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Lung cancer staging in 2011: use of pet Scan and other modalities

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Presentation on theme: "Lung cancer staging in 2011: use of pet Scan and other modalities"— Presentation transcript:

1 Lung cancer staging in 2011: use of pet Scan and other modalities
Nicole Bouchard MD FRCPC Pulmonologist April 29, 2011

2 Disclosure I cannot identify any potential conflict of interest.

3 Objectives 1) Select the appropriate diagnostic tests to accurately stage lung cancer 2) Understand the strengths and weaknesses of PET Scan for lung cancer staging 3) Propose a rational approach to optimally stage mediastinal lymph nodes

4 TNM Lababede O, Chest 2011; 139:

5 Diagnostic tests CT scan: PET-CT: Pulmonary function testing
chest and upper abdomen PET-CT: if a radical treatment is considered Pulmonary function testing Imaging of the head (MRI): if symptoms for small cell lung cancer maybe in stage 3 disease NSCLC Lim E, Thorax 2010; 65 (Suppl III); iii1-iii27 Alberts WM, Chest 2007; 132; 1S-19S

6 Diagnostic tests Bone scintigraphy? PET is more sensitive
to avoid an unnecessary PET-CT PET: from base of skull to upper thighs

7 Diagnostic tests Least invasive approach that provides both the diagnostic and the stage bronchoscopy, transthoracic CT guided needle biopsy, radial probe EBUS EBUS, EUS, mediastinoscopy, VATS US guided needle aspiration: thoracentesis, cervical lymph node, liver EUS: left adrenal metastasis

8 Diagnostic tests → Adequate sample
IASLC/ATS/ERS International Multidisciplinary Classification of Lung Adenocarcinoma NSCLC are to be classified into adenocarcinoma or squamous cell carcinoma gefitinib, pemetrexed, bevacizumab Travis WD, Journal of Thoracic Oncology 2011; 6:

9 Diagnostic tests Wait times and costs 2852 patients
provincial cancer registry: Manitoba ≥ 25% of patients waited more than 55 days Cheung WY, Lung Cancer Sep [ Epub ahead of print ]

10 Diagnostic tests Multidisciplinary team
1222 patients with NSCLC, survival? prior after complete staging 79% 93% multidisciplinary evaluation prior to surgery 62% 96% adherence to guidelines 81% 97% mean days from diagnosis to treatment 29 days 17 days Freeman RK, Eur J Cardiothoracic Surg 2010; 38: 1-5

11 PET-CT Scan Preoperative PET-CT prospective, randomized study
189 patients, NSCLC conventional staging (CT of the abdomen, bronchoscopy) or conventional staging plus PET-CT PET-CT: reduced the number of futile thoracotomies, had no effect on survival Fischer B, NEJM 2009; 361: 32-39

12 PET-CT Scan Preoperative PET-CT prospective, randomized trial
337 patients, stage 1-3A NSCLC PET-CT or conventional (abdominal CT & bone scan) cranial imaging PET-CT: spares more patients from inappropriate surgery, but also incorrectly upstaged disease Maziak DE, Ann Intern Med 2009; 151:

13 PET-CT Scan T stage (SUVmax 2,5)
false positive: infectious and inflammatory lesions false negative: carcinoid, certain adenocarcinomas, uncontrolled diabetes, cavity with necrotic center, lesion < 8 mm Lim E, Thorax 2010; 65 (Suppl III); iii1-iii27

14 PET-CT Scan Solitary pulmonary nodule ( mm) and an initial SUVmax  2.6 retrospective study, CHUS, PET-CT 20 / 65 (31%) patients: diagnosis of cancer; mostly adenocarcinomas risk factors for malignancy: higher 18F-FDG uptake, spiculated nodule SUVmax  1: new threshold? Houle MA, Can Respir J 2010; 17, suppl B: 6B

15 PET-CT Scan N stage CT > 10 mm in short axis diameter
sensitivity 57-61%, specificity 79-82% PET sensitivity 84%, specificity 89% false negative: small volume, low metabolic activity false positive: inflammation → sampling size of the lymph node is important Lim E, Thorax 2010; 65 (Suppl III); iii1-iii27 Alberts WM, Chest 2007; 132; 1S-19S

16 PET-CT Scan M stage sensitivity 93%, specificity 96%
detect metastases: 15%, more with advanced stage Lim E, Thorax 2010; 65 (Suppl III); iii1-iii27

17 PET-CT Scan Sample of any isolated distant lesion 350 patients
21% had a solitary lesion: 46% had a benign lesion or another cancer (second cancer or recurrence) Lardinois D, J Clin Oncol 2005; 23:

18 Mediastinal lymph nodes (LN)
No lymph node sampling if uptake is within normal limits on PET-CT and < 1 cm false negative rate: 5-7% for a peripheral tumor if central tumor, N1 enlargement? N2 or N3 ≥ 1 cm but PET negative? Lymph node sampling if PET uptake is positive, to avoid false positive results EBUS/EUS; +/- mediastinoscopy if negative

