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IntroductionLung cancer continues to be the leading cause of cancer death in the UK and the 2nd most common cancer diagnosed each year. In 2015, the British Thoracic Society (BTS) published the updated guidelines on lung nodule follow-up with the aim of improving early identification of lung malignancies and improving survival. Here we aim to determine the rate of early cancer detection in patients referred to the lung nodule MDT and explore their outcomes.MethodsPatients were identified from the minutes of lung nodule MDTs celebrated during 2018 and information gathered via RIS, PACS and clinical record systems of the hospital.Results92 patients were identified using the method described above. The median age of participants was 67.5 (42–88) and there were slightly more females than males (51 to 41; 55.4 to 44.6%). The rate of compliance with guidelines was very high at 98.9%. We identified 6 lung primary malignancies of which all but 1 (83.3%) were in early stages (stage I or II), compared to 27% in lung cancers detected in the population (figure 1). Of the patients with early-stage lung cancer, 3 were judged not fit for active treatment. The other 2 underwent lobectomies and have had more than 2 disease-free years as of the time of this writing.Abstract P164 Figure 1Comparison between the stages at diagnosis in patients in surveillance programme(grey) vs those in the general population (black)ConclusionThis data shows that implementation of the BTS guidelines in lung nodule follow-up leads to higher rates of early-stage lung cancer detection and improved prognosis for these patients. However, we also note that a relatively high proportion of these detected lung cancers are found in patients with poor functional status making them ineligible for active treatment. We propose that it may be beneficial for future editions of this BTS guidelines to explore including clear entry and retainment criteria for patients which, no matter the outcome, will be unable to withstand active treatment. These could include looking at, for example, elements such as minimum functional or pulmonary status. This would avoid some patients undergoing a 2 to 4-year-long surveillance programme which will ultimately not affect their management options.

IntroductionIndwelling pleural catheters (IPC) provide definitive management of malignant pleural effusion. IPCs offer similar control of dyspnoea to talc pleurodesis without hospital admission but require ongoing management. Up to 47% of patients with IPC undergo auto-pleurodesis facilitating removal. Patient factors leading to this are not well understood.MethodsRetrospective analysis of IPC data at a UK tertiary centre between 2019–2021. Procedure reports, radiology, pathology and electronic patient records were reviewed to assess the most frequent diagnoses, imaging, and pleural fluid biochemistry leading to IPC removal. Outcomes and complications were analysed.Results115 patients underwent IPC insertion and 55 patients (47.8%) underwent IPC removal over the two year period. The median duration between insertion and removal was 97 days (IQR 62–133).Indications71% (39/55) of IPC removals were undertaken due to auto-pleurodesis, with other causes comprising of pain (3.6%; 2/55), blocked catheter (3.6%; 2/55) and non-draining, organised effusions (21.8%; 12/55).The most common primary malignancies associated with auto-pleurodesis included mesothelioma (31%, n=12), lung (18%, n=7), breast (18%, n=7).Lung-Sliding on Ultrasound Prior to IPC insertionOf the patients that underwent auto-pleurodesis, 24 had documentation pertaining to lung sliding on ultrasound. Lung sliding was present pre-insertion in 87.5% (21/24) and absent in 12.5% (3/24).Inflammatory-BiochemistryMedian pleural fluid LDH in patients with auto-pleurodesis was not significantly different vs baseline LDH in all patients with MPE (236.5IU/L auto-pleurodesis vs 326IU/L in all MPE, P>0.05, Mann-Witney).ComplicationsIPC removals resulted in few complications with retained catheter fragment (7.2%; 4/55) being the most reported. No patients required admission for a procedure related complication. Following IPC removal, 4 patients required further pleural aspiration and 3 re-insertion of IPC.Abstract P172 Figure 1a) Chart illustrating number of IPC insertions, removals and indications for removal; b) Chart illustrating number of patients with auto-pleurodesis with lung sliding on ultrasound prior to insertion of IPCConclusionsA significant proportion of patients with IPC undergo auto-pleurodesis. In this cohort of patients IPC removal presents a low risk of complications and offers significant benefits to patient comfort. The presence of lung sliding on ultrasound prior to insertion appears to be correlated with auto-pleurodesis, and this requires further investigation in larger prospective studies. The ability to give patients more information regarding likelihood of auto-pleurodesis could add to the decision making process for definitive fluid control.

