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Mediastinal staging in lung cancer

Mediastinal staging in lung cancer. Tuncay Göksel Ege Üniversitesi Tıp Fakültesi Göğüs Hastalıkları Anabilim Dalı. Clinical and radiological staging is enough. DEFINITIONS. Mediastinoscopy: No Absolute T4 disease. Mediastinoscopy: Yes T 1-3 N2 disease. Mediastinoscopy: ? +/- ?

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Mediastinal staging in lung cancer

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  1. Mediastinal staging in lung cancer Tuncay Göksel Ege Üniversitesi Tıp Fakültesi Göğüs Hastalıkları Anabilim Dalı Clinical and radiological staging is enough

  2. DEFINITIONS

  3. Mediastinoscopy: No Absolute T4 disease

  4. Mediastinoscopy: Yes T1-3 N2 disease

  5. Mediastinoscopy: ?+/-? Central TM or N1 disease

  6. Mediastinoscopy: No T1-3 N0 disease

  7. Mediastinal lymph node met. on CT Silvestri, Chest 2007;132;178-201 Sensitivity: 51% Specificity: 86%

  8. Other metaanalysisCT & mediastinal nodes • Gould et al • Sensitivity: 61% • Specificity: 79% Ann Intern Med 2003; 139:879–892 • Dwamena et al • Sensitivity: 64% • Specificity: 74% Radiology 1999;213:530–536 • Daleset al • Sensitivity: 79% • Specificity:78% Am Rev Respir Dis 1990; 141:1096–1101

  9. Mediastinal lymph node met. on PET Silvestri, Chest 2007;132;178-201 Sensitivity: 74% Specificity: 85%

  10. Meta-analysis of PET and CT in detecting mediastinal lymph node in NSCLCBirim et al, Ann Thorac Surg. 2005;79(1):375-82 . • PET > BT in diagnostic accuracy (all studies)

  11. PET & CT for mediastinal staging, A meta-analysisGould et al, Ann Intern Med 2003; 139:879–892

  12. PET-CT vs PETCerfolio, Ann Thorac Surg 2004;78:1017–23 • Accuracy of of N2 • PET-CT > PET: (96% versus93%, p 0.01) • Accuracy of of N1 • PET-CT > PET: (90% versus 80%, p 0.001)

  13. Mediastinoscopy Detterbeck, Chest 2007;132;202-220 Sensitivity: 78% Specificity: 100% False negative: 11%

  14. The value of mediastinoscopy in NSCLC patients with clinical N0 diasease. Gürses, Turna, Bedirhan et al Thorac Cardiovasc Surg 2002; 50:174-177. • 79 cases with CT negative  mediastinoscopy • Negative prediktive value (all group) • CT  92,4% (73/79) • Mediastinoscopy  93,4% (57/61) p>0.05 • Negative prediktive value (adenokarsinom) • CT  76,5% (13/17) • Mediastinoscopy  87,5% (15/17) p>0.05

  15. Mediastinoscopy vs CT+Mediastinoscopy The Canadian Lung Oncology GroupAnn Thorac Surg. 1995 Nov;60(5):1382-9 • A randomized, controlled trial to decide on the necessity for mediastinoscopy in all cases • Mediastinoscopy in all cases • Mediastinoscopy only in patients with lymph node > 1 cm on CT • Use of CT in comparison with mediastinoscopy in all patientsstrategy was likely to produce the same number of or fewer unnecessary thoracotomies

  16. PET vs MediastinoscopySerra et al, ASCO 2006 Meeting Proceedings • Clinic database review • 655 routine mediastinoscopy • 90 routine PET • Understaged N2 (underwent to thoracotomy) • Routine PET+mediastinoscopy 7.8% • Routine mediastinoscopy  6.1% (p>0.05)

