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The Nuances of Staging Lung Cancer Gerard A. Silvestri MD, MS Professor of Medicine Medical University of South Carolina Charleston, SC silvestri@musc.edu Disclosure: Olympus America COE, grant funding. Disclosures. Olympus America Grant funding Consulting.

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  1. The Nuances of Staging Lung CancerGerard A. Silvestri MD, MS Professor of MedicineMedical University of South CarolinaCharleston, SCsilvestri@musc.eduDisclosure: Olympus America COE, grant funding

  2. Disclosures • Olympus America • Grant funding • Consulting

  3. CHEST 2013; 143(5)(Suppl):e211S–e250S.

  4. Staging • Accurate staging is critical • Treatment options are stage dependent • Prognosis is based upon stage • Enrollment in clinical trials by stage • Provides a common language when discussing cases • Allows for study of large cohorts of patients

  5. Overview of NSCLC Treatment Surgery (Radiation if inoperable) Stage I Surgery With Adjuvant Chemotherapy Stage II Radiation With Chemotherapy Stage III Stage IV or Recurrent Disease Chemotherapy Targeted Therapy

  6. Staging for Lung Cancer Invasive Staging Non-invasive Staging CT PET Non-surgical Surgical EUS EBUS Mediastinoscopy Anterior Mediastinotomy (Chamberlain procedure) VATS

  7. Why do Invasive Staging? Isn’t CT, PET good enough?

  8. Accuracy of CT and PET StagingMediastinal Lymph Nodes Summary of 43 (CT) and 45 (PET) trials Silvestri et al.CHEST 2013; 143(5)(Suppl):e211S–e250S

  9. ACCP Recommendations for CT and PET Silvestri et al.CHEST 2013; 143(5)(Suppl):e211S–e250S.

  10. How will you Confirm Diagnosis and/or Clinical Stage? Sputum cytology Flexible fiberoptic bronchoscopy Transbronchial needle aspiration EBUS or EUS Mediastinoscopy Transthoracic needle biopsy VATS Surgical resection

  11. Confirmation of Intrathoracic Stage CT neg. but central, adeno, N1 Extensive Infiltration Discrete N2, 3 enlargement Peripheral clinical stage I

  12. Radiographic group A Mediastinal infiltration Encircles vessels & airways Discrete lymph nodes can not be discerned or measured Radiographic group B Mediastinal node enlargement Size of discrete nodes can be measured Radiographic group C Central tumor or suspected N1 disease N2,3 nodal involvement relatively high Radiographic group D Peripheral clinical stage I tumor Distant metastases or mediastinal involvement is low Radiographic GroupsEnlarged NodesNormal Nodes Silvestri et al. CHEST 2013; 143(5)(Suppl):e211S–e250S; * J ThoracOncol . 2009 ; 4 ( 3 ): 355 - 363 . Ann ThoracSurg . 2005 ; 80 ( 6 ): 2051 - 2056 ;Thorax . 1992 ; 47 ( 1 ): 3 - 5.

  13. Silvestri et al. CHEST 2013; 143(5)(Suppl):e211S–e250S.

  14. Methods of Obtaining Tissue • Mediastinoscopy • Mediastinotomy • Thoracoscopy • Trans bronchial needle aspirate • EUS with FNA • EBUS with FNA

  15. Accuracy of Staging Tests in Lung Cancer Patients Silvestri et al.CHEST 2013; 143(5)(Suppl):e211S–e250S.

  16. Mediastinoscopyvs. Endosonographyfor Mediastinal Nodal Staging of Lung Cancer: a Randomized Trial • Multicenter RCT - 241 patients • Randomized to either Mediastinoscopyor EBUS/EUS then mediastinoscopy if negative • Futile thoracotomy 18% vs. 7% • Complications 6% vs. 7% though 12 of 13 complications surgically related Annema et al. JAMA 2010.

  17. Recommendations • ACCP Guidelines 2007: Many invasive techniques for the confirmation of the N2,3 node status are suggested as reasonable approaches (eg, mediastinoscopy, EUS-NA, TBNA, EBUS-NA, or TTNA) • ACCP Guidelines 2013: In patients with high suspicion of N2,3 involvement, either by discrete mediastinal lymph node enlargement or PET uptake (and no distant metastases), a needle technique (EBUS- NA, EUS- NA or combined EBUS/EUS - NA) is recommended over surgical staging as a best first test Detterbeck F et al. ACCP 2 guidelines Chest 2007. Silvestri et al.CHEST 2013; 143(5)(Suppl):e211S–e250S.

  18. Extensive Mediastinal Infiltration

  19. Confirmation of Intrathoracic Stage • Extensive mediastinal infiltration: • No discrete nodes visible, encasement of structures • Intrathoracic Stage is clear (stage IIIB) • Issue is simply to confirm the diagnosis (could be SCLC) • Use whatever test is easiest, least invasive • Sputum, Bronchoscopy with TBNA • EUS-NA, TTNA

  20. Discrete Mediastinal Enlargement or Central Tumor In patients with high suspicion of N2,3 involvement, either by discrete mediastinal lymph node enlargement or PET uptake (and no distant metastases) or Central tumor, a needle technique (EBUS- NA, EUS- NA or combined EBUS/EUS - NA) is recommended over surgical staging as a best first test.

  21. Left Upper Lobe Tumors Silvestri et al.CHEST 2013; 143(5)(Suppl):e211S–e250S.

  22. Chamberlain Procedure

  23. Peripheral T1a Tumors

  24. Ilustrative Cases 62 y/o WW with >20 pack year tobacco CT for abnormal CXR prior to elective surgery

  25. PET

  26. EBUS Mediastinum – 4R (11mm) Simultaneously diagnosed & staged Adenocarcinoma stage IIIA Patient went from surgical candidate to unresectable

  27. Case 2 76 y/o never smoker CT chest during evaluation of abd pain

  28. CT – 4R

  29. Patient 2 PET – 4R

  30. CT – 10R

  31. PET – 10R Pre-EBUS T1N2M0 (stage 3a) -> Post-EBUS T1N0M0 (stage IA) RLL resection confirmed stage IA adenocarcinoma

  32. Other Tidbits From Staging Chapter

  33. Other Tidbits From Staging Chapter

  34. Summary • Multiple tools exist for the diagnosis of lung cancer depending on the patient presentation • Stage dictates treatment options and prognosis • Treatment varies significantly by stage • Confirmation of stage by whatever mode available to you provides the best quality care

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