IntroductionHong et al determined, from 2394 patients with stage 1 lung cancer, that needle or intra-operative transthoracic biopsy had a higher risk for pleural recurrence.1 There was local concern that a straight to surgery approach advocated might not be sustainable and/or warranted, that the data might only apply to Asian countries, and that there were missing values for microscopic invasion.MethodsAn analysis of all Stage 1 lung cancers enrolled onto the Somerset cancer register was performed (Caldicott ref 3756). Exclusion criteria were mesothelioma, non-lung cancers and non-diagnostic biopsies. Data collected were demographics, diagnostic procedures, operation, pathology, CT findings, time to recurrence, recurrence type, survival and time to death.Results493 patients with stage 1 cancer were identified (Jan 2013-Dec 2020). Data was insufficient in 34.169 patients had a positive CT guided or pre-operative biopsy: mean age 73 years (range 48–97) and 105 (60%) females. Diagnoses were predominantly 99 (57%) adenocarcinomas and 49 (28%) squamous cell cancers. Any recurrence occurred in 42 (24% vs 19% with Hong et al1) patients and concomitant ipsilateral pleural recurrence in 10 (6%-similar). Of those 10, 8 underwent CT guided biopsies, and 2 pre-operative biopsies, 8 were male, 2 female and 50% (5) were adenocarcinomas. 8 were solid tumours, and 6 had pleural contract. Lympho-vascular-pleural invasion was present in 6 of those 10 patients. Mean time to recurrence was 8.8 months (4–18) and mean time from recurrence to death 8.1 months (1–26). 210 patients had no biopsies, mean age was 77 years (49–99). Any recurrence occurred in 32 (15%); pleural recurrence in 2(1%), mean time 19 months. 2 patients in this group had treatment (surgery with incomplete excision). Differences between the groups did not reach statistical significance.ConclusionsThis single centre retrospective study in a predominantly Caucasian population replicates pleural recurrence rates from Hong et al.1 This data might inform local processes but large prospective databases are required for national guidance. Significant limitations to this are its retrospective nature, reliance on coding, and length of follow up. Local recurrence is associated with Incomplete surgical resection and possibly the preceding biopsy.Referencehttp://dx.doi.org/10.1136/thoraxjnl-2020–216492

IntroductionWe have developed two parallel direct recall CT pathways for patients with abnormal CXRs – a CX3 (NOLCP) pathway where CXR is suspicious for lung cancer, and a CX2 (urgent but non 2ww) pathway where suspicion is low but CT confirmation is warranted. Normal and benign abnormalities are categorised as CX1. We looked at the types of CXR findings reported as suspicious vs low suspicion for cancer and the rates of cancer diagnosis within each pathway to assess how well radiologists were able to identify suspicious lesions.MethodsUsing electronic records, patients that had a direct recall CT following primary care requested CXR from May 2018 – May 2019 were cross-referenced with our local cancer databases. Cancer diagnosis until May 2020 were recorded, such that all patients had 12–24 months of follow up following CXR. A respiratory lung cancer physician then subdivided CXR reports into broad categories of abnormalities and the incidence of cancer within each group was determined.Results622 abnormal CXRs were reported as low suspicion for cancer (CX2) and in this group 43 (6.9%) were diagnosed with cancer. 219 CXRs were reported as suspicious for cancer (CX3) and this was confirmed in 98 (44.7%). Results are summarised in table 1. Radiologists were good at distinguishing high risk from low risk abnormalities in the following categories: defined nodule/mass (cancer rate 60.8% vs 6.5%), collapse/atelectasis (85.7% vs 2.9%), hilar (29% vs 3%) and mediastinum (100% vs 5%) but were less able to distinguish between high and low risk pleural abnormalities (37.5% vs 27.6%) and other/unspecified peripheral opacities (22.6% vs 8.7%).Abstract P165 Table 1Summary of final diagnoses for the two direct recall CT pathways – CX2, CXR with low suspicion of cancer but CT correlation required and CX3, CXR with high suspicion of cancer. CX2 pathway (CXR low suspicion of cancer) CX3 pathway (suspicion of cancer) CXR abnormality Lung cancer Other cancer Non cancer % Cancer Lung cancer Other cancer Non cancer % Cancer Nodule/mass 2 1 43 6.5 54 5 38 60.8 Other/unspecified peripheral opacity (incl. consolidation) 17 7 252 8.7 9 3 41 22.6 Hilum 2 0 67 2.9 8 2 25 28.6 Effusion/pleural abnormality 6 2 21 27.6 5 4 15 37.5 Collapse/atelectasis 1 0 34 2.9 6 0 1 85.7 Artefact/normal variant 3 1 100 3.8 0 0 0 - Mediastinum/paratracheal 1 0 18 5.3 0 2 0 100.0 Normal but concerning symptoms 0 0 19 0.0 0 0 1 0.0 Elevated hemidiaphragm 0 0 8 0.0 0 0 0 - Inappropriate use of pathway (e.g. ILD) 0 0 17 0.0 0 0 0 - Total 32 11 579 6.9 82 16 121 44.7 ConclusionWe found a small but significant percentage of cancers following CXR abnormalities which did not meet NOLCP thresholds, suggesting there is still a role for direct recall CT outside NOLCP in this group. Our data suggests that radiologists should maintain a lower threshold to direct pleural effusions and other (non nodule) peripheral opacities through the fast track NOLCP pathway, as the ability to distinguish benign from malignant causes appears to be lower than for other types of CXR abnormality.

