Lung Cancer In High-risk Patients Research Articles

Sublobar resection is not always superior for early-stage lung cancer in high-risk patients.

The phase III trial, Japan Clinical Oncology Group 0802, illustrated the superiority of sublobar resection for early-stage lung cancer in terms of overall survival, with more non-lung cancer-related deaths after a lobectomy. The advantages of sublobar resection may be more pronounced in high-risk patients. The goal of this study was to elucidate the prognoses of high-risk patients. Patients with a risk of being ineligible for Japan Clinical Oncology Group 0802 for general conditions were classified as the high-risk group, and those who were not at risk of being ineligible were classified as the normal-risk group. Overall survival and prognostic factors were analysed in the high-risk group. There were 254 (19.4%) and 1054 patients in the high- and normal-risk groups, respectively. Five-year survival rates were 94.5% and 79.1% in the normal-risk and high-risk groups, respectively (P < 0.001). More patients in the high-risk group died of lung cancer (P < 0.001) and non-lung cancer deaths (P < 0.001) than patients in the normal-risk group.In the high-risk group, 151 lobectomies and 103 sublobar resections were performed. There was no significant difference in the numbers of lung cancer deaths and of non-lung cancer deaths between the procedures. Stratified survival analyses showed that the diffusing capacity of the lungs for carbon monoxide < 40% tended to favour sublobar resection; being female and having a high carcinoembryonic antigen level tended to favour a lobectomy. Sublobar resection is not always superior for early-stage lung cancer. Even in such cases, the surgical method should be determined by taking into consideration the patient's background and lung cancer surveillance.

Negative Chest Radiograph in Patients with Symptomatic Lung Cancer

Objective: To evaluate the percentage of negative chest radiograph in patients with symptomatic lung cancer. Materials and Methods: The authors retrospectively reviewed the chest radiographs of 263 patients with symptomatic lung cancer. The findings were divided into two categories and three subgroups, negative findings as normal, no abnormality detected or abnormal, or no cancer suspected, and positive findings as abnormal or cancer suspected. The recorded data included the tumor size, location, features of all lesions, the duration of symptom, and time intervals between the first chest radiograph until diagnosis. Computed tomography (CT) scan of the negative finding chest radiographs were reviewed to verify whether the causes of unsuspected malignancy were on a radiograph. Results: Negative chest radiographs in the present study were 12.9%. Three patients (1.1%) were classified as entirely normal. Most findings in the abnormal, no cancer suspected group were patchy infiltration (8.4%), interstitial infiltration (1.9%), and thin wall lung cavity (1.1%). The major causes of negative findings were tumor location, size, conspicuity, obscured primary tumor, pulmonary tuberculosis mimicking lung cancer, and characteristic of lung cavity on the radiograph. Conclusion: Negative chest radiographs can be found even in patients with symptomatic lung cancer, resulting in delayed diagnosis and treatment. Using chest radiograph as a first-line imaging investigation, especially in high-risk lung cancer patients, should be cognizant of false negatives. Keywords: Lung cancer; Chest radiograph

Natural killer cell activity as a biomarker for the diagnosis of lung cancer in high-risk patients

ObjectiveNatural killer (NK) cells play an essential role in the immune response against cancer. However, immune escape mechanisms may cause inferior NK cell activity (NKA) in patients with cancer. This prospective study examined the relationship between NKA and lung cancer in a high-risk cohort.MethodsIn a cohort study, 250 participants referred by their general practitioner for suspicion of lung cancer were included. Before clinical investigation, blood was collected into NK Vue tubes, and the level of interferon gamma after 24 hours served as a surrogate marker for NKA.ResultsAmong 250 patients, 79 were diagnosed with lung cancer. No difference in NKA was found between patients with lung cancer and control participants in which lung cancer was ruled out (median 226 pg/mL vs. 450 pg/mL). However, there was a significant difference in NKA between patients with late-stage lung cancer and controls (median 161 pg/mL vs. 450 pg/mL). A linear regression model showed that NKA was not influenced by age, sex or smoking status.ConclusionsThe significantly lower NKA in patients with late-stage lung cancer warrants further investigation combining NKA with other biomarkers and examining the potential role of NKA as a marker of disseminated disease.

Update on molecular pathology and role of liquid biopsy in nonsmall cell lung cancer.

