Malignant mesothelioma (MM) is an aggressive cancer and diagnosis can be challenging. Typical histology, positive immunohistochemical (IHC) markers and tissue invasion are diagnostic. However it can be difficult to differentiate benign atypical or reactive mesothelial proliferation from MM. Loss of nuclear BAP1 staining is highly specific for MM and can be a useful adjunct. We aimed to identify cases where BAP1 status was instrumental in confirming diagnosis of MM in our regional mesothelioma MDT. We retrospectively reviewed cases of all patients who underwent BAP1 testing on cytology/biopsy samples between 23/2/19-8/12/20. We compared characteristics and identified where BAP1 was instrumental in the diagnosis of MM in the presence of non-diagnostic or inconclusive histology/IHC. 49 patients were identified; 39(80%) were male, with mean age of 74 years. 36(74%) were diagnosed with MM, in whom 20(56%) demonstrated BAP1 loss (Figure 1). This was almost universally associated with epithelioid histology (17/20;85%). All non-neoplastic mesothelial biopsies retained BAP 1. BAP1 loss had 56% sensitivity, 100% specificity, 100% positive predictive value and 30% negative predictive value. BAP1 status was the critical diagnostic test in 25% cases of MM. We confirm moderate sensitivity and excellent specificity of BAP1 loss in MM and reliable differentiation of MM from benign mimics, supporting its use in the diagnostic pathway.

Background and Objectives Ways to assess and track progress of new EBUS operators and trainees is desirable to ensure training goals and procedural competence are achieved and maintained. While important, relying on the diagnostic yield or on question-based assessments alone is not sufficient. Methods This study examined the longitudinal change in times taken between needle passes (needle pass time; NPT) during EBUS lymph node sampling as a metric to monitor progress. The EBUS database of a tertiary hospital that employs 1–2 lung cancer fellow per year was accessed to extract data on the first 50 EBUS procedures for three trainees were collected. The NPT was derived using PACS images that are stored to document every needle pass during an EBUS procedure and an average NPT per procedure was calculated. Results Between the three trainees 157 procedures were carried out within the study period with 302 LN stations sampled. Station 7 was the most commonly sampled (36.9%). The mean NPT (n=204 stations) was 2:49±0:49 mins. The mean lymph node short axis diameter (n=210) was 15.5±8.7 mm. There was a negative correlation between node size and time per pass (r -0.146, p=0.045). The change in average NPT and time between passes during the study period for the trainees is plotted in figure 1 showing a consistent decrease in average times between passes during the first 50 procedures. A point of 'convergence' around the 30th procedure with less variation between procedures was noted (red vertical lines) for the three trainees. On multivariate regression, NPT was significantly associated with procedure order and type of station sampled but not lymph node diameter. Conclusion NPT and time between stations are easy metrics that can potentially help ensure EBUS trainees are advancing in a given training programme.

Background The UK lockdown introduced on 23rd March 2020 to flatten the curve of the COVID-19 pandemic was associated with a decrease, or cessation, of most non-COVID-19 NHS services, affecting other patient groups requiring time-critical access to NHS services. Objectives We assessed the impact of COVID-19 on our pleural service. Methods All patients referred to the pleural service during the official period of lockdown 23/3/20–11/5/20 (7 weeks) were identified alongside those referred in the preceding and following 7 weeks. Patient demographics, number and type of referrals (2 week wait, in-patient or out-patient), length of time to see the patient, procedures performed and ultimate diagnosis from the referral were collected. We defined cancer based on new diagnosis or management of malignant effusions and suspected pleural infection based on investigation for pH<7.2. Results During this 21 week period 401 patients were referred to the pleural service. The mean±SD age was 67.4± 15.4 years and 285/401 (71%) were male. Referrals dropped by 23% during lockdown returning to normal in the 7 weeks post lockdown. From baseline cancer diagnoses increased by 24% during lockdown and 53% in the 7 weeks following lockdown (Graph 1). This increase in cancer diagnosis was secondary to in-patient referrals (pre, during and post lockdown: 6/23(26%), 14/22(63%) and 15/25(60%) respectively (p=0.02). Suspected pleural infection referrals reduced by 21% during the lockdown. Time from referral to review increased from 1[1–2]days to 3[1–5]days during the lockdown, reducing to 2[0–4]days post lockdown (p=0.002). The subsequent delays driven by mandatory swabs to exclude SARS-CoV-2 infection prior to review. Conclusion Due to the national lockdown a reduction in referrals to our pleural service was observed, particularly affecting reviews and suspected pleural infection, but interestingly not cancer diagnoses. However, consequently we have seen an increase in diagnosis in malignancy and pleural infection driven through our in-patient cohort rather than 2 week wait referrals, indicating a probable delay in seeking medical attention or higher threshold for referral during the lockdown. COVID swabbing has impacted our timeliness to review urgent outpatients. The effect of COVID-19 lockdown will continue, and the true impact is yet to be determined.