An Official Journal of the European Society for Medical Oncology The Official Journal of ETOP IBCSG Partners Foundation The Official Journal of the British Thoracic Oncology Group LUNG CANCER AN INTERNATIONAL JOURNAL FOR LUNG CANCER AND OTHER THORACIC MALIGNANCIES Volume 189, March 2024 ISSN 0169-5002 Volume 190S1, April 2024 ELSEVIER
Poster abstracts of the 22nd Annual British Thoracic Oncology Group Conference 2024 ICC Belfast, 17th to 19th April 2024 Publication of this Abstract Book is supported by the British Thoracic Oncology Group (BTOG). co-Editor-in-Chief S. Peters R. Stahel Volume 189 (2024) AN INTERNATIONAL JOURNAL FOR LUNG CANCER AND OTHER THORACIC MALIGNANCIES Amsterdam—Boston—London—New York—Oxford—Paris—Philadelphia—San Diego—St. Louis Volume 190, Supplement 1 (2024) i
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Aims and Scope Lung Cancer is an international publication covering the clinical, translational and basic science of malignancies of the lung and chest region. Original research articles, early reports, review articles, editorials and correspondence covering the prevention, epidemiology and etiology, basic biology, pathology, clinical assessment, surgery, chemotherapy, radiotherapy, combined treatment modalities, other treatment modalities and outcomes of lung cancer are welcome. co-Editor-in-Chief: S. Peters (Switzerland) R. Stahel (Switzerland) Deputy Editors: P. Baas (Netherlands) L. Bazhenova (United States) M. Edelman (USA) J. Remon (France) Y.-L. Wu (China) Section Editors: Epidemiology and Prevention: M. Janssen-Heijnen (Netherlands) Pathology: E. Brambilla (France) S. Finn (Ireland) J. von der Thusen (Netherlands) Systemic Treatments: T. Berghmans (France) B.C. Cho (Korea) N. Girard (France) N. Leighl (Canada) S. Liu (USA) S. Lu (China) I. Okomoto (Japan) A. Passaro (Italy) B. Solomon (Australia) C. Zhou (China) Radiation Oncology: M. Guckenberger (Switzerland) S. Senan (Netherlands) Surgery: M. Tsuboi (Japan) F. Yang (China) Pneumonology: N. Maskell (UK) Radiology and Nuclear Medicine: C.A. Ridge (UK) Preclinical and Translational Research: D. Costa (USA) R. Soo (Singapore) Statistics Editor: U. Dafni (Greece) Social Media Editor: A. Passaro (Italy) Editorial Board: AN INTERNATIONAL JOURNAL FOR LUNG CANCER AND OTHER THORACIC MALIGNANCIES An Official Journal of the European Society for Medical Oncology. The Official Journal of ETOP IBCSG Partners Foundation. The Official Journal of the British Thoracic Oncology Group. L. Bubendorf (Switzerland) C. Faivre–Finn (UK) E. Felip (Spain) S. Lam (Canada) C. Mascaux (France) T. Mitsudomi (Japan) V. Ninane (Belgium) K.J. O’Byrne (Ireland) R. Pirker (Austria) M. Reck (Germany) G. Rocco (USA) C. Rolfo (Belgium) J.-P. Sculier (Belgium) T. Stinchcombe (USA) P. VanderLaan (USA) J.P. Van Meerbeeck (Belgium) A. Vergnenègre (France) G. Veronesi (Italy) H. Wakelee (USA) Y.-C. Wang (Taiwan) S. Yom (USA) Editorial Offi ce: e-mail: lungcancer@elsevier.com Processed at Thomson Digital, Gangtok (India) iii
Vol. 177, March 2023 CONTENTS Cited in: EMBASE/Excertpa Medica, Oncology Information Service, Elsevier BIOBASE/Current Awareness in Biological Sciences; Current Contents/Clinical Medicine; SciSearch, Index Medicus/MEDLINE. Also covered in the abstract and citation database SCOPUS®. Full text available on ScienceDirect®. www.journals.elsevier.com/lung-cancer Poster abstracts of the 21st Annual British Thoracic Oncology Group Conference 2023 ICC Belfast, 26th to 28th April 2023 Basic Science S1 Clinical Networks and Pathways S2 COVID and Cancer S11 Diagnosis and Staging S11 Mesothelioma S19 NSCLC Systemic Treatment S25 Nursing and Allied Health Professionals S38 Other S42 Radiotherapy S53 Screening S66 Small Cell Lung Cancer S74 Supportive Care S76 Surgery S78 Trials in progress S85 Case Reports S90 Author Index S94 Volume 178, Supplement 1, April 2023 Poster abstracts of the 22nd Annual British Thoracic Oncology Group Conference 2024 ICC Belfast, 14th to 17th April 2024 Topic Basic Science Clinical Networks and Pathways Diagnosis and Staging Mesothelioma NSCLC Systemic Treatment Nursing and Allied Health Professionals Other Radiotherapy Screening Small Cell Lung Cancer Supportive Care Surgery Trials in Progress Case Reports Volume 190, Supplement 1 (2024) iv
Poster abstracts of the 22nd Annual British Thoracic Oncology Group Conference 2024 ICC Belfast, 17th to 19th April 2024 Basic Science 1 Fast-tracking NSCLC Standard of Care Genomic Testing with a Formalin-free Fresh EBUS Pathway du Parcq, Persephone1; Awuku, Rochelle1; Santis, George2; Breen, Ronan3; Idika, Monica4; Munonyara, Martina4; Chandegra, Tohral1; Foot, Nicola1; Gerrard, Gareth1; McLean, Emma4 1South East Genomic Laboratory Hub (SEGLH), London, United Kingdom, 2Respiratory Medicine, Guy’s and St Thomas’ Hospital Trust, London, United Kingdom, 3Respiratory Medicine, Guy’s and St Thomas’ Hospital Trust, London United Kingdom, 4Cellular Pathology, Guy’s and St Thomas’ Hospital Trust, London, United Kingdom Introduction: Formalin-fixed paraffin-embedded (FFPE) material is the mainstay for molecular profiling in non-small lung cancer (NSCLC). However, this pathway is suboptimal for both DNA/RNA quality and turnaround time (TAT), so hampering clinical decision-making. To overcome this, fresh endobronchial ultrasound-guided biopsy (EBUS) material was assessed as an alternative formalin-free DNA/ RNA pathway as part of a multidisciplinary quality improvement activity. Methods: Suitable Fresh EBUS material was identified by Rapid On-site Evaluation (ROSE) and split between the standard-of-care (SOC) cell block preparation and a separate aliquot (excess to diagnostic use), which was stabilised in RNAProtect and processed to RLT Buffer for storage. DNA and RNA was extracted from paired fresh and cell block EBUS samples and NGS panel sequenced using primarily the ThermoFisher Genexus Oncomine Precision Assay. Orthogonal testing, such as FISH, supported comparison where NGS failed. Results: 68 paired fresh EBUS/cell block specimens yielded 100% concordance in small, structural (fusion/exon-skipping), and copy number variant detection. DNA was successfully analysed in all specimens and successful RNA analysis was achieved in 42% of cell blocks and 99% of fresh EBUS. National Genomic Test Directory (NGTD) ‘Essential’ and‘Investigational’ events were detected in 62% and 28% of cases, respectively. Median TAT from collection was 19 days (range 12– 47, 29% ≤14 days) for cell blocks, and 14 days (range 6–35, 56% ≤14 days) for fresh EBUS. Conclusion: These data clearly show the potential for a fresh EBUS pathway to improve patient care through viability and rapidity of predictive testing for SOC therapy and trial decision-making, benefitting from higher RNA success and markedly reduced TATs. These results also support the use of first-line assessment of fresh EBUS over FFPE, reducing multidisciplinary laboratory work burden and increasing availability of FFPE material for additional predictive biomarker processes. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107562 https://doi.org/10.1016/j.lungcan.2024.107562 2 The role of cellular pathology departments in the improvement of turnaround times for lung adenocarcinoma biomarker testing Warren, Madhuri V1; Farooque, Taiba2; Rodgers, Stephen3; Grantham, Marianne4; Williams, Leigh5; Jenkins, Richard5; Bennett, Deborah5; Cole, Tracey6; Januszewski, Adam7; Jones, J Louise8; Giaslakiotis, Konstantinos9 1Department of Cellular Pathology, Royal London Hospital, Barts Health NHS Trust. London, United Kingdom, 2Department of Oncology, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom, 3Department of Cellular Pathology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom, 4Department of Cytogenetics & Molecular Haematology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom, 5Amgen UK & Ireland, Uxbridge, United Kingdom, 6North Thames Genomics Medicine Alliance (GMSA), London, United Kingdom, 7Department of Oncology, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom, 8Barts Cancer Institute/ Queen Mary University London, London, United Kingdom, 9Department of Cellular Pathology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom Introduction: Genomic profiling of non-small cell lung cancer was centralised in April 2021 to 7 Genomic Laboratory Hubs (GLHs) to improve turnaround times (TATs) and access to standardised genomic testing for predictive biomarkers. However, challenges remain in delivering a service meeting the NHSE 10-day molecular testing standard1,2. We report a 2-year service evaluation and improvement project at Barts Health NHS Trust (BHT; North Thames GMSA) partnered with Amgen UK & Ireland, which has delivered significant improvements in the key performance indicators (KPIs) of TATs, DNA quality and test inadequate rates. Methods: The study involved the following: 1. Retrospective audit of lung adenocarcinoma (LUAD) pathology pathway from date of tissue acquisition to a clinically relevant report. 2. Process mapping of the pathology pathway. 3. Identification of barriers to faster TATs and implementation of service improvements. 4. Prospective audit of LUAD pathology pathway to identify improvements in KPIs. Lung Cancer 190, Suppl. 1 (2024) Contents lists available at ScienceDirect Lung Cancer journal homepage: www.elsevier.com/locate/lungcan 0169-5002/$ –see front matter © 2024 Elsevier BV. All rights reserved. 1
Results: 60 LUAD specimens were audited between Apr–Jun 2022 and 39 LUAD in Sep–Oct 2023. Service expansion in cut-up facilities, laboratory technicians, staff training and streamlining of the pathology pathway resulted in an improvement (Δ) in almost all parameters including: reduced TATof diagnostic reporting of biopsies (mean TAT-B: Δ3.2 days) and resections (mean TAT-R: Δ12.3 days); molecular reporting (mean TAT-B: Δ2.2 days; mean TAT-R: Δ12.3 days); decreased NGS failure rates (3.3% to 0%); improved TAT for PD-L1 immunohistochemistry (3-dayTAT-B:Δ58%; 3-dayTAT-R: Δ11.6%) and ALK/ROS1 immunohistochemistry (3-dayTAT-B:Δ12%; 3-dayTAT-R: Δ26%) tumour content assessment (71.6% to 98.4%) and reduced overall TAT from tissue acquisition to molecular report (mean TAT-B: 35 to 31 days; mean TAT-R: 56 to 33 days). Conclusions: Our study has service improvement recommendations that may be transferrable to other networks in the UK. Re-evaluation of National Optimal Lung Cancer Pathway (NOLCP) guidelines and implementation of Cellular Pathology Genomics Centres (CPGCs) is recommended. Disclosure: No significant relationships. References 1. NHSE National Optimal Lung Cancer Pathway for suspected and confirmed lung cancer: referral to treatment: UPDATE2020. https:// www.cancerresearchuk.org/sites/default/files/national_optimal_ lung_pathway_aug_2017.pdf 2. Adizie JB et al. Biomarker Testing for People with Advanced Lung Cancer in England JTOClin Res Rep. 2021 Apr 27;2(6):100176 Lung Cancer 190S1 (2024) 107563 https://doi.org/10.1016/j.lungcan.2024.107563 3 The Availability of Molecular Profiling Results at New Patient Review in NSCLC and the Impact on Patient Care Church, Matt1,2; Carter, Mathew1; Summers, Yvonne3,1; Gomes, Fabio1; Taylor, Paul3,1; Hughes, Sarah1; Califano, Raffaele3,1,2; Blackhall, Fiona2,1; Lindsay, Colin2,1; Cove-Smith, Laura3,1 1The Christie NHS Foundation Trust, Manchester, United Kingdom, 2The University of Manchester, Manchester, United Kingdom, 3Manchester University Foundation NHS Trust, Manchester, United Kingdom Introduction: Optimal systemic anti-cancer therapy (SACT) for nonsmall cell lung cancer (NSCLC) is dependent on the results of molecular profiling to direct precision medicine. Delays in the availability of results in the clinic can delay care. Methods: Records of all newly diagnosed medical oncology NSCLC patients assessed between January and June 2023 inclusive were reviewed. Patient, disease and treatment data was obtained along with the date of availability on the hospital system of PD-L1, ALK, ROS1, EGFR, BRAF, KRAS, MET and RNA fusion panel (including RET and NTRK). Date of availability was compared to the date of biopsy and of laboratory