Staging The Mediastinum,

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Staging The Mediastinum, EBUS vs Mediastinoscopy.
Mohammad B Zalt, MD. Interventional
Pulmonology. Advances in Lung Cancer Symposium,
6/8/13.
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Disclosure

• No conflict of interest.

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Introduction

• Lung ca in the leading cause of mortality in both
  men and women in USA.
• NSCLC accounts for 84 of lung cancers.
• TNM system is crucial for
• Staging NSCLC into 4 stages.
• Making clinical decisions (Sx, CT..).
• Incorrect staging of NCLC results in major errors
  in management.

Detterbeck et al, Chest 136 (1), 260-271
(2009)
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Introduction

• N STAGING becomes paramount in making treatment
  decisions.

• OPTIMAL ACCURATE STAGING

Tests Procedures
Lymphnodes Map
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7th TNM system, IASLC
J. Thorac. Oncol. 4(5), 568-577 (2009).
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(4R), Right Lower Paratracheal
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The 7th TNM system.

• N0-N3 station system has been retained.
• Precise landmarks for accurate staging were
  introduced
• N1, N2 zones are distinguished by major vessels
  (Azygous vein on R).
• Midline of trachea to separate R and L
  paratrcheal LNs is shifted to L lateral margin of
  trachea.

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The 7th TNM system.
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The 7th TNM system, EBUS
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Staging the Mediastinum

• Noninvasive tests
• Invasive tests

CT scan
PET scan
Needle Technique.
Minimally invasive EBUS. EUS, EMN, TTNA.
Surgical Mediastinoscopy, VATS.
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Non-invasive staging, Clinical

• Standard CT using gt 10 mm as abnormal
• sensitivity 60
• specificity 80
• FDG-PET Using and SUVgt 2.5 as abnormal
• sensitivity 80
• specificity 90
• Integrated PET-CT improved staging.
• sensitivity 90
• specificity 94

Radiology 1999 213 530 Radiology, Sep 2003
Chest 2003 123 137s
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ACCP, intrathoracic CT categories of NSCLC.
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Clinical staging can differ from pathologic,

• 24 clinically over staged.
• 20 clinically under staged.
• Pathologic Confirmation
• in patients thought to be surgical candidates.

Therefore
Cancer 1992 70 1102 Ann Thorac Surg 1991 51
253 Am J Respir Crit Care Med 1997 156 320
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Invasive staging of the Mediastium
WHEN?
HOW?
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Invasive staging of Mediastium, when?

• Enlarged mediastinal lymphnodes on CT.
• Central tumor.
• N1 enlargement and normal mediastinum.
• Evidence of PET scan uptake in mediastinum.
• INVASIVE STAGING

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ACCP Guidelines. When?
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• Patients with extensive mediastinal infiltration
  of tumor and no distant metastases, it is
  suggested that radiographic (CT) assessment of
  the mediastinal stage is usually sufficient
  without invasive confirmation (Grade 2C)

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• Patients with discrete mediastinal lymph node
  enlargement (and no distant metastases) with or
  without PET uptake in mediastinal nodes, invasive
  staging of the mediastinum is recommended over
  staging by imaging alone (Grade 1C) .

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• In patients with PET activity in a mediastinal
  lymph node and normal appearing nodes by CT (and
  no distant metastases), invasive staging of the
  mediastinum is recommended over staging by
  imaging alone (Grade 1C) .

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• Intermediate suspicion of N2,3 involvement, ie, a
  radiographically normal mediastinum (by CT and
  PET) and a central tumor or N1 lymph node
  enlargement (and no distant metastases), invasive
  staging of the mediastinum is recommended over
  staging by imaging alone (Grade 1C)

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• For patients with a peripheral clinical stage IA
  tumor (negative nodal involvement by CT and PET),
  invasive preoperative evaluation of the
  mediastinal nodes is not required (Grade 2B)

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Invasive Staging of the Mediastium, HOW?
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Location of The LN.
Technique available
Invasive Staging of the Mediastium, HOW?
Proficiency of clinicians
Pts comorbidity fitness
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Location of the LN
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Surgical staging of the mediastinum
Sensitivity () Specificity ()
Cervical Mediastinoscopy (stations 1-2-4-7) 78 100
Anterior Mediastinoscopy (stations 5-6) 75 100
VATS (only ipsilateral) 75 100
De Leyn. Eur L Cardiothrac Surg 2007321-8
Yasufuku et al. Respirology 200712173-183
Lemaire et al. Ann Thorac Surg 2006821185-1189
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Accuracy of mediastinoscopy
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Surgical staging, VATS.
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TTNA, sensitivity 89-94
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Conventional (Blind) TBNA.

