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OBJECTIVE: Rearranged ROS1, present in 1%-2% of non-small cell lung cancer (NSCLC) patients, usually young, never or light smokers, is assessed by fluorescence in situ hybridization (FISH) to determine eligibility for tyrosine kinase inhibitors (TKI). Immunohistochemistry (IHC) for the protein product of ROS1 rearrangement, a cost-effective alternative, is validated on cytology and small biopsy samples.METHODS: From 1 March to 31 December 2019, cytology cell blocks and small biopsy samples from a selected cohort of NSCLC patients were concurrently tested for ROS1 gene rearrangement by Vysis 6q22 Break Apart FISH probe and IHC using Cell Signalling D4D6 antibody. Mismatch cases were tested by an RNA fusion next generation sequencing (NGS) panel.RESULTS: In a prospective population of 95 cases, 91 were negative and two were positive by both FISH and IHC. Both dual positive cases were female never smokers and benefited from TKI treatment. Another two cases were positive by FISH but negative by IHC and repeat by NGS showed one to be negative but one failed. Turnaround time for IHC was 0 to 8 days from request to authorisation, whilst that of FISH was 9 to 42 days at a cost of £51 and £159 respectively.CONCLUSION: IHC to assess for the protein product of ROS1 gene rearrangement on cytology cell blocks and small biopsy samples in a routine setting is a promising screening method to assess eligibility for TKI treatment with positive and indeterminate cases confirmed by FISH or NGS as it has good negative predictive value, faster turnaround time and is cost effective, with proven technical and clinical validation.

Introduction and Objectives Surgical resection for lung cancer is physically and emotionally demanding for patients, with risks of complications and morbidity. Prehabilitation aims to maximise patients’ fitness, nutrition and wellbeing before treatment to improve outcomes. The existing literature on lung cancer prehabilitation points to improved functional capacity, post-operative length of stay & frequency of complications. As such, it is recommended in current guidelines.1 Methods Prehab4Cancer, a Greater Manchester (GM) Cancer funded project, is the first regional system in the UK to introduce large-scale prehab as a standard of care for cancer patients.2 Surgical lung cancer patients are rapidly assessed at one of 17 clinics. Tailored prehab interventions span exercise (re-HIIT: high intensity interval training and muscle strengthening), nutrition, and psychological support. It is delivered by ‘GM Active’, a collective of 12 community organisations utilising cancer rehabilitation-qualified exercise specialists. A 12-week post-op rehabilitation programme follows. Measures of fitness are recorded at baseline, pre-operatively, post-operatively, and after rehabilitation. Results Since April 2019, 380 lung cancer patients have been referred from 11 hospitals, with 75% participating. Average age was 70y; 53% were female. Median duration of prehab was 39 days, with mean 2.2 sessions/week. Physiological assessments such as incremental shuttle walk test (ISWT) improved from median 350 m at baseline to 380 m. Health-related quality of life measures also demonstrated improvement (see table 1). Conclusions Prehab4cancer has successfully implemented a regional cancer prehab programme that demonstrates feasibility and excellent uptake and improved patient experience. Collaboration has been key, between GM-wide healthcare professionals working together with the GM Cancer alliance, people affected by cancer and GM Active. Validated measures of fitness and quality of life show promising trends toward improvement among surgical lung cancer patients. References Batchelor TJP, et al.Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery after Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardio-thoracic Surg 2019;55:91–115. Moore J, Merchant Z, Rowlinson K, et al. Implementing a system-wide cancer prehabilitation programme: The journey of Greater Manchester’s ‘Prehab4cancer’. Eur J Surg OncolPublished Online First: 2020.

IntroductionEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a pivotal test in lung cancer staging and diagnosis, mandating robust audit and performance monitoring of EBUS services. We present the first regional cancer alliance EBUS performance audit against the new National EBUS specification.MethodsAcross the five EBUS centres in the Greater Manchester Cancer Alliance, data are recorded at the point of procedure, when pathological results are available and at 6 months postprocedure to review any further pathological sampling (eg, at surgical resection) and the outcome of clinical–radiological follow-up. Outcomes across all five centres were compared with national standards for all lung cancer EBUS procedures from 01 January 2017 to 31 December 2018.Results1899 lung cancer staging or diagnostic EBUS procedures were performed across the five centres during the study period; 1309 staging EBUS procedures and 590 diagnostic EBUS procedures. Major complications were seen in six cases (85% of procedures performed within 7 days of referral.ConclusionThe National EBUS service specification is an important framework to drive the quality of EBUS services across the UK. Our data provide assurance of appropriate performance and safety while also highlighting specific areas for attention that can be addressed with the support of the cancer alliance.