report. Results: PD-L1 result was available at initial clinic in 76% of the 36 stage II–III patients and 90% of the 20 stage IV squamous patients. Average time from biopsy to PD-L1 report was 17 days and to availability was 21 days. Average time from review to SACT was 18.8 days if PD-L1 was available and 22.5 days if not. For the 97 stage IV non-squamous patients, 53% had a genomic alteration. A full panel of results was available in 38% of cases, and 48% for a‘core’ panel relevant for first-line treatment. Average time from biopsy to availability was 25 days for PDL1, 29 days for ALK, 33 days for EGFR and 41 days for RNA fusions. Time to SACT was 13.5 days if ‘core’ panel was available and 26 days if not. Incomplete results led to 0.7 additional clinics on average prior to SACT. Discussion: A large proportion of patients newly assessed for NSCLC had incomplete profiling results available at first review, delaying time to treatment and creating additional reviews. There was delay between the result from the laboratory becoming available to clinicians. Work is ongoing to integrate genomic results within the region to improve availability. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107564 https://doi.org/10.1016/j.lungcan.2024.107564 4 Clinical and molecular characteristics of BRAF mutant Lung Adenocarcinomas Bulusu, Ramesh1; Bulusu, Ramesh2; Yang, Huiqi3; Patterson, Daniel4; Thippu Jayaprakash, Kamalram5; McGeogh, Adam6; Hutka, Margaret7; Hollingdale, Abigail8; Treece, Sarah8; Thompson, Nicola3; Earwaker, Philip3; Lynskey, Diedre3; Aslam, Shahzeena7; Shiarli, Anna Marie3 1Primrose Oncology Unit Bedford Hospital, Bedford, United Kingdom, 2Primrose Oncology Unit, Bedford, United Kingdom, 3Cambridge University hospitals, Cambridge, United Kingdom, 4West Suffolk Hospital, Bury ST Edmunds, United Kingdom, 5Queen Elizabeth Hosptial, K lynn, United Kingdom, 6Cambridge, United Kingdom, 7Bedford hospital, Bedford, United Kingdom, 8Peterborough City Hospital, Peterborough, United Kingdom Introduction: BRAF mutations occur in 1–4% of lung adenocarcinomas. The most common BRAF mutation is V600E. We present our experience with BRAF mutant LAC. Methods: Case records of LAC patients from the six oncology units in the network were reviewed. BRAF mutant LAC were identified from the molecular pathology reports. Demographics, clinical features, molecular phenotype and treatment data were collected. Molecular data included type of BRAF mutation (Class I–III), co-existing variants, PDL1 expression. Treatment outcomes including responses, adverse events, dose modifications were recorded in cohort of patients treated with Dabrafenib and trametinib combination. Results: 16 LAC patients with BRAF mutations were identified from the datasets. Male:Female 9:7. Age 47–80 years, median 65 years. 15/16 patients were either current or ex-smokers. 15/16 had metastatic disease. Sites of metastases-lymph nodes, effusions, bone, adrenal, Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 2
pituitary and soft tissue. Only 2/16 had brain metastases. All LACs were TTF-1 +ve. PD-L1 expression ranged from 0–100%, 8/14 had≥50%PDL1 expression. Molecular phenotyping results shown in table below. 5 patients were treated with Dabrafenib and Tremetinib combination with partial responses in 3 and stable disease in 2 patients. Other treatments included chemotherapy, immune checkpoint inhibitors and palliative radiotherapy. Conclusion: Our BRAF mutant LAC dataset showed the heterogeneity of BRAF mutations. Co-existent mutations were observed in tumour suppressor and cell cycle checkpoint genes. Dabrafenib and Tremetinib combination is active with acceptable toxicity profile. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107565 https://doi.org/10.1016/j.lungcan.2024.107565 5 Molecular marker expression in non-small cell lung cancer (NSCLC) in Humberside Roejkjaer, Eline1; Saleem, Azeem1 1Hull University Teaching Hospitals (HUTH) NHS Trust, Hull, United Kingdom Introduction: We evaluated the molecular marker expression in NSCLC patients treated at the Hull University Teaching Hospitals (HUTH) NHS Trust, covering Hull, East Riding, North and East Yorkshire, North and North East Lincolnshire to provide information of local distribution of molecular markers. Methods: 1048 patients diagnosed with NSCLC at the HUTH between 01.01.2020 to 31.12.2021 were identified. Patient electronic records (Lorenzo®, WebV® systems and CPD®) were reviewed to obtain information, with the following information gathered: date of histology, patients age at this time, gender, PET scan, histology subtype, molecular markers tested and reported. Results: Histology reports were available for 470 of 1048 (45%) patients. Adenocarcinoma was the most common histological subtype (282/470; 60%), followed by Squamous cell cancer (SCC) (144/470; 31%). SCCs were tested for both PDL1 and ROS1 as per NICE guidelines (n = 128/144; 89% tested). 104 SCC patients were positive (>1%) for PDL1. Patients with non-SCC NSCLC (n = 326) were tested for 1–9markers (median = 5). The most often positive marker in non-SCC was PDL1 (n = 184/302: 61%), followed by EGFR (n = 33/295; 11%), KRAS (n = 13/ 30; 43%) ROS1 (n = 2/297; 67%), ALK (n = 1/298: 0.3%), BRAF (n = 1/208; 0.5%), RET gene fusion (n = 1/13; 8%). The majority of patients with positive PD-L1 were aged 60–79 (n = 214/436; 49%) with slight preponderance of males 1.3:1. There was similar expression of PD-L1 between 1–50% and >50% in all age groups above 50, with no gender differences; however a smaller proportion of females (67/231; 29%) were negative (<1%) for PDL1 expression compared to males (83/205; 40%). 55% of patients with markers tested had PET scans. Conclusions: This study provides a detailed expression on molecular markers in Humberside. About half of NSCLC patients underwent molecular marker analysis with PD-L1 the most often tested and positive markers followed by EGFR. There was good overall compliance to NICE guidelines in the markers tested. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107566 https://doi.org/10.1016/j.lungcan.2024.107566 6 Molecular testing turn around time in NSCLC before and after NGS commissioning in Milton Keynes University Hospital- An Audit 2022–2023 Saleem, Faiza1; Eldeeb, Hany1; Dawyer, Moyna1; Rizvi, Syed Azhar Javed1 1Milton Keynes University Hospital, Milton Keynes, United Kingdom Introduction: Lung cancer is most common malignancy, with nonsmall cell lung cancer (NSCLC) the predominant subtype. Lung cancer accounts for more than 18% cancer related deaths (1). We aim to reflect on our practice of molecular testing on NSCLC, along with PD-L1 expression in 2022–2023 (before and after NGS commissioning) which will define the choice of treatment, based on the expression of this ligand (immunotherapy alone vs chemotherapy plus immunotherapy). Patients/Methods: Patient records were reviewed retrospectively, for turnaround time of molecular testing. Data was stratified according to their pathological subtypes. Biopsy sites, mode of diagnosis and initial staging was also part of case report forms. Results: 84 patients underwent testing of oncogenic driver mutation, 64 patients were diagnosed as non-squamous, rest were squamous cell carcinomas. 11 patients harboured EGFR mutation. 1 patient had ALK rearrangement, and 3 had KRAS mutation. Turnaround time for molecular testing in 2022 was 13.3 days(7–25days), but it increased to 21.0 days (7–75 days) in 2023 as NGS was commissioned and specimens were sent to 2 different providers. 20 patients had >50% expression of PDL-1, 22 weak expression (<1% >50%), whereas the rest were reported negative. Conclusion: Molecular testing is an essential tool in the work up of all NSCLC (2). NGS can detect mutations, which may be missed in conventional immune assays. Testing such mutations either by immune assays or NGS requires resource allocation and may also lead to delays in completing diagnosis. Turnaround time increased from 13.3 days in 2022 to 21.0 days in 2023 as NGS was added in the diagnostic work up. It is also noted that size of biopsy specimen can be limiting factor, as small biopsies can be helpful in identifying morphology of cancer but may be insufficient in detecting Molecular testing. Disclosure: No significant relationships. Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 3
References 1. CA Cancer J Clin. 2018;68:394–424). 2. Molecular testing strategies in non-small cell lung cancer: optimizing the diagnostic journey - PMC (nih.gov) 3. Overall Survival with Osimertinib in Untreated, EGFR-Mutated Advanced NSCLC | NEJM 4. Sotorasib for Lung Cancers with KRAS p.G12C Mutation | NEJM Lung Cancer 190S1 (2024) 107567 https://doi.org/10.1016/j.lungcan.2024.107567 7 Concordance of MET amplification detection between FISH and NGS in NSCLC John, Alexius1; Ketpueak, Thanika2; MacMahon, Suzanne3; Wall, Marianne3; Yuan, Lina3; Tokaca, Nadza2; Bhosle, Jaishree2; Minchom, Anna2; Davidson, Michael2; O’Brien, Mary2,4; McMahon, David2; Nevado Rodriguez, Maria2; Popat, Sanjay2,4 1The Lung Unit, Royal Marsden Hospital, London, United Kingdom, 2The Lung Unit, The Royal Marsden Hospital, London, United Kingdom, 3North Thames Genomic Laboratory Hub, The Royal Marsden Hospital, London, United Kingdom, 4The Institute of Cancer Research, London, United Kingdom Introduction: The INSIGHT-2 trial validated MET amplification as a therapeutic drug target for combination tepotinib-osimertinib in EGFR-mutated NSCLC. Its detection has traditionally relied on fluorescence in situ hybridization (FISH), but this is a separate test to next generation sequencing (NGS), with additional costs. We evaluated the relationship of MET copy number status detected by FISH or NGS to determine if FISH can be abandoned in the diagnostic workup. Methods: Retrospective review of samples undergoing MET FISH testing between 12/2021–02/2023 was undertaken. Baseline demographics were obtained from medical records. MET FISH was performed in-house using a MET/CEN7 dual colour, Zytovision probe; amplification was defined as MET:CEN7 ratio ≥2:1, and copy number gain (CNG) as ratio of 1–2:1, or >2 signals for MET and CEN7 in 1:1 ratio. NGS was performed on contemporaneous DNA extracted from FFPE tissue with >10% tumour content using the RMH200Solid gene panel. Copy number variants were detected using copy number probes, and amplifications calculated using our in-house pipeline. Amplification by NGS was defined as a normalised value >1. Results: 33 tissue samples from 24 patients underwent MET FISH testing, 97% (n = 32/33) had paired NGS. FISH detected MET amplification in 21% (n = 7/33) of samples, CNG without amplification in 36% (n = 12/33), and no MET amplification/CNG in 9% (n = 3/33); 33% (n = 11/33) of samples failed MET FISH testing. Of 7 samples with FISHdetected MET amplification, 71% (n = 5/7) had concordant amplification on NGS, 14% (n = 1/7) had an equivocal NGS MET amplification result (likely due to low tumour content), and NGS panel did not include coverage of MET in 14% (n = 1/7) of samples. 100% of samples (n = 5/5) that were MET amplified by NGS were also amplified by FISH. Table 1: Baseline demographics and results n=, (%) BASELINE DEMOGRAPHICS Sex M 8/24 (33) F 16/24 (67) Median age at time of testing 58yrs Oncogenic driver EGFR 14/24 (58) ALK 4/24 (17) RET 1/24 (4) KRAS 1/24 (4) Lines of prior treatment at time of sampling 0 1/33 (3) 1 16/33 (48) 2 4/33 (12) 3 5/33 (15) 4 3/33 (9) 5 1/33 (3) 6 1/33 (3) Unknown 2/33 (6) RESULTS PairedNGS 32/33 (97) FISH results METamplification 7/33 (21) CNG without amplification 12/33 (36) NoMET amplification/CNG 3/33 (9) Failed 11/33 (33) NGS results Amplified 5/33 (15) Non-amplified 28/33 (85) 2x2 table FISH amplified FISH non-amplified (excluding failed samples) NGS amplified 5 0 NGS non-amplified 2 15 Conclusion: Limited by small numbers, NGS (our pipeline) confidently identifies FISH-validated MET amplification, suggesting FISH should only be considered in NGS non-amplified cases, particularly if tumour content is low. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107568 https://doi.org/10.1016/j.lungcan.2024.107568 8 Audit of a 3-day turnaround time for histopathology reporting in lung cancer cases Winstanley, Rachael1 1Salford Royal Hospital Introduction: The NHS England National Optimal Lung Cancer Pathway (NOLCP) is designed to improve outcomes in lung cancer by reducing delays in diagnosis. According to this document, in cases of suspected lung cancer where the pathological diagnosis will influence treatment and management, then there should be histopathology result with subtype available within 3 working days and biomarkers (molecular markers) in 10 working days. In this audit we compare the Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 4
