Lung Cancer: Practical Application of Imaging In Determining Resectability. Jeremy J. Erasmus, M. D.

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1 Lung Cancer: Practical Application of Imaging In Determining Resectability Jeremy J. Erasmus, M. D.

2 62 year old man with a superior sulcus tumor. Which of the following precludes surgical resection in this patient: A. Extension of tumor into the intervertebral foramen B. Vertebral body involvement C. Invasion of the brachial plexus D. Invasion of the subclavian artery E. Invasion of the rib

3 Superior Sulcus Tumor

4 Superior Sulcus Tumor

5 Superior Sulcus Tumor

6 NSCLC TNM Staging T4 Satellite nodule/s in ipsilateral non-tumor lobe Invasion of vertebral body, heart, trachea, esophagus and mediastinum

7 T4

8 T4

9 T4

10 T4

11 T4 NSCLC Invading Left Atrium (LA) and Greater Vessels 105 patients NSCLC T4N0-2M0 79 men, 26 woman, years (median, 59) Tumor invading LA n=25, SVC n=23, PA n=57 Complete resection possible in 73% 5 year survival 49% complete resection, 18% incomplete N status significant influence on overall 5 year survival (62% N0, 51% N1, 12% N2) Wang XX, et al. Surgical resection of IIIb-T4 lung cancer invading left atrium and great vessels. Chin Med J. 2010;123:265-8.

12 NSCLC Staging Nodal (N) Status N0 N1 N2 N3 No regional nodal metastasis Metastasis to ipsilateral hilar nodes Metastasis to ipsilateral mediastinal and/or subcarinal nodes Metastasis to contralateral hilar, mediastinal or supraclavicular nodes

13 NSCLC Staging Nodal (N) Status Detection of metastasis by CT based on size CT: estimated sensitivity 57%, specificity 82% Toloza EM et al. Noninvasive staging of NSCLC: a review of the current evidence. Chest 2003;123:137S-46S.

14

15

16 NSCLC FDG-PET Nodal (N) Status Test Performance Of PET And CT For Mediastinal Staging In Patients With Non-small-cell Lung Cancer Gould et al., Ann Int Med 2003;139: The Size Of Mediastinal Lymph Nodes And Its Relation With Metastatic Involvement: A Meta-analysis de Langen et al., European J of Cardiothorac Surg 2006;29:26-29

17 NSCLC FDG-PET PET Negative Nodal (N) Status Normal-sized nodes: posttest probability 6% Enlarged nodes: posttest probability 24% PET Positive Normal-sized nodes: posttest probability 63% Enlarged nodes: posttest probability 93% Gould et al. Ann Int Med 2003;139:

18 ?N2

19 ?N2 Post test probability of malignancy 93%

20 N0

21 Revised Staging IASLC M1a Malignant pleural or pericardial effusion Malignant pleural nodule Nodule in contralateral lung M1b Distant metastasis Postmus P et al. The IASLC Lung Cancer Staging Project: Proposals for the Revision of the M descriptors in the Forthcoming (Seventh) Edition of the TNM Classification for Lung Cancer: J Thorac Oncol 2007;2:

22

23 Adrenal M1 M1b

24 Adrenal M1 M1b

25 Evaluation of Adrenals in NSCLC 21 studies, 1391 lesions (824 benign, 567 malignant) Qualitative visual analysis 841 (14 reports), quantitative SUV 824 (13 reports), SUR 562 (8 reports) Mean sensitivity 0.97, specificity 0.91 Lung cancer (5 reports) sensitivity 0.94, specificity 0.82 Visual analysis best characterization of malignant adrenal lesions but no significant difference to SUV, SUR Adrenal masses can be characterized by FDG-PET, subsequent imaging usually unnecessary Boland G, et al. Characterization of adrenal masses by using FDG PET: a systematic review and meta-analysis of diagnostic test performance. Radiology, 2011;259:

26 Bone M1b

27 NSCLC FDG-PET PLUS Trial 188 with potentially resectable NSCLC Randomized to CW (96) or CW + PET (92) 78/96 CW underwent thoracotomy 60/92 CW + PET underwent thoracotomy Van Tinteren, H et al. Effectiveness of PET in the preoperative assessment of patients with suspected NSCLC: the PLUS randomized trial. Lancet 2002;356:

28 NSCLC FDG-PET CW (n=78) PLUS Trial 39 (50%) non-futile 39 (50%) futile CW + PET (n=60) 41 (68%) non-futile 19 (31%) futile Van Tinteren, H et al. Effectiveness of PET in the preoperative assessment of patients with suspected NSCLC: the PLUS randomized trial. Lancet 2002;356:

29 NSCLC FDG-PET PLUS Trial Addition of PET to CW prevented futile surgery in 1 of 5 patients Van Tinteren, H et al. Effectiveness of PET in the preoperative assessment of patients with suspected NSCLC: the PLUS randomized trial. Lancet 2002;356:

30 NSCLC FDG-PET PET in Stage I-II Management 183 patients with stage I-II NSCLC Randomly assigned CW (92) or CW + PET (91) 90/92 CW underwent thoracotomy 87/91 CW + PET underwent thoracotomy Viney, RC et al. Randomized controlled trial of the role of PET in the management of stage I and II NSCLC. J Clin Oncol 2004;22:

31 NSCLC FDG-PET PET in Stage I-II Management PET upstaged 15 patients Stage IIIa (n=11) Stage IIIb (n=2) Distant metastases (n=2) PET improves appropriate stage specific management PET does not significantly reduce thoracotomy Viney, RC et al. Randomized controlled trial of the role of PET in the management of stage I and II NSCLC. J Clin Oncol 2004;22:

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