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Echoendoscopic Lymph Node Staging in Lung Cancer: An endoscopic alternative
Echoendoscopic lymph node staging in lung cancer provides an endoscopic alternative to surgical staging that is minimally invasive, accurate, and prevents unnecessary surgeries. Combined endobronchial ultrasound and endoscopic ultrasound (EBUS/EUS) procedures sample lymph nodes and detect metastasis with a sensitivity of 91% and specificity of 96%, outperforming surgical staging. EBUS/EUS is now considered the new gold standard for mediastinal staging as it is safer, less costly, and more comprehensive than surgical staging alone.
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Echoendoscopic Lymph Node Staging in Lung Cancer: An endoscopic alternative
- 1. Echoendoscopic lymph node stagingin lung cancer : An endoscopic alternative Pravachan Hegde, MD Interventional Thoracic Endoscopy / Interventional Pulmonology Pulmonary & Critical Care Medicine UCSF - Fresno
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- 4. N1, N2, N3Nodes
- 5. Why do westage ? 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 westage ? 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 needstaging ? Peripheral tumor < 3 cm with no lymph node enlargement on CT and no lymph node SUV uptake on PET
- 8. Minimally Invasive Mediastinal Staging EndobronchialUltrasound EBUS Endoscopic Ultrasound EUS
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- 10. Background Testing with minimallyinvasive 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 CancerStaging 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 NoGeneral Anesthesia Multiple stations sampled ASA ok Real-Time Imaging Portable No Radiation Exposure Cheap Safe Tissue
- 14. EBUS EUS CMAM 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 MediastinalAdenopathy 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 inCT 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.
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- 18. EUS Upstaging 44 patientswith 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 + EUSFNA 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 NodeStaging 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.
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- 23. Results 30 months 166 patients Prevalenceof 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 alChest. 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/M1disease 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 possibletracheal 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 withradiologically normal mediastinum
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- 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.
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