¹⁸F-FDG positron emission tomography with computed tomography (PET/CT) is a standard imaging modality for the nodal staging of non-small cell lung cancer (NSCLC). To improve the accuracy of pre-operative staging, we compare the staging accuracy of mediastinal lymph node (LN) standard uptake values (SUV) with four derived SUV ratios based on the SUV values of primary tumours (TR), the mediastinal blood pool (MR), liver (LR), and nodal size (SR). In 2015–2017, 53 patients (29 women and 24 men, mean age 67.4 years, range 53–87) receiving surgical resection have pre-operative evidence of mediastinal nodal involvement (cN2). Among these, 114 mediastinal nodes are resected and available for correlative PET/CT analysis. cN2 status accuracy is low, with only 32.5% of the cN2 cases confirmed pathologically. Using receiver operating characteristic (ROC) curve analyses, a SUVmax of N2 LN performs well in predicting the presence of N2 disease (AUC, 0.822). Based on the respective selected thresholds for each ROC curve, normalisation of LN SUVmax to that for mediastinum, liver and tumour improved sensitivities of LN SUVmax from 68% to 81.1–89.2% while maintaining acceptable specificity (68–70.1%). In conclusion, normalised SUV ratios (particularly LR) improve current pre-operative staging performance in detecting mediastinal nodal involvement.

PURPOSE: Pulmonary thromboembolism (PTE) remains under-diagnosed fatal disease at the emergency units suggesting the need for alternative, easy, noninvasive bedside diagnostic approaches. The aim of this study was to determine the diagnostic role of transthoracic ultrasonography (TUS) in PTE, and to evaluate if there is any additive diagnostic value of Color Doppler over gray-scale TUS.

METHODS: Blinded to 64 multi-detectors CT pulmonary angiography (MDCTPA) examination as a gold standard, 60 patients with clinically suspected PTE underwent gray-scale and Color Doppler TUS examination. Results were compared and diagnostic accuracy of TUS was assessed

RESULTS: In 33 patients out of 40 MDCTPA proved cases of PTE, TUS demonstrated 66 lesions with mean (SD) 2±1.20 lesions /patient. For Gray-scale TUS, sensitivity, specificity, positive and negative predictive values and accuracy were 82%, 90%, 94%, 72% and 85%, meanwhile color Doppler TUS had values of 80%, 95%, 97%, 70.4% and 87.5%, respectively.

CONCLUSIONS: TUS is a reliable screening technique for diagnosing PTE with high specificity but relatively low sensitivity. Adding Color Doppler to Gray-scale TUS increases the specificity and consequently the confidence in the diagnosis of peripheral pulmonary infarctions and differentiates them from other pulmonary lesions.

CLINICAL IMPLICATIONS: TUS, in trained hands, has high specificity and diagnostic accuracy allowing its use as bedside screening method in emergency-based situations, especially for critically ill and immobile patients that allows initiation of anticoagulants.

Introduction: Pulmonary embolism (PE) remains under-diagnosed fatal disease at the emergency units suggesting the need for alternative, easy, noninvasive bedside diagnostic approaches. Objectives: The aim of this study was to determine the diagnostic role of transthoracic ultrasonography (TUS) and echocardiography in PE. Also, to evaluate if there is any additive diagnostic value of Color Doppler over gray-scale TUS in PE. Methods: Blinded to 64 multi-detectors CT pulmonary angiography (MDCTPA) examination as a gold standard, 60 patients with clinically suspected PE underwent gray-scale and Color Doppler TUS examination in addition to echocardiography. Results were compared and diagnostic accuracy of different techniques were assessed. Results:According to Modified Wells Score, 42 (70%) of the cases were defined as moderate risk for PE and 18 (30%) were defined as high risk. In 33 patients out of 40 MDCTPA proved cases of PE, TUS demonstrated 66 lesions with mean (SD) 2±1.20 lesion /patient."Consolidation with little perfusion sign" as detected by colour doppler TUS is helpful in differentiating PE from other peripheral lesions. Using echocardiography, signs of acute right ventricular strain with negative TUS and postive MDCTPA was found in 6 out 7 patients. For Gray-scale TUS, sensitivity, specificity, positive and negative predictive values and accuracy were 82%, 90%, 94%, 72% and 85%, meanwhile color Doppler TUS had values of 80%, 95%, 97%, 70.4% and 87.5%, respectively.. Conclusions: TUS combined with echocardiography is a reliable screening technique for diagnosing PE with high specificity and fair sensitivity. Adding Color Doppler to Gray-scale TUS increases the specificity and consequently the confidence in the diagnosis of peripheral pulmonary infarctions and differentiates them from other pulmonary lesions allowing its use as bedside screening technique in emergency-based situations especially for critically ill and immobile patients that allows initiation of anticoagulants

Objectives: Precise staging of non-small cell lung cancer (NSCLC) determines initial treatment and provides more accurate prognostic information for patients. The aim of this cohort study was to determine factors affecting pre- and post-operative mediastinal nodal staging agreement and its effect on 2-year survival.

Materials and Methods: A retrospective multi-centre cohort study was performed, using prospectively collected and pre-defined data from weekly lung cancer multidisciplinary team meetings in 11 hospitals.  Consecutive patients who underwent surgical resection of NSCLC between 2015 and 2017 were eligible. Factors associated with concordant and discordant pre- and post-operative nodal staging, and subsequent lung cancer-specific 2-year mortality were identified by univariate and multivariate regression.

