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Staging The Mediastinum, EBUS vs Mediastinoscopy.

Staging The Mediastinum, EBUS vs Mediastinoscopy. Mohammad B Zalt, MD. Interventional Pulmonology. Advances in Lung Cancer Symposium, 6/8/13. Disclosure. No conflict of interest. Introduction. Lung ca in the leading cause of mortality in both men and women in USA.

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Staging The Mediastinum, EBUS vs Mediastinoscopy.

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  1. Staging The Mediastinum, EBUS vs Mediastinoscopy. Mohammad B Zalt, MD. Interventional Pulmonology. Advances in Lung Cancer Symposium, 6/8/13.

  2. Disclosure No conflict of interest.

  3. Introduction • Lung ca in the leading cause of mortality in both men and women in USA. • NSCLC accounts for 84%* of lung cancers. • TNM system is crucial for: • Staging NSCLC into 4 stages. • Making clinical decisions (Sx, CT..). • Incorrect staging of NCLC results in major errors in management. * Detterbeck et al, Chest 136 (1), 260-271 (2009)

  4. Introduction “N” STAGING becomes paramount in making treatment decisions. • OPTIMAL & ACCURATE STAGING Tests & Procedures Lymphnodes Map

  5. 7th TNM system, IASLC J. Thorac. Oncol. 4(5), 568-577 (2009).

  6. (4R), Right Lower Paratracheal

  7. The 7th TNM system. • N0-N3 station system has been retained. • Precise landmarks for accurate staging were introduced: • N1, N2 zones are distinguished by major vessels (Azygous vein on R). • Midline of trachea to separate R and Lparatrcheal LNs is shifted to L lateral margin of trachea.

  8. The 7th TNM system.

  9. The 7th TNM system, EBUS

  10. Staging the Mediastinum Noninvasive tests: Invasive tests: CT scan PET scan Needle Technique. • Minimally invasive: • EBUS. EUS, EMN, TTNA. • Surgical: • Mediastinoscopy, VATS.

  11. Non-invasive staging, Clinical • Standard CT: using > 10 mm as abnormal • sensitivity: ~ 60% • specificity: ~ 80% • FDG-PET: Using and SUV> 2.5 as abnormal • sensitivity: ~ 80% • specificity: ~ 90% • Integrated PET-CT: improved staging. • sensitivity: ~ 90% • specificity: ~ 94% Radiology 1999; 213: 530 Radiology, Sep 2003; Chest 2003; 123: 137s

  12. ACCP, intrathoracic CT categories of NSCLC.

  13. Clinical staging can differ from pathologic, • 24% clinically over staged. • 20% clinically under staged. • Pathologic Confirmation • in patients thought to be surgical candidates. Therefore Cancer 1992; 70: 1102 Ann Thorac Surg 1991; 51: 253 Am J Respir Crit Care Med 1997; 156: 320

  14. Invasive staging of the Mediastium WHEN? HOW?

  15. Invasive staging of Mediastium, when? • Enlarged mediastinal lymphnodes on CT. • Central tumor. • N1 enlargement and normal mediastinum. • Evidence of PET scan uptake in mediastinum. INVASIVE STAGING

  16. ACCP Guidelines.When? CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  17. Patients with extensive mediastinal infiltration of tumor and no distant metastases, it is suggested that radiographic (CT) assessment of the mediastinal stage is usually sufficient without invasive confirmation (Grade 2C) CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  18. Patients with discrete mediastinal lymph node enlargement (and no distant metastases) with or without PET uptake in mediastinal nodes, invasive staging of the mediastinum is recommended over staging by imaging alone (Grade 1C) . CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  19. In patients with PET activity in a mediastinal lymph node and normal appearing nodes by CT (and no distant metastases), invasive staging of the mediastinum is recommended over staging by imaging alone (Grade 1C) . CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  20. Intermediate suspicion of N2,3 involvement, ie, a radiographically normal mediastinum (by CT and PET) and a central tumor or N1 lymph node enlargement (and no distant metastases), invasive staging of the mediastinum is recommended over staging by imaging alone (Grade 1C) CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  21. For patients with a peripheral clinical stage IA tumor (negative nodal involvement by CT and PET), invasive preoperative evaluation of the mediastinal nodes isnot required(Grade 2B) CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  22. Invasive Staging of the Mediastium, HOW?

