Slide 1 ___________________________________ Optimal Staging of the - PDF document

Slide 1 ___________________________________ Optimal Staging of the ___________________________________ Mediastinum for Lung Cancer ___________________________________ Jack A. Roth, M.D. University of Texas MD Anderson Cancer ___________________________________ Center Houston, Texas ___________________________________ ___________________________________ ___________________________________ Slide 2 ___________________________________ Why is accurate mediastinal staging important? ___________________________________ Predicts prognosis Helps determine therapy ___________________________________ Allows accurate comparisons across different therapeutic groups ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 ___________________________________ Why is accurate mediastinal staging important? ___________________________________ Adjuvant therapy or induction therapy are now standards of care for Stage II & III ___________________________________ Non-invasive ablative techniques (SBRT/SABR) are being considered as primary local control options for Stage I ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 4 ___________________________________ Staging of NSCLC ___________________________________  Non-invasive: – CT – PET (PET/CT)  Invasive: ___________________________________ – Mediastinoscopy – Chamberlain – Transbronchial needle biopsy / EBUS ___________________________________ – Transthoracic needle biopsy – EUS/FNA – VATS ___________________________________ ___________________________________ ___________________________________ Slide 5 ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 6 ___________________________________ ___________________________________ ___________________________________ ___________________________________ Mediastinoscopy Surgical Staging ___________________________________ ___________________________________ ___________________________________

Slide 7 ___________________________________ Morbidity of Mediastinoscopy ___________________________________ RLN paresis 12 (0.55%) Hemorrhage 7 (0.32%) ___________________________________ Tracheal injury 2 (0.09%) Pneumothorax 2 (0.09%) ___________________________________ Death 1 (0.05%) Lemaire, Ann Thorac Surg 2006;82:1185 ___________________________________ ___________________________________ ___________________________________ Slide 8 ___________________________________ Mediastinoscopy ___________________________________ Little et al, 2005 >11,000 surgically treated patients with ___________________________________ NSCLC Mediastinoscopy 27% ___________________________________ Nodal tissue obtained in 47% !! ___________________________________ ___________________________________ ___________________________________ Slide 9 ___________________________________ ___________________________________ ___________________________________ ___________________________________ Endobronchial ultrasound guided transbronchial needle aspiration for staging of lung cancer Kazuhiro Yasufuku, Masako Chiyo, Eitetsu Koh, Yasumitsu Moriya, Akira Iyoda, Yasuo Sekine, Kiyoshi Shibuya, Toshihiko Iizasa, Takehiko Fujisawa, Chiba University Lung Cancer (2005) 50 , 347 — 354 ___________________________________ ___________________________________ ___________________________________

Slide 10 ___________________________________  Cervical mediastinoscopy Paratracheal and subcarinal nodes ___________________________________  VATS and Chamberlain hilar and A-P window nodes ___________________________________  EUS periaortic, subcarinal, and periesophageal nodes. ___________________________________  EBUS Paratracheal, hilar, and subcarinal nodes ___________________________________ ___________________________________ ___________________________________ Slide 11 ___________________________________ EBUS Accessible ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 12 ___________________________________ EBUS Inaccessible ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 13 ___________________________________ Lymphatic Collectors 3 on each side ___________________________________ Right side: R paratracheal (large) R tracheoesophageal R phrenic ___________________________________ Left side: Paraaortic (large) L phrenic (large) ___________________________________ L paratracheal ___________________________________ ___________________________________ ___________________________________ Slide 14 ___________________________________ Patterns of Nodal Metastases  Right upper lobe – highest rate of skip ___________________________________ metastases (N2 in the absence of N1)  Right upper lobe – metastasizes to 2R,4R  Right middle and lower lobe – subcarinal, ___________________________________ then 2R, 4R  Left upper lobe – AP window and periaortic (5, 6), then subcarinal and paratracheal (2L, 4L) ___________________________________  Left lower lobe – metastasize to 2R, 4R ___________________________________ ___________________________________ ___________________________________ Slide 15 ___________________________________ Lymph Node Dissection 1986- 1993- P- ___________________________________ 1992 2001 value Total nodes 15.7 16.2 0.56 retrieved N2 stations 3.1 3.0 0.68 ___________________________________ sampled 1.5 1.4 0.14 Involved N2 levels: 1 station 66% 70% 0.31 ___________________________________ 2 station 22% 22% 12% 7% >2 station ___________________________________ ___________________________________ ___________________________________

Slide 16 ___________________________________ Lymph Node Dissection 1986- 1993- P- ___________________________________ 1992 2001 value Total nodes 15.7 16.2 0.56 retrieved N2 stations 3.1 3.0 0.68 ___________________________________ sampled 1.5 1.4 0.14 Involved N2 levels: 1 station 66% 70% 0.31 ___________________________________ 22% 22% 2 station 12% 7% >2 station ___________________________________ ___________________________________ ___________________________________ Slide 17 ___________________________________ Lymph Node Dissection 1986- 1993- P- ___________________________________ 1992 2001 value Total nodes 15.7 16.2 0.56 retrieved N2 stations 3.1 3.0 0.68 ___________________________________ sampled 1.5 1.4 0.14 Involved N2 levels: 1 station 66% 70% 0.31 ___________________________________ 22% 22% 2 station 12% 7% >2 station ___________________________________ ___________________________________ ___________________________________ Slide 18 ___________________________________ Survival by Lymph Node Stations Involved 1.0 Cumulative Survival Probability ___________________________________ 0.8 Median Survival 0.6 25.3 ___________________________________ 1 Station 15.5 0.4 2 Stations 16.8 0.2 P<0.001 ___________________________________ >2 Stations 0.0 0 10 20 30 40 50 60 Time (months) ___________________________________ ___________________________________ ___________________________________