  17. PET vs MediastinoscopyVerhagen et al, Lung Cancer (2004) 44, 175—181 • 72 consecutivepatients; PET vs mediastinoscopy • PET, all cases • Negative predictive value: 71% • Positive predictive value : 83% • Mediastinoscopy • Negative predictive value: 92 % • Positive predictive value :100% • PET,in patients with negative N1 nodes and a non-centrally tumor • Negative predictive value: 96% • Negative PET in non-centrally tumor and without N1 node  mediastinoscopy should be omitted • This approach reduces the number of mandatory mediastinoscopy by 46% without an increase in unexpected N2

  18. Mediastinoscopy 2 R L 4 R L • Bilateral paratracheal stations • 2R, 2L, 4R, 4L • Ant and proximal subcarinal station • 7 7 8,9 5, 6

  19. False negative cases on mediastinoscopy • 42 to 57% of the FN cases were dueto nodes that were not accessible by the mediastinoscope • (5,6,8,9 and part of 7) Coughlin, Ann Thorac Surg 1985; 40:556–560 Staples, Radiology 1988; 167:367–372 Gdeedo, Eur Respir J 1997; 10:1547–1551 Van den Bosch, J Thorac CardiovascSurg 1983; 85:733–737 Hammoud, J Thorac Cardiovasc Surg 1999; 118:894–899 Lardinois, Ann Thorac Surg2003; 75:1102–1106

  20. The yield of mediastinoscopy Fibla et al, J Thorac Oncol 2006; 1: 430-33 • False negative: 19.6%

  21. Location of tumor &the most common lymph node metastasis • Tumors in • the rightupper lobe4Rand 2R stations • the right middle lobe  7 station • the right lower lobe  4Rand 7 stations • the left upper lobe 5and 6 stations • the left lowerlobe 5 and 7 stations Cerfolio, Ann Thorac Surg 2006; 81:1969–1973 Kotoulas, Lung Cancer2004; 44:183–191 Naruke T, Eur J CardiothoracSurg 1999; 16:S17–S24

  22. Naruke T, Eur J CardiothoracSurg 1999; 16:S17–S24 Right middle #7,8,9: 27% #8,9: 0% Right lower #7,8,9: 42% #8,9: 4% Right upper #7,8,9: 12% #8,9: 0.5%

  23. Naruke T, Eur J CardiothoracSurg 1999; 16:S17–S24 Left upper lobe #5,6,7,8,9: 66% #5,6,8,9: 56% Left lower lobe#5,6,7,8,9: 68% #5,6,8,9: 28%

  24. Improving the inaccuracies of clinical staging Cerfolio et al, Ann Thorac Surg. 2005 Oct;80(4):1207-13 • A prospective trial to compare clinical stage and pathologic stage • RoutinE PET/CT • Clinical N0  thoracotomy • Clinical N2  • Mediastinoscopywas used to biopsy for 2R, 4R, 2L, 4L, ant 7 • EUS+TBNA was used to biopsy for posteriorN2 (5, 7, 8, and 9) • Unsuspected N2: PET/CT or CT scan negative (clinicallycalled N2 negative) but pathologically metastatic

  25. Improving the inaccuracies of clinical staging Cerfolio et al, Ann Thorac Surg. 2005 Oct;80(4):1207-13

  26. Improving the inaccuracies of clinical staging Cerfolio et al, Ann Thorac Surg. 2005 Oct;80(4):1207-13 Unsuspected N2  #7 : 52% #5-6 : 24% #2-4R : 16% #8-9 : 8%

  27. Routine mediastinoscopy andEUS+FNA in patients with clinically N2 negativeCerfolio et al, CHEST 2006; 130:1791–1795 • A prospective trial, NSCLC • Clinically staged N2 negative byboth PET/CT and CT scan. • Routine both mediastinoscopy and EUS-FNA • Mediastinoscopywas used to biopsy for 2R, 4R, 2L, 4L, ant 7 • EUS+TBNA was used to biopsy for 5, 7, 8, and 9

  28. Cerfolio et al, CHEST 2006; 130:1791–1795 4.4%

  29. Routine Mediastinoscopy andEUS+FNA in Patients With Clinically N2NegativeCerfolio et al, CHEST 2006; 130:1791–1795 Conclusion • Routine mediastinoscopy or EUS-FNA • itis not recommended in clinically N0 but it is recommended in clinically N1 • Since N2 disease was more oftenlocated in the posterior mediastinal lymph nodesthat are not accessible via mediastinoscopy, EUS-FNA should be added to the algorithm.