Personalised medicine, an essential component of modern thoracic oncology, has been evolving continuously ever since the discovery of the epidermal growth factor receptor and its tyrosine kinase inhibitors. Today, screening for driver alterations in patients with advanced lung adenocarcinoma as well as those with squamous cell carcinoma and no/little history of smoking is mandatory. Multiplex molecular platforms are preferred to sequential molecular testing since they are less time- and tissue-consuming. In this review, we present the latest updates on the nine most common actionable driver alterations in nonsmall cell lung cancer. Liquid biopsy, a simple noninvasive technique that uses different analytes, mostly circulating tumour DNA, is an appealing tool that is used in thoracic oncology to identify driver alterations including resistance mutations. Additional roles are being evaluated in clinical trials and include monitoring the response to treatment, screening for lung cancer in high-risk patients and early detection of relapse in the adjuvant setting. In addition, liquid biopsy is being tested in immune-oncology as a prognostic, predictive and pharmacodynamic tool. The major limitation of plasma-based assays remains their low sensitivity when compared to tissue-based assays. Ensuring the clinical validity and utility of liquid biopsy will definitely optimise cancer care.

ECOA-8. Lung adenocarcinoma brain metastasis prediction using tumor DNA methylation profiling

IntroductionThe development of brain metastases from primary cancer profoundly impacts patient prognosis. Up to one quarter of lung cancers develop brain metastases and subsequent median overall survival is one year. Although clinical factors do not reliably predict brain metastasis development, DNA methylation signatures have been recently shown to predict outcomes in other cancers. It is hypothesized that DNA methylation signatures predicting brain metastasis development from lung cancer will be identified. This work may allow for treatment strategies that prevent brain metastasis development in high risk lung cancer patients.MethodsDNA methylation profiling was undertaken on N=124 lung adenocarcinoma patients. In a randomly selected 70% training cohort, differentially methylated CpG sites between patients developing and not developing brain metastases were identified and used to build a generalized boosted regression model. Patients in the independent 30% testing cohort were assigned brain metastasis risk scores by the model.ResultsBrain metastases developed in 49/124 (39.5%) of patients and 2.3K CpG sites were significantly differentially methylated between patients developing and not developing metastases. Methylation-based brain metastasis risk scores predicted time to brain metastasis development in the testing cohort (Univariate cox: HR=3.2, 95% CI 1.1–9.4, p=0.03). A multivariate cox analysis assessing tumor size and nodal positivity together with methylation scores as covariates identified methylation scores as the only independent predictor of brain metastasis development in the testing cohort (HR=4.3, 95%CI 1.1–17, p=0.038).ConclusionsDNA methylation signatures in lung adenocarcinomas predict brain metastasis development independently from the non-metastatic components of cancer stage. Future work developing a comprehensive nomogram utilizing methylation scores together with clinical factors to determine patient specific risk values may aid in treatment decisions and patient prognosis counselling.

P54.03 Multiple Microarray Analyses Identify Key Genes Associated with the Development of NSCLC from COPD

Chronic obstructive pulmonary disease (COPD) is an independent risk factor of non-small cell lung cancer (NSCLC). This study aimed to analyze the key genes and potential molecular mechanisms that are involved in the development from COPD to NSCLC. Expression profiles of COPD and NSCLC in GSE106899, GSE12472, and GSE12428 were downloaded from the Gene Expression Omnibus (GEO) database, followed by identification of the differentially expressed genes (DEGs) between COPD and NSCLC. Based on the identified DEGs, functional pathway enrichment and lung carcinogenesis-related networks analyses were performed and further visualized with Cytoscape software. Then, principal component analysis (PCA), cluster analysis, and support vector machines (SVM) verified the ability of the top modular genes to distinguish COPD from NSCLC. Additionally, the corrections between these key genes and clinical staging of NSCLC were studied using the UALCAN and HPA websites. Finally, a prognostic risk model was constructed based on multivariate Cox regression analysis. Kaplan-Meier survival curves of the top modular genes on the training and verification sets were generated. A total of 2350, 1914, and 1850 DEGs were obtained from GSE106899, GSE12472, and GSE12428 datasets, respectively. Following analysis of protein-protein interaction networks, the identified modular gene signatures containing H2AFX, MCM2, MCM3, MCM7, POLD1, and RPA1 were identified as markers for discrimination between COPD and NSCLC. The modular gene signatures were mainly enriched in the processes of DNA replication, cell cycle, mismatch repair, and others. Besides, the expression levels of these genes were significantly higher in NSCLC than in COPD, which was further verified by the immunohistochemistry. In addition, the high expression levels of H2AFX, MCM2, MCM7, and POLD1 correlate with poor prognosis of lung adenocarcinoma (LUAD). The Cox regression prognostic risk model showed the similar results and the predictive ability of this model is independent of other clinical variables. This study revealed several key modules that closely relate to NSCLC with underlying disease COPD, which provide a deeper understanding of the potential mechanisms underlying the malignant development from COPD to NSCLC. This study provides valuable prognostic factors in high-risk lung cancer patients with COPD.

