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P. Antippa
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MINI 20 - Surgery (ID 137)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 1
- Moderators:G. Veronesi, R. Flores
- Coordinates: 9/08/2015, 16:45 - 18:15, 201+203
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MINI20.13 - A Prospective Comparison of FDG-PET & EBUS for Determining the Extent of Mediastinal Lymph Node Involvement in NSCLC (ID 2323)
17:55 - 18:00 | Author(s): P. Antippa
- Abstract
- Presentation
Background:
Non-small cell lung cancer (NSCLC) may be treated with curative intent using radiotherapy, either as single modality or in combination with systemic chemotherapy. Most commonly, radiation treatment is planned based on findings at 18-Fluorodeoxyglucose Positron Emission Tomography (PET), following pathologic confirmation of involvement at a single mediastinal site. We hypothesized that systematic mediastinal evaluation with EBUS-TBNA in NSCLC patients considered for radical radiation therapy may identify disease extent discrepant with that indicated by PET-CT.
Methods:
This prospective ethics board-approved multi-centre cohort study in three Austrailan tertiary centres consented patients prior to mediastinal evaluation with Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) for NSCLC,where non-invasive imaging indicated the likely treatment modality would include radical radiotherapy. EBUS evaluation was performed systematically with sampling of any lymph node (LN) exceeding 6mm diameter.
Results:
Thirty eligible patients with NSCLC form the basis of this report. No procedural complications occurred during performance of EBUS-TBNA. LN sampling was performed from a mean 2.5 lymph node stations per patient (median 3,range 1–5). Adequate samples were obtained from all sites examined by EBUS-TBNA. Mean long-axis size of sampled LN was 16+7.8mm (median 13mm,range 5–36mm). 24% of sampled LN were 10mm or less. Discordant findings were observed in 10 of 30 patients (33%) (Figure 1) EBUS-TBNA identified a greater extent of mediastinal involvement than PET in four patients, with invasive sampling resulting in upstaging in three patients. In one further patient, extent of disease was greater than noted on PET due to more proximal involvement of LN disease not resulting in stage advancement. Median size of LN upstaged by EBUS was 7.5mm (range 7–9). In eleven mediastinal LN in six patients, EBUS identified a lesser extent of mediastinal disease than PET, including two patients down-staged from N3 à N2. Median size of LN down-staged by EBUS was 12mm (range 6–21). FIGURE 1. Flowchart of patients Figure 1
Conclusion:
Our findings demonstrate clinically significant discrepancy between two modalities frequently used to stage mediastinal disease extent in NSCLC patients being considered for radiotherapy. PET-based radiotherapy planning alone may not be appropriate given the risk of excessively large, or insufficiently large, radiation fields where planning is not based on invasive LN sampling. These results suggest minimally invasive comprehensive/systematic mediastinal staging should be considered for all patients prior to radiotherapy to accurately assess pathologic stage and extent of disease, and to ensure treatment fields most accurately encompass all sites of disease.
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P1.02 - Poster Session/ Treatment of Localized Disease – NSCLC (ID 209)
- Event: WCLC 2015
- Type: Poster
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.02-023 - The Role of Selective EBUS-TBNA Mediastinal Sampling in Early Lung Cancer (ID 542)
09:30 - 09:30 | Author(s): P. Antippa
- Abstract
Background:
Accurate pre-operative staging of the mediastinum in lung cancer is essential to determine the type of treatment. The commonly used investigations are CT scan, PET scan, EBUS-TBNA (Endobronchial ultrasound-guided transbronchial needle aspiration) and mediastinoscopy, and often these tests complement each other to increase the accuracy of staging. With advances in technology and increased experience, EBUS has the potential to replace mediastinoscopy to stage the mediastinum. Surgical mediastinal dissection, though commonly performed, has not been convincingly proven to have a therapeutic value. We postulate that if the mediastinum can be staged accurately with EBUS-TBNA (a low morbid procedure) then a surgical staging of the mediastinum (mediastinoscopy and / or dissection) can be avoided and therefore, avoid the morbidity associated with these procedures. We have studied the use of selective EBUS-TBNA which is sampling abnormal nodes on imaging (CT, PET scan) and compared it with the mediastinal dissection done surgically.
Methods:
This is a retrospective study of patients who underwent surgery (lobectomy/pneumonectomy + mediastinal lymphnode dissection) for early stage lung cancer (stage I/II).Patients who had negative N2 lymph nodes on EBUS-TBNA evaluation were included in the study. All patients had CT and PET scans which assisted the EBUS study. The results of EBUS-TBNA were compared with that of the surgical mediastinal lymph node dissection.
Results:
A total of 86 patients were included in the study. EBUS-TBNA correctly staged the mediastinum in 78 patients (90.7%, negative predictive value (NPV) = 0.90). Eight patients had false negative (FN) evaluation by EBUS-TBNA. On review, two of these patients had a sampling error. Three patients had incomplete evaluation of the mediastinum. All these 3 patients had left lung cancer whose level 5 lymph nodes could not be sampled, and surgical sampling displayed these nodes to be involved with extracapsular spread. There were three other patients with FN results, and they had mediastinal nodes biopsied by EBUS which with surgical removal showed metastasis. Two of these patients had metastatic deposits < 3mm in size. We feel that diligent and systematic EBUS would have avoided the FN result in most of the above patients except for sampling of level 5 nodes which may not be technically accessible by EBUS. The NPV for right lung cancers, especially right upper lobe (NPV=0.96) was higher as compared to left sided cancers.
Conclusion:
This study shows that selective EBUS-TBNA mediastinal staging in early lung cancer is feasible, has an acceptable NPV and provides evidence to facilitate studies on systematic EBUS. This study draws attention thorough the identified 8 FNs to the real and potentially avoidable limitations of selective EBUS mediastinal lymphnode sampling. The accuracy of systematic EBUS evaluation should be superior to a selective study and can therefore potentially avoid a surgical staging of the mediastinum and its associated complications.
