Echoendoscopic Lymph Node Staging in Lung Cancer: An endoscopic alternative

1. Echoendoscopic lymph node
staging in lung cancer : An
endoscopic alternative
Pravachan Hegde, MD
Interventional Thoracic Endoscopy /
Interventional Pulmonology
Pulmonary & Critical Care Medicine
UCSF - Fresno

2. Outline

3. Lymph node map

4. N1, N2, N3 Nodes

5. Why do we stage ?
 Staging decides therapy – ?? Surgery
or no surgery
 To identify lymph node metastasis in N2,
N3 nodes and there by prevent “ futile
thoracotomies “ – There are very few
exceptions
 To identify N 1 node metastasis in
candidates with poor lung functions
before deciding on SBRT (Cyberknife)

6. Who do we stage ?
 Central tumor even if mediastinum normal
radiologically
 Tumor > 3 cm even if peripheral ( Some
experts say 2 cm )
 N1 lymph node on CT / PET
 CT showing lymph nodes > 1 cm
 PET positivity even if lymph nodes < 1 cm
 Low SUV uptake in the primary tumor in the
setting of radiologically normal mediastinum
ACCP 2013 Guidelines

7. Who doesn't need staging ?
 Peripheral tumor < 3 cm with no lymph
node enlargement on CT and no lymph
node SUV uptake on PET

8. Minimally Invasive Mediastinal
Staging
Endobronchial Ultrasound
EBUS
Endoscopic Ultrasound
EUS

9. Invasive Mediastinal
Staging
Mediastinoscopy
Anterior Mediastinotomy
VATS
VAMLA / TEMLA

10. Background
Testing with minimally invasive tests can prevent surgery
and resection in patients with advanced disease
Ideal Test:
Tissue diagnosis
High accuracy staging
Low procedure-related morbidity
Low cost

11. Minimally Invasive Lung
Cancer Staging
Staging
Mediastinal LN Staging (N2/N3)
N1 LN Staging
Liver
Adrenal Glands
Celiac axis
Pleura
Chest Wall
T4: Aorta, SVC, Trachea, Atrium
Factors to Consider
Accuracy
Cost
Safety
Completeness

12. Why EBUS / EUS?
Real-Time Imaging
Portable
No Radiation Exposure
No General Anesthesia
Requirements
Fast
Cheap
Safe
Tissue

13. Convenience
Outpatient procedure
Fast
No scar
No General Anesthesia
Multiple stations sampled
ASA ok
Real-Time Imaging
Portable
No Radiation Exposure
Cheap
Safe
Tissue

14. EBUS EUS CM AM VATS
1 – Highest Mediastinal
 
2R – Upper paratracheal
right    
2L – Upper Paratracheal
Left    
3A – Pre-vascular

3P - Retrotracheal
  
4R – Lower Paratracheal
Right   
4L – Lower Paratracheal
Left    
5 – Subaortic (AP window)
  
6 – Para-Aortic NEW
 
7 - Subcarinal
   
8 - Paraesophageal
 
9 – Pulmonary ligament
 
10 - Hilar
  
11 - Interlobar
 

15. EBUS – TBNA
Mediastinal Adenopathy
503 patients
572 LN punctured
535 diagnoses (94%)
Mean diameter 1.6mm
Sensitivity = 94%
Specificity = 100%
PPV = 100%
Herth FJF, et al. Real-time EBUS TBNA for sampling mediastinal lymph nodes. Thorax 2006;61:795-
798.

16. EBUS TBNA in CT Negative
Mediastinum
100 NSCLC patients with
no LN > 1cm in the
mediastinum
Identifiable LN in
mediastinum aspirated
2, 4, 7, 10, 11
All patients underwent
surgical staging
119 LN sampled
Malignancy detected in
19
Malignancy missed in 2
Sensitivity = 92.3%
Specificity = 100%
NPV = 96.3%
No complications
Herth FJF, et al. EBUS-guided TBNA of lymph nodes in the radiologically
normal mediastinum. Eur Respir J 2006;28:910-914.