Multiple microarray analyses identify key genes associated with the development of Non-Small Cell Lung Cancer from Chronic Obstructive Pulmonary Disease.

Introduction: Chronic obstructive pulmonary disease (COPD) is an independent risk factor of non-small cell lung cancer (NSCLC). This study aimed to analyze the key genes and potential molecular mechanisms that are involved in the development from COPD to NSCLC.Methods: Expression profiles of COPD and NSCLC in GSE106899, GSE12472, and GSE12428 were downloaded from the Gene Expression Omnibus (GEO) database, followed by identification of the differentially expressed genes (DEGs) between COPD and NSCLC. Based on the identified DEGs, functional pathway enrichment and lung carcinogenesis-related networks analyses were performed and further visualized with Cytoscape software. Then, principal component analysis (PCA), cluster analysis, and support vector machines (SVM) verified the ability of the top modular genes to distinguish COPD from NSCLC. Additionally, the corrections between these key genes and clinical staging of NSCLC were studied using the UALCAN and HPA websites. Finally, a prognostic risk model was constructed based on multivariate Cox regression analysis. Kaplan-Meier survival curves of the top modular genes on the training and verification sets were generated.Results: A total of 2350, 1914, and 1850 DEGs were obtained from GSE106899, GSE12472, and GSE12428 datasets, respectively. Following analysis of protein-protein interaction networks, the identified modular gene signatures containing H2AFX, MCM2, MCM3, MCM7, POLD1, and RPA1 were identified as markers for discrimination between COPD and NSCLC. The modular gene signatures were mainly enriched in the processes of DNA replication, cell cycle, mismatch repair, and others. Besides, the expression levels of these genes were significantly higher in NSCLC than in COPD, which was further verified by the immunohistochemistry. In addition, the high expression levels of H2AFX, MCM2, MCM7, and POLD1 correlate with poor prognosis of lung adenocarcinoma (LUAD). The Cox regression prognostic risk model showed the similar results and the predictive ability of this model is independent of other clinical variables.Conclusions: This study revealed several key modules that closely relate to NSCLC with underlying disease COPD, which provide a deeper understanding of the potential mechanisms underlying the malignant development from COPD to NSCLC. This study provides valuable prognostic factors in high-risk lung cancer patients with COPD.

Lung Cancer Screening Registry Reveals Low-dose CT Screening Remains Heavily Underutilized

BackgroundSince 2013, the United States Preventive Services Task Force has recommended annual screening for lung cancer in high-risk patients with low-dose computed tomography (LDCT). Current literature has provided estimates of the lung cancer screening rate and only prior to appropriate insurance coverage for LDCTs. The aim of this study was to use newly established registry data to assess the lung cancer screening rate across the United States. Materials and MethodsUsing data from the Lung Cancer Screening Registry provided by the American College of Radiology in 2016, we collected the total number of LDCT screens performed from all 1962 accredited radiographic screening sites. The 2015 National Health Interview Survey was used to estimate screening eligible smokers per United States Preventive Services Task Force criteria. These data were compared to calculate screening rate. ResultsIn 2016, 2.0% of 7.6 million eligible smokers were screened. Rates varied by region from 1.1% in the West to 3.9% in the Northeast. The South consisted of 40.4% of eligible smokers and the most accredited screening sites (37%); however, their screening rate was among the lowest (1.7%) in the nation. Smoking cessation counseling was offered to 84% of screened current smokers prior to receiving LDCTs. ConclusionsLung cancer screening remains heavily underutilized despite guideline recommendation since 2013, insurance coverage, and its potential to prevent thousands of lung cancer deaths annually.

