Approach to the Solitary Pulmonary NoduleNew Staging System for NSCLCLymph Node Map-Update<br />Bassel Ericsoussi, MD<br /...
The Peripheral Pulmonary Nodule<br />Small focal radiographic opacities that may be solitary or multiple<br />The term “Co...
Prevalence<br />Prevalence of SPNs in screening trials of populations at high risk for lung neoplasm<br />8-51%<br />Nodul...
The Dilemma<br />Malignant SPN can represent a potentially curable form of lung cancer<br />Stage I survival: > 60% at 5 y...
Detection<br />5<br />UIC   Bassel Ericsoussi, MD<br />
Evaluation<br />?<br />6<br />UIC   Bassel Ericsoussi, MD<br />
Tools<br />Clinical History  <br />Chest CT<br />Observation<br />Bronchoscopy<br />Old Films<br />FDG-PET<br />TTNA<br />...
Goal<br />Likely Benign<br />?<br />Indeterminate<br />Likely Malignant<br />8<br />UIC   Bassel Ericsoussi, MD<br />
Management<br />Follow<br />Likely Benign<br />???<br />Indeterminate<br />Likely Malignant<br />Take Action<br />9<br />U...
First Steps<br />Obtain old films and compare sizes<br />Determine nodule growth<br />Any evidence of growth should prompt...
Growth Rate of the SPN<br />Growth rate is usually expressed in volume doubling time (VDT):<br />One doubling in volume of...
Adenocarcinoma<br />(3 months)    Relatively slow growth<br />12<br />UIC   Bassel Ericsoussi, MD<br />
Infection<br />	                                       (2 weeks)    Fast growth<br />13<br />UIC   Bassel Ericsoussi, MD<b...
Pure Ground-Glass Nodules<br />More likely to be malignant than solid nodule (59-73% vs. 7-9%)<br />Bronchoalveolar carcin...
Ground-Glass Opacities<br />              Pure Ground Glass (BAC)      Part-Solid (Adenocarcinoma)<br />15<br />UIC   Bass...
Pre-Test Probability<br />In every patient with SPN, the clinical pre-test probability of malignancy should be estimated e...
Clinical Factors Influence Pre-Test Clinical Probability of Malignancy<br />Size<br />Calcification<br />Margins<br />Morp...
SPN Size<br />Wahidi, MM. Chest 2007; 132:94s-107s<br />18<br />UIC   Bassel Ericsoussi, MD<br />
Calcification Patterns of SPN<br />SPNs that are calcified in a clearly benign pattern do not warrant additional diagnosti...
“Popcorn” Calcification<br />Hamartoma<br />20<br />UIC   Bassel Ericsoussi, MD<br />
Benign Calcifications<br />   Diffuse: Benign granuloma<br />Central: Benign disease<br />Laminated<br />21<br />UIC   Bas...
Markedly Enhancing Nodule<br />Pulmonary Arteriovenous Malformation<br />22<br />UIC   Bassel Ericsoussi, MD<br />
Malignant Calcifications<br />Eccentric<br />Speckled<br />Adenocarcinoma<br />Adenocarcinoma<br />Carcinoid tumor<br />23...
Margins<br />Risk of malignancy is 20-30% in nodules with smooth edges<br />Risk of malignancy is 33-100% in nodules with ...
Margins<br />Cavitary<br />SCC<br />Lobulated<br />SCC<br />Spiculated<br />BAC<br />Smooth<br />Granuloma<br />25<br />UI...
Managements<br />Low clinical pre-test probability of malignancy (<5%): serial chest CT at 3, 6, 12 and 24 months<br />Hig...
Talk to Your Patient<br />Discuss the risks and benefits of alternative management strategies and elicit patient preferenc...
Choice of Sampling Modality<br />TTNA if nodule is peripherally located<br />Bronchoscopy:<br />Air-bronchogram or bronchu...
Small Subcentimeter Pulmonary Nodules(<8 mm)<br />For patients with no risk factors for lung cancer:<br />Nodules < 4 mm<b...
Small Subcentimeter Pulmonary Nodules(<8 mm)<br />For patients with risk factors for lung cancer:<br />Nodules < 4 mm<br /...
Summary<br />SPN is a common problem and can present a diagnostic dilemma<br />Best strategy is determined on assessment o...
Clinical Scenario: Low Clinical Pre-Test Probability of Malignancy<br />A 44 Y.O. man with history of HTN<br />Had a fall ...
