Restaging of Bronchogenic Carcinoma Based on 7th Edition of
TNM Classification - Using Integerated PET CT
Page 1 of 44
Restaging of bronchogenic carcinoma based on 7thedition
of TNM classification - using integerated PET CT.
Pos...
Page 2 of 44
Learning objectives
1.To restage the recently diagnosed cases of bronchogenic carcinoma in our clinical
setup...
Page 3 of 44
Fig. 1: 7th Edition TNM Staging
Fig. 2: Lung cancer staging in 6th and 7th edition of TNM classification. The...
Page 4 of 44
Fig. 3
Page 5 of 44
Imaging findings OR Procedure details
We retrospectively looked at the data of 115 patients with lung cancer,...
Page 6 of 44
Fig. 1: Fig. 20: PET CT scanner.(Picture courtesy Philips Medical Systems)
Page 7 of 44
Fig. 2: Well defined solitary pulmonary nodule of size 1.6 cms in left lower lobe
with no mediastinal lymph n...
Page 8 of 44
Page 9 of 44
Fig. 3: T1a - 1.3cms lesion more than 2cms from carina abutting right upper lobe
bronchus & no invasion proxi...
Page 10 of 44
Fig. 4: T1b - Peripherally located 2.5 cms sized lesion surrounded by lung. Final Staging
(stage IV by 6th e...
Page 11 of 44
Fig. 5: T2a - 3.3 cms sized mass lesion (>3cms)with N2 lymphnodes (ipsilateral hilar &
subcarinal nodes ) an...
Page 12 of 44
Page 13 of 44
Fig. 6: T2b - 5.8 cms (>5 cms )sized mass lesion.Fusion images show the FDG avid
peripheral component with t...
Page 14 of 44
Fig. 7: T3 -6.6 cms sized mass with areas of necrosis in left upper lobe with mediastinal
and chest wall ple...
Page 15 of 44
Fig. 9: N stage Two different cases of right upper lobe mass lesion with sub carinal
lymphadenopathy (N2). A...
Page 16 of 44
node (Presence of ipsilateral hilar adenopathy alone would indicate N1 disease) in
addition to the subcarina...
Page 17 of 44
Page 18 of 44
Fig. 10: N3 left upper lobe mass lesion with CONTRALATERAL lower paratracheal &
supra clavicular lymph nodes...
Page 19 of 44
Page 20 of 44
Fig. 12: M1b - Left upper lobe mass with renal & bony metastases. Stage IV in both
editions.
Fig. 13: Serial...
Page 21 of 44
Fig. 14: Same patient as in fig. 13 shows a 6.3 cms sized broncho alveolar type of
adenocarcinoma in right u...
Page 22 of 44
Fig. 15: Mass lesion in right lower lobe with carina, mediastinal and great
vessel (right pulmonary artery) ...
Page 23 of 44
Fig. 16: Non small cell ca in right upper lobe with mediastinal invasion & non FDG avid
spiculated nodule me...
Page 24 of 44
Page 25 of 44
Fig. 17: 7. 3 cms sized mass in right upper lobe with no mediastinal lymph nodes or
intrathoracic/distant me...
Page 26 of 44
Page 27 of 44
Fig. 18: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partial
atelectasis of ante...
Page 28 of 44
Conclusion
Re-staging of bronchogenic carcinoma based on 7th edition and assessment of variation
between 6th...
Page 29 of 44
Images for this section:
Fig. 1: The application of 7th edition criteria altered the overall staging in 11% ...
Page 30 of 44
Fig. 2: Distribution of the change based on TNM descriptors.
Fig. 3: Distribution of cases changed in Final ...
Page 31 of 44
Page 32 of 44
Fig. 4
Fig. 5: Organ wise distribution of metastases in 39 cases.
Page 33 of 44
Page 34 of 44
Fig. 6: Case of small cell carcinoma presented with hyper metabolic mass lesion in right
upper lobe with rig...
