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3S
degree of the resected lung specimen after neoadjuvant therapy can
predict the survival outcome (Yamane, Y. et al. JTO 2010, Cascone T, et
al. Ann Thorac Surg. 2018). Pathological response to neoadjuvant
therapy is highlighting as a surrogate endpoint for survival or recur-
rence. The assessment method for regression grade of resected lung
specimen after neoadjuvant therapy was reported in 1997 (Junker K et
al. J Cancer Res Clin Oncol. 1997). IASLC multidisciplinary group has
recently proposed the comprehensive recommendation for pathologic
assessment of lung cancer resection specimens following neoadjuvant
therapy in 2020 (Travis WD et al. JTO 2020). Major pathologic response
(MPR) has been proposed as a surrogate marker defined as a 10%
residual viable tumor following neoadjuvant therapy (Hellmann M.D. et
al. Lancet Oncol. 2014). In their proposal, the pathological surrogate
should have optimum qualities (Table 1). MPR is defined as less than
10% residual viable tumor after neoadjuvant therapy. MPR can be
observed more frequently than a pathological complete response
(pCR), defined as no viable residual tumor. The 10% cutoff is deter-
mined based on the previous studies on the pathologic assessment of
resected lung after neoadjuvant chemoradiotherapy (Junker K, et al. J
Cancer Res Clin Oncol. 1997; Pataer A et al. JTO 2012). According to
IASLC recommendation, the resected lung specimen should be cut in 5-
10mm serial section, then sampled optimal section to evaluate the
tumor bed. A tumor bed is defined as the area composed of 1) viable
tumor tissue, 2) necrosis, and 3) stromal tissue. Stromal tissues include
both fibrosis and inflammation, which can be observed in a non-neo-
adjuvant specimen and have variable histologic features. It is difficult,
sometimes impossible, to judge necrosis and stromal tissue whether it
was the therapeutic response or not. The semiquantitative approach is
practically recommended. The percentage of three components should
be estimated as 10% in increments unless 5% in a single count and the
total should be 100%. The pathologic response degree is calculated as a
residual viable tumor percentage in the tumor bed. Pathologic assess-
ment must sample the optimal area by careful pathologists’ observation
in collaboration with surgeons and radiologists. The sections should
include enough sections to determine the tumor bed and the tumor
periphery to define the borderline. Pretreatment CT images may help to
determine the complexity in the resected specimen. Lastly, several is-
sues are on assessing pathologic response degree: reproducibility,
reliability, and feasibility. It has been mentioned that neoadjuvant
therapy response pathological features were different between
chemotherapy and immunotherapy (Cottrell TR et al. Annals of
Oncology. 2018); the optimal cutoff value may differ in several settings,
including histology (Qu Y et al. JTO 2019). References: Yamane Y, et al.
A Novel Histopathological Evaluation Method Predicting the Outcome
of Non-small Cell Lung Cancer Treated by Neoadjuvant Therapy; The
Prognostic Importance of the Area of Residual Tumor. J Thorac Oncol.
2010;5:49-55. Cascone T et al. Induction Cisplatin Docetaxel Followed
by Surgery and Erlotinib in Non-Small Cell Lung Cancer. Ann Thorac
Surg. 2018;105(2):418-24. Junker K, et al. Tumour regression in non-
small-cell lung cancer following neoadjuvant therapy. Histological
assessment. J Cancer Res Clin Oncol. 1997;123(9):469-77. Travis WD,
et al. IASLC multidisciplinary recommendation for pathologic assess-
ment of lung cancer resection specimens following neoadjuvant ther-
apy. Journal of Thoracic Oncology. 2020. Hellmann MD, et al.
Pathological response after neoadjuvant chemotherapy in resectable
non-small-cell lung cancers: proposal for the use of major pathological
response as a surrogate endpoint. Lancet Oncol. 2014;15(1):e42-50.
Pataer A et al. Histopathologic response criteria predict survival of
patients with resected lung cancer after neoadjuvant chemotherapy. J
Thorac Oncol. 2012;7(5):825-32. Forde PM, et al. Neoadjuvant PD-1
Blockade in Resectable Lung Cancer. N Engl J Med. 2018;378(21):1976-
86. Cottrell TR, et al. Pathologic features of response to neoadjuvant
anti-PD-1 in resected non-small-cell lung carcinoma: a proposal for
quantitative immune-related pathologic response criteria (irPRC).
Annals of Oncology. 2018;29(8):1853-60. Qu Y, et al. Pathologic
Assessment After Neoadjuvant Chemotherapy for NSCLC: Importance
Journal of Thoracic Oncology Vol. 16 No.
and Implications of Distinguishing Adenocarcinoma from Squamous
Cell Carcinoma. J Thorac Oncol. 2019;14(3):482-93.
Table 1. Optimum qualities of a pathological surrogate for
survival after neoadjuvant therapy (modified from Hellman
MD, Lancet Oncol. 2014)
Factors Requirement
Valid Improvement in the surrogate outcome should correlate
with improvement in overall survival, including in specific
histologic and molecular subgroups.
Reflective Surrogate outcome should reflect the biologic impact of
treatment as well as the magnitude of the effect of the
treatment on survival.
Moderately Surrogate outcome should be sufficiently frequent to
frequent permit statistically relevant assessments using reasonable
sample sizes, but sufficiently infrequent enough that
improvement is attainable.
Defined Surrogate outcome should have an unequivocal definition.
Feasible Surrogate outcome should be easily and feasibly assessable
with universally acceptable methods.
Reproducible Surrogate outcome should be reproducible with minimal
inter-observer variability.
Keywords: Major Pathologic Response (MPR), pathological complete
response (pCR), Pathologic response degree of neoadjuvant therapy
ES07 PLEURAL EFFUSION IN A CANCER PATIENT FRIDAY,
JANUARY 29, 2021 - 15:30-16:30
ES07.01
Radiological Evaluation of Pleural Effusion in a
Cancer Patient
Y. Chang Department of Medical Imaging, National Taiwan University
Hospital, Taipei/TW
Pleural effusion (PE) is not infrequently seen in cancer patients. Ma-
lignant pleural effusion (MPE) is an exudative effusion with malignant
cells. MPE is a common symptom and accompanying manifestation of
metastatic disease. It affects up to 15% of all patients with cancer and is
the most common in lung, breast cancer, and gastrointestinal tract
adenocarcinoma or ovarian, gynecological malignancies and malignant
mesothelioma. Once PE is identified in a cancer patient, the most
important issue is to clarify the nature of pleural effusion which is
benign or malignant. The most common radiographic evaluation of
cancer patients is chest radiograph. Radiographical detection of small
PE is difficult on chest PA view unless significant amount to obscured
the lateral costophrenic angles. Computed tomography (CT) is
commonly used for clinical staging which may reveal the presence of
pleural effusion, thickening, nodularity or mass(es). The presence of
pleural nodularity or masses in a cancer patient is frequently due to
pleural metastasis or tumor seeding. Pleural effusion in patients with
lung cancer may raise high suspicion of malignant pleural effusion
(M1a) unless there is associated pneumonia or heart failure which may
be the etiology of pleural effusion. Clinical workup of the persistent PE
in a cancer patient should be carried out even nonvisualization of
pleural nodularity or tumor seeding. Microscopic evidence or analysis
of the cell block from PE is important to diagnose the etiology of pleural
effusion. In this refreshed lecture, we are going to show typical MPE
and suggested algorithm if PE is found in a cancer patient. Keywords:
pleural effusion, Radiology