turnaround times (TAT) in our centre against the desired standard set out by NOLCP. Method: Two audit methods were used, one was a retrospective analysis of TAT of lung samples for one month period (n = 48) and a prospective analysis of cases discussed in multidisciplinary meeting (MDT) for 6-week period (n = 65) in 2023. Results: The median TAT for retrospective audit was 6 calendar days from procedure to diagnosis for malignant cases. Only 15% cases were reported in 3 or less calendar days. The median TAT for all biomarker testing (NGS, Alk1, ROS1 &PD-L1) was 25 days with in-house biomarkers having a quicker TAT of 11 days compared to external testing. In the prospective audit, 73% of non-small cell carcinoma cases were given provisional verbal report at the MDT within 3 days of procedure. Conclusion: A 3-day TAT is difficult to achieve when there is lack of resources in terms of workforce in pathology. The prospective audit has shown that careful selection of patient with adequate clinical details and radiological correlation which is available to a pathologist in a MDT leads to improvement in 3-day TAT of 73% compared to 15%.TAT for biomarkers reported externally is comparatively longer than in-house reporting. Disclosure: No significant relationships. Reference National-Optimal-Lung-Cancer-Pathway-3.0 (1).pdf. Lung Cancer 190S1 (2024) 107569 https://doi.org/10.1016/j.lungcan.2024.107569 Clinical Networks and Pathways 9 Lung cancer physician grading of radiology alerted chest xrays to optimise diagnostic pathways in a resource limited setting Dean, Katrina1; O’Donnell, Paul1; Naseer, Rehan1 1Fairfield General Hospital, Northern Care Alliance, Bury, United Kingdom Background: Optimising lung cancer diagnostic pathways, reduces upstaging and benefits 5-year survival. Resource-limited settings may have difficulty attaining 62-day or National Optimal Lung Cancer Pathway targets. One stop, hot-reported CT/physician clinics provide an opportunity to consolidate appointments, but are resource intensive, therefore not practical for all abnormal chest x-rays (CXRs). Aim: We propose a methodology, using lung cancer physician grading of radiology flagged CXRs to allocate ring-fenced weekly slots on a riskstratified basis. Method: Prospectively, lung cancer physicians reviewed all radiology flagged CXRs over a 6 month period, grading outcomes as Likely, Possible or Unlikely cancer. Retrospectively, date of CXR alert, outpatient appointment (OPA), MDT, and final diagnosis were reviewed. Projected one-stop clinic pathway (Figure 1.) with 6, weekly, hot-reported CT/clinic slots, using likely (and remaining slots for possible cancer) were compared to current CT, OPA and MDT dates to project potential reductions in diagnostic pathway length. Results: 321 CXRs were flagged (8 excluded). Of 313, 74 (23.6%) had a new cancer. Physician grading deemed cancer Likely 45 (14.4%), Possible 72 (23.0%) and Unlikely 196 (62.6%). The positive predictive value of likely cancer was 62.2%. The negative predictive value of unlikely cancer was 88.8%. For patients deemed Likely or Possible cancer on CXR, current pathway vs proposed pathway, time from CXR alert to OPAwould be 9.3 vs 5.7 days respectively, and alert to MDT 27.1 vs 24.3 days respectively. For all patients who ultimately had a new cancer identified, current pathway compared to proposed pathway, time from CXR alert to OPA would be 10.4 vs 7.7 days respectively, and alert to MDT 31.1 vs 29.2 days respectively. Conclusion: Lung cancer physician grading of alerted CXRs, provides suitable risk stratification to ensure efficient use of ring-fenced onestop clinics in resource limited settings, with potential to reduce lung cancer pathway lengths. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107570 https://doi.org/10.1016/j.lungcan.2024.107570 10 Current challenges and delays in the lung cancer diagnostic pathway Fowell, Andrew1; Bhaskar, Phebe1; Mulrooney, Michael1; Al-Najjar, Haider1 1Manchester Royal Infirmary, Manchester, United Kingdom Introduction: National Optimal Lung Cancer Pathway (NOLCP) aims to achieve diagnosis or exclusion of lung cancer within 28 days1 from GP referral or abnormal imaging. The first investigation, usually CT thorax, should be performed within 72 hours. A diagnostic“bundle”follows in which delays could occur. Objectives: We aimed to determine turnaround time (TAT) for investigations performed on NOLCP at our institute to identify and remedy delays. Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 5
