LUNG CANCER STAGING 7th Edition

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LUNG CANCER STAGING 7th Edition

• Jaime Palomino, MD
• Pulmonary, Critical Care Medicine
• Tulane University

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Lung Cancer - Staging

• Objectives/Content
• 7th Edition staging system NSCLC
• LN anatomy
• TNM classification
• SCLC
• Staging work up
• Staging of mediastinum
• Pleural mesothelioma

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TNM Staging Lung CA

• Initial proposal by Dr. Clifton Mountain
• AJCC 1973, UICC 1974
• 2155 patients from MD Anderson
• Last revision 1997
• 5319 patients

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Lung Cancer Staging 6th ed.
Lababede O et al. CHEST 1999115233-35
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Lung Cancer Staging. 7th Edition. TNM
Classification
Staging Manual In Thoracic Oncology. IASLC. 2009
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Lung Cancer Staging 7th ed.
Goldstraw P et al. J Thorac Oncol 20072706-714
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Lung Cancer Staging. 7th Edition. Nodal Chart
Staging Manual In Thoracic Oncology IASLC. 2009
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Staging Manual In Thoracic Oncology IASLC. 2009
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Staging Manual In Thoracic Oncology IASLC. 2009
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Staging Manual In Thoracic Oncology IASLC. 2009
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Staging Manual In Thoracic Oncology IASLC. 2009
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Staging Manual In Thoracic Oncology IASLC. 2009
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Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. T1
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. T2
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. T3
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. T4
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. N0, N1
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. N2
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. N3
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. M1a
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. M1b
Staging Manual In Thoracic Oncology IASLC. 2009
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Lung Cancer Staging. 7th Edition. TNM
Classification
Clinical Stage
Pathologic Stage
Detterbeck et al. CHEST 2009136260-271
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Lung Cancer Staging. 7th Edition. Stage 0, I
Detterbeck et al. CHEST 2009136260-271
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Lung Cancer Staging. 7th Edition. Stage II
Detterbeck et al. CHEST 2009136260-271
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Lung Cancer Staging. 7th Edition. Stage III
Detterbeck et al. CHEST 2009136260-271
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Lung Cancer Staging. 7th Edition. Stage IV
Detterbeck et al. CHEST 2009136260-271
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Lung Cancer Staging. 7th Edition. TNM
Classification
Staging Manual In Thoracic Oncology. IASLC. 2009
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Lung Cancer Staging. 7th Edition. TNM
Classification
Detterbeck et al. CHEST 2009136260-271
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Lung Cancer Staging 7th ed.
Goldstraw P et al. J Thorac Oncol 20072706-714
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Lung Cancer Staging. SCLC

• Limited Disease
• No detectable disease outside of hemithorax
• With or without ipsilateral or contralateral,
  hilar, mediastinal, or supraclavicular LN
  involvement
• Unilateral pleural effusion
• Single radiation therapy port
• Extensive Disease
• Any disease occurring beyond sites of limited
  disease

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Lung Cancer Staging. 7th Edition. SCLC
Shepherd et al. J Thorac Oncol. 200721067-1077
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Lung Cancer Staging. 7th Edition. SCLC
Vallieres et al. J Thorac Oncol. 200941049-1059
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Lung Cancer Staging

• Staging work up
• History PE (ECOG score)
• CT chest with contrast down to adrenal glands
• Whole body CT-PET
• Brain imaging
• MRI, CT head with contrast
• Neurological symptoms
• SCLC
• Stage III and above
• Adenocarcinoma?
• Bone Scan Abdominal CT (if CT-PET not
  available)
• Full PFTs (Spirometry, DLCO)

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Sampling Of The Mediastinum

• ACCP Lung Cancer Practice Guidelines 2007
• Mediastinal LN biopsy indications
• LN 1cm regardless PET results (1B)
• Abnormal PET in mediastinum (1B)
• Central tumor or N1 disease (2C)
• Non-malignant result from needle techniques
  should be confirmed by mediastinoscopy (1C)

Detterbeck et al. CHEST 2007132202S-220S
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Sampling Of The Mediastinum

• Mediastinoscopy ? Gold standard
• Minimally Invasive
• TBNA
• EBUS FNA
• EUS - FNA

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Gomez et al. Proc Am Thorac Soc 20096180-186
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TBNA Sampling Of The Mediastinum

• Sensitivity
• 15 - 85
• Meta-analysis
• Sensitivity 39
• Dependence on lung cancer prevalence
• ROSE increases yield
• Underutilized (1997)
• 10 fellows ? routinely
• 40 fellows ? occasionally
• 20 practicing pulmonologists

El Bayoumi et al. SRCCM 200829261-270 Haponik
et al. CHEST 1997112251-253 Rafanan et al. SRCC
200021405-420
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EUS/FNA Sampling Of The Mediastinum
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EUS/FNA Sampling Of The Mediastinum

• Mediastinal approach from esophagus
• Stations 3, 4L, 7, 8 and 9
• Left adrenal gland
• Left lobe of liver
• Sensitivity
• 72 100
• Specificity
• 88 100

El Bayoumi et al. SRCCM 200829261-270
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EBUS Linear (Convex) Probe
El Bayoumi et al. SRCCM 200829261-270
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EBUS Linear (Convex) Probe
Yasufuku et al. CHEST 2004126122-128
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EBUS Linear Probe
Gomez et al. Proc Am Thorac Soc 20096180-186
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EBUS/TBNA Sampling Of The Mediastinum

• Linear (convex) Probe
• Real time visualization and sampling
• Depth 5cm
• LN stations 8,9,6, and 5 are not accessible
• 8 and 9 ? EUS
• 5 and 6 ? Left median sternotomy (Chamberlain
  procedure)
• Sensitivity 92 94
• Specificity 100
• Maximum diagnostic values are achieved with three
  aspirations per LN station

Herth et al. Eur Respir J 200628910-914 Lee et
al. CHEST 2008134368-374
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EBUS/TBNA Sampling Of The Mediastinum
Shulman et al. Curr Opin Pulm Med 200713271-277
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Gomez et al. Proc Am Thorac Soc 20096180-186
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EBUS EUS LN FNA
Wallace et al. JAMA 2008299540-546
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Gomez et al. Proc Am Thorac Soc 20096180-186
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Pleural Mesothelioma Staging. 7th Edition. TNM
Classification
Staging Manual In Thoracic Oncology. IASLC. 2009
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Pleural Mesothelioma Staging. 7th Edition. TNM
Classification
Staging Manual In Thoracic Oncology. IASLC. 2009
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