symposium st. gallen 28 november 2013. update on clincial staging. christophe dooms, md, phd
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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 - PowerPoint PPT PresentationTRANSCRIPT
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