Clinical Scenario: High Clinical Pre-Test Probability of Malignancy<br />A 64 Y.O. woman developed an episode of bronchiti...
Clinical Scenario: High Clinical Pre-Test Probability of Malignancy<br />Her physician ordered a PET scan which showed inc...
Indeterminate Pre-Test Probability of Malignancy<br />Obtain PET scan<br />Consider management options:<br />Radiographic ...
Rational for Staging<br />Aid in planning treatment<br />Indicate prognosis<br />Assist in evaluating results of treatment...
STAGING OF LUNG CANCER HAS CHANGED AS OF JANUARY 1, 2010<br />37<br />UIC   Bassel Ericsoussi, MD<br />
Problem with the Previous System<br /><ul><li>Lack of validation for individual T, N, and M descriptors
Multiple discrepancies in published literature, particularly with T stage
Relatively small database from a single institution series
2,155 patients from the MD Anderson Cancer Center in Houston, TX
Mainly surgical based</li></ul>38<br />UIC   Bassel Ericsoussi, MD<br />
39<br />UIC   Bassel Ericsoussi, MD<br />
40<br />UIC   Bassel Ericsoussi, MD<br />
International Association for the Study of Lung Cancer (IASLC)<br />100,869 cases from 45 sources in 20 countries<br />81,...
Treatment Modalities – 67,725 NSCLC<br />    54% involved surgery<br />Surgery<br />42%<br />Surgery<br />RT<br />5%<br />...
Stage Groupings<br />The major determinant is the overall survival, based on the best stage <br />Pathologic, if available...
Prognosis According to Size Category<br />44<br />UIC   Bassel Ericsoussi, MD<br />
Prognosis According to Additional Nodules, T4 Invasion, and Pleural Dissemination<br />45<br />UIC   Bassel Ericsoussi, MD...
T Descriptor<br /><ul><li>T0: No primary tumor
T1: (T1a < 2 cm, T1b 2-3 cm) (used to be T1)
Not more proximal than the lobar bronchus
T2: (T2a 3-5, T2b 5-7 cm) (used to be T2) or
In the main bronchus > 2 cm distal to the carina
Invades visceral pleura
Atelectasis/obstructive pneumonia but not involving the entire lung
T3 > 7 cm or
Central location: In the main bronchus  < 2 cm distal to the carina
Invasion: chest wall, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium (used to be T4)
Atelectasis/obstructive pneumonitis of entire lung
Satellite nodules: separate tumor nodules in the same lobe (used to be T4)
T4 any size tumor
Invades heart, great vessels, trachea, carina, recurrent laryngeal nerve, esophagus, vertebral body
Separate tumor nodules in a different ipsilateral lobe (used to be M1)</li></ul>46<br />UIC   Bassel Ericsoussi, MD<br />
Special Situations<br />TX: Status not able to be assessed<br />Tis: Focus of in situ cancer<br />T1ss: Superficial spread...
Prognosis According to the N Category<br />48<br />UIC   Bassel Ericsoussi, MD<br />
N Descriptor<br /><ul><li>N0: no LN involvement
N1:  (stations 10-14)</li></ul>Ipsilateral peribronchial LN<br />Ipsilateral perihilar LN<br />Ipsilateral intrapulmonary ...
The Effect of Skip Metastases<br />Involvement of N2 node station with/without involvement of any N1 nodes have same survi...
M Descriptor<br />M0: No distant metastasis<br />M1a: <br />Separate tumor nodules in a contralateral lobe (used to be M1)...
Stage Groups According to TNM Descriptor and Subgroups<br />52<br />UIC   Bassel Ericsoussi, MD<br />
Overall Survival by Clinical Stage<br />53<br />UIC   Bassel Ericsoussi, MD<br />
Overall Survival by Pathologic Stage<br />54<br />UIC   Bassel Ericsoussi, MD<br />
55<br />UIC   Bassel Ericsoussi, MD<br />
56<br />UIC   Bassel Ericsoussi, MD<br />
57<br />UIC   Bassel Ericsoussi, MD<br />
58<br />UIC   Bassel Ericsoussi, MD<br />
59<br />UIC   Bassel Ericsoussi, MD<br />
Lymph Node Map Update<br />The International Association for the Study of Lung Cancer (IASLC) Lymph Node Map 2009<br />60<...
