Invasive Staging for NSCLC. Allan Pickens, MD Assistant Professor of Surgery Section of Thoracic Surgery Emory University

Transcription

1 Invasive Staging for NSCLC Allan Pickens, MD Assistant Professor of Surgery Section of Thoracic Surgery Emory University

2 Presentation IA IB IIA IIB IIIA IIIB IV Stage Mountain CF, Chest 1997;111:1710

3 Survival % Alive IA IB IIA IIB IIIA IIIB IV Stage Mountain CF. Chest 1997; 111:

4 Need for Accurate Staging: Clinical v. Pathologic Staging Mountain CF, A Handbook for Staging 1999

5 Requirement for Cure Accurate Staging Localized Disease Complete Resection

6 Revised 7 th Edition TNM Classification = Change in Classification T and M N0 N1 N2 N3 UICC6 and Descriptor New T/M Stg Stg Stg Stg T1 (<=2cm) T1a IA IIA IIIA IIIB T1 (>2 3 cm) T1b IA IIA IIIA IIIB T2(<=5cm) T2a IB IIA IIB IIIA IIIB T2 (>5-7cm) T2b IIA IB IIB IIIA IIIB T2 (>7cm)) IIB IB IIIA IIB IIIA IIIB T3 invasion T3 IIB IIIA IIIA IIIB T4 (same lobe nodules) IIB IIIB IIIA IIIB IIIA IIIB IIIB T4 (extension) IIIA IIIB IIIA IIIB IIIB IIIB T4 M1 (ipsilateral lung) IIIA IV IIIA IV IIIB IV IIIB IV T4 (pleural effusion) IV IIIB IV IIIB IV IIIB IV IIIB M1 (contralateral lung) M1a IV IV IV IV M1 (distant) M1b IV IV IV IV

7 The Differences in Stage Classification

8 Revisions: T size Subclassify T1 as T1a ( 2 cm) or T1b (> 2 cm to 3 cm) Subclassify T2 as T2a (> 3 cm to 5 cm) or T2b (> 5 cm to 7 cm) Reclassify T2 > 7cm as T3 c-size: Europe p-size: Asia Consistent in most databases Validated by SEER results both in the overall and surgical populations

9 <

10 Revisions: additional pulmonary nodules Reclassify T4 tumors by additional nodules in the primary lobe as T3 Reclassify M1 by additional nodules in a different ipsilateral lobe as T4 Australasian and European data and most databases, and SEER The take home message is that multiple nodules in the same lobe act like Stage II and that nodules in different lobes on the same side act like Stage III

11 >7

12 Revisions: M Categories Reclassify M1 due to additional pulmonary nodules in the contralateral lung as M1a Reclassify T4 due to pleural effusion as M1a Reclassify M1 due to distant metastases as M1b Europe and North America, most databases, and SEER Consistent across all regions, databases and SEER.

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14 Unchanged: N categories Retain current N descriptors Consistent across all geographical areas, all types of database, and SEER

15 Lymph Node Stations Mountain, Chest 1997

16 Mediastinal (N2) Lymph Nodes

17 Mediastinal Lymph Node Metastases: Upper Lobe Tumors Weyant MJ and Flores RM, CTSNet Throacic Surgical Techniques

18 Mediastinal Lymph Node Metastases: Middle and Lower Lobe Tumors Weyant MJ and Flores RM, CTSNet Throacic Surgical Techniques

19 Node status dictates survival! Get it right!

20 Lung Cancer Staging of Mediastinal Lymph Nodes Non-invasive CT MRI PET Integrated PET-CT Invasive Non-surgical TBNA EBUS-TBNA EUS-FNA Surgical Mediastinoscopy TEMLA Anterior mediastinotomy VATS Intraoperative SAMPLING or COMPLETE DISSECTION

21 Test Non-Invasive Staging of Mediastinal Lymph Nodes CT Alone (%) PET Alone (%) Sensitivity Specificity Accuracy PPV NPV PET-CT (%) Comparison of CT Alone, PET Alone, and PET-CT for Detection of Residual Mediastinal Nodal Disease After Induction Chemotherapy

22 Invasive Staging of Mediastinal Lymph Nodes Cerfolio showed in a prospective trial that mediastinoscopy and EUS-FNA only found unsuspected or non-imaged N2 in 2.9% and 3.7% respectively in early stage NSCLC patients with negative integrated PET-CT, thus routine mediastinocopy was not recommended Myers showed that clinical stage IA (T1N0) by CT and PET do not need invasive mediastinal staging Mediastinoscopy added 0.01 years of life expectancy at a cost of $200,000 per life-year gained

23 Relative indications for invasive mediastinal staging Central tumors PET hilar N1 disease Low FDG uptake tumors Nodes 16mm on CT

24 Invasive Non-Surgical Mediastinal Staging Endoscopies for all!

25 Transbronchial Needle Aspiration (TBNA) TBNA was originated in 1958 by Schiepatti Wang and Terry later used a 22-guage needle to perform aspirations Sensitivity 50%, Specificity 96% Mostly done blind; fluoroscopy increases diagnostic yield Complications: pneumothorax (1.6-17%) hemoptysis (5-10%)