Page 35 of 44
Fig. 7: CT and PET/CT images of the same patient showed in figure 6: Brain lesions were
not hyper metabolic ...
Page 36 of 44
Page 37 of 44
Fig. 8: Mass lesion with SVC obstruction shows response to Cyber knife therapy.Top
image shows the mass with...
Page 38 of 44
Page 39 of 44
Fig. 10: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partial
atelectasis of ante...
Page 40 of 44
Fig. 12: Well defined non FDG avid mass lesion in left upper lobe. Histo pathology is
proved to be broncho a...
Page 41 of 44
Page 42 of 44
Fig. 13: Hyper metabolic spiculated mass lesion in left upper lobe with a non FDG avid
subcentimeter nodule ...
Page 43 of 44
Personal Information
Dr.Bagyam Raghavan, Senior consultant radiologist, Apollo speciality hospitals,Chennai,...
Page 44 of 44
2009; 4:300-310
11. Hage R, de la Riviere AB, Seldenrijk CA, van den Bosch JM. Update in
pulmonary carcinoid...
Apollohospitals:http://www.apollohospitals.com/
Twitter:https://twitter.com/HospitalsApollo
Youtube:http://www.youtube.com...
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Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT.

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The new 7th edition of the TNM classification system features a number of revisions, including subdivision of tumor categories on the basis of size, differentiation between local intra thoracic and distant metastatic disease, recategorization of malignant pleural or pericardial disease etc, on the basis of evidence from a significantly larger worldwide data base that has been subjected to extensive validation which attempts to better correlate disease with prognostic value and treatment strategy.

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Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT.

  1. 1. Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT
  2. 2. Page 1 of 44 Restaging of bronchogenic carcinoma based on 7thedition of TNM classification - using integerated PET CT. Poster No.: C-0943 Congress: ECR 2011 Type: Educational Exhibit Authors: B. RAGHAVAN 1 , G. SIVARAMALINGAM 2 ; 1 CHENNAI, TA/IN, 2 CHENNAI, tamilnadu/IN Keywords: PET-CT, Oncology DOI: 10.1594/ecr2011/C-0943 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to third- party sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org
  3. 3. Page 2 of 44 Learning objectives 1.To restage the recently diagnosed cases of bronchogenic carcinoma in our clinical setup based on the 7th edition of TNM classification. 2.To assess the staging variation between the 6th and 7th editions using a combined PET/CT scanner by evaluating the primary and metastatic lesions on both metabolic and anatomic basis. 3.To assess the role of PET/CT in staging . Background In 2009, the seventh edition of the TNM staging system for lung cancer was published by the International Union Against Cancer and the American Joint Committee on Cancer, based on proposals from the International Staging Project of the International Association for the Study of Lung Cancer (IASLC) using the 46 different data bases collected across 19 countries between 1990 and 2000, from 100,869 cases of newly diagnosed primary lung cancer.(1) The new 7th edition of the TNM classification system features a number of revisions, including subdivision of tumor categories on the basis of size, differentiation between local intra thoracic and distant metastatic disease, recategorization of malignant pleural or pericardial disease etc, on the basis of evidence from a significantly larger worldwide data base that has been subjected to extensive validation which attempts to better correlate disease with prognostic value and treatment strategy. Two primary methods of lung cancer staging are available clinical staging and pathologic staging. Clinical staging includes minimally inasive & non invasive methods of which imaging has a key role to play. Integrated PET CT with its depiction of anatomy & function delineates the various TNM stages non-invasively.(2) Images for this section:
  4. 4. Page 3 of 44 Fig. 1: 7th Edition TNM Staging Fig. 2: Lung cancer staging in 6th and 7th edition of TNM classification. The red box indicates unresectable disease.