Methods: We reviewed TAT for these investigations at our institution, 20 consecutive patients for each except pleural aspirations (5). Results: On average for GP-referrals, CT thorax is requested after 4.35 days, then performed/reported after 8.05 days. Abnormal chest x-ray (CXR) reports are referred directly to the lung cancer team, however often with significant delays. Mean reporting time of CXRs is 6.35 days (over twice the 72-hour standard in itself) with subsequent delays reaching our triage inbox. CT thoraces are performed within 3.65 days on average, with fifteen protected appointments weekly (usually full). CT thorax delay is typically due to patient choice or non-attendance. Scansare“hot-reported”the same day. On average, PFTs are performed within 7.4 days of requests with three protected appointments weekly. Echocardiograms are performed within 18.3 days and MR brain scans within 13.4 days, neither with protected appointments. Inspection bronchoscopies are performed within 18.9 days and pleural aspirations within a mean of 1.00 day of request. Conclusion: Our TAT for certain investigations doesn’t meet NOLCP’s targets. Part of this delay can be attributed to weekends and processing issues with referrals. CXR reporting TAT may be improved with AIreporting tools. With more protected appointments, faster reporting and automatic referral-processing, NOLCP targets could be met more consistently. Disclosure: No significant relationships. Reference 1. Lung Clinical Expert Group (2017) National Optimal Lung Cancer Pathway, https://www.cancerresearchuk.org/sites/default/files/ national_optimal_lung_pathway_aug_2017.pdf Lung Cancer 190S1 (2024) 107571 https://doi.org/10.1016/j.lungcan.2024.107571 11 Making an accurate diagnosis of anterior mediastinal lesions: A proposal for a new diagnostic algorithm from the BTOG Thymic Interest Group Robinson, Stephen1,2; Evison, Matthew3,4; Datta, Shalini5; Sharman, Anna6; Rammohan, Kandadai4; Duerden, Rebecca7; Gilligan, David8 1Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex, Brighton, United Kingdom, 2Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Brighton, United Kingdom, 3Manchester Academic Health Science Centre (MAHSC), Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom, 4Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom, 5Department of Radiology, Royal Alexandra Hospital, NHS Glasgow and Clyde, Glasgow, United Kingdom, 6Manchester Thoracic Oncology Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom, 7Department of Radiology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, United Kingdom, 8Department of Oncology, Addenbrookes Hospital, Cambridge University NHS Foundation Trust, Cambridge, United Kingdom Due to rising demand in cross-sectional thoracic imaging, anterior mediastinal lesions are being identified with increasing frequency. Following iterative and multidisciplinary discussions, the BTOG Thymic Interest Group have developed an algorithm (Figure 1) to standardise the diagnostic approach for these relatively uncommon but important conditions which span from benign (thymic remnant, thymic hyperplasia and thymic cysts) to low grade malignancy (thymoma) to high grade malignancy (thymic carcinoma, lymphoma and germ cell tumours). In this algorithm, we also highlight the role of magnetic resonance imaging for the characterisation of anterior mediastinal masses in specific indications when the necessary local resources and expertise exists and hope this provides the rationale for service development in MR of the anterior mediastinum where current resource and expertise requires development. In this diagnostic algorithm, we emphasise the importance of reviewing prior imaging and relevant clinical history plus using contrast enhanced portal venous/delayed phase CT imaging to visualise the anterior mediastinum. We propose rationalised surveillance schedules, including discharging patients with no follow up when thymic remnant and appropriately characterised thymic hyperplasia is identified. By highlighting optimal lesion characterisation steps, we seek to reduce the unnecessary resection of benign entities with its associated morbidity. Finally, in defining a streamlined diagnostic work-up prior to the appropriate treatment of anterior mediastinal malignancies, we underscore the importance of direct to surgery pathways in patients with a suspected low-grade thymomas. Through this standardised pathway, we hope to drive improvements in the care of all patients with anterior mediastinal masses. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107572 https://doi.org/10.1016/j.lungcan.2024.107572 Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 6
12 Understanding reasons for deviation from lung cancer multidisciplinary team meeting (MDM) recommendations –an audit in a large NHS Foundation Trust Yip, Kay Por1; Wardere, Gibril2; Adizie, Bhavani2; Glynn, Patricia2 1University of Birmingham, Birmingham, United Kingdom, 2Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom Introduction: Effective MDM decision-making is essential to an efficient lung cancer pathway. Audits of MDM processes are not only central to quality assurance and patient care but are also recommended by NHS England & NHS Improvement(1) and the West Midlands Cancer Alliance.(2) We present data from University Hospitals Birmingham (UHB) NHS Trust (comprising four hospitals). Methods: Data from lung MDMs held at UHB NHS Trust conducted between January and February 2023 were obtained from Somerset Cancer Registry. Electronic patient records were analysed to obtain information about further decision-making in the patient’s pathway. Results: 165 patients were discussed in lung MDMs across the four general hospitals between January and February 2023. The mean age was 71.8 ± 10.5 years old, with 94 (57.0%) males. 145 (87.9%) patients discussed had a cancer diagnosis. Of these, approximately one-fifth of patients’ treatment decisions deviated from lung MDM recommendations. Documented reasons included: inadequate information available which included patient views and comorbidities, inconsistent performance status assessment as well as clinical deterioration before specialist review. Conclusions: A multidisciplinary model of care can overcome barriers to treatment and promote adherence to guidelines. However, we show that lessons can be learned from examining discrepancies in treatment decisions, which can inform team learning and reflection. A significant finding was a lack of essential information presented at lung MDMs despite using well-adhered proformas. A quality improvement plan has been formulated to improve the above factors, and we advocate that other MDMs conduct a similar review. Disclosure: No significant relationships. References 1. NHS England & NHS Improvement. Streamlining Multi-Disciplinary Team Meetings: Guidance for Cancer Alliances. 2020. 2. West Midlands Cancer Alliance. Cancer Multidisciplinary Meeting Best Practice Standardisation Guidance. 2022. Lung Cancer 190S1 (2024) 107573 https://doi.org/10.1016/j.lungcan.2024.107573 13 Survey of patients undergoing procedures in a suspected lung cancer and pleural service Probyn, Ben1,2; Trevelyan, Gareth1; Howell, Timothy3; Iyer, Aparna1; Nicholson, Thomas1; Taylor, Lindsey1; Waine, David1; Corcoran, John1; Daneshvar, Cyrus1,2 1University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom, 2University of Plymouth, Plymouth, United Kingdom, 3University of Plymouth Hospitals NHS Trust, Plymouth, United Kingdom Introduction: Access to diagnostic procedures is instrumental in the faster diagnostic framework and the national optimal lung cancer pathway (NOLCP). We undertook a service evaluation of patient experiences. Figure: (abstract 11). Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 7