Combined Endosonographic Mediastinal Lymph Node Staging in Positron Emission Tomography and Computed Tomography Node-Negative Non–Small-Cell Lung Cancer in High-Risk Patients

Positron emission tomography (PET) with computed tomography (CT) is routinely utilized to investigate lymph node (LN) metastases in non-small-cell lung cancer. However, it is less sensitive in normal-sized LNs. This study was performed in order to define the prevalence of mediastinal LN metastases discovered on combined endosonography by endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS) fine needle aspiration in patients with a radiologically normal mediastinum. This study consists of a retrospective, single-institution, tertiary care referral center review of a prospectively maintained database. Patients were identified from a cohort between January 2009 and December 2014. One hundred and sixty-one patients with biopsy-proven, non-small-cell lung cancer were identified in whom both the preendosonography CT and PET-CT were negative for mediastinal LN metastases. Combined endosonography (EBUS + EUS-FNA) was performed in all patients. Z test was used for statistical analysis. A P value of <0.05 was considered statistically significant. A total of 161 consecutive patients were included. Patients were staged if they had central tumor, tumor size >3 cm, N1 lymph node involvement on PET-CT/CT, or if there was low SUV (<2.5) in the primary tumor. A total of 416 lymph nodes were biopsied in the 161 patients using combined endosonography; 147 with EBUS and 269 with EUS. Mean and median number of lymph nodes biopsied per patient using combined EBUS/EUS was 2.5 and 3, respectively (mean and median EBUS: 0.91 and 2.5; mean and median EUS 1.6 and 3). Endosonographic staging upstaged 13% of patients with radiologically normal lymph nodes in the mediastinum, hilum, lobar, and sublobar regions (confidence interval 8.22-19.20). Twenty-one out of 161 patients (13%) with radiologically normal mediastinum were positive on combined EBUS/EUS staging. Out of 21 patients upstaged on endosonography, 15 (71%) had tumor size >3 cm. Six (28%) had occult N1 disease. Thirteen (61%) had occult N2 disease and 2 (9%) had adrenal involvement. None of the upstaged patients had N1 LN involvement on PET-CT or CT scan. Combined endosonographic lymph node staging should be considered in the pretreatment staging of high-risk patients with non-small-cell lung cancer in the presence of radiologically normal mediastinal lymph nodes due to the significant rate of radiologically occult lymph node metastases.

Quantile regression for survival data in modern cancer research: expanding statistical tools for precision medicine.

Quantile regression links the whole distribution of an outcome to the covariates of interest and has become an important alternative to commonly used regression models. However, the presence of censored data such as survival time, often the main endpoint in cancer studies, has hampered the use of quantile regression techniques because of the incompleteness of data. With the advent of the precision medicine era and availability of high throughput data, quantile regression with high-dimensional predictors has attracted much attention and provided added insight compared to traditional regression approaches. This paper provides a practical guide for using quantile regression for right censored outcome data with covariates of low- or high-dimensionality. We frame our discussion using a dataset from the Boston Lung Cancer Survivor Cohort, a hospital-based prospective cohort study, with the goals of broadening the scope of cancer research, maximizing the utility of collected data, and offering useful statistical alternatives. We use quantile regression to identify clinical and molecular predictors, for example CpG methylation sites, associated with high-risk lung cancer patients, for example those with short survival.

Inhaled IL-10 Suppresses Lung Tumorigenesis via Abrogation of Inflammatory Macrophage-Th17 Cell Axis.

Intratracheal administration of a novel IL-10 formulation suppressed IL-17-driven, CD4+ T cell-dependent tumorigenesis in the LSL-K-rasG12D murine lung cancer model. Analysis of lung lymphocyte populations demonstrated that antitumor activity of IL-10 was associated with a 5-fold decline in Th17 cell prevalence and a concurrent suppression of inflammatory M1-like macrophage activity. Further phenotypic characterization revealed that macrophages and dendritic cells, but not Th17 cells, expressed IL-10RA on the cell surface with the CD11b+F4/80+CX3CR1+ interstitial macrophages representing the dominant IL-10RA+ subset. Consistent with these observations, in vitro stimulation of sorted CD4+ T cells with IL-10 did not affect their ability to produce IL-17, whereas similar treatment of purified interstitial macrophages resulted in a dramatic M1 to M2 phenotypic switch. Importantly, preconditioning of macrophages (but not of CD4+ T cells) with IL-10 led to potent suppression of CD4+ T cell IL-17 production in an in vitro coculture assay, suggesting that IL-10 suppressed Th17 cell activity primarily via its upstream effects on macrophages. In support of this notion, in vivo macrophage depletion resulted in a 5-fold decline in Th17 cell numbers and a concurrent 6-fold reduction in tumor burden. Collectively, these data demonstrate that in the LSL-K-rasG12D murine lung cancer model, inflammatory macrophage-Th17 cell axis is critical to tumorigenesis and that IL-10 blocks this process primarily via a direct effect on the former. Inhaled IL-10 formulations may be of use in prophylaxis against lung cancer in high-risk patients.