  5. 5. Page 4 of 44 Fig. 3
  6. 6. Page 5 of 44 Imaging findings OR Procedure details We retrospectively looked at the data of 115 patients with lung cancer, who reported to our PET CT centre ( Apollo speciality hospitals, Chennai) from october 2009 to january 2011, out of which 60 untreated HPE proven cases were included in the study. All paients fasted for at least six hours before the PET/CT examination, although oral hydration with glucose- free water was allowed after ensuring a normal blood glucose level in the peripheral blood, patients received an IV injection of 5 Mci of F-18 flurodeoxyglucose and then rested for approximately 45 minutes before scanning. Scans were accquired using a PET/CT Scanner (Philips Gemini TF 64 Slice). Image accquisition was done from the vertex of the skull to midthigh after IV administration of non- ionic iodinated contrast agent (1ml/kg body weight with saline chasing) for attenuation correction & diagnosis. We compared and analysed the variation in individual T,N,M and the final staging, and thereby the prognostic factors and survival differences in the patient data according to the sixth and the seventh edition of the TNM system. Images for this section:
  7. 7. Page 6 of 44 Fig. 1: Fig. 20: PET CT scanner.(Picture courtesy Philips Medical Systems)
  8. 8. Page 7 of 44 Fig. 2: Well defined solitary pulmonary nodule of size 1.6 cms in left lower lobe with no mediastinal lymph nodes or distal metastases.CT guided lung Bx was done HPE was adenocarcinoma followed by surgery. 6th edition(T1N0M0)stage IA,7th edition(T1aN0M0)stage IA - no stage variation.
  9. 9. Page 8 of 44
  10. 10. Page 9 of 44 Fig. 3: T1a - 1.3cms lesion more than 2cms from carina abutting right upper lobe bronchus & no invasion proximal to lobar bronchus. The coronal image shows the distance from the carina (3.1 cm). Final staging of 6th (III B) and 7th (III B) edition did not alter in this case as the patient was N3 supraclavicular and lower cervical nodes.
  11. 11. Page 10 of 44 Fig. 4: T1b - Peripherally located 2.5 cms sized lesion surrounded by lung. Final Staging (stage IV by 6th edition and 7th edition) did not change due to vertebral metastases.
  12. 12. Page 11 of 44 Fig. 5: T2a - 3.3 cms sized mass lesion (>3cms)with N2 lymphnodes (ipsilateral hilar & subcarinal nodes ) and M1b rib metastases. Final staging (Stage IV)did not alter in 6th & 7th edition because of rib metastases.
  13. 13. Page 12 of 44
  14. 14. Page 13 of 44 Fig. 6: T2b - 5.8 cms (>5 cms )sized mass lesion.Fusion images show the FDG avid peripheral component with the central area of necrosis. Final Stage III A did not alter in both editions because of N2 lymph nodes ( not shown in image ).
  15. 15. Page 14 of 44 Fig. 7: T3 -6.6 cms sized mass with areas of necrosis in left upper lobe with mediastinal and chest wall pleural invasion. Final Stage IIIA did not change in 6th and 7th edition because of N2 nodes (ipsilateral hilar, lower paratracheal, and subcarinal nodes ). *The delineation of the hyper-metabolic area facilitated proper targeting of the area to be biopsied. Fig. 8: T4-right upper lobe mass lesion with right main bronchus, carina and Superior venacava (arrow) invasion. In both editions the Final stage is T4N0M0 but it is down staged from IIIB to IIIA in 7th edition.
  16. 16. Page 15 of 44 Fig. 9: N stage Two different cases of right upper lobe mass lesion with sub carinal lymphadenopathy (N2). Additionally the lower image shows FDG avid ipsilateral hilar
  17. 17. Page 16 of 44 node (Presence of ipsilateral hilar adenopathy alone would indicate N1 disease) in addition to the subcarinal node however the presence of rib metastases has upstaged the disease to Stage IV.
  18. 18. Page 17 of 44
  19. 19. Page 18 of 44 Fig. 10: N3 left upper lobe mass lesion with CONTRALATERAL lower paratracheal & supra clavicular lymph nodes Fig. 11: M1a - Adeno carcinoma right upper lobe with diffuse pleural dissemination. No significant mediastinal adenopathy. 6th edition it is T4N0M0 - STAGE IIIB, 7th edition T3N0M1a - STAGE IV and the lesion has been upstaged.
