a. kır*, İ. İskender*, h.b. takır**, m. halaç***, s.z. kadıoğlu*,
DESCRIPTION
Mediastinal Lymph Node Staging in Nonsmall Cell Lung Cancer: Comparison of Positron Emission Tomography and Mediastinoscopy. A. Kır*, İ. İskender*, H.B. Takır**, M. Halaç***, S.Z. Kadıoğlu*, O. Kapıcıbaşı*, A. Yılmaz**, A. Atasalihi* - PowerPoint PPT PresentationTRANSCRIPT
Mediastinal Lymph Node Staging in Mediastinal Lymph Node Staging in Nonsmall Cell Lung Cancer: Nonsmall Cell Lung Cancer:
Comparison of Positron Emission Comparison of Positron Emission Tomography and MediastinoscopyTomography and Mediastinoscopy
A. Kır*, İ. İskender*, H.B. Takır**, A. Kır*, İ. İskender*, H.B. Takır**, M. Halaç***, S.Z. Kadıoğlu*, M. Halaç***, S.Z. Kadıoğlu*,
O. Kapıcıbaşı*, A. Yılmaz**, A. Atasalihi*O. Kapıcıbaşı*, A. Yılmaz**, A. Atasalihi*
Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Investigation Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Investigation Hospital Hospital
**II. II. Thoracic SurgeryThoracic Surgery Department Department****X. X. PulmonologyPulmonology Department Department
***İ.Ü. Cerrahpaşa Medical Faculty, Department of Nuclear Medicine***İ.Ü. Cerrahpaşa Medical Faculty, Department of Nuclear Medicine
In this study, the results of PET and In this study, the results of PET and MediastinoscopyMediastinoscopy are comparatively are comparatively analysed on patients withanalysed on patients with NSCLC, for NSCLC, for mediastinal staging.mediastinal staging.
Materials and MethodsMaterials and Methods
September 2005 – December 2006September 2005 – December 2006 Known or suspicious for NSCLCKnown or suspicious for NSCLC Results of PET/CT and mResults of PET/CT and mediastinoscopyediastinoscopy
are recorded are recorded
Complete history and physical examinationComplete history and physical examination Blood analysesBlood analyses Chest radiographyChest radiography SpirometrySpirometry Cardiac investigationCardiac investigation Thorax CTThorax CT PET/CTPET/CT Cranial MRICranial MRI
PET Imaging:PET Imaging: 90 patients (%85) Siemens Biograph LSO HI-90 patients (%85) Siemens Biograph LSO HI-
REZ integrated PET/CT; two centersREZ integrated PET/CT; two centers Serum glucose concentration <150 mg/dlSerum glucose concentration <150 mg/dl Imaging from neck to hipImaging from neck to hip 90-150 minute after intravenous injection of 90-150 minute after intravenous injection of
FDG-18 FDG-18 Fusion of PET and CT imagesFusion of PET and CT images
FDG uptake was considered to be FDG uptake was considered to be positive in mediastinum if tracer activity positive in mediastinum if tracer activity was significantly higher than mediastinal was significantly higher than mediastinal background activity.background activity.
**Gonzalez-Stawinski GV, Lemaire A, Merchant F, O’Halloran E, Coleman RE, Gonzalez-Stawinski GV, Lemaire A, Merchant F, O’Halloran E, Coleman RE,
Harpole DH, D’Amico TA. A comparative analysis of positron emission Harpole DH, D’Amico TA. A comparative analysis of positron emission tomography and mediastinoscopy in staging non-small cell lung cancer. J tomography and mediastinoscopy in staging non-small cell lung cancer. J Thorac Cardiovasc Surg. 2003 Dec;126(6):1900-5.Thorac Cardiovasc Surg. 2003 Dec;126(6):1900-5.