IntroductionPleural effusion is common in lung cancer. Metastatic disease may be confirmed on imaging or fluid sampling. A minority of patients however with otherwise radically treatable disease have a small effusion not amenable to aspiration, or from which fluid cytology is negative; termed minimal pleural effusion (mini-PE). Previous retrospective studies associate significantly shorter survival in mini-PE than stage-matched cases without mini-PE and hypothesise this reflects occult pleural metastases (OPM) in up to 80% of patients. STRATIFY (Staging by Thoracoscopy in Potentially Radically Treatable Non-Small Cell Lung Cancer (NSCLC) Associated with Minimal Pleural Effusion) is a multicentre, prospective observational study, which will determine the true prevalence of OPM in this setting. An update on the study is provided here.MethodsSTRATIFY was funded by Chief Scientist Office and opened to recruitment in Jan-20. Target n=96 across 8 UK centres in 18 months. Key eligibility criteria include Mini-PE (defined by an ipsilateral effusion <1/3 hemithorax on chest radiograph), radically treatable NSCLC and LAT feasibility (defined by sufficient fluid ± lung sliding on screening ultrasound). Primary endpoint: Prevalence of OPM, defined as NSCLC cells in parietal pleural biopsies. Key secondary endpoints include LAT safety, the impact of LAT results on NSCLC treatment plans and non-invasive MRI-derived measures of cardiac function and altered body composition (as alternative explanations for mini-PE). Study progress, including the impact of COVID19 was reviewed and summarised.ResultsSTRATIFY was rapidly halted due to COVID19 after 1 patient was recruited. The study was allowed to reopen in July-20 but given a dramatic reduction in lung cancer referrals across the UK and delayed site set up processes, the study team took the decision to close recruitment from Oct-20 to Apr-21. This was supported by the funder who provided a costed 6-month extension. By June-21, 4/8 sites have opened. 4/6 six screened patients have been recruited, 2/4 have entered the MRI sub-study.ConclusionsSTRATIFY will determine the true prevalence of OPM in patients with radically treatable NSCLC and mini-PE. The study outcomes will be important in defining an extended role for LAT as a pleural staging tool.

IntroductionTargeted lung cancer screening requires identification of current and ex-smokers. In the NHS England Targeted Lung Health Check Programme this relies on smoking history data in GP records. There are concerns about the completeness and accuracy of this data, meaning some eligible people may not be invited. We interrogated GP records at several practices in Wales to examine the completeness of smoking data and used an automated text message system to update smoking data for people with no smoking status recorded.MethodsGP records for patients aged 50 to 74 years (+ 364 days) were searched for the collective tobacco ‘137’ Read code. Patients with no tobacco-related code were sent a standardised text message with the option of three replies to indicate their smoking status. On successful reply, a tobacco Read code was automatically recorded in the patient record, and a confirmation text including a link to ‘Help Me Quit’ was sent to the patient.ResultsAcross six GP practices, 670/20,402 patients (3.3%) aged 50–74 had no tobacco code recorded. Of these, 293 (43.7%) had a validated mobile phone number recorded, of whom 166/293 (56.7%) successfully replied to the text. Of these, 71/166 (42.8%) were current or ex-smokers, including 21 (12.7%) current smokers.ConclusionsAn automated text message system was used to successfully update smoking data in patients with no smoking status recorded. Of the respondents, almost half proved to be current or ex-smokers who would be eligible for a Targeted Lung Health Check. This system could be used to improve the completeness of GP records smoking data, particularly as a resource-sparing method at practices with lower levels of data completeness.