  20. 20. Page 19 of 44
  21. 21. Page 20 of 44 Fig. 12: M1b - Left upper lobe mass with renal & bony metastases. Stage IV in both editions. Fig. 13: Serial pre-operative X-rays show a right upper lobe mass which showed progression. PET scan (PET images are in Fig 14 )was performed for staging after the CT guided biopsy showed bronchoalveolar carcinoma.Patient underwent surgery. Post op X-ray of the same patient(right bottom image). Post-op HPE findings confirmed the histopathology with node -ve disease.
  22. 22. Page 21 of 44 Fig. 14: Same patient as in fig. 13 shows a 6.3 cms sized broncho alveolar type of adenocarcinoma in right upper lobe. Non FDG avid right lower para tracheal lymph node . 6th edition(T2N0M0)STAGE IB, 7th edition(T2bN0M0)STAGE IIA- upstaged because of size criteria.
  23. 23. Page 22 of 44 Fig. 15: Mass lesion in right lower lobe with carina, mediastinal and great vessel (right pulmonary artery) invasion.Ipsilateral para tracheal and para aortic lymphadenopathy,pericardial dissemination and non FDG avid right sided pleural effusion are seen. 6th edition (T4N3M0)-STAGE IIIB, 7th edition(T4N3M1a) - STAGE IV; lesion upstaged because of pericardial dissemination.
  24. 24. Page 23 of 44 Fig. 16: Non small cell ca in right upper lobe with mediastinal invasion & non FDG avid spiculated nodule measuring (0.8 cms ) in superior basal segment of right lower lobe and FDG avid necrotic right subpectoral lymph node . 6th edition (T4N3M1)-STAGE IV, 7th edition (T4N3M0)- STAGE IIIB , the presence of satellite nodule in the same lung but different lobe down staged the disease. PET is not sensitive in sub-centimeter nodules and CT morphology was used in deciding the stage.
  25. 25. Page 24 of 44
  26. 26. Page 25 of 44 Fig. 17: 7. 3 cms sized mass in right upper lobe with no mediastinal lymph nodes or intrathoracic/distant metastasis. 6th edition (T2N0M0)-STAGE IB,7th edition (T3N0M0) - STAGE IIB, the lesion is upstaged according to the size criteria (>7 cms - T3 in 7th edition).
  27. 27. Page 26 of 44
  28. 28. Page 27 of 44 Fig. 18: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partial atelectasis of anterior segment of right upper lobe. The lesion was T2 in 6th edition and remained T2a in 7th edition due to the size criteria and metabolically inactive partial collapse of right upper lobe. Fig. 19: Small cell carcinoma in right hilar region with great vessels (right pulmonary artery and vein), pericardium and bronchus intermedius invasion.Right supraclavicular and contralateral hilar lymph nodes are also seen.(arrows) 6th edition-(T4N3M0)STAGE IIIB,7th edition-(T4N3M1a) STAGE IV;the lesion is upstaged from IIIB to IV due to pericardial invasion.