Surgical stagingSurgical staging Cervical mediastinoscopyCervical mediastinoscopy Extended cervical mediastinoscopyExtended cervical mediastinoscopy Naruke classificationNaruke classification
• paratracheal (2R-2L), paratracheal (2R-2L), • tracheobronchial (4R-4L)tracheobronchial (4R-4L)• subcarinal (7)subcarinal (7)• Subaortic (5), paraaortic (6)Subaortic (5), paraaortic (6)
ThoracotomyThoracotomy
Patients excluded from the study:Patients excluded from the study: Mediastinoscopy; not performedMediastinoscopy; not performed Stage IV Stage IV Time interval between PET and Time interval between PET and
mediastinoscopy > 6 weeksmediastinoscopy > 6 weeks Neoadjuvant therapyNeoadjuvant therapy Mediastinoscopy; not able to be done Mediastinoscopy; not able to be done
(tracheostomy, kyphosis, bleeding etc.)(tracheostomy, kyphosis, bleeding etc.) PET Imaging performed after PET Imaging performed after
mediastinoscopymediastinoscopy
Results Results A total of 425 mediastinal lymph node samplings A total of 425 mediastinal lymph node samplings
were done from 106 patients, among 138 were done from 106 patients, among 138 investigated patients, having above criteria (4.01 investigated patients, having above criteria (4.01 stations/patient)stations/patient)
100 male, 6 female100 male, 6 female Mean age: 58.9 years (39-80 )Mean age: 58.9 years (39-80 ) PET scan – Mediastinoscopy: 14.1 days (2-37 )PET scan – Mediastinoscopy: 14.1 days (2-37 ) The diagnosis was put in 85 (%80.2) patients The diagnosis was put in 85 (%80.2) patients
preoperativelypreoperatively
Cell typesCell types
Sqamous cell carcinomaSqamous cell carcinoma 6363
AdenocarcinomaAdenocarcinoma 3030
NSCLCNSCLC 77
Adenosquamous carcinomaAdenosquamous carcinoma 33
Large cell carcinomaLarge cell carcinoma 22
Bronchoalveolar carcinomaBronchoalveolar carcinoma 11
Type of the OperationsType of the Operations
mediastinoscopy25 (%23.6)
pneumonectomy30 (%28.3)lobectomy
49 (%46.3)
exploratory thoracotomy2 (%1.8)
Pathological stagingPathological staging
Stage IA14 (%13.2)
Stage IB25 (%23.6)
Stage IIB23 (%21.7)
Stage IIIA27 (%25.5)
Stage IIIB17 (%16)
PET/CT and Mediastinoscopy PET/CT and Mediastinoscopy
PET PET positivepositive
PET PET negativenegative
TotalTotal
Mediastinoscopy Mediastinoscopy positivepositive
2727 11 2828
Mediastinoscopy Mediastinoscopy negativenegative
2424 5454 7878
TotalTotal 5151%48.1%48.1
5555%51.9%51.9
106106
PET/CT and MediastinoscopyPET/CT and Mediastinoscopy
SensitivitySensitivity %96.4%96.4
Spesificity Spesificity %69.2%69.2
Positive predictive valuePositive predictive value %52.9%52.9
Negative predictive valueNegative predictive value %98.2%98.2
Accuracy Accuracy %76.4%76.4
PET/CT and Mediastinoscopy PET/CT and Mediastinoscopy
PET PET positivepositive
PET PET negativenegative
TotalTotal
Mediastinoscopy Mediastinoscopy positivepositive
5757 1111 6868
Mediastinoscopy Mediastinoscopy negativenegative
4545 312312 357357
TotalTotal 102102%24%24
323323%76%76
425425
PET/CT and MediastinoscopyPET/CT and Mediastinoscopy
SensitivitiySensitivitiy %83.8%83.8
Spesificity Spesificity %87.4%87.4
Positive predictive valuePositive predictive value %55.8%55.8
Negative predictive valueNegative predictive value %96.6%96.6
Accuracy Accuracy %86.8%86.8
Evaluation PET negative 11 lymph nodesEvaluation PET negative 11 lymph nodes 1 patient N01 patient N0N2 ( single station)N2 ( single station) 2 patient N22 patient N2N2 (two stations)N2 (two stations) 2 patient N22 patient N2N3 (three stations)N3 (three stations) 3 patient N33 patient N3N3 (five stations)N3 (five stations)
Mediastinoscopy is still gold standart on Mediastinoscopy is still gold standart on
the assessment of the mediastinal lymph the assessment of the mediastinal lymph nodes.nodes.