26 Endobronchial Ultrasound - Transbronchial Needle Aspiration (EBUS-TBNA) Improves the accuracy and safety of TBNA Sensitivity 85-96%, Specificity 100% Allows biopsy of stations 1-5, 7, 10 (hilar) and 11 (intrapulmonary)

27 Endoscopic Ultrasound Fine Needle Aspiration (EUS-FNA) Allows sampling of lymph nodes in the posterior mediastinum that may not be accessible by mediastinoscopy Blind spot immediately anterior to trachea Sensitivity 88-96%, Specificity %

28 Invasive Non-Surgical Mediastinal Staging Wallace and associates studied 138 patients and showed EUS-FNA plus EBUS-FNA combined had higher sensitivity (93%) and higher NPV (97%) for detecting mediastinal lymph nodes in any location and for patients without node enlargement Concluded that EUS-FNA and EBUS-FNA may allow near-complete minimally invasive mediastinal staging in lung cancer patients Wallace et al, JAMA 2008

29 Invasive Surgical Mediastinal Staging

30 Invasive Staging Procedures Cervical Mediastinoscopy Video mediastinoscopy Extended cervical mediastinoscopy Anterior Mediastinoscopy (Chamberlain Procedure) Video Assisted Thoracoscopy Mediastinal lymph nodes Pleural space

31 Cervical Mediastinoscopy

32 Mediastinoscopy

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34 Cervical Mediastinoscopy Inominate Artery Recurrent Laryngeal Nerve Azygous Vein/SVC Pulmonary Artery

35 30-45 minutes, Outpatient Contraindications Absolute = none Relative = previous mediastinoscopy, SVC syndrome, cervical spine disease Accessible Lymph nodes Upper and lower paratracheal (2,4) Subcarinal (7) Mortality < 0.1% Morbidity 1-2% Cervical Mediastinoscopy

36 Cervical Mediastinoscopy Results

37 Aorto-Pulmonary Lymph Nodes (5,6)

38 Extended Cervical Mediastinoscopy Rarely used Aorta and PA are at risk for injury Sensitivity 69% to 81% False negative ~ 10%

39 Anterior Mediastinotomy/Mediastinoscopy (Chamberlain Procedure)

40 Anterior Mediastinoscopy LN stations (5,6); LUL cancers Outpatient/Inpatient Mortality < 0.1% Morbidity 5-10% Sensitivity 87%-94%, Specificity -100% Accuracy - 96%

41 Video Assisted Thoracoscopic (VAT) Staging Left Side AP window (5,6) Subcarinal (7) Lower paraesophageal (9) Right Side Paratracheal (2,4) Subcarinal Lower Paraesophageal Left/Right Evaluation of the pleural space Pleural effusions

42 VATS- Staging General anesthesia Double lumen tube, single lung ventilation Excellent visualization Replacing Chamberlain procedure Help to diagnose pleural disease Difficult with significant adhesions Difficult with large left upper lobe cancers Chest tube +/-

43 VATS Mediastinal Lymph Node Staging Few small studies Sebastian-Quetglas et al, Lung Cancer Dec patients with NSCLC 11 patients had T status upstaged Revealed 25% clinical false negative rate for clinical N0 63% accuracy in N2 lesions Roberts JR et al, Ann Thorac Surg Oct patients with NSCLC VATS correctly T staged in 96% of patients v. 24% for CT Ruled out malignant effusion in 7 patients Identified malignant effusions in 3, not seen on CT

44 VATS and Pleural Disease Pleural fluid cytology negative up to 50% of cases VATS 90% accurate with pleural disease

45 Comparison of Techniques Detterbeck FC, Chest 2003 Test Sens% Spec% FP% FN% N Stage Clinical CM N0-N2 AM N0-N2 TTNA N2 EUS- FNA N2 TBNA N2

46 ACCP Guidelines Detterbeck FC, Chest Jan T4 w/ extensive mediastinal infiltration: TTNA=EUS-FNA >TBNA>>CM 2. Enlarged mediastinal LN on CT and M0: CM>>TTNA=EUS-FNA=TBNA 3. Enlarged APW w/ LUL Cancer: AM=EM=VATS=EUS-FNA 4. Normal lymph nodes on CT and M0: CM*,no rec for TBNA,TTNA or EUS-NA 5. Normal lymph nodes on CT w/ LUL Cancer: AM=EM=VATS* 6. PET+ in mediastinum: CM 7. PET- in mediastinum: CM *Most current studies do not recommend invasive staging on peripheral T1 lesions w/o evidence of distant disease

47 Summary Lung cancer staging is critical to survival Invasive staging is confirms proper pathologic staging Cervical Mediastinoscopy is safe and accurate Anterior mediastinotomy safe and accurate for bulky AP window nodes VATS becoming favored approach to assess AP window nodes and pleural space

48 Questions?