19 Mediastinal lymph nodes (LN)
EBUS: 2, 4, 7, 10, 11 EUS: 2L, 4L, 7, 8, 9 mediastinoscopy: 2R, 4R, anterior part of 7 Goldstraw P, IASLC Staging Manual in Thoracic Oncology, 2009

20 EBUS: meta-analysis (1)
Study caracteristics Adams K, Thorax 2009; 64:

21 EBUS: meta-analysis (1)
Study results

22 EBUS: meta-analysis (1)
Sensitivity 88% Specificity 100%

23 EBUS: meta-analysis (2)
Sensitivity 93% Specificity 100% Only 2 complications 2 / 1299 patients (0,15%) pneumothorax patient with COPD: hypoxemia during the procedure Gu P, European Journal of Cancer 2009; 45:

24 EBUS: false negative rate
False negative rates 20-25% External validity other studies have been published

25 EBUS: learning curve Learning curves 500 patients 5 EBUS operators
no learning from prior experience operators 3 & 5: still in the learning phase after 100 procedures Kemp SV, Thorax 2010; 65:

26 EBUS: cost effectiveness
cost-beneficial in comparison with surgical mediastinoscopy, for a prevalence as low as 30% negative results confirmed by mediastinoscopy: cost-beneficial according to the prevalence of LN metastases (>79%) Steinfort D, J Thorac Oncol 2010; 5:

27 EBUS: how many aspirations?
650 aspirations (163 MLN stations) in 102 patients, ROSE not available best diagnostic value: 3 aspirations (sensitivity: 69.8%, 83.7%, 95.3%, 95.3%) 2 aspirations: when at least one tissue core Lee H, Chest 2008; 134:

28 EBUS: which needle? 21-gauge versus 22-gauge aspiration needle
45 lesions same diagnostic yield 21G: better histological preservation but more blood contamination Nakajima T, Respirology 2010 Sep [ Epub ahead of print ]

29 EBUS: mutations and SCLC
Mutation analysis EGFR and KRAS mutations can be performed in cytologic specimens (EUS/EBUS) also EML4-ALK fusion gene SCLC: high diagnostic yield Schuurbiers OC, J Thorac Oncol 2010: 5: Nakajima T, J Thorac Oncol 2011; 6: Wada H, Ann Thorac Surg 2010; 90:

30 EUS: meta-analysis 18 studies
No major complications; minor complications: 10 cases (0.8%), Sensitivity Specificity 18 studies 83% 97% 8 studies (abnormal MLN on CT scans) 90% 4 studies (no abnormal MLN on CT scans) 58% - Micames CG, Chest 2007; 131:

31 TBNA, EBUS, EUS 138 consecutive patients
known or suspected lung cancer on CT Sensitivity Negative predictive value Blind TBNA 36% (15/42) 78% (96/123) EUS-FNA 69% (29/42) 88% (96/109) EBUS-FNA EUS-FNA + EBUS-FNA 93% (39/42) 97% (96/99) Wallace MB, JAMA 2008; 299:

32 EBUS & EUS: single scope
139 consecutive patients, enlarged LN (CT) EBUS & EUS: single linear US bronchoscope by one operator Number of nodes sampled Sensitivity Specificity Negative predictive value EUS 229 (37%) 63 (89%) 100% 82% EBUS 390 (63%) 65 (91%) 92% Combined 619 (100%) 68 (96%) 96% Herth FJ, Chest 2010: 138:

33 EBUS & EUS: single scope
150 potentially operable patients, prospective study EBUS +/- EUS used for MLN inaccessible or difficult to access by EBUS 2 false negative (by mediastinoscopy) Sensitivity Specificity Negative predictive value Accuracy EBUS 84% (38/45) 100% 93% 95% EBUS + EUS 91% (41/45) 96% 97% p value 0.332 - 0.379 0.360 Hwangbo B, Chest 2010; 138:

34 EBUS versus mediastinoscopy
66 patients, prospective crossover trial Prevalence of malignancy: 89% Diagnostic yield EBUS: 91% versus mediastinoscopy: 78% (p=0.007) disagreement: subcarinal lymph nodes (24%; p=0.011) no difference: true pathologic N stage (per patient) Ernst A, Journal of Thoracic Oncology 2008; 3;

35 ASTER study Randomized controlled multicenter trial 241 patients
Lung or mediastinal abnormality on CT, no extrathoracic metastases EUS & EBUS (systematic sampling) and surgical staging if negative or surgical staging (mediastinoscopy): N2 & N3 Annema JT, JAMA 2010; 304:

36 ASTER study Nodal metastases Thoracotomy unnecessary
62 patients by combined staging (p=0.02) 41 patients by surgical staging mediastinoscopy: 11 patients to identify 1 with nodal metastasis Thoracotomy unnecessary 21patients in the mediastinoscopy group 9 patients in the combined group (p = 0.02) No increase rate of complications

37 Conclusion PET-CT: before surgery and radiotherapy
When N2 or N3 is suspected on PET: EBUS; mediastinoscopy if negative Complete mediastinal staging: EBUS +/- EUS; role of mediastinoscopy? Further studies are ongoing preoperative EBUS, EBUS vs mediastinoscopy, surgical staging vs endosonography

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