Title: Endoscopic Ultrasound in the Diagnosis and Staging of Lung Cancer
1Endoscopic Ultrasound in the Diagnosis and
Staging of Lung Cancer
- Klaus Gottlieb, MD
- FACP, FACG
- Spokane, WA
- 1-888-PEG-TUBE
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3Advantages of EUS
- Superior resolution of target organs and
structures. - Image not compromised by intervening bowel gas.
- Lesions as small as 2-3mm in diameter can be
imaged. - Ability to obtain real-time guided biopsies
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6EUS-Traditional Indications
- 1. Staging of esophageal, gastric and rectal
cancer - 2. Evaluation of abnormalities of the
gastrointestinal wall or adjacent structures
(submucosal masses, extrinsic compression) - 3. Evaluation of thickened gastric folds
- 4. Diagnosis (FNA) and staging of pancreatic
cancer - 5. Evaluation of pancreatic abnormalities
(suspected masses, cystic lesions including
pseudocysts, suspected chronic pancreatitis)
7EUS-Traditional Indications
- 6. Staging of ampullary neoplasms
- 7. Diagnosis and staging of cholangiocarcinoma
- 8. Evaluation of suspected choledocholithiasis
- 9. Celiac plexus neurolysis for chronic pain due
to intra-abdominal malignancy or chronic
pancreatitis - 10. Evaluation of fecal incontinence with
endo-anal ultrasound
8The esophagus a window into the mediastinum
9Lung CancerA Brief Overview
- In the US, lung cancer is the most common cause
of cancer deaths among both men and women. - In fact, north Americans have the highest rates
of lung cancer in the world. In 1997, some
178,100 new cases were diagnosed and roughly
160,400 deaths occurred from the disease. - Sadly, the 5-year survival rate for patients with
lung cancer is only 14.
10Histology
- Nonsmall cell lung cancer is more common than
small cell lung cancer, and it generally grows
and spreads more slowly. There are three main
types of non-small cell lung cancer squamous
cell carcinoma (also called epidermoid
carcinoma), adenocarcinoma, and large cell
carcinoma. - Small cell lung cancer, sometimes called oat cell
cancer , is less common than non-small cell lung
cancer. This type of lung cancer grows more
quickly and is more likely to spread to other
organs in the body.
11T-Staging
- A T1 cancer is less than 3 cm in size and
completely surrounded by lung tissue. - A T2 cancer is larger than 3 cm still surrounded
by lung tissue - A T3 cancer is a cancer of any size that invades
the chest wall or the structures of the chests
center. - A T4 cancer is a tumor of any size that invades
vital structures
12N-Staging
- N0 absence of any lymph node involvement.
- N1 presence of cancer in the hilar lymph nodes.
- N2 refers to an involvement of the mediastinal
lymph nodes on the cancer side. - N3 cancers involve the lymph nodes on the other
side of the chest, or in the supraclavicular
area.
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14Stage II Non-small Cell Lung Cancer T1, N1, M0
or T2, N1, M0 or T3, N0, M0
- 1. Lobectomy pneumonectomy or segmental, wedge,
or sleeve resection as appropriate. - 2. Radiation therapy with curative intent (for
potentially operable patients who have medical
contraindications to surgery). - 3. Clinical trials of adjuvant chemotherapy with
or without other modalities following curative
surgery. - 4. Clinical trials of radiation therapy following
curative surgery.
15Stage IIIA Non-small Cell Lung CancerT1, N2, M0
or T2, N2, M0 or T3, N1, M0 or T3, N2, M0
- 1. Surgery alone in operable patients without
bulky lymphadenopathy. - 2. Radiation therapy alone, for patients who are
not suitable for neoadjuvant chemotherapy plus
surgery. - 3. Chemotherapy combined with other modalities.
16Stage IIIB Non-small Cell Lung Cancer
- Patients with stage IIIB non-small cell lung
cancer (NSCLC) do not benefit from surgery alone
and are best managed by initial chemotherapy,
chemotherapy plus radiation therapy, or radiation
therapy alone, depending on sites of tumor
involvement and performance status.
17Stage IV Non-small Cell Lung Cancer
- 1. External-beam radiation therapy, primarily for
palliative relief of local symptomatic tumor
growth. - 2. Chemotherapy. The following regimens are
associated with similar survival outcomes - cisplatin plus vinblastine plus mitomycin
- cisplatin plus vinorelbine
- cisplatin plus paclitaxel
- cisplatin plus docetaxel
- cisplatin plus gemcitabine
- carboplatin plus paclitaxel
18Endoscopic Ultrasound guided fine-needle
aspiration biopsy (EUS-FNA)
- A minimally-invasive complementary tool for
diagnosis and staging of lung cancer.