Introduction and ObjectivesThere has been a significant increase in EBUS services across the UK since the recognition of transbronchial needle aspiration (TBNA) guided by endobronchial ultrasound (EBUS) as a key diagnostic step in the diagnosis and staging of suspected lung cancer.1 However, there has been no national study to look at how EBUS services are delivered in the UK. The purpose of this study was to assess any variations in the operational setup and practice of EBUS services across the UK.MethodsWe conducted an online survey of EBUS practices in the UK between January and March 2020. A response from the EBUS operators was sought from every U.K. Hospital Trust, looking at potential variables in the delivery of EBUS services. One response per site was accepted.Results218 responses by senior clinicians were received from 118 centres delivering EBUS service in England, Wales, Scotland, and Northern Ireland. Results are summarised in table 1.Abstract P167 Table 1Results Number (percentage) of responses Type of EBUS session Dedicated31 (26.3) Combined with bronchoscopy79 (66.9) Other8 (6.8) Number of operators Single27 (22.8) Two83 (70.3) Variable8 (6.8) Second operator, when present Consultant40 (44) Trainee or Fellow48 (52.7) Practitioner3 (3.3) Number of weekly EBUS sessions Less than two46 (39) Two to Four61(51.7) Other11 (9.3) Number of patient slots per list Less than two8 (6.8) Two to Four100 (84.7) More than four10 (8.5) Allocated time per case <45 minutes5 (4.2) 45–60 minutes110 (93.2) >60 minutes3 (2.5) Cyto-pathologist present Yes12 (10.2) No106 (89.8) Suspension medium Normal saline26 (25.0) Formalin37 (35.6) Formalin and saline32 (30.8)Others 9 (8.7) Slides prepared Yes 18 (15.3) No 100 (84.7) DiscussionMore than two thirds of the centres deliver EBUS in sessions combined with bronchoscopy, whilst 61% of centres offered at least two weekly sessions; There may be cost-effectiveness in pooling EBUS into dedicated sessions.In more than 70% of cases, two operators were utilised whilst a single operator performed EBUS in only 23% of centres; More than 50% of the hospitals used a trainee or fellow to assist in the procedure, demonstrating a range of operational practices.Almost 90% of trusts had no pathologists to guide real-time sampling. The predominant medium used for suspension of cytopathological samples was formalin (35.6%), reducing degradation of cytopathological samples compared to normal saline.ConclusionThis survey demonstrates notable differences in EBUS practice across the UK, which could result in variation in cost-effectiveness, quality, and safety; A national consultation group may allow dissemination of best-practice.ReferenceNational Institute for Health and Care Excellence. Endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal masses. Interventional procedures guidance, 27 February 2008.

BackgroundNeuroimaging is recommended for stage II and III lung cancer when radical treatment is being considered. Furthermore, patients with an initial non contrast scan may require a second contrast chest CT to delineate mediastinal structures, e.g. prior to surgery. We have developed a protocol for contrast enhanced PET-CT scan, which enables a PET scan and contrast CT brain and chest to be obtained during a single examination, reducing three separate patient appointments to one. We present outcome data for the first 12 months of the pathway.MethodsPatients are selected for contrast PET-CT if at risk of stage II or III disease on initial CT– i.e., tumour >2cm/central or suspicious N1/2/3 nodes. Contrast PET-CT imaging is undertaken on a Siemens mCT Flow Edge Biograph 128 scanner; CT slice thickness 1.5mm. Initial imaging is taken from base of skull to proximal thigh 60–70 minutes post FDG tracer and 70 seconds post IV contrast. CT Brain imaging is undertaken immediately after completion of PET component of scan (~20 minutes post IV-contrast). Data was collected retrospectively for patients undergoing contrast PET-CT from June 2020 to June 2021.Results44 patients have had contrast PET-CT scans via this novel pathway. Scanning protocols were optimised until diagnostic quality images of brain and mediastinum were obtained in all patients. Final staging is summarised in table 1. 4 patients (9.1%) with stage II disease did not require further neuroimaging. One patient (2.3%) was found to have brain metastases, which were confirmed on MRI. 9 of the patients with stage III disease on PET-CT went on to have negative MRI brain imaging as per national guidelines.Abstract P166 Table 1Summary of final NSCLC staging/diagnosis for all patients who have undergone contrast enhanced PET-CT Final staging/diagnosis Number % Stage I 6 13.6 Stage IIA 2 4.5 Stage IIB 2 4.5 Stage IIIA 7 15.9 Stage IIIB 6 13.6 Stage IIIC 1 2.3 Stage IVa 6 13.6 Stage IVb 5 11.4 Carcinoid 2 4.5 Metastatic cancer 4 9.1 Non-malignant diagnosis 3 6.8 ConclusionContrast PET-CT is feasible and can provide diagnostic quality CT images of brain and mediastinum. This removes the need for a separate contrast CT brain in patients with stage II disease and enables contrast CT mediastinal images to be obtained following a low dose non contrast initial CT, eg lung cancer screening. Further work is required to assess the additional benefit/cost effectiveness of MRI brain where contrast CT-PET demonstrates stage III disease.

