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Jessica S Donington
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IBS25 - Optimal GGO Management (Ticketed Session) (ID 56)
- Event: WCLC 2019
- Type: Interactive Breakfast Session
- Track: Treatment of Early Stage/Localized Disease
- Presentations: 1
- Now Available
- Moderators:
- Coordinates: 9/10/2019, 07:00 - 08:00, Melbourne (1991)
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IBS25.02 - Western Perspective (Now Available) (ID 3393)
07:00 - 08:00 | Presenting Author(s): Jessica S Donington
- Abstract
- Presentation
Abstract
Ground glass opacities (GGOs) are a 21st century diagnostic and therapeutic challenge. These are defined as focal areas of increased attenuation on computed tomography (CT), where visualization of normal parenchyma and pulmonary structures such as airways and vessels is preserved. Prior to the advent of high-resolution thin-slice CT scanning we had little evidence for the wide spread existence of these lesions or their association with adenocarcinomas of the lung. The opacities develop because of reduced volumes of air the alveolar airspaces due to partial by cells as they grow in a lepidic pattern along the alveolar surface, typically, the abnormal cells only occupy a portion of the airspace and therefore consolidation of the lung parenchyma does not occur. GGOs are typically divided into two categories: 1) pure GGOs, which contain no solid component and 2) part-solid GGOs, with both solid and pure ground glass regions.
The introduction of CT screening for lung cancer should dramatically increase the number of patients presenting with small nodules and GGOs. Interpretation and management guidelines are essential and several have been developed and updated. They are derived by expert consensus and management recommendations are based primarily on the GGO’s size, percent solid component, and number in
combination with the patient’s baseline risk for lung cancer development. The most prominent guidelines are from the British Thoracic Society1 and the Fleischner Society2.
We have a growing understanding of the role of GGOs in the pathogenesis of adenocarcinomas of the lung. A strong correlation exists between CT appearance and the extent of histologic tumor invasion, which is outlined in the IASLC/ATS/ERS Classification of Lung Adenocarcinomas.3 There exists a continuum from pre-invasive lesions, atypical adenomatous hyperplasia (AAH) and adenocarcinoma in situ (AIS), to minimally invasive adenocarcinoma (MIA), and finally to invasive adenocarcinoma. This has also resulted in a new subclassification of T1 lesions in the 8th edition of lung cancer staging system4 that includes precise definitions for these pre-invasive and minimally invasive lesions.
Although we all agree on terminology to define these lesions radiographically and pathologically, there is less consensus on the ideal management and more specifically when to intervene surgically and what type of resection is best. The Japanese Clinical Oncology Group have served as the leaders in this realm, carrying out a series of prospective trials to define the appropriate extent of resection and lymph node dissection for pure and part-solid GGOs.
I believe one of the greatest disparity between eastern and western lung cancer treatment is in the management of small GGOs. The pre-invasive and minimally invasive lesions, those < 2cm and with solid component < 5mm or with consolidation to tumor ratio < 0.25. Numerous retrospective series and prospective trials from Asia outline the high potential for cure with a limited resection and no lymph node dissection, but most western thoracic surgeons would argue whether if resection is warranted at all for lesions that we reliably know are pre-invasive, or iss surgery for these lesions overtreatment for a “pseudo disease”?
It is difficult to put forth the management ideology for the entire western hemisphere, but I believe that the concept of “do no harm” prevails with regard to these small lesions. The western thoracic community has a far greater tendency toward “watching and waiting” than our eastern counter parts. This is based on the understanding that even though these lesions exist within the adenocarcinoma spectrum, only a small percentage will become invasive cancers. Less than 30% of pure GGOs detected in the NELSON trial5 and only < 2% in the I-ELCAP cohort6 ever developed a solid component. We also take comfort in the fact that these lesions have slow doubling times >800 days7, allowing for change in appearance over time to help define the potential for invasion and risk to the patient.
Some of the hesitation for rapid surgical intervention in these pre-malignant lesions is because thoracic resections are invasive, even simple wedge resections typically require general anesthesia and a hospital stay and carry a risk for complication especially in the frail or elderly. In addition, the lungs are vital organs, and in that sense quite different from the breast or prostate where we have taken on a much more aggressive approach to the treatment of pre-malignant and minimally invasive tumors. Even in those tumors, we are now investigating de-escalation of treatment protocols and active surveillance for lesions that may never affect a patient’s survival. There is also a tendency for multiplicity with GGOs and the potential for many interventions treatments over a patient’s lifetime, if each GGO is to be removed.
We are in the early phase of our clinical proficiency with GGOs; as our experience and knowledge grows there will likely be a more uniformed approach to intervention, but in 2019, management varies by geography.
Callister ME, Baldwin DR, Akram AR, et al. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax 2015;70 Suppl 2:ii1-ii54.
MacMahon H, Naidich DP, Goo JM, et al. Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 2017;284:228-43.
Travis WD, Brambilla E, Noguchi M, 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;6:244-85.
Travis WD, Asamura H, Bankier AA, 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.
van Klaveren RJ, Oudkerk M, Prokop M, et al. Management of lung nodules detected by volume CT scanning. N Engl J Med 2009;361:2221-9.
International Early Lung Cancer Action Program I, Henschke CI, Yankelevitz DF, et al. Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med 2006;355:1763-71.
Lee SW, Leem CS, Kim TJ, et al. The long-term course of ground-glass opacities detected on thin- section computed tomography. Respir Med 2013;107:904-10.
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PL02 - Presidential Symposium including Top 7 Rated Abstracts (ID 89)
- Event: WCLC 2019
- Type: Plenary Session
- Track:
- Presentations: 1
- Now Available
- Moderators:Giorgio Vittorio Scagliotti, Ramon Rami-Porta
- Coordinates: 9/09/2019, 08:00 - 10:15, Barcelona (2005)
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PL02.07 - Discussant - PL02.06 (Now Available) (ID 3913)
08:00 - 10:15 | Presenting Author(s): Jessica S Donington
- Abstract
- Presentation
Abstract not provided
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