Methods: All two week wait patients undergoing ultrasound guided, pleural or endobronchial procedures by the interventional pulmonology team at University Hospitals Plymouth NHS Trust between the 29/ 09/2023–22/12/2023 were invited to partake in the service evaluation. Results: In total, 158/238 (66.3%) patients completed an evaluation form. Of these, 77/158 (49%) reported meeting a LCNS prior to their procedure and viewed as very beneficial (median score 10 IQR [10– 10]). Same day procedures were reported in 38/158(24%) patients and the overall wait for a procedure was scored as acceptable (median score = 10[10–10]). Receiving pre-procedure written information was reported in 78/158 (49%) of patients and when present was considered useful in all but one patient. Whether patients felt they needed more information prior to undergoing their procedure was influenced by whether they received written information beforehand (17.5% 14/80 vs 5% 4/78). In 18/158 (11%) patients who wished for more information, paper (44%), verbal (28%) and online (17%) were the commonest requested. In nearly all cases (145/158 (92%) patients felt they were prepared for the procedure being untaken on the day. Moreover, patients deemed all interventions as highly acceptable with the median acceptability of the interventions being 10/10 in all bar chest wall biopsy (which obtained 8.5/10) (See table 1). Conclusion: This service evaluation has highlighted the importance of LCNS and patient information in rapidly organised investigations. Furthermore, diagnostic procedures were deemed as highly acceptable. We did not see any evidence of tests being organised too quickly, important in factoring in delivery of the fast diagnostic pathway. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107574 https://doi.org/10.1016/j.lungcan.2024.107574 14 Widening access and addressing inequalities for patients with lung cancer consenting to systemic anti-cancer therapies (SACT) Nally, Elizabeth1; Reeves, Annie1; Lerner, Anna1; Bhowmik, Angshu2; Leonard, Pauline3; Hawkins, Oliver4; Wald, David5; Januszewski, Adam1 1St Bartholomew’s Hospital, London, United Kingdom, 2Homerton University Hospital, London, United Kingdom, 3Barking, Havering & Redbridge University Hospital, London, United Kingdom, 4North East London Cancer Alliance, London, United Kingdom, 5Explain My Procedure Ltd, London, United Kingdom Introduction: Cancer services nationally are under increasing pressure. With new and rapidly emerging therapy lines the consent process for SACT is becoming more complex. Moreover our patient population is more diverse. Research has shown that language services and visual guides can improve patient experience, adherence to treatment and overall health outcomes. We are developing a multi-lingual digital library of animations to support the consent process for SACT with the aim to reduce inequalities in cancer care. Methods: These animations are being developing in collaboration with ‘Explain My Procedure’ and North East London Cancer Alliance (NELCA). A steering committee of cancer physicians, patient advocates and CNS will ensure quality review. The animations will be piloted within the lung cancer clinic at St Bartholomew’s Hospital. Once evaluated and established the aim will be to roll out across Northeast London and beyond. Results: The intended impact will focus on improving patient’s understanding of their cancer treatment leading to better engagement and overall outcome. The animations will support lung cancer patients Figure: (abstract 14). Figure: (abstract 13). Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 8
across wider socioeconomic groups addressing inequality in cancer care and research. The benefits will also be identified within the clinical setting, improving the efficiency of the consent process and therefore relieving pressure on health care professionals and clinic capacity. Conclusion: We will present pilot data on a new multi-lingual digital tool that aims to support the consent process for cancer therapy improving patient engagement, addressing inequalities and improving patient experience. Disclosure: D Wald is director of explain my procedure which will create and own the animations used in the project. Lung Cancer 190S1 (2024) 107575 https://doi.org/10.1016/j.lungcan.2024.107575 15 The Integration and Analysis of Data using Artificial Intelligence to Improve Patient Outcomes with Thoracic Diseases (DART) research programme. Gleeson, Fergus1 1Oxford University, Oxford, United Kingdom Introduction: DART is a multi-centre multi-collaborator research programme aiming to improve multiple facets of Lung Cancer Screening (LCS) and provide a very large data set for future research into early lung cancer detection and prognosis. It collects all the clinical metadata, CT scans and PET-CT scans, and pathology from participants both screened and invited to participate in NHS England’s Targeted Lung Health Checks (TLHC) screening programme. Materials and Methods: DART has Health Research Authority (HRA - 301420) and Confidentiality Advisory Group (CAG 22/CAG/0010) approvals and has uniquely linked the data collected to Health Episode Statistic (HES) data, to enable long term