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

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

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

17. EUS

18. EBUS

19. 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

20. 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

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

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

23. 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

24. 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