61<br />UIC   Bassel Ericsoussi, MD<br />
Supraclavicular Nodes(Station 1R/1L)<br /><ul><li>Includes:
Low cervical
Supraclavicular
Sternal notch
Upper border: lower margin of cricoid
Lower border: clavicles and upper border of manubrium
The midline of the trachea serves as border between 1R and 1L </li></ul>62<br />UIC   Bassel Ericsoussi, MD<br />
63<br />UIC   Bassel Ericsoussi, MD<br />
Upper Paratracheal(stations 2R/2L)<br />2R. Right Upper ParatrachealUpper border: upper border of manubriumLower border: i...
Prevascular and Prevertabral nodes(Stations 3A/3P)<br />3A anterior to the vessels <br /> 3P posterior to the esophagus, w...
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Approach to the Solitary Pulmonary Nodule - New Staging System for NSCLC - Lymph Node Map-Update

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Approach to the Solitary Pulmonary Nodule
New Staging System for NSCLC
Lymph Node Map-Update

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  • liked ii good presentation. Allow it to download for contribution to community for teaching purpose. pl discuss differential diagnosis also other than carcinoma
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Approach to the Solitary Pulmonary Nodule - New Staging System for NSCLC - Lymph Node Map-Update

  1. 1. Approach to the Solitary Pulmonary NoduleNew Staging System for NSCLCLymph Node Map-Update<br />Bassel Ericsoussi, MD<br />Fellow, Pulmonary and Critical Care<br />University of Illinois Medical Center at Chicago<br />
  2. 2. The Peripheral Pulmonary Nodule<br />Small focal radiographic opacities that may be solitary or multiple<br />The term “Coin Lesion” should be discouraged<br />The solitary pulmonary nodule (SPN)<br />Round lesion<br /><3 cm (if > 3 cm called mass)<br />Completely surrounded by pulmonary parenchyma<br />2<br />UIC Bassel Ericsoussi, MD<br />
  3. 3. Prevalence<br />Prevalence of SPNs in screening trials of populations at high risk for lung neoplasm<br />8-51%<br />Nodules detected in screening trials are different than those detected in clinical routine practice:<br />Smaller<br />Prevalence of malignancy is lower<br />Tumor volume doubling time is longer<br />Prevalence of malignancy in patients with SPNs:<br />1.1-12% in screening trials<br />46-82% in PET trials<br />Wahidi, MM. Chest 2007; 132:94s-107s<br />3<br />UIC Bassel Ericsoussi, MD<br />
  4. 4. The Dilemma<br />Malignant SPN can represent a potentially curable form of lung cancer<br />Stage I survival: > 60% at 5 years<br />The flip side is unnecessary procedures and surgeries with resultant morbidities<br />Cost implications<br />4<br />UIC Bassel Ericsoussi, MD<br />
  5. 5. Detection<br />5<br />UIC Bassel Ericsoussi, MD<br />
  6. 6. Evaluation<br />?<br />6<br />UIC Bassel Ericsoussi, MD<br />
  7. 7. Tools<br />Clinical History <br />Chest CT<br />Observation<br />Bronchoscopy<br />Old Films<br />FDG-PET<br />TTNA<br />Surgery<br />7<br />UIC Bassel Ericsoussi, MD<br />
  8. 8. Goal<br />Likely Benign<br />?<br />Indeterminate<br />Likely Malignant<br />8<br />UIC Bassel Ericsoussi, MD<br />
  9. 9. Management<br />Follow<br />Likely Benign<br />???<br />Indeterminate<br />Likely Malignant<br />Take Action<br />9<br />UIC Bassel Ericsoussi, MD<br />
  10. 10. First Steps<br />Obtain old films and compare sizes<br />Determine nodule growth<br />Any evidence of growth should prompt immediate tissue diagnosis<br />In every patient with an indeterminate SPN that is visible on CXR, Chest CT should be performed<br />10<br />UIC Bassel Ericsoussi, MD<br />
