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• W4207065402 abstract "Presenter: Dr Elliot L. Servais Dr Michael T. Jaklitsch (Boston, Mass). The American Association for Thoracic Surgery and the members are indebted to the Lahey Clinic multispecialty team. You taught the world how to do free LCS about a decade ago and how to make it cost-effective. I remember when we were having the politically charged debates with the Centers for Medicare & Medicaid Services about whether there should be insurance coverage for LDCT. The Lahey clinic provided invaluable data from their program to quell speculation on the harms of CT screening from projections about the stress of having to tell a 30-pack/year smoker that he had a lung nodule, to the overdiagnosis of lung cancer. In that time of sometimes heated debate, the Lahey Clinic provided us a lot of data and showed us that you can safely run an outpatient LDCT screening program. What is the risk for the benign diagnosis of patients who go through this entire workup? I have 3 questions that are intended to round out the total understanding of this program. The first is in regard to the stage shift that you saw to smaller T-stages—some minimally invasive adenocarcinomas and a large number of stage 1 patients is everything we would want of an LDCT-screening program. To reference for us the significance of this finding, can you compare that to what is the current stage distribution in a nonscreened population and compare yourself to the NLST? Additionally, closely related to that, when it comes to organ preservation with segmentectomies and wedges, how does your cohort stack up against the average reports for stage 1 in the databases and the experience from the NLST? Dr Elliot L. Servais (Burlington, Mass). I think the stage shift that you brought up is the key. This is what is allowing patients to realize the benefits of more surgically resectable disease. For the first time in 2016, we began diagnosing more early- than late-stage disease when you look at our overall lung cancer registry. If you look at stage I to IV diagnoses, the ratio is 1.8 to 2, so we're actually diagnosing almost twice as much stage I disease compared with stage IV disease, and that's definitely a win. What's interesting is that over time we've actually seen an increase in the early-stage disease even in the nonscreened patients. I think this is multifactorial. In our group, it's about 50/50, meaning that in the nonscreened patients, we have about an equivalent number of early- and late-stage disease cases. To your point regarding the NLST, if you look at the NLST, you see a similar phenomenon. In the screened population, stage I patients made up approximately 60%, whereas stage III or IV was approximately 30% of that group. In the nonscreened patients, it's the reverse, so you had about 60% as stage III or IV and 30% as stage I. This is key, and I think this is an important thing for us to remember that benefits patients and the surgeon, hopefully as I said, diagnosing more surgically resectable, curable disease. Your question about lung preservation and sublobar resections is also an important question. If you look at the NLST, about 80% of those patients underwent lobectomy and about 15% underwent wedge resection or segmentectomy. In the data I presented today, we have a higher rate of sublobar resection. About 47% underwent wedge or segmentectomy, and there are many reasons for this. We have to remember that the NLST study period was 2002 to 2004. I think since that time, even as we await the results from large clinical trials, like the CALGB 140503, there has been an increased acceptance of sublobar resections for small peripheral nodules. We value lung preservation in our group, especially in patients with marginal pulmonary function. There has been significant improvement in our ability to localize some of these small nodules. Some groups may be doing navigational bronchoscopy for marking. Our group uses an interventional radiology coil-localization procedure, but regardless of specific technique, we are now able to localize these small lesions during minimally invasive surgery. I think this lends itself to lung preservation, potentially offering curative resections to more patients. Dr Jaklitsch. In the recently published Nelson data and in a retrospective analysis of the NLST, there's been a disproportionate advantage for women. I noticed that in your breakdown, you had 55% men and 45% women. Did you look to see if there was an advantage for the female gender? Dr Servais. This is a real phenomenon, and it's important. The Nelson trial saw a 48% mortality risk reduction in women. In our study population, we found an equivalent rate of diagnostic procedures, surgery or invasive procedures for benign disease, as well as an identical stage distribution for men and women. However, it's important to note that our study did not look at survival or mortality