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ERS Annual Congress Vienna

15 September 2012

Postgraduate Course 3 Radiologicalpathological correlation of tumoural and non-tumoural pathology: an interdisciplinary approach

Saturday, 1 September 2012 09:3013:00 Room: C7

An interdisciplinary radiological-pathological approach of tumoural pathology

Dr. Johan Coolen University Hospital Gasthuisberg Dept of Radiology Herestraat 49 3000 Leuven Belgium johan.coolen@uzleuven.be Aims
The basic knowledge of the role of a multidisciplinary oncologic consult To recognise the benefit of a radiological pathological correlation To be aware of new diagnostic tools in radiology and pathology which leads to better diagnosis, staging and therapies

Summary
Practice organisation of lung cancer care leads to a multidisciplinary oncologic team for respiratory diseases. Cancer care can be complex, and given the wide range of healthcare professionals involved, an enormous potential for poor coordination and miscommunication can exist. The multidisciplinary cancer conference (MCC) has the following primary and secondary functions:

Primary function
Ensure that all appropriate diagnostic tests, all suitable treatment options, and the cost appropriate treatment recommendations are generated for each cancer patient discussed prospectively in a multidisciplinary forum. Provide a forum for the continuing education of medical staff and healthcare professionals. Contribute to patient care quality improvement activities and practice audit. Contribute to the development of standardised patient management protocols. Contribute to innovation, research and participation in clinical trials. Contribute to linkages among regions to ensure appropriate referrals and timely consultation and to optimise patient care.

Secondary function

In our hospital the LLCG (Leuven Lung Cancer Group) organise weekly an MCC consisting of three parts. First, the thoracic surgeons go through the operation list from last week and comment on interesting cases. Secondly, an item of the week is presented by a staff member; these are short speeches with various content like recent congress overview, research etc. In the third part of the meeting, new patient records with suspected or known respiratory tumours (lungs, pleura and mediastinum) are discussed. On the basis of file data, including diagnostic, imaging and biopsy procedures, staging is proposed and if possible a treatment plan in line with the multidisciplinary guidelines is performed or additional procedures are scheduled. The cooperation between and presence of pulmonary oncologist, thoracic surgeon and radiation oncologist is primordial. Because imaging plays an integral role in detection, staging and follow-up evaluation of malignancies, also the input of anatomopathology, radiology and radioisotope is useful. If possible the general practitioner (GP) of the patient should attend this meeting. Otherwise the staging and advice has to be fully and clearly communicated to the GP and/or specialist of the patient. In this session we focus on the radiologicalpathological correlation of tumours and tumour-like conditions; it is a case-based presentation.

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Some of these cases have perhaps a trivial diagnosis, but others reflect the need of this correlation. The arsenal of diagnostic radiological tools for detecting and staging will pass in review. The concept of functional magnetic resonance will be explained and the applications will be demonstrated in practice. Also hybrid techniques that combine functional and morphologic imaging show promise. Hopefully we clarify some difficulties in an alphabet soup of immunohistochemistry and cytogenetics. Closer communication between radiologist, pathologist and treating clinician becomes important to ensure selection of the ideal imaging modalities and correct therapy for each clinical scenario. The session summary consists further of the slides.