19Diagnosis of Lung Cancer (Histology)
- In 70 of patients the diagnosis of suspected
lung cancer and its histology can be confirmed by
bronchoscopy, including brushings, washings, and
transbronchial biopsy. - Other methods are employed in the remainder of
the cases are - CT-guided transthoracic fine needle aspiration
(FNA) - Mediastinoscopy
- Thoracoscopic biopsy
- EUS-FNA
20Mediastinal Lymphadenopathy
- The mediastinum may be a suitable location to
obtain tissue when mediastinal lymphadenopathy is
shown by CT or PET scan and a peripheral lesion
is relatively inaccessible or the risk of
pneumothorax is prohibitive
21Modalities
- CT-guided transthoracic fine needle aspiration
(FNA)Limited by surrounding vascular
structures, size of the targeted lesion.
Pneumothorax risk. - MediastinoscopyInvasive, requires general
anesthesia. Subcarinal and subaortic (a-p
window) nodes inaccessible. - Thoracoscopic biopsy (video-assisted
thoracoscopy)Limited to inferior mediastinum. - EUS-FNA
22EUS-FNA Med LN
- Endoscopic Ultrasound guided fine needle
aspiration biopsy is a safe and accurate method
of evaluating lower paratracheal, subcarinal,
aortopulmonic and posterior mediastinal
lymphadenopathy.
23Studies
- Role of Transesophageal Endosonography-Guided
Fine-Needle Aspiration in the Diagnosis of Lung
CancerFritscher-Ravens A, Soehendra N, Schirrow
L, Sriram PV, Meyer A, Hauber HP, Pforte
A.Chest. 2000117339-345
24Fritscher-Ravens Chest 2000
- This is a prospective study in which 283
consecutive patients with lung cancer underwent
bronchoscopy. In 214 a final diagnosis was
established by (trans)bronchial biopsies,
washings and brushings. In 69 patients routine
investigations were inconclusive.Those with a
demonstrated lung lesion and mediastinal lymph
nodes on CT were enrolled in the study and
underwent EUS guided FNA of suspicious lymph
nodes. Patients were excluded if there was a
prior history of malignancy, an extrathoracic
primary, esophageal stenosis or a severe bleeding
diathesis (35 patients enrolled).
25Fritscher-Ravens
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27Size of malignant lymph nodes
28Conclusions
- Suspected lung cancer and/or mediastinal
adenopathy initial thoracic CT followed by
bronchoscopy with cytology and biopsy. - If inconclusive, EUS and guided FNA of the
mediastinal nodes avoids further tests in
patients with SCLC and in those with NSCLC and
contralateral metastasis. These patients are
usually treated by chemotherapy and/or
radiotherapy. - No evidence of lymph nodes on EUS and those with
NSCLC and ipsilateral involvement of nodes,
further work-up will be mandatory before surgery.
29Literature
Wiersema MJ, Vazquez-Sequeiros E, Wiersema
LM.Evaluation of mediastinal lymphadenopathy
with endoscopic US-guided fine-needle aspiration
biopsy.Radiology 2001 Apr219(1)252-7
30Wiersema Radiology 2001
Eighty-six consecutive patients with mediastinal
lymphadenopathy who did not have a primary
gastrointestinal neoplasm were examined. In 29
patients, endoscopic US-guided FNAB of
mediastinal lymphadenopathy was performed as a
component of staging non-small cell lung cancer
(NSCLC) in the remaining 57 patients, it was
performed to obtain a primary diagnosis. Final
diagnosis was based on clinical follow-up,
cytologic, and/or surgical results.
31Wiersema Radiology 2001
In 82 patients in whom a final diagnosis was
available, the sensitivity, specificity,
accuracy, negative predictive value, and positive
predictive value of endoscopic US-guided FNAB in
distinguishing benign from malignant mediastinal
lymph nodes were 96, 100, 98, 94, and 100,
respectively. In those patients who underwent
staging of NSCLC, endoscopic US-guided FNAB had
superior mediastinal lymph node staging accuracy
compared with endoscopic US alone (79) and CT
alone (79) (P .01). The results of endoscopic
US-guided FNAB prompted a change to nonsurgical
management in 66 (80) of 82 patients who
underwent the procedure.