• Meta-analysis showed pooled sensitivity of 39
  and FN 28.
• 11.8 of physicians routinely used TBNA for
  staging malig, in an ACCP survey, 1991

Thorax 60(11), 949-955 (2005)
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Conventional (Blind) TBNA.
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Ultrasound Guided Needle techniqueEBUS/EUS-NA
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EUS-NA
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EUS-NA in staging the mediastinum.
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EBUS in staging the mediastium.
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EBUS is also sensitive in patients with lung
cancer and negative med LNs on CT

• 100 patients with NSCLC and CT with no
  mediastinal LN gt 10mm ? EBUS-TBNA of all
  identifiable nodes ? surgical staging with med
  (15) or thoracotomy (85)
• Mean LN diameter 8.1mm
• 2 aspirates / node
• Cancer seen in 19 LN, missed in 2 LN
• Sensitivity 92.3, Specificity 100, NPV 96.3
• Could avoid surgery in 17 of patients with no CT
  evidence of disease

Herth et al, Eur Respir J 2006 28 910
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EBUS may be preferred in the histologic sampling
of paratracheal and subcarinal mediastinal
adenopathy because the diagnostic yield can
surpass mediastinoscopy
66 patients with know cancer in a cross over study
Linear EBUS-TBNA
Mediastinoscopy
Diagnostic yield 91
Specificity 100
Specificity 100
Diagnostic yield 78
Ernst A. et al. Journal of Thoracic Oncology
3(6)577-82, 2008 Jun
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JAMA . 2010 304 ( 20 ) 2245 - 2252
EBUS/EUS-NA (Medical Mediastinoscopy)

• RCT, 241 Pts with resectable NSCLC.
• Surgical staging alone

Combined (EBUS EUS)-NA followed by sx
staging ( if no mets found)
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JAMA . 2010 304 ( 20 ) 2245 - 2252

• Sensitivity
• Surgical staging 79.
• Endosonographic staging 85.
• Endosonographic followed by surgical 94.
• Nodal Mets
• 62 Pts by combined staging.
• 41 pts by surgical staging.
• Thoracotomy unnecessary
• 21 pts in the mediastinoscopy group.
• 9 Pt in the combined group.

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EBUS/EUS-NA (Medical Mediastinoscopy
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Is Ultrasound-Guided FNA replacing Surgical
Staging ?
?
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Staging of Mediastium, How?

• High suspicion of N2,3 involvement, either by
  discrete mediastinal lymph node enlargement or
  PET uptake (and no distant metastases), a needle
  technique (EBUS, EUS or combined) is recommended
  over surgical staging as a best first test (Grade
  1B)

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Staging of Mediastium, How?

• Intermediate suspicion of N2,3, ie,
  radiographically normal mediastinum (by CT and
  PET) and a central tumor or N1 lymph node
  enlargement, a needle technique (EBUS, EUS or
  combined) is suggested over surgical staging as a
  best first test (Grade 2B)

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NEGATIVE STAGIN using a needle technique,
Operating Room
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Or N1 Ln
Clinical Approach. Flow sheet
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CONCLUSION

• Accurate Mediastinal staging is critical in the
  management of NSCLC.
• Variety of techniques are available.
  (Complimentary NOT Competitive).
• Non-invasive tests are not sufficient to
  accurately stage NSCLC.
• Minimally invasive techniques are becoming more
  preferred in the staging paradigm.
• Surgery remains the Gold standard. All (-)
  EBUS/EUS-NA need surgical confirmation.

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