Combined Transbronchial Needle Aspiration And PET/CT For Mediastinal Staging Of Lung Cancer

1. Combined Transbronchial Needle Aspiration And PET/CT For Mediastinal Staging Of Lung Cancer Şermin Börekçi1, Osman Elbek1, Nazan Bayram1, Nevin Uysal1, Kemal Bakır2 1Department of Pulmonary Diseases, University of Gaziantep, School of Medicine 2Department of Pathology, University of Gaziantep, School of Medicine

2. 1.INTRODUCTION AND AIM-I • The most common cancer is lung cancer on the world • Lung cancer responsible for %12.8 of all cancer cases, %17.8 of all death due to cancer on the world, acording to 1999’s datas The Turkish Thoracic Society. The guide for diagnosis and treatment of lung cancer. Thorax Journal. 2006;7(2):1-35.

3. 1.INTRODUCTION AND AIM-II • The %70 of all lung cancer cases are at advanced (stage IV) or localy advanced stage (stage IIIA and IIIB) when diagnosed and they have no chance to surgery options for radical treatment The Turkish Thoracic Society. The guide for diagnosis and treatment of lung cancer. Thorax Journal. 2006;7(2):1-35.

4. 1.INTRODUCTION AND AIM-III • Staging of patient is important for; • Evoluation of patient for surgery • Planning of treatment options • Determination of prognosis Detterbeck FC, DeCamp MM, Kohman LJ, Silvestri GA. Lung cancer. Invasive staging: the guidelines. Chest 2003; 123 (suppl): 167S-75S.

5. 1.INTRODUCTION AND AIM-IV • Procedures for mediastinal staging are clasified into two groups as Invasive and noninvasive • Noninvasive procedures; • Thorax CT, Thorax MRG, PET • İnvasive procedures; • TBNA, TTNA, EUS-NA • Mediastinoscopy / Mediastinostomi, VATS

6. 1.INTRODUCTION AND AIM-V • Mediastinoscopy is gold standart for mediastinal staging; • İnvasive • General anesthesia • Usually hospitalization Bayram N, Borekci S, Uyar M, Bakır K and Elbek O. Transbronchial needle aspiration in the diagnosis and staging of lung cancer. Indian J Chest Dis Allied Sci 2008; 50: 273-276.

8. 1.INTRODUCTION AND AIM-VI • 1949; Schieppati: • The first sampling from tracheal carina by using rigid bronchoscopy • 1978; Wang: • Paratracheal lymph node sampling by TBNA • 1979; Oho: • Using of flexible neddle with Fiberoptic bronchoscopy • 1983; Wang: • Mapping and new kind of neddle for TBNA

11. FACTORS FOR SUCCESS • Cell type of Cancer (small cell) • Right sided lesions • Large lymph nodes and masses • Localization of lesions (paratracheal, subcarinal) • Experience Harrow E. Chest, 1991. Haponik EF. Am J Respir Crit Care Med, 1995. Harrow EM. Am J Respir Crit Care Med, 2000. Herth FJ. Eur Respir J, 2006.

12. 1.INTRODUCTION AND AIM-VII • A limited studies were present abouth using PET/CT instead of CT with TBNA to increase the success of TBNA. Hsu LH, Ko JS, You DL, Liu CC, Chu NM. Respirology 2007; 12: 848-55. Bernasconi, Gambazzi F, Bubendorf L, Rasch H, Kneilfel S, Tamm M. Eur Respir J 2006; 27: 889-94.

13. 1.INTRODUCTION AND AIM-VIII • In our study we aimed to determine; • The role of TBNA with thorax CT and PET/CT for lung staging • The comparision with mediastinoscopy • If this approach can reduce to need for mediastinoscopy.

14. 2. MATERIAL AND METHODS-I • Prospective, invasive, uncontrolled study • Department of Pulmonary Diseases, University of Gaziantep • From march 2006 to March 2008 • The patients who suspected lung cancer • Enlarged mediastinal lymph nodes (≥1 cm) localized on CT • Underwent PET/CT scanning • Consecutive 25 patients

15. 2. MATERIAL AND METHODS-II • TBNA sampling: • Flexible bronchoscopy • Thorax CT and PET/CT combination • Acording to Wang’s map of lymph node • 22 Gauge aspiration needle • 4 sampling from each lymph node station • Starting from the lymph node that the most advanced stage • The other kind of sampling procedures were done after TBNA sampling

16. 2. MATERIAL AND METHODS-III • Evaluation of samples: • Adequate Sample:presence of numerous benign lymphoid cells • Negative Malignite: absence of malignant cells • Positive Malignite: presence of malignant cells

17. 2. MATERIAL AND METHODS-IV • Statistical Analysis: • Mediastinoscopy was used as “gold standart”. • The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rate for prediction of lymph node staging of PET/CT combined TBNA were calculated. • Descriptive statistics were expressed as mean±standart deviation (SD), interquartile range (IQR) or percent (%) according to kind of data.