17. EBUS Published results

18. EUS Upstaging
44 patients with resectable tumor on CT
scan
EUS changed management in 8 (18%)
Upstaging Tumor to:
Stage IV 7%
Stage IIIA or IIIB 7%
Stage II to IIIA 4%
EUS-FNA led to avoidance of thoracotomy in 13.6% of
patients with CT findings of a resectable tumor
EUS as the First Test in Diagnosis and Staging of Lung Cancer
Singh P, et al. American Journal of Respiratory and Critical Care Medicine.
2007;175:345-354.

19. EBUS + EUS FNA
160 patients with
enlarged mediastinal LN
EBUS = 85% success
EUS = 78% success
EBUS + EUS = 97%
No Complications
33 patients with med
adenopathy
119 nodes sampled
59 EUS
60 EBUS
11 additional positive nodes by
EBUS over EUS
12 additional positive nodes by
EUS over EBUS
Combination EBUS + EUS =
100% AccuracyHerth FJF, et al. Am J Resp Crit Care Med
2005;171:1164-1167.
Vilman P, et al. Endoscopy 2005;37:833-839.

20. Combined EBUS + EUS
Suspected Lung
Cancer
TBNA, EBUS-FNA,
EUS-FNA - Combined
138 Patients
Wallace et al. JAMA 2008;299(5):540-546.

21. Endosonographic Mediastinal
Lymph Node Staging of Lung
Cancer
Prospective comparison of diagnostic test findings
on a consecutive case series
Each subject serving as his or her own control
Sample Size = 166
ClinicalTrials.gov: NCT01011595
Liberman et al Chest. 2014;146(2):389-
397.

22. Methodology
EBUS
EUS
Cervical Mediastinoscopy
VATS
Anterior Mediastinotomy

23. Results
30 months
166 patients
Prevalence of N2/N3
disease = 32%
Liberman et al Chest. 2014;146(2):389-
397.
Mean LN
Stations
EBUS 2.2
EUS 1.7
EBUS/EUS 3.9
SMS 3.1

24. Liberman et al Chest. 2014;146(2):389-397.
Sensitivity NPV Accuracy
EBUS 72% 88% 91%
EUS 62% 85% 88%
EBUS+EUS 91% 96% 97%

25. EBUS-EUS diagnosed N2/N3/M1 disease in 24
patients in whom SMS was negative
Preventing thoracotomy in an additional 14%

26. Morbidity
MEDIASTINOSCOPY
2,145 patients
23 complications (1.07%)
Bleeding – 7
Vocal Cord Dysfunction –
12
Tracheal Injury – 2
Pneumothorax – 2
Death – 1
PA Injury
EBUS
100 patients
0 complications
Chest 2004;125:322-325.
1,174 patients
0 major complications
5.5% transient atrial
tachycardia
Eur Resp J 2002;20:118-121.
50 lung biopsies
1 pneumothorax
Eur Resp J 2002;20:972-974.
Lemaire A, et al. Ann Thorac Surg 2006;82:1185-
1190.

27. Rare but possible tracheal
injury
CETOC - Journal of Bronchology 2010;17:264-265.

28. COST
Mediastinoscopy =
$2,100* - $12,900**
EUS-FNA = $1,867**
EBUS-FNA =
$2,000**
Pulmonary Resection
= $22,000*
*J Clin Oncol 2001;20:263-273.
**Ann Thorac Surg 2005;80:1231-1239.

29. RUL tumor with radiologically
normal mediastinum

30. Left Adrenal Gland

31. Left Adrenal Gland
SUV = 4.3

32. EBUS 4 R

33. Complete Staging

34. EUS Adrenal biopsy

36. Take home message
 Standard mediastinoscopy is no longer the gold
standard.
 Combined endosonographic procedures (EBUS/EUS)
are safe,cost-effective, and superior to surgical
mediastinal staging. It allows for the biopsy of lymph
nodes and metastases that are unattainable with
standard mediastinoscopy techniques thereby preventing
futile thoracotomies.
 Combined endosonographic procedures (EBUS/EUS)
are the new gold standard in mediastinal staging of non-
small-cell lung cancer when performed by an
experienced operator.

37. Thank You !