References
1. Alberts WM, Bepler G, Hazelton T et al. Practice Organisation. Chest 2003; 123:332S-337S. 2. Alberts WM. Diagnosis and management of lung cancer executive summary: ACCP evidencebased clinical practice guidelines (2nd Edition). Chest 2007; 132: 1S-19S. 3. Cadranel J, Zalcman G, Sequist L. Genetic profiling and epidermal growth factor receptordirected therapy in non-small cell lung cancer. Eur Respir J 2011; 37: 183-93. 4. Chernoff D, Stark P. Magnetic resonance imaging of the thorax. www.uptodate.com. 5. Coolen J, De Keyzer F, Nafteux P et al. Maligant pleural disease: diagnosis by using diffusion-weighted and dynamic contrast-enhanced MR imaging: initial experience. Radiology 2012;263:884-892. 6. De Wever W, Stroobants S, Coolen J and Verschakelen JA. Integrated PET/CT in the staging of nonsmall cell lung cancer: technical aspects and clinical integration. Eur Respir J 2009; 33: 1-12. 7. Felip E, Gridelli C, Baas P, Rosell R, Stahel R. Metastatic non-small cell lung cancer: consensus on pathology and molecular tests, first-line, second-line, and third-line therapy: 1st ESMO Consensus Conference in Lung Cancer; Lugano 2010. Ann Oncol 2011; [Epub ahead of print DOI: 10.1093/annonc/mdr150]. 8. Geisinger KR and Ptman MB. Cytohistology of small tissue samples: lung and mediastinal cytohistology. Cambridge Medicine 2012. ISBN 978-0-521-51658-7. 9. Gridelli C, Maione P, Rossi A, Ferrara ML, Castaldo V, Palazzolo G, Mazzeo N. Treatment of advanced non-small cell lung cancer in the elderly. Lung Cancer 2009;66: 282-86. 10. Husain AN. Thoracic Pathology. Elsevier 2012. ISBN 978-1-4377-2380-9. 11. Kane B, Luz S. Information sharing at multidisciplinary medical team meetings. Group Decis Negot 20011; 20: 437-464. 12. Leary A. Lung cancer: a multidisciplinary approach. Wiley-Blackwell 2012. ISBN:978-14051-8075-7. 13. Leuven Lung Cancer Group 2012. http://www.lungcancergroup.be 14. Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, Sunpaweravong P, Han B, Margono B, Ichinose Y, Nishiwaki Y, Ohe Y, Yang JJ, Chewaskulyong B, Jiang H, Duffield EL, Watkins CL, Armour AA, Fukuoka M. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med 2009;19;361: 947-57. 15. Raez LE, Silva OE. Lung cancer: a practical guide. Saunders Elsevier 2008. ISBN:978-07020-2889-2. 16. Ruhstaller T, Roe H, Thrlimann B and Nicoll JJ. The multidisciplinary meeting: an indispensable aid to communication between different specialities. Eur. J. Cancer 2006;42: 2459-2462. 17. Scherpereel A, Astoul P, Baas P et al. Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma. Eur. Respir. J. 2010; 35:479-495. 18. Sculier JP, Moro-Sibilot D. First- and second-line therapy for advanced non-small cell lung cancer. Eur Respir J 2009; 33: 915-30. 19. Taylor C, Munro AJ, Glynne-Jones R et al. Multidisciplinary team working in cancer: what is the evidence? BMJ 2010; 340: 743-745. 20. Travis WD, Brambilla E, Noguchi M et al. International Association for the study of lung cancer / American Thoracic Society / European Respiratory Society International

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Multidisciplinary Classification of lung adenocarcinoma. J. Thoracic Oncology 2011; 6: 244285. 21. Vansteenkiste J, Dooms C, De Leyn P. Early stage non-small-cell lung cancer: challenges in staging and adjuvant treatment: evidence-based staging. Ann of Oncology 2010; 21: 189-195.

Evaluation
1. What different health-care professionals are present here? a. General Practitioner b. Oncologist c. Pathologist d. Pneumologist e. Radiologist f. Radiotherapist g. Nuclearist h. Others 2. Which lesion is malignant? a. irregular peripheral lesion b. bean-shaped lesion with a pleural tag and FDG negative c. subpleural irregular lesion with spiculation and sharp contours d. great mass in upper lobe 3. Which FDG-avide lesion is benign? a. mass with possible vascular association b. nodule in patient with haemoptysis c. nodule with small calcifications d. hilair/mediastinal conglomerates with vena cava superior syndrome 4. Which statement is correct? a. Radiological imaging lacks information on the biological nature of lung lesions (ESMO 2010) b. In the diagnostic procedures for MPM, MRI is not relevant (1B) (ERS 2011) c. Functional MRI seems a promising tool for characterisation of lung lesions (ESTI 2012) d. According to the recent published IASLC/ATS/ERS International Multidisciplinary Classification of lung adenocarcinoma complete sampling of the lesion is required and image-guided percutaneous lung biopsy plays no role in the assessment of part-solid nodules. (STR 2012) Please find all answers at the back of your handout materials.

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