18. 2. MATERIAL AND METHODS-V • Statistical Analysis: • The factors that might effect positive TBNA result were analysed through logistic regression model • P value less than 0.05 was deemed statistically significant. • The statistical analysis was performed using SPSS 13.0 for Windows

19. 3.RESULTS-I Age (year, mean±SD) 58.7±7.6 Gender Male (n,%)25 (100) Female 0 (0) Smoking (n,%) 25 (100) Smoking (pack/year) (median, IQR) 40 (30-55) Comorbidities (n,%) DM 2 (8) COPD 1 (4) HT 3 (12) Karnofsky performance score (mean±SD) 80.4±10.6 ECOG (mean±SD) 0.9±0.6 Characteristics of the patients

20. 3.RESULTS-II Clinical properties of patients Symptoms (n,%) cough 23 (92) increase of sputum amount 10 (40) shortness of breath 22 (88) Hemoptizi 9 (36) lack of appetite 11 (44) loss of weight (total amount/last 2 month) 11 (44) loss of weight (median±SD) 11.4±6.2 Weakness 11 (44) back pain 2 (8) chest pain 8 (32) Paraneoplastik syndroms 1 (4) Karnofsky’s score 80.4±10.6 ECOG (median±SD) 0.9±0.6

21. 3.RESULTS-III

22. 3.RESULTS-IV

23. 3.RESULTS-V • Total 43 enlarged mediastinal lymph nodes were sampled from 25 patients

24. 3.RESULTS-VI

25. 3.RESULTS-VII

26. 3.RESULTS-VIII

27. 3.RESULTS-IX

28. 3.RESULTS-X p > 0.05

29. 3.RESULTS-XI p > 0.05

30. 3.RESULTS-XII TBNA Sensitivity %87 TBİA Specificity %100 Positive predictive value %100 Negative predictive value %89 TBNA false positivity %0 TBNA false negativity %12

31. 3.RESULTS-XIII The clinical factors that might effect positive TBNA result Factor p Lymph node location 0.18 LAP on CT 0.33 PET SUV Max ≥5 <0.05* Broncoscopic properties ( precence of direct or indirect findings) 0.10 Adequate or inadequate TBNA sampling 0.09 Tumor tissue group 0.37 * The PET SUV max≥5 was 11 times increased positive TBNA results [OR=10.68 (1.91-59.62), P<0.01

32. 3.RESULTS-XIV

33. 3.RESULTS-XV • Tissue diagnosis could done by TBNA for all 14 lymph node (%100) stations with malign result

34. 3.RESULTS-XVI • The staging was completed with TBNA in 5/19 (%26) patients without mediastinoscopy.

37. 4. DISCUSSION-I • TBNA could done during first broncoscopic procedure with local anestezia, could decrease to need adding procedure for staging so good for patient’s comfort and cost effective. • In our study staging of 5 (%26) in 19 patients were done without mediastinoscopy and TBNA decreased the need of mediastinoscopy.

38. 4. DISCUSSION-II • Acording to literatures lymph node location can effect TBNA result . Patelli and collagues showed that, TBNA sensitivity was %52 for left paratracheal, %84 for right paratracheal and %84 for subcarinal lymph node (Patelli M, et al. Ann Thoracic Surg, 2002). • In our study there is no statistical differance between lymph node location and TBNA positivity (p>0.05).

39. 4. DISCUSSION-III • If combination of PET with TBNA increase the succes of diagnosis is unknown. There is limited study to show that this combination is increase the succes of diagnosis (Bernasconi, et al. Eur Respir J, 2006 ve Hsu LH, et al. Respirology, 2007). • In our study the sencitivity, spesificity, PPV, NPV of the procedure that combined PET/CT with TBNA were found very high like Bernasconi’s and Hsu’s study (respectively %87, %100, %100, %89).

40. 4.DISCUSSION-IV The clinical factors that might effect positive TBNA result Factor p Lymph node location 0.18 LAP on CT 0.33 PET SUV Max ≥5 <0.05* Broncoscopic properties ( precence of direct or indirect findings) 0.10 Adequate or inadequate TBNA sampling 0.09 Tumor tissue group 0.37 * The PET SUV max≥5 was 11 times increased positive TBNA results [OR=10.68 (1.91-59.62), P<0.01

41. 4. DISCUSSION-V • In previous study tahat we done in our clinic we found that sencitivity of TBNA combined with CT were %58 (Bayram N, et al. Indian J Chest Dis Allied Sci, 2008). And also now, we found that sensitivity of of TBNA combined with PET/CT is incresed to %87. This positive result may be due to increase of TBNA experience and olso due to PET/BT that shows details.

42. 4. DISCUSSION-VI • It is showed that TBNA combined with PET can reduce the %57 of mediastinoscopy need (Bernasconi, et al. Eur Respir J, 2006). • In our study this ratio was %26. This lower ratio than Bernasconi’s is may be due to most of our patients were operable and toracotomy was carried out after mediastinoscopy in the same operation session.

43. 5. LIMITATIONS • There is no control group • The distribution of lymph node station were right • There were no rapid on-site cytological examination.

44. 6. RESULTS-I • TBNA is less invasive and has less complication than mediastinoscopy and can be used for correct staging of lung cancer.

45. 6. RESULTS-II • Combination of TBNA with PET/CT can increase sensitivity • Increse of TBNA positivity is meningfull on lymph nodes with SUV Max ≥ 5 • TBNA decreased the need of mediastinoscopy

46. SUGGESTION • Our experience suggest that TBNA should be routinly performed during the standart diagnostic bronchoscopy for staging of lung cancer to all patients with mediastinal lympadenopathy on CT and/or PET/CT.

47. THANKS