This first European case series demonstrates that EBUS-TBNA, well established in the diagnosis of mediastinal and hilar adenopathy in adults, is a safe and useful diagnostic alternative to invasive surgical biopsy in the paediatric populationhttp://bit.ly/389Uvq4

Background: Endobronchial Ultrasound (EBUS) in the diagnostic pathway of lung malignancy is widely studied. However, of the patients that undergo EBUS some are found to have non-lung primary carcinoma. It is important these cases are diagnosed to ensure the correct oncological treatment is provided. We analysed our local incidence of such cases diagnosed via EBUS. Methods: Analysis was performed of prospectively maintained EBUS/cytology databases to identify all cases of non-lung primary carcinoma at our unit between 1/1/2013 and 31/12/2018. All identified cases had medical notes, EBUS report including Rapid On-Site Evaluation and final cytology report reviewed. Malignant mesothelioma were excluded. Results: In total 50 patients were identified out of 2130 patients undergoing EBUS (including benign cases) in the study period, 68% male 32% female, age range 30 to 94 years average age 86.6. A total of 66 nodes were sampled with average nodal size 1.74cm and average of 3.7 passes per node. Final pathology showed 24% renal, 20% Gastrointestinal, 10% sarcoma, 10% breast, 10% urological 2% melanoma, 2% olfactory neuroblastoma, 2% squamous cell tongue and 20% of unknown but non-lung primary carcinoma based on radiology and pathology. 36% of all cases had a previous diagnosis of extra thoracic malignancy of these 78% were proven recurrence of the same malignancy. Conclusion: Our experience is that non-lung primary carcinoma is not uncommonly diagnosed via EBUS, removing the need for invasive investigations and ensuring correctly targeted systemic oncological treatment. Further studies with pooling of data from multiple centres are required to study this area.

Background: Differentiating NSCLC pathological subtypes as well as molecular testing is paramount to guide choice of chemotherapy and targeted EGFR and ALK therapies. The 2017 National Lung Cancer Audit( 1) highlighted the need to minimise the rate of NSCLC not otherwise specified (NSCLC-NOS). The objective of our study was to determine whether samples obtained by EBUS-TBNA in the presence of ROSE could be used to subtype NSCLC and provide sufficient material for molecular testing. Methods: A prospective database from a regional thoracic oncology centre was evaluated. All patients diagnosed with NSCLC by EBUS-TBNA cytology between January 2016 and January 2017 were included. Our institute performs reflex testing for EGFR and ALK on all adenocarcinoma or NSCLC-NOS cases. Results: A total of 128 patients were diagnosed with NSCLC via EBUS-TBNA. 11 were NSCLC-NOS (8.6%), 55 were squamous (43%), 56 adenocarcinoma (43.8%), 4 were large cell neuroendocrine (3.1%)and 2 were other NSCLC. 66 appropriate non-squamous lung cancer samples were sent for molecular analysis. For EGFR mutation, 62/66(94%) had sufficient material and 3 were positive (4.5%). For ALK, 63/66 (95%) had sufficient material and 2 (3%) were positive. Conclusions: Our study has illustrated EBUS-TBNA cytology with ROSE can achieve accurate subtyping of NSCLC and a high proportion of sufficient material for molecular analysis. In addition our NSCLC-NOS rate (8.6%)is lower than UK national average (9%) in 2017. References: 1- Royal College of Physicians. National Lung Cancer Audit annual report 2017

A cough is the single most common presenting complaint in primary care; it is a major burden on the UK economy in terms of both health care costs and lost productivity. The vast majority of these cases are an acute cough, primarily due to self-limiting upper respiratory tract infections. However, a significant proportion of the general population (between 10 and 20%) will experience chronic cough, which can have a debilitating and often overlooked impact on the patient’s quality of life. This article describes the primary care evaluation and management of chronic cough in adults, particularly when there is no obvious underlying cause, based on the recommendations of the British Thoracic Society. There is also a brief discussion regarding which cases of acute cough should be referred early before they become chronic. The article does not discuss the management of a cough in children.

Introduction: Surgical resection is optimal for patients with early stage lung cancer. Physiological measurements help predict mortality associated with surgery, particularly in high-risk patients. These include spirometry(FEV1%) diffusion capacity(DLCO%) Cardiopulmonary Exercise Testing(CPET) plus predicted post-operative(PPO) data derived from segment-counting based on proposed surgery. We aim to identify parameters best predicting post-operative mortality in this group. Method: All patients having pre-op CPET at a tertiary thoracic oncology centre between 01/01/2012 and 31/12/2015 were reviewed. Data from physiology, survival and clinical databases were analysed for those undergoing surgery. Results: 158 patients were included for statistical analysis. Single-variable analysis showed BMI

Introduction: The National Institute for Health and Care Excellence (NICE) Lung Cancer Guidelines recommend Positron Emission Computed Tomography (PET-CT) in patients with CT evidence of early stage lung cancer prior to invasive sampling. This study examined adherence to this practice Method: We conducted a retrospective audit of all PET-CT requests across the Manchester Cancer Network (10 trusts) from March 2011 to December 2013. Patients with early stage lung cancer (CT-stage T1-3N0M0) were included. The primary outcome measure was the proportion of patients with a pathologically confirmed diagnosis of lung cancer prior to PET-CT Results: 3904 PET-CTs were performed during this period of which 1057 were for CT-stage T1-3N0M0 disease. In 7.7% of cases a pathological diagnosis was recorded prior to PET-CT. There was no statistically significant variation between trusts (p=0.85)[Table 1]. However, there was significant variability in the proportion of PET-CT requests with incomplete CT stage (29.2%-77.9%; p=