  23. Location of The LN. Technique available Invasive Staging of the Mediastium, HOW? Pt’s comorbidity & fitness Proficiency of clinicians

  24. Location of the LN

  25. Surgical staging of the mediastinum: De Leyn. Eur L Cardiothrac Surg 2007;32:1-8 Yasufuku et al. Respirology 2007;12:173-183 Lemaire et al. Ann Thorac Surg 2006;82:1185-1189

  26. Accuracy of mediastinoscopy CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  27. Surgical staging, VATS. CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  28. TTNA, sensitivity 89-94%

  29. Conventional (Blind) TBNA. • Meta-analysis showed pooled sensitivity of 39% and FN 28%. • 11.8% of physicians routinely used TBNA for staging malig, in an ACCP survey, 1991 Thorax 60(11), 949-955 (2005)

  30. Conventional (Blind) TBNA. CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  31. Ultrasound Guided Needle techniqueEBUS/EUS-NA

  32. EUS-NA

  33. EUS-NA in staging the mediastinum. CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  34. EBUS in staging the mediastium. CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  35. EBUS is also sensitive in patients with lung cancer and negative med LNs on CT • 100 patients with NSCLC and CT with no mediastinal LN > 10mm EBUS-TBNA of all identifiable nodes  surgical staging with med (15) or thoracotomy (85) • Mean LN diameter: 8.1mm • 2 aspirates / node • Cancer seen in 19 LN, missed in 2 LN • Sensitivity 92.3%, Specificity 100%, NPV 96.3% • Could avoid surgery in 17% of patients with no CT evidence of disease Herth et al, Eur Respir J 2006; 28: 910

  36. EBUS may be preferred in the histologic sampling of paratracheal and subcarinal mediastinal adenopathy because the diagnostic yield can surpass mediastinoscopy 66 patients with know cancer in a cross over study Mediastinoscopy Linear EBUS-TBNA Diagnostic yield 91% Specificity 100% Specificity 100% Diagnostic yield 78% Ernst A. et al. Journal of Thoracic Oncology: 3(6):577-82, 2008 Jun

  37. JAMA . 2010 ; 304 ( 20 ): 2245 - 2252 EBUS/EUS-NA (MedicalMediastinoscopy) • RCT, 241 Pts with resectable NSCLC. Surgical staging alone • Combined (EBUS & EUS)-NA • followed by sx staging • ( if no mets found)

  38. JAMA . 2010 ; 304 ( 20 ): 2245 - 2252 • Sensitivity: • Surgical staging: 79%. • Endosonographic staging: 85%. • Endosonographic followed by surgical: 94%. • Nodal Mets: • 62 Pts by combined staging. • 41 pts by surgical staging. • Thoracotomy unnecessary: • 21 pts in the mediastinoscopy group. • 9 Pt in the combined group.

  39. EBUS/EUS-NA (Medical Mediastinoscopy CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  40. Is Ultrasound-Guided FNA replacing Surgical Staging ? ?

  41. Staging of Mediastium, How? • High suspicion of N2,3 involvement, either by discrete mediastinal lymph node enlargement or PET uptake (and no distant metastases), a needle technique (EBUS, EUS or combined) is recommended over surgical staging as a best first test (Grade 1B) CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  42. Staging of Mediastium, How? • Intermediate suspicion of N2,3, ie, radiographically normal mediastinum (by CT and PET) and a central tumor or N1 lymph node enlargement, a needle technique (EBUS, EUS or combined) is suggested over surgical staging as a best first test (Grade 2B) CHEST / 143 / 5 / MAY 2013 SUPPLEMENT e227S

  43. NEGATIVE STAGIN using a needle technique, Operating Room

  44. Or N1 Ln Clinical Approach. Flow sheet

  45. CONCLUSION: • Accurate Mediastinal staging is critical in the management of NSCLC. • Variety of techniques are available. (Complimentary NOT Competitive). • Non-invasive tests are not sufficient to accurately stage NSCLC. • Minimally invasive techniques are becoming more preferred in the staging paradigm. • Surgery remains the Gold standard. All (-) EBUS/EUS-NA need surgical confirmation.

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