MA08.02 Prophylactic Cranial Irradiation Reduces the Risk of Brain Metastases in High-Risk Lung Cancer Patients: EGFR and ALK Mutations

MA08.02 Prophylactic Cranial Irradiation Reduces the Risk of Brain Metastases in High-Risk Lung Cancer Patients: EGFR and ALK Mutations

A national survey of primary care physicians: Perceptions and practices of low-dose CT lung cancer screening

Soon after the National Lung Screening Trial, organizations began to endorse low-dose computed tomography (LCDT) screening for lung cancer in high-risk patients. Concerns about the risks versus benefits of screening, as well as the logistics of identifying and referring eligible patients, remained among physicians. This study aimed to examine primary care physicians' knowledge, attitudes, referral practices, and associated barriers regarding LDCT screening. We administered a national survey of primary care physicians in the United States between September 2016 and April 2017. Physicians received up to 3 mailings, 1 follow-up email, and received varying incentives to complete the survey. Overall, 293 physicians participated, for a response rate of 13%. We used weighted descriptive statistics to characterize participants and their responses. Over half of the respondents correctly reported that the US Preventive Services Task Force recommends LDCT screening for high-risk patients. Screening recommendations for patients not meeting high-risk criteria varied. Although 75% agreed that the benefits of LDCT screening outweigh the risks, fewer agreed that there is substantial evidence that screening reduces mortality (50%). The most commonly reported barriers to ordering screening included prior authorization requirements (57%), lack of insurance coverage (53%), and coverage denials (31%). The most frequently cited barrier to conducting LDCT screening shared decision making was patients' competing health priorities (42%). Given the impact of physician recommendations on cancer screening utilization, further understanding of physicians' LDCT screening attitudes and shared decision-making practices is needed. Clinical practice and policy changes are also needed to engage more patients in screening discussions.

Inhaled IL-10 Suppresses Lung Tumorigenesis via Abrogation of the Inflammatory Macrophage - T17-cell Axis

Abstract Lung tumorigenesis has been linked to chronic type 17 inflammation in both murine models and patients. Interleukin-10 is a pleiotropic regulatory cytokine with profound inhibitory effects on type 17 responses. Intratracheal administration of a sustained-release IL-10 formulation resulted in suppression of tumor development in the LSL-K-ras spontaneous lung cancer model. Analysis of lung lymphocyte populations demonstrated that the antitumor activity of IL-10 was associated with a rapid 3 to 5-fold decline in IL-17-producing T-cell populations. Type 17 T-cells did not express detectable levels of IL-10RA suggesting that IL-10 was not directly acting on T-cells. In contrast, select myeloid cell populations including macrophages and a small subset of dendritic cells were found to express IL-10RA in the lung. In tumor-bearing control mice macrophages displayed a pro-inflammatory phenotype that reverted to a naive-like state following IL-10 treatment. Importantly, depletion of phagocytes resulted in a 3 to 5-fold decline in type 17 T-cell numbers with a concurrent 7-fold reduction in tumor burden. These findings demonstrate that in the LSL-K-ras model lung tumorigenesis is driven by the inflammatory macrophage - type 17 T-cell axis and that IL-10 abrogates this process via its direct activity on macrophages. Inhaled IL-10 formulations may be of utility in prophylaxis of lung cancer in high-risk patients.