Introduction: The aim of this study was to examine if there is a relationship between PET-CT use and surgical resection rates across a UK Lung Cancer Network. Methods: Manchester Cancer consists of 10 UK NHS trusts. The use of PET-CT per trust was analysed for two time periods, 2011 and 2013, and compared to NSCLC resection rates using spearman correlation and non-parametric Wilcoxon signed ranks tests. Results: PET-CT requests for the staging of NSCLC increased by 66.8% from 1027 in 2011 to 1713 in 2013 across the Network. NSCLC surgical resection increased from 15.3% to 19.4% in the same time period. There was a moderate positive correlation between changes in PET-CT use and NSCLC resection rate (spearman rho 0.59, p=0.073). If we exclude the only Trust with a negative correlation, this becomes significant (spearman rho 0.803 ,p=0.009). Using linear regression an expected change in resection rate based on change in PET use can be calculated; Resection change (y) = 1.645 + (0.212 x PET change). The PET change coefficient is 0.212 with 95% CI (0.086 to 0.338), the model R-squared is 0.693 and is significant (p=0.005) . Conclusions: This study has demonstrated that an increase in PET use is associated with a predictable increase in resection rate. Trusts that fall outside of this predicted change warrant more detailed investigation into the reasons why.

Background: IMHL may be pathological (malignancy, TB, sarcoid) or 'reactive'. EBUS transbronchial needle aspiration (EBUS-TBNA) is the first line investigation but has a reported (Navani, N. et al. Am J Respir Crit Care Med 2012) low negative predictive value (NPV). We devised a risk stratification model to classify patients as high or low risk of false negative sampling after negative EBUS-TBNA (Evison, M et al. BMJ Open Respir Res 2014). The aim of this study was to validate our model in a 2nd cohort. Methods: A retrospective review of prospectively collected data on consecutive patients undergoing EBUS-TBNA for IMHL (Sept 2013-July 2014). Patients with negative EBUS-TBNA were classified high or low risk (low risk defined: max lymphnode diameter

We herein report a case of primary pulmonary hepatoid adenocarcinoma in a 71 year old man and provide an overview on knowledge and existing reports of this rare tumour. Primary pulmonary hepatoid adenocarcinoma is an AFP-producing lung tumour composed of neoplastic cells morphologically resembling hepatocellular carcinoma. The main challenge for physicians encountering such tumours is distinguishing between hepatocellular carcinomas and pulmonary hepatoid adenocarcinomas. Previous literature is conflicting, particularly around the distinguishing immunohistochemical characteristics of the two tumours. Given the rarity of this tumour and paucity of published literature, we believe the clinical–radiological characteristics provide the key to diagnosis and aim to demonstrate this in our case.

Introduction The categorisation of NSCLC into squamous and non-squamous subtypes is an important requirement for the optimisation of patient care as this may modify chemotherapy regimens and direct molecular testing. The lung cancer national audit highlights the need to minimise the rate of NSCLC not otherwise specified (NSCLC-NOS). 1 The aim of our study was to determine whether samples obtained by endobronchial ultrasound guided-transbronchial needle aspiration (EBUS-TBNA) could be used to pathologically subtype NSCLC and provide sufficient material for molecular testing. Methods A prospectively maintained database of consecutive patients with suspected lung cancer referred to our unit, a UK regional thoracic oncology centre, was analysed. All patients diagnosed with NSCLC by EBUS-TBNA cytology at our centre between Sept 2013 and Sept 2014 were included in the study. Results A total of 89 patients were diagnosed with NSCLC using EBUS-TBNA. The pathological subtypes were: n = 46 (51.7%) squamous cell carcinoma, n = 41 (46%) adenocarcinoma and n = 2 (2.2%) NSCLC-NOS. All samples with a new diagnosis of non-squamous subtype were sent for EGFR mutation analysis, with sufficient material in 97% (n = 35/36) and one activating mutation was identified. ALK analysis was successfully performed in all 5 samples in which this was requested. Additional molecular testing was requested in 9 samples with sufficient material in 89% (n = 8/9). Conclusions EBUS-TBNA cytology can be used to successfully subtype NSCLC and provide adequate material for molecular testing in the majority of cases. The rate of NSCLC-NOS in our study (2.2%) compares favourably with local cancer network (13.5%) and national (12.9%) figures. Reference 1 National lung cancer audit report 2014 doi http://www.hscic.gov.uk/catalogue/PUB16019/clin-audi-supp-prog-lung-nlca-2014-rep.pdf

Macrolides are commonly prescribed for chronic obstructive pulmonary disease (COPD) exacerbations and community-acquired pneumonia. The short-term cardiovascular effects, probably due to QT prolongation, are well documented and some studies have implicated macrolides with increased mortality in patients with pre-existing coronary disease. This study evaluated the association between clarithromycin use and cardiovascular events in patients treated for lower respiratory tract infections in a secondary analysis of two prospective …