  11. 11. Growth Rate of the SPN<br />Growth rate is usually expressed in volume doubling time (VDT):<br />One doubling in volume of SPN usually represents 26% increase in diameter on chest CT<br />VDT for malignant nodules: 20-300 days<br />Because VDT for malignant SPNs rarely exceed 300 days, a 2–year radiographic stability predicts a benign process<br />For ground-glass nodules, longer follow-up is recommended (>2 years)<br />Gould, MK. Chest 2007, 132:108s-130s<br />11<br />UIC Bassel Ericsoussi, MD<br />
  12. 12. Adenocarcinoma<br />(3 months) Relatively slow growth<br />12<br />UIC Bassel Ericsoussi, MD<br />
  13. 13. Infection<br /> (2 weeks) Fast growth<br />13<br />UIC Bassel Ericsoussi, MD<br />
  14. 14. Pure Ground-Glass Nodules<br />More likely to be malignant than solid nodule (59-73% vs. 7-9%)<br />Bronchoalveolar carcinoma is the most common histological subtype<br />Longer VDT<br />Better prognosis<br />Wahidi, MM. Chest 2007; 132:94s-107s<br />14<br />UIC Bassel Ericsoussi, MD<br />
  15. 15. Ground-Glass Opacities<br /> Pure Ground Glass (BAC) Part-Solid (Adenocarcinoma)<br />15<br />UIC Bassel Ericsoussi, MD<br />
  16. 16. Pre-Test Probability<br />In every patient with SPN, the clinical pre-test probability of malignancy should be estimated either:<br />Qualitatively by clinical judgment<br />Quantitatively by using validated quantitative model<br />The SPN calculator: http://www.chestx-ray.com/spn/spnprob.html<br />This facilitates the selection and interpretation of subsequent diagnostic tests <br />16<br />UIC Bassel Ericsoussi, MD<br />
  17. 17. Clinical Factors Influence Pre-Test Clinical Probability of Malignancy<br />Size<br />Calcification<br />Margins<br />Morphology<br />17<br />UIC Bassel Ericsoussi, MD<br />
  18. 18. SPN Size<br />Wahidi, MM. Chest 2007; 132:94s-107s<br />18<br />UIC Bassel Ericsoussi, MD<br />
  19. 19. Calcification Patterns of SPN<br />SPNs that are calcified in a clearly benign pattern do not warrant additional diagnostic evaluation<br />Benign calcification patterns:<br />Diffuse<br />Central<br />Popcorn<br />Laminated<br />Potentially malignant calcification patterns:<br />Stippled<br />Eccentric<br />19<br />UIC Bassel Ericsoussi, MD<br />
  20. 20. “Popcorn” Calcification<br />Hamartoma<br />20<br />UIC Bassel Ericsoussi, MD<br />
  21. 21. Benign Calcifications<br /> Diffuse: Benign granuloma<br />Central: Benign disease<br />Laminated<br />21<br />UIC Bassel Ericsoussi, MD<br />
  22. 22. Markedly Enhancing Nodule<br />Pulmonary Arteriovenous Malformation<br />22<br />UIC Bassel Ericsoussi, MD<br />
  23. 23. Malignant Calcifications<br />Eccentric<br />Speckled<br />Adenocarcinoma<br />Adenocarcinoma<br />Carcinoid tumor<br />23<br />UIC Bassel Ericsoussi, MD<br />
  24. 24. Margins<br />Risk of malignancy is 20-30% in nodules with smooth edges<br />Risk of malignancy is 33-100% in nodules with irregular, lobulated, or spiculated borders<br />Wahidi, MM. Chest 2007; 132:94s-107s<br />24<br />UIC Bassel Ericsoussi, MD<br />
  25. 25. Margins<br />Cavitary<br />SCC<br />Lobulated<br />SCC<br />Spiculated<br />BAC<br />Smooth<br />Granuloma<br />25<br />UIC Bassel Ericsoussi, MD<br />
  26. 26. Managements<br />Low clinical pre-test probability of malignancy (<5%): serial chest CT at 3, 6, 12 and 24 months<br />High clinical pre-test probability of malignancy (>60%): proceed to surgical resection<br />Indeterminate clinical pre-test probability of malignancy (5-60%): careful consideration of options in conjunction with patient’s preferences<br />26<br />UIC Bassel Ericsoussi, MD<br />
  27. 27. Talk to Your Patient<br />Discuss the risks and benefits of alternative management strategies and elicit patient preferences<br />27<br />UIC Bassel Ericsoussi, MD<br />
  28. 28. Choice of Sampling Modality<br />TTNA if nodule is peripherally located<br />Bronchoscopy:<br />Air-bronchogram or bronchus sign are present<br />Experience with advanced tools exists:<br />Electromagnatic Navigation<br />Radial EBUS<br />CT-guided biopsy<br />28<br />UIC Bassel Ericsoussi, MD<br />