outcome data to be collected. The collection of this data has involved linking TLHCs and their associated Hospitals, Radiology and Pathology departments, and transferring the data into the Oxford University Hospital’s (OUHNHS FT) Secure Data Environment/Trusted Research Environment (SDE/ TRE) and to multiple academic and commercial collaborators. Results: DART is now linked to 10 TLHCs, and 7 further sites are in the process of linking. It has data on 263,578 participants, and has currently/is currently transferred/transferring, 114,598 CT scans, and 640 digital pathology samples and these numbers are increasing daily. Conclusion: The DART collaborators have already developed and validated a novel prediction algorithm to optimise patient selection for screening, and DART is already enabling the development, testing and validation of Artificial Intelligence (AI) algorithms that improve: the detection of pulmonary nodules and lung cancers on CT scans; the diagnosis of lung cancer and its subtyping on digital pathology images; and prognostic algorithms that may be used to determine the need for neoadjuvant or adjuvant treatment pre and post resection. DART also remains keen to increase the number of collaborating TLHCs and NHS Trusts working with it. Our collaborators alongside the TLHCs and NHS Trusts are: Disclosure: F Gleeson is the PI of DART and has shares in Optellum. Lung Cancer 190S1 (2024) 107576 https://doi.org/10.1016/j.lungcan.2024.107576 16 The impact of implanting ctDNA testing on day 0 of the lung cancer pathway in patients with advanced stage disease in Manchester Ghoshal, Avik1; Goodley, Patrick1; Ahuja, Gaurav2; De Silva, Heshani2; Alsaaty, Alaa2; Watson, Charlotte2; Booton, Richard2; Balata, Haval2; Crosbie, Phil2; Sinnott, Nicola2; Chung, Jonathan Hiu Nian2; Craig, Christopher2; Krebs, Matthew3; Sutcliffe, Anthony3; Evison, Matthew2 1Wythenshawe Hospital, Manchester University NHS Foundation Trust, 2Wythenshawe Hospital, Manchester University NHS Foundaton Trust, 3North West Genomics Laboratory Hub Background: Circulating tumour DNA (ctDNA) can be detected in peripheral blood of cancer patients and tested for genomic alterations and could support the delivery of the Lung Cancer Optimal Pathway (LCOP). Methods: Manchester University NHS Foundation Trust (MFT) has been part of the NHS England ctDNA in lung cancer pilot. At MFT, patients referred with suspected lung cancer undergo a CT scan (day 0) with same day hot reporting and physician consultation. This has allowed integration of ctDNA testing for patients with stage III/IV (and deemed suitable for tissue sampling) on Day 0 of the lung cancer pathway. We compare the time to treatment decision of a tissue plus ctDNA pathway (tissue for pathological diagnosis/immunohistochemistry testing and ctDNA for genomic profiling) versus a tissue alone pathway. Results: From January-July 2023, we performed ctDNA tests for 70 patients with radiological suspicion of stage III/IV lung cancer. These were ultimately diagnosed as 50 NSCLC cases (26 adenocarcinoma, 16 squamous cell carcinoma, 8 Not Otherwise Specified), 9 small cell lung cancers, and 11 metastases from extrapulmonary malignancies. 7 samples found no ctDNA mutation, five of which were limited to thoracic disease, stage III-IVA. Median interval from CT date to histological diagnosis with all genomic markers on tissue specimen was 33 days (IQR 20–47), whereas that for CT date to ctDNA result was 10 days (IQR 8–13, p < 0.001). The time from CT to a treatment decision point for the tissue alone pathway was 33 days (IQR 20–47) versus 18 days (IQR 13–29, p < 0.001) for the tissue pus ctDNA pathway. For patients with non-squamous NSCLC this was 43 days (IQR 36–55) versus 18 days (IQR 13–28, p < 0.001). Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 9
Conclusion: The introduction of ctDNA testing on day 0 of the lung cancer pathway in patients with advanced stage lung cancer saves an average of 15 days. Disclosure: No significant relationships. Lung Cancer 190S1 (2024) 107577 https://doi.org/10.1016/j.lungcan.2024.107577 17 A third treatment pathway: is there a place for a nurse-led Best Supportive Care service for the management of patients diagnosed with lung cancer at an acute NHS Trust? Fox-Hewitt, Laura1 1University Hospital of North Midlands, Royal Stoke, Stoke-on-Trent, United Kingdom Introduction: Cheng et al (2021) identified that patient choice accounted for 56% of BSC decisions in patients who presented as outpatients and 51.3% of those patients managed by BSC were PS 0–2, highlighting the need for a follow-up service. Following review of this data, the lung cancer CNS team at the UHNM proposed and developed a third treatment arm, running alongside surgery and oncology. This included the implementation of a Best Supportive Care pathway, a standardised electronic assessment tool, and piloting a nurse-led clinic to provide assessment and on-going support. Method: An outpatient telephone appointment was arranged for an initial assessment and follow-up arranged as appropriate. A satisfaction survey was offered to all participants contacted in the nurse-led clinic, using a combination of multiple choice and free-text questions. All surveys were anonymous and not completed by the CNS running the service. Patients excluded from the service: patients who had died, patients being managed at the end of life, patients who declined contact. Results 70% reduced anxiety Two Patients changed their decision and had further palliative treatment. Conclusion: Results provide evidence that this third treatment pathway reduced stress and anxiety, enabled a holistic needs approach, enhanced communication and understanding and improved liaison with community support services. It highlighted the requirement of extra information resources and referrals to other allied health professionals. This is a proactive approach rather than reactive. This Table: (abstract 17). Poster abstracts of the 22nd Annual BTOG / Lung Cancer 190S1 (2024) 10
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