optimizing nsclc staging:...
TRANSCRIPT
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Optimizing NSCLC Staging: Mediastinoscopy
Stephen G. Swisher, MD
University of Texas M.D. Anderson Cancer Center
13th Annual International Lung Cancer Congress
Huntington Beach, CA
July 19, 2012
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Why is accurate mediastinal staging important?
• Non-invasive ablative methods are utilized
increasingly and target only the primary
– SBRT, RFA
• Presence of multi-level N2 or N3 favors
non-surgical approach (CRT) and helps
define RT field
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Staging of NSCLC
• Non-invasive:
– CT
– PET (PET/CT)
• Invasive:
– Mediastinoscopy (Standard, Extended)
– EBUS/FNA
– EUS/FNA
– Transthoracic FNA (CT guided)
– Thoracoscopy
– Chamberlain
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Non-Invasive Mediast Staging CT and PET Imaging
False
Negative
False
Positive Prevalence
CT (n=3438) 43% 18% 28%
PET (n=1045) 16% 11% 32%
Toloza, CHEST 2003;123:137S Birim, Ann Thorac Surg 2005;79:375
Toloza et al., Chest, 2003
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False Positive PET
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0
10
20
30
40
0-2.0 2.1-3.0 >3.0
Peripheral
Central
N2 m
eta
sta
se
s %
Tumor size (cm) Lee et al., Ann Thor Surg, 2007
False Negative PET
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Personal Indications for Mediastinal Nodal Sampling
• Positive CT or PET
• Negative CT and PET
– Centrally located tumors
– ‘High Risk’ Surgery
– Ablative Therapy (SBRT/RFA) ?
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Mediastinoscopy vs EBUS
Leyn et al., MMCTS, 2004
Standard Cerv Med Extended Cerv Med
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Leschber et al., EJTCVS, 2003; 24:192-95
Invasive Mediastinal Staging Video-assisted Mediastinoscopic Lymphadenctomy
(VAMLA)
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Kuzdzal et al., EJTCVS, 2005; 27: 384-90
Zielinski et al., MMCTS, 2007
Invasive Mediastinal Staging Transcervical Extended Mediastinal Lymphadenctomy
(TEMLA)
Mean Op Time - 191 minutes
Op Mort – 2.2%
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Invasive Mediastinal Staging EBUS vs Mediastinoscopy – ACCP
False
Negative
False
Positive Prevalence
EBUS (n=918) 20% 0% 78%
Med.(n=6505) 11% 0% 39%
Detterbeck et al., Chest, 2007
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Mediastinal Staging EBUS vs Mediastinoscopy – ACCP
False
Negative
False
Positive Prevalence
CT (n=3438) 43% 18% 28%
PET (n=1045) 16% 11% 32%
EBUS (n=918) 20% 0% 78%
Med.(n=6505) 11% 0% 39%
Detterbeck et al., Chest, 2007
Toloza et al., Chest, 2003
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E
n
r
o
l
l
e
d
cT1-4 N0-3 M0
NSCLC
CT+/- PET
Mediastinoscopy
N=153
Yasufuku et al., JTCVS, 2011
EBUS
N=153
Surgery
EBUS Mediastinoscopy NSCLC Staging - Toronto
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Yasufuku et al., JTCVS, 2011
EBUS Mediastinoscopy LN Stations Inadequately Sampled
LN Station EBUS
Adequate
EBUS
Inadeq.
Med.
Adequate
Med.
Inadeq.