ES 05.05 Lung Cancer Surgery for High Risk Patients

ES 05.05 Lung Cancer Surgery for High Risk Patients

Development of a Trigger Tool for Identifying Emergency Department Visits in Patients With Lung Cancer

Lung cancer is a major cause of morbidity and mortality in the United States, as well as cost. During their treatment over half of lung cancer patients visit the emergency department (ED), which may contribute to increased cost of lung cancer care and decreased quality of life. In this study, we evaluate characteristics of lung cancer patients presenting to an ED at a tertiary care referral center. We develop a model for ED visits (LungConnect) and generate real-time alerts for high risk patients. All lung cancer patients with an outpatient encounter with a primary diagnosis of lung cancer between July 2013 and July 2016 were included on an institutional-review board approved retrospective cohort study. Patients were randomly separated into a training and validation dataset. Clinical features were selected based on relevance and data availability. Predictions for ED visits were made within 14 days of a clinical encounter. Random forest plot modeling was used to generate an area under the receiver operative characteristic curve (AUROC). Parsimonious regression was used to obtain odds ratios (OR) for the most relevant predictors in the model. Patients were a median of 68 years old and 54% were female. The most common presenting symptoms were pain and difficulty breathing. Two thousand five hundred patients were included in the training dataset and 450 in the validation dataset. One hundred five clinical features were evaluated. An AUC of 0.79 was seen in the training set and 0.77 in the validation set. The largest ORs for ED visit were a diagnosis of fluid and electrolyte disorder (1.44; 95% CI = 1.41-1.47) and outpatient clinical visits in radiology (1.35; 95% CI = 1.32-1.39) and radiation oncology (1.34; 95% CI = 1.31-1.38). An average of 220 patient queries was made each weekday. Using a threshold value of 0.12, 25 positive alerts are obtained daily and 33% of ED visits overall are predicted. ED visits occur frequently in patients with lung cancer and may contribute to decreased quality of life and increased treatment cost. We have successfully designed a continuous predictive model (LungConnect) that can be utilized in real-time to identify patients at a high risk of ED visit. An intervention using this model may allow the outpatient team to prevent ED visits in high risk lung cancer patients.

Computerized detection of lung nodules through radiomics.

Lung cancer is a major cause of cancer deaths, and the 5-year survival rate of stage IV lung cancer patients is only 2%. However, the 5-year survival rate of stage I lung cancer patients significantly increases to 50%. As such, spiral computed tomography (CT) scans are necessary to diagnose high-risk lung cancer patients in early stages. In this study, a computer-aided detection (CAD) system with radiomics was proposed. This system could automatically detect pulmonary nodules and reduce radiologists' workloads and human errors. In the proposed scheme, a nodular enhancement filter was used to segment nodule candidates and extract radiomic features. A synthetic minority over-sampling technique was also applied to balance the samples, and a random forest method was utilized to distinguish between real nodules and false positive detections. The radiomics approach quantified intratumor heterogeneity and multifrequency information, which are highly correlated with lung nodules. The proposed method was used to evaluate 1004 CT cases from the well-known Lung Image Database Consortium, and 88.9% sensitivity with four false positive detections per CT scan was obtained by randomly selecting 502 cases for training and 502 other cases for testing. The proposed scheme yielded a high performance on the LIDC database. Therefore, the proposed scheme is possibly effective for various CT configurations used in routine diagnosis and lung cancer screening.

Clinical and quality of life outcomes following anatomical lung resection for lung cancer in high-risk patients.

BACKGROUND:Surgery remains the gold standard for patients with resectable nonsmall cell lung cancer. Current guidance identifies patients with poor pulmonary reserve to fall within a high-risk cohort. The aim of this study was to determine the clinical and quality of life outcomes of anatomical lung resection in patients deemed high risk based on pulmonary function measurements.METHODS:A retrospective review of patients undergoing anatomical lung resection for nonsmall cell lung cancer between January 2013 and January 2015 was performed. All patients with limited pulmonary reserve defined as predicted postoperative forced expiratory volume in 1 s or transfer factor of the lung for carbon monoxide of <40% were included in the study. Postoperative complications, admission to the Intensive Care Unit, length of stay, and 30-day in-hospital mortality were recorded. The European Organization for Research and Treatment of Cancer quality of life questionnaire lung cancer 13 questionnaire was used to assess quality of life outcomes.RESULTS:Fifty-three patients met the inclusion criteria. There was no in-hospital mortality, and 30-day mortality was 1.8%. No complications were seen in 64% (n = 34), minor complications occurred in 26% (n = 14), while 9% had a major complication (n = 5). Quality of life outcomes were above the reference results for patients with early stage lung cancer.CONCLUSION:Anatomical lung resection can be performed safely in selected high-risk patients based on pulmonary function without significant increase in morbidity or mortality and with acceptable quality of life outcomes. Given that complications following lung resection are multifactorial, fitness for surgery should be thoroughly assessed in all patients with resectable disease within a multidisciplinary setting. High operative risk by pulmonary function tests alone should not preclude surgical resection.