benefit. There may be an increased survival benefit in our cohort for women compared with men, but we're not positioned to comment on that. I think the advantage that you're talking about for women in the major trials is significant. Dr Jaklitsch. I noticed that you had a significant contribution from what's called NCCN group 2. To review, group 1 is a 30-pack/year smoking history, 55 to 79 years of age, and having quit in the last 15 years. NCCN group 2 is down to age 50 years, 20-pack/years, and 1 other factor. What was the 1 other factor that you had in the Lahey Clinic population? Dr Servais. Our group published on this in 2018 in the Journal of the National Comprehensive Cancer Network. Since starting our LCS program in 2012, we included both group 1 and group 2 patients. What we found and published is that the results are equivalent for both high-risk groups, and that's an important concept. Group 1 and Group 2 patients had the same rates of positive and suspicious findings, same false-negative rate, same rate of finding infectious or inflammatory disease—and that's across all rounds of screening. To specifically answer your question, the most common reason for our patients to enter group 2 is a first-degree relative with lung cancer. The next most common cause is chronic lung disease. Carcinogen exposure, radon, and personal history of cancer are other reasons, but chronic lung disease and first-degree relative with cancer were the predominant reasons for our patients. Dr Benjamin D. Kozower (St Louis, Mo). It's interesting, in the era of minimally invasive surgery, to think about what is an acceptable benign rate for these interventions. You know, you're around 16% to 17%. I see Dr Cooper is in the bottom of my screen. I think his benign rate was about half of that. So, in the current era what's an acceptable threshold? Dr Servais. I don't think we have defined a specific acceptable threshold. However, certainly we need to think about how we can improve that number. Does that mean more CT-guided biopsies? Well in our data, and this is a topic we are currently evaluating in an ongoing study, we have a fairly high false-negative rate in the patients receiving CT lung screening, or at least nondiagnostic rate for CT lung biopsy, which is different from our nonscreened population. There are several reasons why that may be. Maybe smaller nodules, maybe nodules that are more difficult for the interventional radiologists to sample, but we had almost a 35% nondiagnostic rate of CT-guided biopsy. So, doing more invasive procedures for diagnosis before the operation may not be the answer. I think the holy grail would be a biomarker, a reliable biomarker, or maybe incorporating risk models to help guide our decisions. Clearly, we want that number as low as possible. I don't think 15% to 16% is unacceptable, but I think we want to get that number even lower. Dr Wayne L. Hofstetter (Houston, Tex). I come from an institution where we have difficulty gaining traction with our LCS program, and I seek your advice. I looked at your numbers, and it seems that you're operating on approximately 1.8% of the people whom you screen. So, the index to screen is approximately 1.8%. If you take everybody who's been intervened on, including those who were operated outside of your institution, the index was approximately 2.5%. What should be an appropriate number for index to screened case? Is it 2.5%? Or is it 5% or 10%? If 2.5% or 1.8% is too low, how do you enrich that population? How do we improve on who we're screening and making this more cost-effective? Dr Servais. We need to balance that yield with not missing cancers as well. We have a well-developed, multidisciplinary approach to this. The key to LCS is keeping the patients in the screening program. In other words, you can't do a single screening study and not act on that study if you're not sure whether the patient is going to come back for the next screening study. In light of that, if you're following these patients closely, and they're staying in the program, and you have navigators to ensure that follow-up, I think the rate we report is appropriate. We minimize unnecessary intervention, but I don't think that we're missing cancers either. Your point is well taken, and I think the key is to have reliable follow-up and to have a multidisciplinary approach to deciding when to intervene on each patient. I cannot quote you an exact percentage that I think would be appropriate for index to screen. But again, I think we have an appropriate rate in our program. Dr Jaklitsch. If I could briefly comment on that. I think 2.5 is what is accepted by most screening programs for other malignancies. If you want to drive that up closer to 5%, the easiest way to do it is to stop screening between 55 and 60 years. So if you shift your screening population to a slightly older population, you'll have a richer group that screens positive. The problem is that the quality