  29. 29. Page 28 of 44 Conclusion Re-staging of bronchogenic carcinoma based on 7th edition and assessment of variation between 6th and 7th edition: • In our series the overall change in final Stage was seen in only 11 % ( Fig 1) of cases and in all the cases there was change in the management. Population based case study by strand et al [3] revealed that based on the current indications of therapy, nearly one-fifth (17%) of the patients could be offered different treatment options because of the rearrangement of some TNM subsets in different stages. • Our case load consisted of more than 50 % of stage IV disease & we did not have any N1 in our series & hence there was a limitation to predict the impact of 7th edition in early T & N staging [4]. • In our series maximum change was seen in M category (Fig 2) due to the sub-categorisation as local or distant metastatic disease to subdivision of M1 a & M1b. • TNM staging applies to Small cell carcinoma (fig 6)& Carcinoid.[10],[11]. • The 7th edition clinical staging by imaging, helped in sub classification of the various TNM stages and to arrive at the final Staging. And it also helped in deciding various treatment options like surgery, chemotherapy, radiotherapy including targeted therapies like cyber knife (fig.8), for better survival rates (fig.4). ROLE OF INTEGRATED PET/ CT: • PET helped in nodal & metastatic staging work-up however it did not have any impact in any of our cases which altered in the final staging.[7] • PET/CT detected metastases in 39 out of the 60 cases of which maximum were skeletal metastases(fig.5) • PET did not have a bearing on T staging however it is able to accurately delineate the tumor load & boundaries (fig 9) & differentiate it from associated collapse / consolidation(fig.10) or area of necrosis,guiding targeted biopsy from the metabolically representative area. • PET/CT has a definite role in assessing recurrent disease based on metabolic activity (fig.11). • PET has limitation in brain metastases (fig.7), bronchoalveolar carcinoma (fig.12) and in subcentimeter satellite nodules (fig.13). • Hyper metabolism can also be seen in cases of infective lung lesions (fig.14) and in reactive lymphadenopathy causing false positivity in PET imaging. In these instances we use Contrast MDCT characteristics for diagnosis and confirm by histopathological evaluation using minimally invasive techniques like CT guided biopsy, mediastinoscopy and VATS.
  30. 30. Page 29 of 44 Images for this section: Fig. 1: The application of 7th edition criteria altered the overall staging in 11% of cases in our study.
  31. 31. Page 30 of 44 Fig. 2: Distribution of the change based on TNM descriptors. Fig. 3: Distribution of cases changed in Final Staging.
  32. 32. Page 31 of 44
  33. 33. Page 32 of 44 Fig. 4 Fig. 5: Organ wise distribution of metastases in 39 cases.
  34. 34. Page 33 of 44
  35. 35. Page 34 of 44 Fig. 6: Case of small cell carcinoma presented with hyper metabolic mass lesion in right upper lobe with right adrenal and brain metastases (top three images).Post radiotherapy follow up images (bottom three images) showed regression in metabolic activity as well as size of the lesions.
  36. 36. Page 35 of 44 Fig. 7: CT and PET/CT images of the same patient showed in figure 6: Brain lesions were not hyper metabolic in comparison to the normal brain parenchyma in PET CT,contrast enhanced CT images helped in diagnosis of metastatic lesion.This illustrates the poor sensitivity of PET in identifying brain metastases.
  37. 37. Page 36 of 44
  38. 38. Page 37 of 44 Fig. 8: Mass lesion with SVC obstruction shows response to Cyber knife therapy.Top image shows the mass with fiducials in the planning CT,post treatment response seen in the bottom 2 images. Fig. 9: 43 year old male with Pan coast tumor - non-small cell lung carcinoma shows tumor regression in the post chemotherapy follow-up scan.
  39. 39. Page 38 of 44
  40. 40. Page 39 of 44 Fig. 10: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partial atelectasis of anterior segment of right upper lobe. The lesion was T2 in 6th edition and remained T2a in 7th edition due to the size criteria and metabolically inactive partial collapse of right upper lobe. Fig. 11: case of non small cell carcinoma right upper lobe, underwent right upper lobectomy, patient received post surgery radiotherapy also.Follow up PET/CT after 2 year showed a recurrent FDG avid focus (top right image)in right upper lobe abutting the right side of trachea. PET/CT helped in identifying and localising this local recurrence which with CT alone will be difficult to detect in post operative scenario.
  41. 41. Page 40 of 44 Fig. 12: Well defined non FDG avid mass lesion in left upper lobe. Histo pathology is proved to be broncho alveolar carcinoma and PET has poor sensitivity for brochoalveolar type of adenocarcinoma.