  29. 29. Small Subcentimeter Pulmonary Nodules(<8 mm)<br />For patients with no risk factors for lung cancer:<br />Nodules < 4 mm<br />No further follow up<br />Nodules 4-6 mm<br />Reevaluate with a chest CT at 12 months<br />No further follow-up if unchanged at 12 months<br />Nodules 6-8 mm<br />Reevaluate with a chest CT between 6-12 months and between 18-24 months<br />29<br />UIC Bassel Ericsoussi, MD<br />
  30. 30. Small Subcentimeter Pulmonary Nodules(<8 mm)<br />For patients with risk factors for lung cancer:<br />Nodules < 4 mm<br />Reevaluate with a chest CT at 12 months<br />Nodules 4-6 mm<br />Reevaluate with a chest CT between 6-12 months and between 18-24 months<br />Nodules 6-8 mm<br />Reevaluate with a chest CT between 3-6, between 9-12 months, and between 18-24 months<br />30<br />UIC Bassel Ericsoussi, MD<br />
  31. 31. Summary<br />SPN is a common problem and can present a diagnostic dilemma<br />Best strategy is determined on assessment of the risk of cancer in an individual patient<br />Determine patient’s risk of malignancy<br />Low risk: serial chest CTs<br />High risk: surgical resection<br />Indeterminate risk: consider PET scan, diagnostic sampling, or surgical resection<br />Discuss risks and benefits of various strategies and elicit patient’s preferences<br />31<br />UIC Bassel Ericsoussi, MD<br />
  32. 32. Clinical Scenario: Low Clinical Pre-Test Probability of Malignancy<br />A 44 Y.O. man with history of HTN<br />Had a fall and developed chest pain<br />A chest CT was done and showed a 5 mm nodule in the LUL<br />Patient has never smoked<br />Analysis of case:<br />Likelihood of malignancy is very low<br />Best strategy is observation with serial chest CTs<br />32<br />UIC Bassel Ericsoussi, MD<br />
  33. 33. Clinical Scenario: High Clinical Pre-Test Probability of Malignancy<br />A 64 Y.O. woman developed an episode of bronchitis<br />RUL nodule was found incidentally on CXR<br />A prior CXR a year ago showed no abnormalities<br />30 pack-year tobacco use, quit a year ago<br />A chest CT showed a 1.3 cm spiculated pulmonary nodule<br />33<br />UIC Bassel Ericsoussi, MD<br />
  34. 34. Clinical Scenario: High Clinical Pre-Test Probability of Malignancy<br />Her physician ordered a PET scan which showed increased FDG uptake in the nodule<br />He performed a bronchoscopy with BAL growing klebsiella and negative biopsy<br />He decided to treat patient with antibiotics and to follow with serial chest CTs<br />Analysis of the case:<br />The likelihood of malignancy was very high (100% in the SPN calculator)<br />Smoking history<br />Age<br />Growth of nodule<br />Increased metabolic activity on PET scan<br />Best course of action is surgical resection<br />34<br />UIC Bassel Ericsoussi, MD<br />
  35. 35. Indeterminate Pre-Test Probability of Malignancy<br />Obtain PET scan<br />Consider management options:<br />Radiographic observation if:<br />Clinical probability is low (30-40%) and no activity on PET<br />Sampling by bronchoscopy or TTNA if:<br />Discordance between clinical pre-test probability and imaging tests (high suspicion but lesion is not active on PET)<br />A benign diagnosis is suspected that requires specific treatment (fungal infection)<br />A fully-informed patient desires proof of malignancy diagnosis prior to surgery<br />Surgery is high risk<br />35<br />UIC Bassel Ericsoussi, MD<br />
  36. 36. Rational for Staging<br />Aid in planning treatment<br />Indicate prognosis<br />Assist in evaluating results of treatment <br />Facilitate exchange of information between treatment centers<br />Cancer research<br />36<br />UIC Bassel Ericsoussi, MD<br />
  37. 37. STAGING OF LUNG CANCER HAS CHANGED AS OF JANUARY 1, 2010<br />37<br />UIC Bassel Ericsoussi, MD<br />