Results: 973 patients fulfilled the eligibility criteria. Concordant pre- and post-operative nodal staging was observed in 783/973 (80%). 123/973 (13%) were under-staged pre-operatively. 67/973 (7%) were over-staged.In 173 patients with clinical N1 or N2 disease (in whom invasive mediastinal staging was indicated), staging EBUS was performed in 55/173 (32%). In these patients, younger age and use of staging EBUS were independent predictors of concordant pre- and post-operative staging.In all patients pre-operative under-staging was independently associated with increased lung cancer-specific 2-year mortality.

Conclusion: Invasive mediastinal staging with EBUS was independently associated with more accurate pre-operative staging. Pre-operative nodal under-staging was associated with increased lung cancer specific mortality. Nodal staging accuracy in potentially curable NSCLC is of fundamental importance to ensure patients receive the correct first-line treatment and to improve survival.

Introduction: The evidence base for follow up of NSCLC following surgery remains limited, with variation between guidelines and in clinical practice.

Aims: Review follow up practice, recurrence and subsequent treatment across 11 centres within the West of Scotland.

Methods: Data for 963 consecutive patients treated from 2015-17 were collected prospectively with follow up practice and recurrence within 2 years examined using electronic case notes.

Results: 55% of patients were followed up with plain film, 39% had planned CT scanning with a small proportion lost to follow up.

Overall 26% of patients recurred and this increased with stage (Table 1). Method of recurrence detection is shown in Table 2. 68% of patients had distant metastatic disease at the time of their recurrence diagnosis.

Conclusion: There is significant variability in follow up practice across the West of Scotland. A high proportion of patients who recurred had distant metastatic disease at the time of diagnosis with a small proportion suited for radical treatment. Regular post surgical imaging for patients with higher risk of recurrence may allow more patients to have further radical treatment.

Introduction: Precise pre-treatment staging of non-small cell lung cancer (NSCLC) determines initial treatment and provides more accurate prognostic information for patients.

Aim: To determine the agreement between clinical and pathological stage for patients with NSCLC, and its effect on 2-year survival in a cohort of patients who had modern staging investigations.

Methods: Patient data were prospectively collected from 11 local MDTs. We included consecutive patients in the West of Scotland who underwent surgical resection from 2015 to 2017. Clinical and pathological TNM stages were recorded and compared and we investigated the effect of stage change on survival.

Results: 975 patients had a complete data and fulfilled the inclusion criteria. 55% were female and the mean age was 69. Concordance between clinical and pathological TNM was achieved in 558 (57%) patients, 280 (29%) were pathologically upstaged, and 137 (14%) downstaged after surgery. 124 patients (13%) had a higher pathological N stage, of which 70 (56%) had unforeseen N2 or N3 disease. Patients who were pathologically upstaged had poorer survival(Figure 1, p< 0.0001).However, this difference was explained by pathological stage.

Conclusions: Accuracy of pre-operative NSCLC staging is poor despite the widespread availability of PET-CT and endobronchial ultrasound. Improvement in pre-operative staging is necessary to ensure the correct first treatment is delivered to patients.

Introduction Lung cancer is relatively common in patients with fibrotic ILD. The presence of ILD can influence patient selection for treatment and raises concerns about treatment risks and outcomes.

Aim To investigate the prevalence of ILD among patients with advanced lung cancer who received chemotherapy as an initial treatment and to explore clinical features and prognosis in this group compared to other lung cancer patients without ILD.

Method We studied consecutive lung cancer patients in the West of Scotland Lung Cancer Database treated with chemotherapy in one year (2017). Pre-treatment chest CT scans were evaluated by two radiologists with double reading of a proportion to assess consistency. If present, ILD was further classified into 3 groups: usual interstitial pneumonia (UIP), possible UIP, and inconsistent with a UIP pattern according to ATS/ERS/JRS/ALAT guidance.

Results 448 patients were included in the study, with 44 (9.8%) identified as having ILD (15 UIP, 14 possible UIP and 15 inconsistent with UIP). Compared with those without ILD, patients with ILD were older (mean:72 vs 66 years, p<0.001), predominantly male (77% versus 46%, P >0.01), had a significantly higher performance status score (p=0.014) and earlier TNM stage (49% stage IV versus 70% stage IV, p=0.009). Small Cell Lung Cancer was the most common histologic type in the ILD group (50%), while in the non-ILD group adenocarcinoma (37.4%) was followed by squamous cell carcinoma (36.4%). Pre-treatment pulmonary function tests showed that patients with ILD had significantly lower forced vital capacity (FVC) (median: 92% versus 105%, P = 0.002) and diffusing capacity for carbon monoxide (DLco) (median: 55% versus 72.5%, P<0.001).

Median survival times for ILD and non-ILD group were not significantly different at 319 and 344 days respectively (log-rank test P=0.3).

Conclusion Lung cancer patients with concomitant ILD have specific demographic, histological and functional features. However, concomitant ILD does not confer a survival disadvantage after receiving chemotherapy in this group with advanced lung cancer. These patients should not be denied the chance of treatment based solely on their underlying ILD.