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Restaging after Induction Therapy 3A – B Disease

This presentation by Dr. Shaf Keshavjee discusses important considerations in re-staging patients with Stage 3A-B lung cancer after induction therapy. It emphasizes the necessity of thorough re-staging strategies, including CT scans, MRIs, PET scans, and invasive staging methods like EBUS-TBNA or mediastinoscopy. Key findings reveal discrepancies between clinical and pathologic staging, underscoring the importance of accurate pathological evaluation prior to surgical intervention. The presentation aims to guide thoracic surgeons in optimizing treatment plans for high oncologic risk patients.

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Restaging after Induction Therapy 3A – B Disease

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  1. Restaging after Induction Therapy 3A – B Disease • Shaf Keshavjee MD MSc FRCSC FACS • Surgeon-in-Chief, University Health Network • James Wallace McCutcheon Chair in Surgery • Professor, Division of Thoracic Surgery and Institute of Biomaterials and Biomedical Engineering • University of Toronto 2012 Lung Cancer Summit – Focus on Thoracic Surgery: Lung Cancer Boston, MA, 16 November 2012

  2. Presenter Disclosure Shaf Keshavjee MD No Relationships to Disclose

  3. Considerations in Re-Staging after Induction Therapy • High oncologic risk patients  can progress during induction  must re-stage fully • Plan treatment and re-staging strategy at the outset • CT Chest and abdomen • MRI Head • PET scan • Invasive staging: EBUS-TBNA or mediastinoscopy? • Induction therapy • Re-staging • Re-do invasive staging: EBUS - FNA or mediastinoscopy?

  4. Re-Staging the Mediastinum

  5. Mediastinal Staging • Clinical staging can markedly differ from pathologic staging • 24% clinically overstaged • 20% clinically understaged • 190 cN2 patients: 38% pN0 / pN1, 6% pN3 • 119 cN2 patients: 14% with pN2 • Need pathologic evaluation in all patients thought to be a surgical candidate before thoracotomy Bülzebruck et al, Cancer 1992; 70: 1102 Watanabe et al, Ann ThoracSurg 1991; 51: 253 Am J RespirCrit Care Med 1997; 156: 320 Cerfolio et al Ann ThoracSurg 2005; 80: 1207 De Leyn et al, Eur J CardiothoracSurg 2007; 32: 1

  6. Cervical Mediastinoscopy (First Time) • “Gold Standard”- Sensitivity 80%, Specificity 100% • FN rate: 10% • Downside • Invasive • Non-operable candidates may have to undergo surgical staging • Operable candidates may need a re-do mediastinoscopy Yasufuku K, Keshavjee S. Clinical Pulmonary Medicine. 2010; 17(5): 223-231

  7. EBUS-TBNA • Access to all LN stations accessible by Med as well as N1 nodes • Minimally invasive modality • Sensitivity 85-96% • First time EBUS does not significantly affect 2nd time EBUS FNA or mediastinoscopy

  8. EBUS-TBNA – Yieldvs. CT and PET10 studies (n=817) • EBUS-TBNA Systematic Review and Meta-analysis • Sensitivity = 0.88 (95%CI, 0.79-0.94), Specificity = 1.00 (95%CI, 0.92-1.00) • Results compare favorably with published results for PET and CT Adams et al. Thorax; 2009; 64: 757-62

  9. Lung Cancer Staging (EBUS vs. Med) • Prospective cross-over trial (Ernst et al) • n=66, prevalence of malignancy 89% • Disagreement in the yield for #7 (24%; p=0.011). • Prospective controlled study (Yasufuku et al) • n=153, operable patients • No difference between EBUS and Med Ernst et al. J Thorac Oncol. 2008; 3: 577-82 Yasufuku et al. J Thorac Cardiovasc Surg. 2011 142: 1393-1400

  10. Re-Staging Mediastinoscopy or EBUS -FNAHow will you use the information? Rule out N3 disease What about persistent disease? What about single station vs. Multi-Station involvement? Complete Pathological Response vs. Partial?

  11. Lung Cancer Re-staging (EBUS) • EBUS-TBNA following neo-adjuvant chemotherapy • * All cases confirmed by thoracotomy • ** EBUS –ve cases confirmed by TEMLA (Transcervical bilateral extended mediastinal lymphadenectomy • TEMLA results suggest -ve EBUS may not require surgical restaging Herth et al. JCO. 2008; 26: 3346-50 Szlubowski et al. Eur J Cardiothorac Surg. 2009

  12. Lung Cancer Re-staging (Mediastinoscopy) Eur J Cardiothorac Surg. 2010 Apr;37(4):776-80

  13. Risk of Re-Do Mediastinoscopy • Scar tissue  from previous mediastinoscopy or chemo/RT • Risks  Bleeding, recurrent nerve, incomplete assessment • Higher false negative rate

  14. Performance of Mediastinal Restaging Tests Candela and Detterbeck, J ThoracOncol 2010 5(3):389.

  15. Staging and Post Induction Re-Staging Algorithm Surgery

  16. Summary • Surgery for 3A-B disease • Staging and treatment must be carefully planned • Conventional imaging staging: CT, PET • Invasive Staging: EBUS-FNA, Mediastinoscopy • Optimal combination: • Initial: CT, PET, EBUS-FNA • Induction chemoradiation • Restaging: CT, PET response, Mediastinoscopy • Don’t forget systemic re-staging!

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