  38. 38. Problem with the Previous System<br /><ul><li>Lack of validation for individual T, N, and M descriptors
  39. 39. Multiple discrepancies in published literature, particularly with T stage
  40. 40. Relatively small database from a single institution series
  41. 41. 2,155 patients from the MD Anderson Cancer Center in Houston, TX
  42. 42. Mainly surgical based</li></ul>38<br />UIC Bassel Ericsoussi, MD<br />
  43. 43. 39<br />UIC Bassel Ericsoussi, MD<br />
  44. 44. 40<br />UIC Bassel Ericsoussi, MD<br />
  45. 45. International Association for the Study of Lung Cancer (IASLC)<br />100,869 cases from 45 sources in 20 countries<br />81,015 cases included in analyses<br />16% SCLC: 13290<br />84% NSCLC: 67,725<br />41<br />UIC Bassel Ericsoussi, MD<br />
  46. 46. Treatment Modalities – 67,725 NSCLC<br /> 54% involved surgery<br />Surgery<br />42%<br />Surgery<br />RT<br />5%<br />Surgery<br />Chemo<br />4%<br />Tri-modality<br />3%<br />RT<br />8%<br />Chemo<br />15%<br />Chemo<br />RT<br />12%<br />42<br />UIC Bassel Ericsoussi, MD<br />
  47. 47. Stage Groupings<br />The major determinant is the overall survival, based on the best stage <br />Pathologic, if available; otherwise clinical<br />43<br />UIC Bassel Ericsoussi, MD<br />
  48. 48. Prognosis According to Size Category<br />44<br />UIC Bassel Ericsoussi, MD<br />
  49. 49. Prognosis According to Additional Nodules, T4 Invasion, and Pleural Dissemination<br />45<br />UIC Bassel Ericsoussi, MD<br />
  50. 50. T Descriptor<br /><ul><li>T0: No primary tumor
  51. 51. T1: (T1a < 2 cm, T1b 2-3 cm) (used to be T1)
  52. 52. Not more proximal than the lobar bronchus
  53. 53. T2: (T2a 3-5, T2b 5-7 cm) (used to be T2) or
  54. 54. In the main bronchus > 2 cm distal to the carina
  55. 55. Invades visceral pleura
  56. 56. Atelectasis/obstructive pneumonia but not involving the entire lung
  57. 57. T3 > 7 cm or
  58. 58. Central location: In the main bronchus < 2 cm distal to the carina
  59. 59. Invasion: chest wall, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium (used to be T4)
  60. 60. Atelectasis/obstructive pneumonitis of entire lung
  61. 61. Satellite nodules: separate tumor nodules in the same lobe (used to be T4)
  62. 62. T4 any size tumor
  63. 63. Invades heart, great vessels, trachea, carina, recurrent laryngeal nerve, esophagus, vertebral body
  64. 64. Separate tumor nodules in a different ipsilateral lobe (used to be M1)</li></ul>46<br />UIC Bassel Ericsoussi, MD<br />
  65. 65. Special Situations<br />TX: Status not able to be assessed<br />Tis: Focus of in situ cancer<br />T1ss: Superficial spreading tumor of any size but confined to the wall of the trachea or mainstem bronchus<br />47<br />UIC Bassel Ericsoussi, MD<br />
  66. 66. Prognosis According to the N Category<br />48<br />UIC Bassel Ericsoussi, MD<br />
  67. 67. N Descriptor<br /><ul><li>N0: no LN involvement
  68. 68. N1: (stations 10-14)</li></ul>Ipsilateral peribronchial LN<br />Ipsilateral perihilar LN<br />Ipsilateral intrapulmonary nodes<br /><ul><li>N2</li></ul>Ipsilateral mediastinal LN<br />Subcarinal LN (station 7)<br /><ul><li>N3</li></ul>Contralateral mediastinal LN<br />Contralateral hilar LN<br />Scalene LN<br />Supraclavicular LN (station 1)<br />49<br />UIC Bassel Ericsoussi, MD<br />
  69. 69. The Effect of Skip Metastases<br />Involvement of N2 node station with/without involvement of any N1 nodes have same survival<br />50<br />UIC Bassel Ericsoussi, MD<br />
  70. 70. M Descriptor<br />M0: No distant metastasis<br />M1a: <br />Separate tumor nodules in a contralateral lobe (used to be M1)<br />Tumor with pleural nodules or malignant pleural dissemination (used to be T4)<br />M1b: Distant metastasis (used to be M1)<br />51<br />UIC Bassel Ericsoussi, MD<br />
