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FJF Herth Thoraxklinik , University of Heidelberg, Germany BIDMC, Harvard Medical School, Boston, USA

Restaging following neoadjuvant treatment Bronchoscopic evaluation. FJF Herth Thoraxklinik , University of Heidelberg, Germany BIDMC, Harvard Medical School, Boston, USA. Multimodality treatment (N2 disease). Role of surgical multimodality is still investigational

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FJF Herth Thoraxklinik , University of Heidelberg, Germany BIDMC, Harvard Medical School, Boston, USA

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  1. Restagingfollowingneoadjuvanttreatment Bronchoscopicevaluation FJF Herth Thoraxklinik, University of Heidelberg, Germany BIDMC, Harvard Medical School, Boston, USA

  2. Multimodality treatment (N2 disease) • Role of surgical multimodality is still investigational • Role in potentially resectable N2 NSCLC • Important prognostic factors • Tumour clearance of mediastinal LNs (mediastinal downstaging) • Pathologic response of the primary tumour

  3. Potentially resectable N2 disease

  4. Unresectable N2 disease Multilevel extracapsular disease

  5. Restaging 90 patients 3 cycles Cisplatin/Doxetacel Sugerbaker: ASCO Educational book, 1994 Betticher et al., JCO, 2003

  6. Downstaging of mediastinal LN’s

  7. positron emisson tomography

  8. PET – Mediastinal staging 44 trials; 2865 patients Prevalence mediastinal nodes 29 % (5-64 %) Sensitivity 74 % (69-79 %) Specificity 85 % (82-88 %) ACCP, Chest 2007, 132: 178S-201S

  9. Reassessment of N-status : CT and PET scan POST CHEMOTHERAPY PET : NO DISEASE CT : N2 DISEASE

  10. Reassessment N-status : PET

  11. Reassessment N-status : CT and PET • CT scan • Moderate accuracy for LN evaluation • Poor correlation with outcome • PET scan • Better than CT, but lower accuracy than baseline LN evaluation • Better than CT in correlation with outcome

  12. Mediastinal Restaging • Precise restaging after induction chemo or chemoradiotherapy is of great importance to determine subsequent treatment and prognosis. • Restaging methods: • Non invasive: CT, MRI, PET and PET-CT. • Invasive: reMS, VATS and TEMLA. • Minimally invasive: TBNA, EBUS and EUS.

  13. TBNA Schieppati • 1949 • Station 7 nodes Schiessle • 1962 • Mediastinal tumors Versteegh & Swierenga • 1969 • Determine inoperability for lung cancer Schieppati. Rev As Med Argent 1949; 663: 497 Schiessle. J Fr Med Chir Thor 1962; 16: 551 Versteegh, Acta Oto-laryng 1963; 56: 603

  14. Working channel Needle 30° side view optique Linear curved arrayUltrasound transducer

  15. EUS

  16. EBUS

  17. Endoscopic restaging with US & FNA Annema et al. Lung Cancer 2003; 42: 311-8. Herth et al. J Clin Oncol 2008; 26: 3346-50 Szlubowski et al. EJCTS, 2010 Varadarjulu S et al, Respiration 2006 Stigt J et al, Lung Cancer 2009 Kunst et al., JTO 2007

  18. Provide access to different areas of the mediastinum. In combination most mediastinal LNs can be sampled • In four series the accuracy of EUS-FNA and EBUS-TBNA in combination for the diagnosis of mediastinal cancer was 95% Herth et al., AJRCCM, 2005; Rintoul et al., Eur Respir J, 2005; Vilman et al., Endoscopy, 2006; Walace et al., JAMA 2008

  19. Endoscopic restaging : Pro´s • outpatient procedure • no complications, no morbidity • value increased compared to imaging • value equivalent to invasive procedures

  20. Endoscopic restaging : Con´s • availability • reimbursement • limited number of trials • no comparison trials • strongly dependent on cytopathologist

  21. Restaging: Possibl3 algorythmn PET CT: single N2 EBUS-EUS negative positive Neoadjuvante CT surgery Repeat PET-CT negative positive surgery EBUS-EUS negative positive CRT MES

  22. neoadjuvant chemotherapy still under discussion • Reassessment of N- factor is important • PET-CT is superior to PET for restaging after induction Tx • However, in positive cases tissue confirmation is required • After induction endoscopic techniques are feasible • New staging algorithm. • Baseline PET-CT and EBUS or EUS-FNA • Restaging with PET-CT and EBUS or EUS-FNA, if necessary mediastinoscopy

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