Sensitivity %80, spesificity %100Sensitivity %80, spesificity %100 %0.5 complication risk%0.5 complication risk
*Graeter TP, Hellwig D, Hoffmann K, Ukena D, Kirsch CM, Schafers *Graeter TP, Hellwig D, Hoffmann K, Ukena D, Kirsch CM, Schafers HJ. A Mediastinal lymph node staging in suspected lung cancer: HJ. A Mediastinal lymph node staging in suspected lung cancer: comparison of positron emission tomography with F-18-comparison of positron emission tomography with F-18-fluorodeoxyglucose and mediastinoscopy. Ann Thorac Surg. 2003 fluorodeoxyglucose and mediastinoscopy. Ann Thorac Surg. 2003 Jan;75(1):231-5Jan;75(1):231-5
PET; helps the surgeon to sample more PET; helps the surgeon to sample more lymph nodes, precisely during lymph nodes, precisely during mediastinoscopy, avoiding unnecessary mediastinoscopy, avoiding unnecessary thoracotomies.thoracotomies.
How many mediastinoscopies can be How many mediastinoscopies can be avoided in all PET negatif cases?avoided in all PET negatif cases?
N:55/106 %51.9N:55/106 %51.9• 54/55 %98.2 Negative predictive value54/55 %98.2 Negative predictive value
Mediastinoscopy is necessary for exact Mediastinoscopy is necessary for exact lymph node staging in PET positive lymph node staging in PET positive patients patients
Mediastinoscopy can be omitted in Mediastinoscopy can be omitted in patients with negative PET scan.patients with negative PET scan.
Calculations of SUVCalculations of SUV Mean of mass SUV: 15.7 (4.0-36.4) Mean of mass SUV: 15.7 (4.0-36.4) For the mediastinum cut off value 2.5; For the mediastinum cut off value 2.5;
sensitivity %94, spesificity %93 *sensitivity %94, spesificity %93 * PET true positive 57 stations PET true positive 57 stations
Mean SUV: 8.6 (3.3 – 22.3)Mean SUV: 8.6 (3.3 – 22.3) PET false positive 45 stations PET false positive 45 stations
3 stations SUV< 2.53 stations SUV< 2.5
*Duhaylongsod FG, Lowe VJ, Patz E, Vaughn AL, Coleman RE, Wolfe *Duhaylongsod FG, Lowe VJ, Patz E, Vaughn AL, Coleman RE, Wolfe W. Detection of primary and recurrent lung cancer by means of F-18 W. Detection of primary and recurrent lung cancer by means of F-18 fluorodeoxyglucose positron emission tomography (FDG PET). J. fluorodeoxyglucose positron emission tomography (FDG PET). J. Thorac Cardiovasc Surg 1995;110:130-40Thorac Cardiovasc Surg 1995;110:130-40
PET/CT and MediastinoscopyPET/CT and Mediastinoscopy
PET PET positivepositive
PET PET negativenegative
TotalTotal
Mediastinoscopy Mediastinoscopy positivepositive
5757 1111 6868
Mediastinoscopy Mediastinoscopy negativenegative
4242 315315 357357
TotalTotal 9999%23.3%23.3
326326%76.7%76.7
425425
PET/CT and MediastinoscopyPET/CT and Mediastinoscopy
SensitivitySensitivity %83.8%83.8
SpesificitySpesificity %88.2%88.2
Positive predictive valuePositive predictive value %57.6%57.6
Negative predictive valueNegative predictive value %96.7%96.7
Accuracy Accuracy %87.5%87.5