  71. 71. Stage Groups According to TNM Descriptor and Subgroups<br />52<br />UIC Bassel Ericsoussi, MD<br />
  72. 72. Overall Survival by Clinical Stage<br />53<br />UIC Bassel Ericsoussi, MD<br />
  73. 73. Overall Survival by Pathologic Stage<br />54<br />UIC Bassel Ericsoussi, MD<br />
  74. 74. 55<br />UIC Bassel Ericsoussi, MD<br />
  75. 75. 56<br />UIC Bassel Ericsoussi, MD<br />
  76. 76. 57<br />UIC Bassel Ericsoussi, MD<br />
  77. 77. 58<br />UIC Bassel Ericsoussi, MD<br />
  78. 78. 59<br />UIC Bassel Ericsoussi, MD<br />
  79. 79. Lymph Node Map Update<br />The International Association for the Study of Lung Cancer (IASLC) Lymph Node Map 2009<br />60<br />UIC Bassel Ericsoussi, MD<br />
  80. 80. 61<br />UIC Bassel Ericsoussi, MD<br />
  81. 81. Supraclavicular Nodes(Station 1R/1L)<br /><ul><li>Includes:
  82. 82. Low cervical
  83. 83. Supraclavicular
  84. 84. Sternal notch
  85. 85. Upper border: lower margin of cricoid
  86. 86. Lower border: clavicles and upper border of manubrium
  87. 87. The midline of the trachea serves as border between 1R and 1L </li></ul>62<br />UIC Bassel Ericsoussi, MD<br />
  88. 88. 63<br />UIC Bassel Ericsoussi, MD<br />
  89. 89. Upper Paratracheal(stations 2R/2L)<br />2R. Right Upper ParatrachealUpper border: upper border of manubriumLower border: intersection of the innominate (left brachiocephalic) vein with the trachea<br />2L. Left Upper ParatrachealUpper border: upper border of manubriumLower border: superior border of aortic arch<br />2R nodes extend to the left lateral border of the trachea<br />64<br />UIC Bassel Ericsoussi, MD<br />
  90. 90. Prevascular and Prevertabral nodes(Stations 3A/3P)<br />3A anterior to the vessels <br /> 3P posterior to the esophagus, which lies prevertebrally<br />3A not accessible with mediastinoscopy<br />3P accessible with EUS<br />65<br />UIC Bassel Ericsoussi, MD<br />
  91. 91. <ul><li>2R node in front of the trachea
  92. 92. Prevascular 3A (not accessible with mediastinoscopy)</li></ul>66<br />UIC Bassel Ericsoussi, MD<br />
  93. 93. Prevascular 3A node (not accessible with mediastinoscopy)<br />Lower paratracheal 4R nodes<br />67<br />UIC Bassel Ericsoussi, MD<br />
  94. 94. Right Lower Paratracheal(Station 4R)<br />4R. Right Lower ParatrachealUpper border: intersection of the innominate (left brachiocephalic) vein with the tracheaLower border: lower border of azygos vein<br />4R nodes extend to the left lateral border of the trachea<br />68<br />UIC Bassel Ericsoussi, MD<br />
  95. 95. <ul><li>4R paratracheal nodes
  96. 96. Station 6 node: aortic node lateral to the aortic arch </li></ul>69<br />UIC Bassel Ericsoussi, MD<br />
  97. 97. Left Lower Paratracheal(Station 4L)<br />Located left of the left tracheal border, medially to the ligamentum arteriosum<br />Station 5 (AP-window) nodes are located laterally to the ligamentum arteriosum<br />70<br />UIC Bassel Ericsoussi, MD<br />
  98. 98. Just above the level of the pulmonary trunk <br />4R/4L lower paratracheal nodes <br />Station 3 node<br />Station 5 (AP window) nodes.<br />71<br />UIC Bassel Ericsoussi, MD<br />
  99. 99. At the level of the lower trachea just above the carina<br />4L nodes are between the pulmonary trunk and the aorta, but are not located in the AP-window, because they lie medially to the ligamentum arteriosum<br />The node lateral to the pulmonary trunk is a station 5 <br />72<br />UIC Bassel Ericsoussi, MD<br />
  100. 100. 73<br />UIC Bassel Ericsoussi, MD<br />
  101. 101. Subaortic and Para-aortic Nodes(Stations 5,6)<br /><ul><li>5. Subaortic nodes (AP window nodes) are lateral to the ligamentum arteriosum 6. Para-aortic nodes located anteriorly and laterally to the ascending aorta and the aortic arch from the upper margin to the lower margin of the aortic arch</li></ul>74<br />UIC Bassel Ericsoussi, MD<br />
