Symposium St. Gallen 28 November 2013.

Update on clincial staging.

Christophe Dooms, MD, PhD.

Respiratory DivisionRespiratory Division

University Hospitals University Hospitals LeuvenLeuven

Leuven Lung Cancer GroupLeuven Lung Cancer Group

Belgium.Belgium.

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 ?

Multidisciplinarity of staging.

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.

BronchoscopyBronchoscopyo Extension : T2 if main bronchus >2cmExtension : T2 if main bronchus >2cm

T3 if main bronchus <2cm T3 if main bronchus <2cm T4 tracheaT4 trachea

o Resectability : (sleeve)lobectomy / pneumonectomyResectability : (sleeve)lobectomy / pneumonectomyo Detection of synchronous radio-occult diseaseDetection of synchronous radio-occult disease

Lung cancer staging : T-factor.

Mediastinal nodal staging.

ASTER EUS-FNA – EBUS-TBNA combinedWCLC 2013 : EBUS or EUS centered ?Or is EBUS and EUS-B good enough ?

no confirmation needed

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%

Study Year N Population Study question Comparison Findings

Fischer et al. 2009 189 Resectable Number of CS -> S 52%Stage I-III NSCLC

'futile thoracotomies’ PET-CT -> S

vs. 35%(P=0.05)

Maziak et al. 2009 337 Resectable Proportion in CS -> S 7%stage I-IIIA

NSCLCwhom correct

upstaging PET-CT -> Svs. 14%

(P=0.046)

Ung et al. 2009 310 Unresectable Proportion in CS -> RT 3%Stage III NSCLC

whom correct upstaging PET-CT -> RT

vs. 15%. (P=0.0002)

Chin Yi et al. 2013 300 Resectable Proportion in PET-CT -> S 22%Stage I-IIIA

NSCLCwhom correct

upstaging MRI-PET -> Svs. 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 + 11%thoracotomies

Maziak et al. 2009 337 90% + 7 % correct + 4%overall upstaging

Ung et al. 2009 310 0% + 12% correct + 10%overall upstaging

Yi et al. 2013 300 97% + 9-13%

Impact of PET on treatment selection

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

clinical M1a clinical M1b

Thoracocentesis ?

Pericardiocentesis ?

Thoracoscopy ?

Stage IV disease ?

if clinical M1

solitary multiple

Stage IV !Stage IV ?

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)

* MLNs 10mm

* any PET+ MLN

if normal mediastinum but

* central cT3/4 cN0

* cT1-3 cN1

combined E(B)US-FNA

Surgical stagingProven N2/3 No N2/3

Multimodal therapy

if clinical M0