P3.04-027 Feasibility of Lung Cancer Surgery for the Patient with Previous History of Coronary Artery Bypass Grafting: Topic: Miscellaneous I

Owning to the aging society all over the world, high-risk lung cancer patients with severe cardio-pulmonary complications is more common. Among them, thea likelihood to encounter lung cancer patient with a previous history of coronary artery bypass grafting (CABG) has been increasing in our daily practice. However, pulmonary resections after CABG are technically challenging due to the critical adhesions around the CABG field, which need meticulous surgery. Owning to the aging society all over the world, high-risk lung cancer patients with severe cardio-pulmonary complications is more common. Among them, the likelihood to encounter lung cancer patient with a previous history of coronary artery bypass grafting (CABG) has been increasing in our daily practice. However, pulmonary resections after CABG are technically challenging due to the critical adhesions around the CABG field, which need meticulous surgery. Overall patients with previous CABG were comprised of 35 (88%) male with an average age of 70 years and high-smoking rate (40 pack-year smoking). Location of the lung cancer was 26 (65%) in right side, while 27 (68%) were in upper or middle lobe and 11 (28%) in lower lobe.[a1] [y2] Clinical-stage of lung cancers were 22 (55%) in IA, 6 (15%) in IB and 12 (30%) in II or more. Coronary CT was performed before the operation in 13 (35%). Lobectomy was performed in 27 (68%), segmentectomy in 6 (15%), wedge resection in 7 (18%), and mediastinal node dissection in 12 (30%), respectively. Regarding CABG surgery, harvest of left / right internal thoracic artery was performed in 20 (50%) / 21 (53%). Adhesions around CABG fields were observed in 7 (58%) / 5 (23%), including 9 (75%) upper or middle lobe lung cancer needing perivascular exfoliation without any intraoperative graft damage. Postoperative complications were shown in 13 (33%), but the 30days mortality was 0%. The 3-year survival rate was 71.6%, 3-year lung cancer specific survival rate was 76.1%. Results Owning to the aging society all over the world, high-risk lung cancer patients with severe cardio-pulmonary complications is more common. Among them, the likelihood to encounter lung cancer patient with a previous history of coronary artery bypass grafting (CABG) has been increasing in our daily practice. However, pulmonary resections after CABG are technically challenging due to the critical adhesions around the CABG field, which need meticulous surgery.

Overall survival in patients with lung cancer using a web-application-guided follow-up compared to standard modalities: Results of phase III randomized trial.

LBA9006 Background: We developed a web-application for an early detection of symptomatic relapse, complications and early supportive care in high-risk lung cancer patients between visits. A dynamical analysis of the weekly self-reported symptoms automatically triggered physician visit. Methods: We performed a national multi-institutional phase 3 prospective randomized study to compare web-application follow-up (experimental arm) for which patient’s self-scored symptoms that were weekly sent (between planned visits) to the oncologist and a clinical routine assessment with a CT-scan (every 3-6 months or at investigator’s discretion - standard arm). High risk lung cancer patients without progression and with a 0-2 performance status (PS) after an initial treatment were included. Maintenance chemotherapy or TKI therapy were allowed. In the experimental arm, an email alert was sent to the oncologist when some predefined clinical criteria were fulfilled: an imaging was then quickly prescribed. Early supportive cares were provided if adequate. The primary endpoint was to detect an improvement of 12% in 9 months survival in favor of the experimental arm (α = 5%, β = 20%, unilateral test). The boundary for declaring superiority with respect to overall survival at the pre-planned interim analysis was a p-value of less than 0.006. The PS at relapse, the quality of life (QOL) and cost-effectiveness were also investigated. Results: 121 patients were included in the intent-to-test survival analysis (90% were stage III/IV, median age: 65 y): 60 (61) in the experimental (standard) arms with equivalent baseline characteristics. Median follow-up was 9 months. Median overall survival in months was 19 (11.8), p=0.0014 (n = 121; HR = 0.33; 95 % CI, 0.16-0.67) and the PS at the first relapse was 0-1 for 81.5% (35.3%) of the patients (p&lt;0.001) in the experimental (standard) arm. Conclusions: This trial shows a significant survival improvement using Web-application-guided follow-up that allowed better PS at relapse, earlier supportive care and reduction of routine imaging. QOL and cost analysis results will be presented during the meeting. Clinical trial information: NCT02361099.