  102. 102. 75<br />UIC Bassel Ericsoussi, MD<br />
  103. 103. Subcarinal Nodes(Station 7)<br /><ul><li>Located caudally to the carina of the trachea
  104. 104. On the right they extend to the lower border of the bronchus intermedius
  105. 105. On the left they extend to the upper border of the lower lobe bronchus</li></ul>76<br />UIC Bassel Ericsoussi, MD<br />
  106. 106. Station 7 subcarinal node to the right of the esophagus<br />77<br />UIC Bassel Ericsoussi, MD<br />
  107. 107. Paraesophageal Nodes(Station 8)<br />Below the subcarinal nodes and extend to the diaphragm<br />78<br />UIC Bassel Ericsoussi, MD<br />
  108. 108. Station 8 node to the right of the esophagus <br />79<br />UIC Bassel Ericsoussi, MD<br />
  109. 109. <ul><li>PET scan: FDG uptake in a station 8 node
  110. 110. On the corresponding CT image the node is not enlarged
  111. 111. The probability that this is a lymph node metastasis is extremely high since the specificity of PET in unenlarged nodes is higher than in enlarged nodes</li></ul>80<br />UIC Bassel Ericsoussi, MD<br />
  112. 112. Pulmonary Ligament Nodes(Station 9)<br />The pulmonary ligament is the inferior extension of the mediastinal pleural reflections<br />81<br />UIC Bassel Ericsoussi, MD<br />
  113. 113. 82<br />UIC Bassel Ericsoussi, MD<br />
  114. 114. 83<br />UIC Bassel Ericsoussi, MD<br />
  115. 115. Hilar, Interlobar, Lober, Segmental, and SubsegmentalNodes (Station 10, 11-14)<br /><ul><li>Adjacent to the main stem bronchus
  116. 116. On the right they extend from the lower rim of the azygos vein to the interlobar region
  117. 117. On the left they extend from the upper rim of the pulmonary artery to the interlobar region</li></ul>Nodes in station 10 - 14 are all N1-nodes, since they are not located in the mediastinum<br />84<br />UIC Bassel Ericsoussi, MD<br />
  118. 118. 85<br />UIC Bassel Ericsoussi, MD<br />
  119. 119. Conventional Mediastinoscopy<br />2R and 2L: right and left upper paratracheal nodes <br />4R and 4 L: right and left lower paratracheal nodes <br />Station 7: subcarinal nodes (but not 7 posterior)<br />Does not access :<br /> 1R and 1L: supraclavicular nodes <br /> 3A: prevascular nodes<br /> 5-6: Subaortic (AP window), para-aortic nodes <br />7 posterior<br />8: paraesophageal nodes<br /> 9: pulmonary ligaments nodes<br />86<br />UIC Bassel Ericsoussi, MD<br />
  120. 120. Conventional Mediastinoscopy<br />Necessary to confirm negative endoscopic biopsies<br />Sensitivity 85.2%<br />Specificity 100%<br />Morbidity 2%<br />Mortality 0.08%<br />Complications<br />Death - Pneumothorax<br />Esophageal perforation - Hypotension <br />Pulmonary artery laceration - IV fluid extravasation<br />Excessive bleeding - Arrhythmia<br />Hammoud et al. J Thoracic Cardiovasc Surg. 1999; 118:894-9<br />87<br />UIC Bassel Ericsoussi, MD<br />
  121. 121. Extended MediastinoscopyLeft Anterior MediastinoscopyChamberlain Procedure<br />Station 5: subaortic (AP window) LN<br />Station 6: paraaortic nodes <br />Contraindications:<br />Calcified aorta<br />Post operative aorta<br />Far less easy and therefore less routinely performed than conventional mediastinoscopy<br /><ul><li> Mobidity 8%
  122. 122. Mortality < 1%</li></ul>88<br />UIC Bassel Ericsoussi, MD<br />
  123. 123. Endoscopic Ultrasound with Fine Needle Aspiration EUS-FNA<br />Lower mediastinum LN<br /><ul><li>Station 7: subcarinal, including posterior subcarinal
  124. 124. Station 8: paraesophageal
  125. 125. Station 9: Pulmonary ligament
  126. 126. 3P: prevertebral
  127. 127. Left adrenal gland
  128. 128. Left liver lobe</li></ul>89<br />UIC Bassel Ericsoussi, MD<br />
  129. 129. Endobronchial Ultrasound Transbronchial Needle AspirationEBUS-TBNA<br />90<br />UIC Bassel Ericsoussi, MD<br />

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