IntroductionLung Health Check (LHC) programmes have used varying invitation strategies, from contacting all patients in the target age range (Manchester), identifying ever-smokers from GP records (NHS England Targeted LHC programme), and inviting people recorded on GP records as a current smoker in the last 20 years (SUMMIT). We modelled the impact different inclusion criteria would have on a future Lung Health Check programme in Wales.MethodsGP records from 6 practices were included. Searches were run varying the age range (50–74 years, 55–74, 60–74) and smoking codes included. Four different search strategies for smoking codes were used: BROAD (including a wide range of current and ex-smoker codes), VOLUME (as for ‘BROAD’ but excluding the ‘trivial ex-smoker’ code), FOCUSSED (looking for cigarette-related tobacco codes only), and RECENT (searching for current smoker codes recorded in the last 20 years, to capture current smokers and more recent ex-smokers). We compared the results of these search strategies and extrapolated to the Welsh population.ResultsThe included practices had a total population of 68,571, reflecting 2.17% of the Welsh population. There was negligible difference between the results for the BROAD, VOLUME and FOCUSSED search strategies, with ≤0.1% variation between the strategies. Just over half of patients would be eligible for a LHC using the BROAD strategy, whilst using the RECENT strategy reduced this to around a third. Full results and extrapolation across the Welsh population are shown in table 1.Abstract P162 Table 1Results of search strategies and extrapolation to Welsh population Age (yrs) BROAD search strategy RECENT search strategy All ages Sample 68,571 Sample=2.2% of Wales population Wales 3,152,879 50- 74 Sample 20,406 29.8% of total population 10,733 52.6% of age group 6,887 33.7% of age group Wales 938,263 493,501 316,663 55- 74 Sample 15,766 23.0% of total population 8,426 53.4% of age group 5,200 33.0% of age group Wales 724,917 387,426 239,095 60- 74 Sample 11,031 16.1% of total population 6,075 55.1% of age group 3,504 31.8% of age group Wales 507,203 279,327 161,113 ConclusionsThe selection criteria for a future LHC programme in Wales would profoundly influence the number of people eligible. Across Wales the eligible population could vary from 493,000 using an age range of 50–74 years and a broad search strategy, down to 161,000 using an age range of 60–74 years and limiting the search strategy to current and more recent ex-smokers. As radiology reporting capacity may be the limiting factor for a national programme, focussing invitations to those at highest risk may be desirable in the early stages of project development.

IntroductionStereotactic Ablative Body Radiation Therapy (SABR) is a treatment for inoperable stage 1 non-small cell lung cancer. Surgery is the gold standard (5-year survival rates ~70%).1 2 In a review of 4570 patients treated with SABR, overall local control rates were on average 92.7% at 1 year, 89.9% at 2 years, 86.7% at 3 years and 89.6% at 4–5 years with corresponding overall survival rates of 87%, 82.9%, 59.6% and 39.6% with a mean follow-up of 29.4 months.1 No local review has ever been performed. We sought to add to the literature and inform local practice.MethodsAll patients with Stage 1 lung cancer receiving SBAR from the local Somerset cancer register were identified (local Caldicott guidance). on radiology reports Basic demographics and outcomes were collated.Results100 patients received SBAR from Jan 2013-Dec 2020. 61 were female, mean age was 76.5 years (range 48–97. Overall recurrence rate was 19% (n=19) [8 local recurrences and 11 metastatic]. Mean time to recurrence was 24.3 months. Due to concerns about biopsies causing recurrence, those with no pre-SBAR biopsy were analysed separately. 72% (72) patients were identified: recurrence rate was 13 (18%)- 4 local and 9 metastatic; mean time to recurrence 26 months. Survival was 90% at 1 year, 89% at 2 years, 65% at 3 years and 40% at 4–5 years. In the biopsy group (n=28), 25 did not have surgery and had SABR. 3 had post-operative SABR. Recurrence rate was 21% (6), mean time to recurrence in this cohort was 20 months, 4 local recurrences, 2 metastatic. Survival at the same above intervals were much lower (15% at 5 years). There was no statistical difference between the groups. Data on immediate toxicity was not available due to SBAR being performed in a regional centre but no adverse events were noted on local scans.ConclusionsThis review shows that recurrence rates are comparable to previous evidence and surgical recurrence rates (30–77%).2 SABR seems safe. There are significant limitations to this data set (retrospective nature, reliance on coding, no matched controls and no comparison to surgery locally).Referenceshttps://www.sabr.org.uk/wp-content/uploads/2019/04/SABRconsortium-guidelines-2019-v6.1.0.pdfhttps://erj.ersjournals.com/content/47/2/374