analysis, the quality of average life years comes disproportionately from that younger group. So even though you find less cancer in those aged 55 to 60 years, you get more qualities out of that group, so that's why I think it drives public policy. Dr Joel D. Cooper (Philadelphia, Pa). You noted in the abstract that a certain number of patients—I think 21—had SBRT without a diagnosis because there was “prohibitive risk for diagnostic intervention.” Under what circumstances, is the risk of a needle biopsy too great, but the risk of SBRT treatment for what might turn out to be a benign lesion is considered to be less than that of a needle biopsy? Dr Servais. It's a great question and something our group has talked about extensively. What I would say is, the numbers are slightly different in the abstract—we did do some postabstract analysis, but it's 25 patients who underwent SBRT. Twenty-five patients underwent SBRT, and 19 of those were for presumed lung cancer. Again, I think that we've become a bit more aggressive over time with attempting biopsies of these patients, but that in part depends on your interventional radiology group. Many of these patients have very advanced bullous emphysema, and our radiologists are understandably not always comfortable sticking needles through the bulla. As we all know, a pneumothorax after CT-guided biopsy is no big deal unless they have severe bullous disease and then they're in the hospital with an air leak forever. So again, this is a tough question. We would like that number to be 0—we would like a biopsy-proven diagnosis for all patients undergoing SBRT—but sometimes we just do not think it's safe to stick a needle in there. In that case, we rely on serial scans to make sure that there's growth. It's not perfect, but we do use PET–CT, and again, we rely on the multidisciplinary approach. It's a fantastic question. I think that this number is high. I agree, 76% presumed lung cancer in our SBRT cohort, but there are risks to biopsying every one of those patients. Dr Cooper. I would agree that a biopsy isn't innocuous in a patient who has bullous disease. I think you've answered the question to my satisfaction, because my alternative would be watchful waiting, repeated scans, and looking at the behavior of the lesion as an alternative to proceeding with SBRT. I don't disagree with your approach, as long as it is not done in early lesions where the risk of following it closely is an acceptable alternative. Dr Servais. Very good points and an important part of our program as well. Dr Hofstetter. I'd also like to point out the 32% recurrence with SBRT on this slide, which is different from the high local control rates of 95% or better that our radiation oncology colleagues are quoting to patients. I think this is a more real-world example of what's happening with SBRT. Dr Servais. I do as well. In all fairness, we can't comment on some of this because we don't know the pathology for all of these nodules. Our radiation oncologists raise the question as to whether those could all be small cells? It may be comparing apples to oranges, but I agree with you and think this is what we see. The definition of recurrence also matters; we included any recurrence here, and some of these patients had recurrence in the pleura. Some of these patients had recurrence adjacent to the site of SBRT, but I appreciate your comment and I think it's true. Dr John A. Howington (Nashville, Tenn). You mentioned sublobar resection, and specifically a significant number of patients had wedge resection as their surgical resection for their small peripheral lesions. In that group, what percentage of those patients had systematic lymph node dissection? We know from the American College of Surgeons Oncology Group trials that performing a lymph node dissection does not add significant morbidity to the operation. So, if we're in there and had the patient under general anesthetic, and we're resecting lung tissue, what precludes us from doing a systematic lymph node dissection 5 stations and distinguishing ourselves from the radiation oncologist just pointing a beam at the lesion? Dr Servais. I could not agree with you more, and I appreciate your comment. We perform a lymphadenectomy for every wedge. I don't have those data here for you, but certainly in the manuscript that can be included. We are aggressive about our lymph node dissection, both in segmentectomy and wedge resection. We perform our minimally invasive operations robotically, which I think lends itself to a nice lymph node dissection, and we make a real effort to do a full dissection. Your point about what distinguishes doing a wedge from SBRT—it is the lymphadenectomy." @default.
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• W4207065402 date "2021-03-01" @default.
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• W4207065402 title "Discussion" @default.
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