  42. 42. Page 41 of 44
  43. 43. Page 42 of 44 Fig. 13: Hyper metabolic spiculated mass lesion in left upper lobe with a non FDG avid subcentimeter nodule in same lobe. Subcentimeter lesions are beyond the resolution of PET acquisition. Fig. 14: Hyper metabolic lesion in the left lower lobe in a 30 year old patient who had hemoptysis. The contrast enhanced CT showed a separate arterial branches from the descending thoracic aorta and the venous drainage is into the hemiazygos vein suggestive of sequestration. Histopathology confirmed the same with super added infection.
  44. 44. Page 43 of 44 Personal Information Dr.Bagyam Raghavan, Senior consultant radiologist, Apollo speciality hospitals,Chennai, Tamil nadu, India. Dr.Geethapriya Sivaramalingam, Senior resident, Apollo speciality hospitals, Chennai, Tamil nadu, India. References References 1. Stacy J.UyBico et.al: Lung Cancer Staging Essentials: The New TNM Staging System and Potential Imaging pitfalls, RadioGraphics,10.1148/ rg.305095166 September 2010; 30, 1163-1181. 2. Seth Kligerman and Subba Digumarthy: Staging of Non-Small Cell Lung Cancer - Using Integrated PET/CT, American Journal of Radiology 2009; 193:1203-1211. 3. Strand TE, Rostad H, Wentzel-Larsen T, et al. A population - based evaluation of the seventh edition of the TNM system for lung cancer. Eur Respir J 2010; 36: 401-407. 4. R. Rami-Porta* and P. Goldstraw#:Strength and weakness of the new TNM classification for lung cancer,Eur Respir J 2010; 36: 237-239. 5. Makoto Suzuki .et.al: Applicability of the revised International Association for the Study of Lung Cancer staging system to operable non-small-cell lung cancers, European Journal of Cardio-thoracic Surgery 36 (2009);1036. 6. Blodgett et al.speciality imaging. PET/CT oncologic imaging with correlative diagnostic CT;1st ed. 7. Erasmus JJ, Rohren E, Swisher SG. Prognosis and reevaluation of lung cancer by positron emission tomography imaging. Proc Am Thorac Soc 2009;6:171-179 8. Seth Kligerman and Gerald Abbott: a radiologic review of the new TNM classification for lung cancer, American Journal of Radiology 2010; 194:562-573 9. Takayuki Fukui et al.Prognostic evaluation based on a new TNM staging system proposed by the International Association for the Study of Lung Cancer for resected non-small cell lung cancers, The Journal of Thoracic and Cardiovascular Surgery November 2008 (Vol. 136, Issue 5, Pages 1343-1348), 15 August 2008 10. Ignatius Ou SH, Zell JA. The applicability of the proposed IASLC staging revisions to small cell lung cancer (SCLC) with comparison to the current UICC 6th TNM edition. J Thorac Oncol
  45. 45. Page 44 of 44 2009; 4:300-310 11. Hage R, de la Riviere AB, Seldenrijk CA, van den Bosch JM. Update in pulmonary carcinoid tumors:a review article. Ann Surg Oncol 2003;10:697-704 12. Goldstraw P, Crowley J, Chansky K, et al. TheIASLC LungCancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of Malignant Tumours. J Thorac Oncol2007; 2: 706-714 13. Behnaz Goudarzi and Richard Wahl, PET/CT evaluation of bronchioloalveolar carcinoma: Correlation with CT and FDG/PET findings Nucl Med. 2007; 48 (Supplement 2):122P
  46. 46. Apollohospitals:http://www.apollohospitals.com/ Twitter:https://twitter.com/HospitalsApollo Youtube:http://www.youtube.com/apollohospitalsindia Facebook:http://www.facebook.com/TheApolloHospitals Slideshare:http://www.slideshare.net/Apollo_Hospitals Linkedin:http://www.linkedin.com/company/apollo-hospitals Blog:Blog:http://www.letstalkhealth.in/

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