagnosed with transformation into a new primary lung cancer, which warrants different treatment than metastatic NCSLC. For these reasons, an attempt should be made to obtain a fresh tissue sample if disease progression/relapse are suspected. Pleural fluid cytology has been shown to be an excellent source of tumor cells with high yield in detection of both EGFR and ALK mutations(5). In all instances, bronchoscopist should work closely with cytopathologists seeking feedback on tissue quality, quantity for ancillary testing (5).

      1. Thai AA, Solomon BJ. Treatment of ALK-positive nonsmall cell lung cancer: recent advances. Current opinion in oncology. 2017.

      2. Lindeman NI, Cagle PT, Beasley MB, Chitale DA, Dacic S, Giaccone G, et al. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. The Journal of molecular diagnostics : JMD. 2013;15(4):415-53.

      3. Leighl NB, Rekhtman N, Biermann WA, Huang J, Mino-Kenudson M, Ramalingam SS, et al. Molecular testing for selection of patients with lung cancer for epidermal growth factor receptor and anaplastic lymphoma kinase tyrosine kinase inhibitors: American Society of Clinical Oncology endorsement of the College of American Pathologists/International Association for the study of lung cancer/association for molecular pathology guideline. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2014;32(32):3673-9.

      4. Kim E, Feldman R, Wistuba, II. Update on EGFR Mutational Testing and the Potential of Noninvasive Liquid Biopsy in Non-Small-cell Lung Cancer. Clinical lung cancer. 2018;19(2):105-14.

      5. Czarnecka-Kujawa K, Yasufuku K. Molecular alterations in non-small-cell lung cancer: perspective for targeted therapy and specimen management for the bronchoscopist. Respirology (Carlton, Vic). 2014;19(8):1117-25.

      6. Arcila ME, Oxnard GR, Nafa K, Riely GJ, Solomon SB, Zakowski MF, et al. Rebiopsy of lung cancer patients with acquired resistance to EGFR inhibitors and enhanced detection of the T790M mutation using a locked nucleic acid-based assay. Clinical cancer research : an official journal of the American Association for Cancer Research. 2011;17(5):1169-80.

      7. Wolchok JD, Hoos A, O'Day S, Weber JS, Hamid O, Lebbe C, et al. Guidelines for the evaluation of immune therapy activity in solid tumors: immune-related response criteria. Clinical cancer research : an official journal of the American Association for Cancer Research. 2009;15(23):7412-20.

      8. Billah S, Stewart J, Staerkel G, Chen S, Gong Y, Guo M. EGFR and KRAS mutations in lung carcinoma: molecular testing by using cytology specimens. Cancer cytopathology. 2011;119(2):111-7.

      9. Sakakibara R, Inamura K, Tambo Y, Ninomiya H, Kitazono S, Yanagitani N, et al. EBUS-TBNA as a Promising Method for the Evaluation of Tumor PD-L1 Expression in Lung Cancer. Clinical lung cancer. 2017;18(5):527-34.e1.

      10. McLaughlin J, Han G, Schalper KA, Carvajal-Hausdorf D, Pelekanou V, Rehman J, et al. Quantitative Assessment of the Heterogeneity of PD-L1 Expression in Non-Small-Cell Lung Cancer. JAMA oncology. 2016;2(1):46-54.

      Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.

      Only Active Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login or select "Add to Cart" and proceed to checkout.

  • +

    P2.01 - Advanced NSCLC (Not CME Accredited Session) (ID 950)

    • Event: WCLC 2018
    • Type: Poster Viewing in the Exhibit Hall
    • Track:
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/25/2018, 16:45 - 18:00, Exhibit Hall
    • +

      P2.01-76 - The Impact of Concordance with a Lung Cancer Diagnosis Pathway Guideline on Treatment Access in Patients with Stage IV Lung Cancer (Now Available) (ID 12628)

      16:45 - 18:00  |  Author(s): Kasia Czarnecka-Kujawa

      • Abstract
      • Slides

      Background

      Lung cancer is the leading cause of cancer mortality with the majority of cases diagnosed at an advanced stage. Timely access to treatment is dependent on efficient and appropriate patient assessment and early referral for diagnostic workup. This study aims to assess the impact of referral concordance with a new Lung Cancer Diagnostic Pathway Guideline (LCDPG) on access to treatment in patients with stage IV lung cancer.

      Method

      This is a retrospective cohort study of patients with clinical stage IV lung cancer referred to the Diagnostic Assessment Program (DAP) at a Canadian tertiary cancer centre between November 1, 2015 and May 31, 2017. Patient referrals were defined as concordant or discordant based on Cancer Care Ontario LCDPG. The primary outcome; time to treatment from initial healthcare presentation; was compared between the concordant and discordant referrals.

      Result

      Two hundred patients were referred for clinical stage IV lung cancer during the study period. Of these referrals, 151 (75.5%) were assessed and referred in concordance with LCDP guidelines. Guideline concordant referrals were associated with reduced time to treatment from first healthcare presentation compared with guideline discordant referrals (55.3 vs 108.8 days, p<0.001). Time to diagnostic procedure (32.2 vs 86.7 days, p<0.001) and decision to treat (38.5 vs 93.8 days, p<0.001) was also reduced with guideline concordance. The most common reason for discordant assessment and referral was delayed or inadequate investigation of symptoms in a high risk patient (32.7% of discordant referrals).

      The mean time from referral to diagnostic procedure (19.4 [SD 16.0] days), decision to treat (23.3 [SD 17.1] days), and treatment initiation (39.7 [SD 26.3] days) did not significantly differ between concordant and discordant groups. Time from referral to decision to treat was within 28 days in 71.5% of patients. The mean number of hospital visits from referral to treatment was 4.9 (SD 3.5). Diagnosis was achieved with a single diagnostic test in the majority of patients (91%). The most common method of diagnosis was EBUS-TBNA (33.5%). The most common treatment modalities initiated were radiation (60.5%) followed by chemotherapy (43%) and targeted therapy (21.5%).

      Conclusion

      Guideline concordant assessment and referral of patients with stage IV lung cancer results in reduced time to diagnosis and treatment. The utilization of a LCDPG for lung cancer provides a streamlined and efficient framework to facilitate early diagnosis and treatment. Future research and education should focus on improving factors leading to a delay in DAP referral.

      Only Active Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login or select "Add to Cart" and proceed to checkout.

  • +

    WS03 - Endoscopic Diagnosis and Staging of Lung Cancer – Interventional Pulmonology Hands-On Workshop (Ticketed Session) (ID 986)

    • Event: WCLC 2018
    • Type: Workshop
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/23/2018, 08:00 - 11:30, Room 205 BD
    • +

      WS03.04 - Radial Probe EBUS – Methods and Results (Now Available) (ID 14660)

      08:50 - 09:10  |  Presenting Author(s): Kasia Czarnecka-Kujawa

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

      Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.

      Only Active Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login or select "Add to Cart" and proceed to checkout.