32But what about PET ?
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34- EUS FNA for LN is highly accurate for lower
paratracheal (level 4), subcarinal (level 7),
aortopulmonic (level 5), and posterior
mediastinal (level 8) lymph nodes.
35Practical Aspects of FNA Biopsy
36Non-Small-Cell Lung Cancer (NSCLC), subcarinal
adenopathy
- EUS is able to safely access lymph nodes in the
posterior mediastinum. Metastatic involvement of
a subcarinal node 25mm in longest axis, discrete
borders and hypoechoic echotexture.
37NSCLC, Stage IIIA, ipsilateral nodal metastases
- EUS-guided FNA is more accurate than CT in
identifying mediastinal nodal metastases. A 20mm
rounded hypoechoic mediastinal lymph node is
identified 35 cm from the incisors in a patient
with a right upper lobe primary tumor. EUS-guided
FNA biopsy confirmed nodal metastases
38NSCLC, aorto-pulmonary window lymphadenopathy
- A 15mm discrete rounded hypoechoic lymph node is
located in the aorto-pulmonary window in a
patient with a left upper lobe primary tumor
(Olympus GF-UM30P).
39NSCLC, Stage IIIB, contralateral nodal metastases
- Identification of contralateral disease selects
out patients for nonsurgical therapies.
Mediastinal staging in a patient with a left
lower lobe primary tumor revealed a small
malignant pleural effusion and bilateral
mediastinal nodal metastases.
40NSCLC, Stage IIIB, contralateral nodal metastases
- Mediastinal staging in a patient with a right
middle lobe primary tumor revealed a small right
pleural effusion (arrow) and a small rounded
hypoechoic contralateral lymph node
41NSCLC, Stage IIIA, subcarinal nodal metastases
- Multiple discrete subcarinal lymph nodes were
identified in a patient with a left upper lobe
primary tumor. EUS-guided FNA biopsy (Olympus
GF-UM30P) confirmed nodal metastases.
42NSCLC, mediastinal lymph node, FNA biopsy
- EUS-guided FNA biopsy (Olympus GF-UM30P) was
performed on a subcarinal lymph node. Cytology
confirmed metastatic disease. The needle tip is
clearly seen in the lymph node (arrow).
43NSCLC, aortic abutment
- Vascular invasion represents nonoperative
disease. A hypoechoic mediastinal mass is seen
abutting the aortic arch (in cross-section) for a
distance of 12mm (arrow).
44Mediastinal Mass, venous compression
- A rounded hypoechoic mass can be seen compressing
the azygous vein (in longitudinal section).
EUS-guided FNA biopsy confirmed NSCLC.
45NSCLC, T4, aortic invasion
- The thoracic aorta is seen to be invaded by a
large irregular mediastinal mass.
46Small Cell Lung Cancer, pleural mass
- The mediastinal pleura is markedly thickened by
an irregular, hypoechoic mass (arrows) and an
anechoic malignant effusion is also visible.
47Bhutani MS.Transesophageal endoscopic
ultrasound-guided mediastinal lymph node
aspiration does the end justify the means?
Editorial.Chest 2000 Feb117(2)298-301
48Dr. Bhutani concludes that in patients with known
or suspected lung cancer with mediastinal lymph
nodes or in patients with mediastinal
lymphadenopathy of unknown etiology, EUS-guided
transesophageal FNA is a safe and minimally
invasive method with high accuracy. When EUS is
available, it should be used as the next logical
step for mediastinal lymph node sampling if
transbronchial methods are nondiagnostic,
provided the lymph nodes are not located anterior
and lateral to the trachea. Locations such as
subcarina, aortopulmonary window, and
paraesophageal area are especially suited for
EUS-guided FNA, as these locations are hard to
access during mediastinoscopy. Physicians
performing EUS-guided transesophageal FNA can
play an important role in helping pulmonary and
thoracic surgery colleagues in the workup of
mediastinal lymphadenopathy. Even with the
development of endobronchial ultrasound-guided
FNA, certain lymph node locations may be best
approached transesophageally. Future research in
this area should focus on the cost,
complications, and technical feasibility based on
the location of the lymph nodes and accuracy of
current and evolving techniques for mediastinal
lymph node sampling. This will allow physicians
to select the most appropriate sequential
application of technology on a case-to-case
basis.
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