2R 24 6 (20%) 113 2 (2%)
4R 99 38 (28%) 150 1 (2%)
2L 1 1 (50%) 24 2 (8%)
4L 54 54 (50%) 130 2 (2%)
7 126 23 (15%) 146 3 (2%)
Total 304 122 (29%) 563 10 (2%)
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Yasufuku et al., JTCVS, 2011
EBUS Mediastinoscopy False Negative Patients (n=153)
EBUS
False Neg
Med
False Neg
EBUS + Med
False Neg
2R/L 3 0 0
4R 1 1 1
4L 1 4 0
7 1 2 0
5 or 6 ---- ---- 3
False Neg 6% 6% 3%
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Yasufuku et al., JTCVS, 2011
EBUS Mediastinoscopy Conclusions - NSCLC Staging - Toronto
• EBUS and Mediastinoscopy complementary
• EBUS needs LMA for 2R nodes
• EBUS more difficult for small nodes
• EBUS and Standard Cerv Med miss Level 5, 6
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EBUS: Cost/Expertise
BF-UC160F-OL8 EU-C60
$45,900 $20,000
$65,900 $114,300
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EBUS Accessible
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EBUS Inaccessible
Leyn et al., MMCTS, 2004
Level: 5 and 6
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EBUS Inaccessible
Leyn et al., MMCTS, 2004
Level: 5 and 6
Accessible by Extended
Cervical Mediastinoscopy
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Invasive Mediastinal Staging Extended Med. Vs Chamberlain– LUL Tumors
False
Negative
False
Positive Prevalence
Ext. Med. Alone 25% 0% 39%
Chamb. Alone 27% 0% 39%
Ext. Med +
Chamberlain 15% 0% 39%
Detterbeck et al., Chest, 2007
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EBUS Inaccessible
Extend Cerv Med
Accessible
EUS Access EUS Access
Leyn et al., MMCTS, 2004
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R
a
n
d
o
m
i
z
e
d
Non-Metastatic
NSCLC
CT Node Pos
or
PET Node Pos
or
Central Tumor
Thoracotomy
N=65
Mediastinoscopy
N=65
Annema et al., JAMA, 2010
EBUS/EUS
N=123
Mediastinoscopy
N=111
Thoracotomy
N=57
Med vs EBUS/EUSSelect Med NSCLC Staging - ASTER
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Annema et al., JAMA, 2010; Sharples et al., HTA, 2012
Med vs EBUS/EUSSelect Med NSCLC Staging - ASTER
Med Alone
(n=118)
EBUS/EUS
Select Med
(n=123)
P
Value
False Pos 0 0 NS
False Neg 21% 6% 0.02
Futile Thorac 21 9 0.02
Complication 7 6 NS
EQ-5D 0.117 (0.042 to 0.192) 0.003
Cost £10,459 £9713 NS
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Annema et al., JAMA, 2010
Med vs EBUS/EUSSelect Med Conclusions-NSCLC Staging - ASTER
EBUS/EUSSelect Med optimal strategy vs Med Alone
• Reduced false negatives
• Reduced futile thoracotomies
• Similar complications
• Improved quality of life
• Slightly reduced cost
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Mediastinoscopy High Risk Procedure / PET Negative
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Mediastinoscopy High Risk Procedure / PET Negative
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Mediastinoscopy High Risk Procedure / PET Negative
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Sarwate et al., JTCVS, 2012; 144: 81-6
Invasive Mediastinal Staging STRT or RFA; PET NEGATIVE, Peripheral EBUS Alone
10/50 patients occult LNs
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Conclusions
• Optimal staging for PET/CT + Med LNs is combination of EBUS and Cerv Med
– EBUS Select Med for EBUS Neg
• EBUS inaccessible Level 5, 6 require Extended Cerv Med (Chamb, VATS or CT fna)
• EBUS inaccessible Level 8 require EUS
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Conclusions • PET/CT Negative Med LNs but central
tumors, high risk procedure
– EBUS Select Med for EBUS Neg
• PET/CT Negative Med LNs but ablative treatment
– EBUS Alone
• PET/CT Negative Med LNs, Peripheral, Small, Lobect + MLND
– EBUS optional
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Thank You!
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Tournoy et al., Lancet Onc, 2012
Invasive Mediastinal Staging Abnormal vs normal Imaging
Normal Mediastinal Imaging Abnormal Mediastinal Imaging
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Morbidity of Mediastinoscopy
• RLN paresis 12 (0.55%)
• Hemorrhage 7 (0.32%)
• Tracheal injury 2 (0.09%)
• Pneumothorax 2 (0.09%)
• Death 1 (0.05%)
• Total Cerv Med n=2145
Lemaire et al., Ann Thor Surg, 2006
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Tournoy et al., Lancet Onc, 2012
Invasive Mediastinal Staging Abnormal vs normal Imaging
Abnormal Mediastinal Imaging
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Annema et al., Tech Gastro Endosc, 2007
Invasive Mediastinal Staging EUS vs EBUS
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EBUS Expertise Number of Aspirations or ROSE for Accuracy
False
Negative
False
Positive Accuracy
Aspiration No 1 30% 0% 90%
Aspiration No 2 16% 0% 94%
Aspiration No 3 5% 0% 98%
Aspiration No 4 5% 0% 98%
Lee et al., Chest, 2008; 134;368-374
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Consensus Statements
• European Society of Thoracic Surgeons:
‘PET positive mediastinal findings should be histologically or
cytologically confirmed.’
2007
• American College of Chest Physicians:
‘In patients with abnormal FDG-PET scan findings, further evaluation of the mediastinum with sampling of the abnormal lymph node should be performed prior to surgical resection of the primary tumor.’
2003