1 / 37

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

Nicole Bouchard MD FRCPC Pulmonologist April 29, 2011. Lung cancer staging in 2011: use of pet Scan and other modalities. Disclosure. I cannot identify any potential conflict of interest. Objectives. 1) Select the appropriate diagnostic tests to accurately stage lung cancer

betty_james
Télécharger la présentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  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: 183-189

  5. Diagnostic tests • CT scan: • 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: 244-285

  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 2010 Sep [ Epub ahead of print ]

  10. Diagnostic tests • Multidisciplinary team • 1222 patients with NSCLC, 2001-2007 • survival? 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: 221-228

  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 (8 - 30 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: 6846-6853

  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: 757-762

  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: 1389-1396

  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: 534-538

  26. EBUS: cost effectiveness • 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: 1564-1570

  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: 368-374

  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: 1664-1667 Nakajima T, J Thorac Oncol 2011; 6: 203-206 Wada H, Ann Thorac Surg 2010; 90: 229-234

  30. EUS: meta-analysis • 18 studies • No major complications; minor complications: 10 cases (0.8%), Micames CG, Chest 2007; 131: 539-548

  31. TBNA, EBUS, EUS • 138 consecutive patients • known or suspected lung cancer on CT Wallace MB, JAMA 2008; 299: 540-546

  32. EBUS & EUS: single scope • 139 consecutive patients, enlarged LN (CT) • EBUS & EUS: single linear US bronchoscope by one operator Herth FJ, Chest 2010: 138: 790-794

  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) Hwangbo B, Chest 2010; 138: 795-802

  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; 577-582

  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: 2245-2252

  36. ASTER study • Nodal metastases • 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

More Related