Symposium St. Gallen 28 November 2013.
Update on clincial staging.
Christophe Dooms, MD, PhD.
Respiratory Division
University Hospitals Leuven
Leuven Lung Cancer Group
Belgium.
Multidisciplinarity of staging.
Precise TNM stage with pathological diagnosis and
technical feasibility should be available before treatment :
•
cT : mainly by CT scan and bronchoscopy
•
cN : mainly by endosonography and/or surgical techniques
•
cM : mainly by integrated PET/CT and MRI/CT brain
•
Pathological procedures :
•
- frequently small diagnostic biopsies
- molecular testing on small tissue samples
Technical : Resectability ? Concurrent CRT ?
Role of PET in diagnosis of SPN.
Ost and Gould. AJRCCM 2012;185:363.
Management algorithm for SPN.
Patel V, et al.
Chest 2013;143:840.
Management algorithm for SPN.
Patel V, et al.
Chest 2013;143:840.
Lung cancer staging : T-factor.
Bronchoscopy
o Extension : T2 if main bronchus >2cm
T3 if main bronchus <2cm
T4 trachea
o Resectability : (sleeve)lobectomy / pneumonectomy
o Detection of synchronous radio-occult disease
Mediastinal nodal staging.
no confirmation needed
ASTER EUS-FNA – EBUS-TBNA combined
WCLC 2013 : EBUS or EUS centered ?
Or is EBUS and EUS-B good enough ?
Mediastinal nodal staging.
Studies of complete endosonography
N of Pts
enrolled
Received
E(B)US
Prev N2/3
N stations
NPV
Szlubowski,2010
120
120
23%
3 (LA)
91%
Herth,2010
150
150
51%
4 (GA)
96%
Hwangbo,2010
150
149
31%
3 (LA)
96%
Annema,2010
242
123
54%
3 (LA)
85%
Yasufuku,2010
150
150
35%
3 (GA)
91%
Ohnishi,2011
120
115
28%
3 (LA)
94%
Szlubowski, 2012
214
214
50%
3 (LA)
82-91%
Kang, 2013
160
160
32-43%
3.5 (LA)
89-96%
Impact of PET on treatment selection
Study
Year
N
Fischer et al. 2009 189
Maziak et al. 2009 337
Ung et al.
2009 310
Chin Yi et al. 2013 300
Population
Study question Comparison
Findings
Resectable
Stage I-III
NSCLC
Number of
'futile
thoracotomies’
52%
vs. 35%
(P=0.05)
Resectable
stage I-IIIA
NSCLC
Proportion in
whom correct
upstaging
Unresectable
Stage III
NSCLC
Proportion in
whom correct
upstaging
Resectable
Stage I-IIIA
NSCLC
Proportion in
whom correct
upstaging
CS -> S
PET-CT -> S
CS -> S
PET-CT -> S
CS -> RT
PET-CT -> RT
PET-CT -> S
MRI-PET -> S
7%
vs. 14%
(P=0.046)
3%
vs. 15%.
(P=0.0002)
22%
vs. 26%
(P=0.43)
Impact of PET on treatment selection
Study
Year
N
Stage I-II
PET impact
Stage IV
Fischer et al.
2009
189
33%
- 17% futile
thoracotomies
+ 11%
Maziak et al.
2009
337
90%
+ 7 % correct
overall upstaging
+ 4%
Ung et al.
2009
310
0%
+ 12% correct
overall upstaging
+ 10%
Yi et al.
2013
300
97%
+ 9-13%
Fischer et al. NEJM 2009;361:32. Maziak et al. Ann Intern Med 2009;151:221.
Ung et al. J Clin Oncol 2009;27:15s(7548). Yi et al. Cancer 2013;119:1784-91.
Conclusion : staging algorithm.
CE integrated PET-CT + MRI/CT brain
• PET justified to detect unsuspected extrathoracic disease
• PET has the abitity to direct invasive technique
if clinical M1
clinical M1a
Thoracocentesis ?
clinical M1b
solitary
multiple
Stage IV ?
Stage IV !
Pericardiocentesis ?
Thoracoscopy ?
Stage IV disease ?
Conclusion : staging algorithm.
CE integrated PET-CT + MRI/CT brain
• PET justified to detect unsuspected extrathoracic disease (verification!)
• PET has the abitity to direct invasive technique (endosonography)
if clinical M0
* MLNs 10mm
if normal mediastinum but
* any PET+ MLN
combined E(B)US-FNA
* central cT3/4 cN0
* cT1-3 cN1
Surgical staging
Proven N2/3
Multimodal therapy
No N2/3