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C.P. Heussel



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    MS 20 - Joint Imaging/Therapy Conference (ID 38)

    • Event: WCLC 2015
    • Type: Mini Symposium
    • Track: Treatment of Locoregional Disease – NSCLC
    • Presentations: 1
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      MS20.01 - Imaging for Surgical Treatment Decision and Planning (ID 1937)

      14:20 - 14:40  |  Author(s): C.P. Heussel

      • Abstract
      • Presentation

      Abstract:
      When patients with early-stage non-small cell lung cancer (NSCLC) are accurately staged inappropriate surgery is avoided and on the other hand potentially curative surgical resection is not refused. The clinical algorithms using imaging studies for staging lung cancer patients with regard to surgical treatment decision and planning as recommended by current guidelines will be presented and discussed. Low-dose CT screening is now recommended for asymptomatic select patients who are at high risk for lung cancer and an increasing number of patients may come to clinical attention during screening. CT findings suggestive of malignancy in a patient with a solitary pulmonary nodule include larger lesion size, irregular or spiculated borders, upper lobe location, thick-walled cavitation, presence or development of a solid component within a ground glass lesion, and detection of growth by follow-up imaging. The general approach to patients suspected of having lung cancer begins with a thorough history and physical examination (1). Following that, essentially every patient suspected of having lung cancer should undergo a contrast-enhanced diagnostic CT scan of the chest. The diagnostic chest CT scan is an important first step, not only to help define the clinical diagnosis, but to structure the subsequent staging and diagnostic evaluation (1). In patients in whom lung cancer has been demonstrated, consideration must turn toward determining the extent of the disease to identify patients with stage IA, IB, IIA, and IIB disease who can benefit from surgical resection. **Extrathoracic (M) Staging** The purpose of extra thoracic imaging in NSCLC is to detect metastatic disease. Current literature continues to demonstrate that PET and PET-CT scans are superior to conventional staging tests (bone scan and abdominal CT scan) in terms of performance characteristics (1). Recent data confirm the superiority of the performance characteristics of PET and PET-CT scans compared with conventional scans in the evaluation of metastatic disease in key specific distant sites (1). Recommendation (1): In patients with a normal clinical evaluation and no suspicious extra thoracic abnormalities on chest CT being considered for curative-intent treatment, PET imaging (where available) is recommended to evaluate for metastases (except the brain) (Grade 1B). However, positive PET/CT scan findings for distant disease need pathologic or other radiologic confirmation (e.g., MRI of bone) (2). Brain MRI (to rule out asymptomatic brain metastases) is recommended for patients with stage II and higher (2). Patients with stage IB NSCLC are less likely to have brain metastases; therefore, brain MRI is only a category 2B recommendation in this setting (2). **Mediastinal Nodal (N) Staging** Mediastinal lymph node staging in NSCLC is particularly important, because in many cases, the nodal status actually determines whether there is surgically resectable disease. If the contrast-enhanced CT scan shows nodal mediastinal infiltration that encircles the vessels and airways, so that discrete lymph nodes can no longer be discerned or measured, non-resectable disease is evident and no further imaging studies are required to determine the exact N status (1). In patients with discrete mediastinal node enlargement further evaluation is recommended (1, 2). The NCCN Panel assessed studies that examined the sensitivity and specificity of chest CT scans for mediastinal lymph node staging. Depending on the clinical scenario, a sensitivity of 40% to 65% and a specificity of 45% to 90% were reported. PET/CT scans may be more sensitive than CT scans (2). However, in patients with discrete mediastinal node enlargement, the risks of false positive test results from either CT scanning and/or PET scanning are too high to rely on imaging alone to determine the mediastinal stage of the patient, and tissue confirmation is necessary (1). Transesophageal EUS-FNA and EBUS-TBNA have proven useful to stage patients or to diagnose mediastinal lesions; these techniques can be used instead of invasive staging procedures in select patients. When compared with CT and PET, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has a high sensitivity and specificity for staging mediastinal and hilar lymph nodes in patients with lung cancer. In patients with positive nodes on CT or PET, EBUS-TNBA can be used to clarify the results. In patients with negative findings on EBUS-TNBA, conventional mediastinoscopy can be done to confirm the results. **Thoracic Tumor (T) Staging** The size of the tumor, its location and invasion of adjacent structures as reflected in the T status determines resectablity and - in cases with given resectablity - the extent of resection. In patients with T3 tumors or centrally located tumors that may necessitate a pneumonectomy, additional functional evaluation of the patient may be required to determine operability. Contrast-enhanced CT scan is the most commonly used imaging modality for T staging and can provide all the information needed. In select cases (e.g. Pancoast-Tumors) MRI may be useful to diagnose involvement of the brachial plexus and extension into the neural foramina and the spinal canal (3). Infiltration of the mediastinal great vessels, esophagus, trachea, and vertebral body is staged as T4 and usually defines unresectability. Findings on CT scan like obliteration of fat plane between the tumor and the mediastinum, circumference of contact between the tumor and the aorta, and the length of anatomical contact between the tumor and the mediastinum are not definitive signs for invasion. Both CT scan and MRI have similar diagnostic accuracy (56-89% for CT and 50-93% for MRI) in predicting mediastinal invasion, with no modality being considered to be distinctly superior (3). References: 1. Silvestri GA, et al. Methods for Staging Non-small Cell Lung Cancer. Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2013; 143(5)(Suppl):e211S–e250S 2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Non-Small Cell Lung Cancer, Version 7.2015, NCCN.org 3. Nilendu C Purandare and Venkatesh Rangarajan.Imaging of lung cancer: Implications on staging and management. Indian J Radiol Imaging. 2015 Apr-Jun; 25(2): 109–120.

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