  30. EUS+FNA in patients with negative mediastinoscopyEloubeidi,Ann Thorac Surg 2005;80:1231– 40 • 35 patients who had a priornegative mediastinoscopy • EUS TBNA • 13 patients (37.1%) had malignantN2 or N3 • Cost for per patient (avarage) • Initial EUS-FNA: $1,867 • Initial mediastinoscopy: $12,900

  31. EUS FNA Detterbeck, Chest 2007;132;202-220 Sensitivity: 84% Specificity: 99.% False negative: 19%

  32. EBUS TBNA Detterbeck, Chest 2007;132;202-220 Sensitivity: 90% Specificity: 100% False negative: 20%

  33. EBUSin negative mediastinum in the CT-ScanHerth, et al, Eur Respir J 2006 Nov; 28 (5):910-4 • 100 patients with NSCLC • 119 lymph nodes punctured • all LN controlled by surgery • Sensitivity: 92.3% • Specificity: 100.0% • NPV: 96.3%

  34. Comparison of EBUS, PET, CT in staging in lung cancerYasufuku, Chest 2006; 130; 710-718 • Prospective study • 102 patients with NSCLC • all patients planned for surgery

  35. TBNA 2R, 2L, 4R, 4L 7 10R, 10L, 11 TBNA Specimen adequate: 80–90% Sensitivity: 78% False negative rate: 28% Specifity: 99% False positive rate: 1% Detterbeck FC et. Al. Chest 2007; 132: 202S-220S

  36. EUS-FNA for mediastinal restaging after induction CT for NSCLC Annema et al., Lung Cancer 2003;42:311-18. • 19 patients • N2 positive • induction chemotherapy • Re-staging by EUS TBNA • Sensitivity:75% • Specificity:100%

  37. EBUS-TBNA for mediastinal restaging after induction CT for NSCLC Herth et al, Chest 2007 Vol 132 (S4): 466S • 123 patients • N2 positive • Induction chemotherapy • Restaging by EUS TBNA • Sensitivity:76% • Specificity:100% Accuracy : 77%

  38. Summary-1 • Specificity is more important than sensitivity for CT and PET because of exclusion • CT  specificity: 86% • PET specificity: 85% • <1 cm LAP on CT: PET specificity: 93% • Negative N1 nodes and a non-centrally tumor  NPV: 96% • The specificity and the FP of mediastinoscopy  100% and 0% • Reliably? No confirmation such as thoracotomy • Understaged N2 (unnecessary thoracotomy) • Routine CT+mediastinoscopy or Routine PET+mediastinoscopy same or fewer

  39. Summary-2 • The yield of mediastinoscopy is low in • node < 1cm  8.5% • squamous and clinical N0  3.3% • Left lobe tumor 18.6% • FN 11% of mediastinoscopy • 50% of the FN not accessible by the mediastinoscopy (#5,6,8,9 and part of 7) • ~30-66% left lung  # 5,6,8,9,7 • Risk of N2-3  5-8% in Clinically N0  20-30% in Clinically N1 (but majority is posterior N2)

  40. Summary-3 • EUS and EBUS • Specifity and sensitivite ↑↑ as mediastinoscopy • Detecting of N2-3 in clinically N0 • EUS or EBUS  mediastinoscopy • Re-staging after induction CT • EBUS and EUS are successful(hopeful)

  41. ConclusionToday Routine mediastinoscopy  NO • NO • cN0 disease • cN1 disease in left lung • Absolute T4 • YES • cN2 disease • cN1 disease in right lung

  42. ConclusionFuture Routine mediastinoscopy  NO • NO • cN0 disease • Absolute T4 • cN2 disease • cN1 disease EBUS EUS

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