Combined Transbronchial Needle Aspiration And PET/CT

For Mediastinal Staging Of Lung Cancer

Şermin Börekçi1, Osman Elbek1, Nazan Bayram1, Nevin Uysal1, Kemal Bakır2

1Department of Pulmonary Diseases, University of Gaziantep, School of Medicine

2 Department of Pathology, University of Gaziantep, School of Medicine

1.INTRODUCTION AND AIM-I

The most common cancer is lung cancer on the world

Lung cancer responsible for %12.8 of all cancer cases, %17.8 of all death due to cancer on the world, acording to 1999’s datasThe Turkish Thoracic Society. The guide for diagnosis and treatment of lung cancer. Thorax Journal.

2006;7(2):1-35.

1.INTRODUCTION AND AIM-II

The %70 of all lung cancer cases are at advanced (stage IV) or localy advanced stage (stage IIIA and IIIB) when diagnosed and they have no chance to surgery options for radical treatment

The Turkish Thoracic Society. The guide for diagnosis and treatment of lung cancer. Thorax Journal. 2006;7(2):1-35.

1.INTRODUCTION AND AIM-III

Staging of patient is important for;Evoluation of patient for surgery

Planning of treatment options

Determination of prognosisDetterbeck FC, DeCamp MM, Kohman LJ, Silvestri GA.

Lung cancer. Invasive staging: the guidelines. Chest 2003; 123 (suppl): 167S-75S.

1.INTRODUCTION AND AIM-IV

Procedures for mediastinal staging are clasified

into two groups as Invasive and noninvasive

Noninvasive procedures;Thorax CT, Thorax MRG, PET

İnvasive procedures;TBNA, TTNA, EUS-NA

Mediastinoscopy / Mediastinostomi, VATS

Mediastinoscopy is gold standart for mediastinal staging;

İnvasive

General anesthesia

Usually hospitalization

1.INTRODUCTION AND AIM-V

Bayram N, Borekci S, Uyar M, Bakır K and Elbek O. Transbronchial needle aspiration in the diagnosis and staging of lung cancer. Indian J Chest Dis Allied Sci 2008; 50: 273-276.

1949; Schieppati:

The first sampling from tracheal carina by using rigid bronchoscopy

1978; Wang:

Paratracheal lymph node sampling by TBNA

1979; Oho:

Using of flexible neddle with Fiberoptic bronchoscopy

1983; Wang:

Mapping and new kind of neddle for TBNA

1.INTRODUCTION AND AIM-VI

FACTORS FOR SUCCESS

Cell type of Cancer (small cell)

Right sided lesions

Large lymph nodes and masses

Localization of lesions

(paratracheal, subcarinal)

Experience Harrow E. Chest, 1991.Haponik EF. Am J Respir Crit Care Med, 1995.Harrow EM. Am J Respir Crit Care Med, 2000.

Herth FJ. Eur Respir J, 2006.

1.INTRODUCTION AND AIM-VII

A limited studies were present abouth using PET/CT instead of CT with TBNA to increase the success of TBNA.

Hsu LH, Ko JS, You DL, Liu CC, Chu NM. Respirology 2007; 12: 848-55.Bernasconi, Gambazzi F, Bubendorf L, Rasch H, Kneilfel S, Tamm M. Eur Respir J 2006; 27:

889-94.

1.INTRODUCTION AND AIM-VIII

In our study we aimed to determine;

The role of TBNA with thorax CT and PET/CT

for lung staging

The comparision with mediastinoscopy

If this approach can reduce to need for

mediastinoscopy.

2. MATERIAL AND METHODS-I

Prospective, invasive, uncontrolled study

Department of Pulmonary Diseases, University of Gaziantep

From march 2006 to March 2008The patients who suspected lung cancer

Enlarged mediastinal lymph nodes (≥1 cm) localized on CT

Underwent PET/CT scanning

Consecutive 25 patients

2. MATERIAL AND METHODS-II

TBNA sampling:Flexible bronchoscopyThorax CT and PET/CT combinationAcording to Wang’s map of lymph node 22 Gauge aspiration needle 4 sampling from each lymph node station Starting from the lymph node that the most advanced stage The other kind of sampling procedures were done after TBNA sampling

2. MATERIAL AND METHODS-III

Evaluation of samples:Adequate Sample: presence of numerous benign lymphoid cells

Negative Malignite: absence of malignant cells

Positive Malignite: presence of malignant cells

2. MATERIAL AND METHODS-IVStatistical Analysis:

Mediastinoscopy was used as “gold standart”. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rate for prediction of lymph node staging of PET/CT combined TBNA were calculated.

Descriptive statistics were expressed as mean±standart deviation (SD), interquartile range (IQR) or percent (%) according to kind of data.

2. MATERIAL AND METHODS-V

Statistical Analysis:The factors that might effect positive TBNA result were analysed through logistic regression model P value less than 0.05 was deemed statistically significant.

The statistical analysis was performed using SPSS 13.0 for Windows

3.RESULTS-I

Age (year, mean±SD) 58.7±7.6 Gender Male (n,%) 25 (100) Female 0 (0)Smoking (n,%) 25 (100)Smoking (pack/year) (median, IQR) 40 (30-55)

Comorbidities (n,%) DM 2 (8) COPD 1 (4) HT 3 (12)Karnofsky performance score (mean±SD) 80.4±10.6 ECOG (mean±SD) 0.9±0.6

Characteristics of the patients

3.RESULTS-II

Clinical properties of patientsSymptoms (n,%)

cough 23 (92) increase of sputum amount 10 (40) shortness of breath 22 (88) Hemoptizi 9 (36) lack of appetite 11 (44) loss of weight (total amount/last 2 month) 11 (44) loss of weight (median±SD) 11.4±6.2 Weakness 11 (44) back pain 2 (8) chest pain 8 (32)

Paraneoplastik syndroms 1 (4) Karnofsky’s score 80.4±10.6 ECOG (median±SD) 0.9±0.6

3.RESULTS-IIIHistopathologic Diagnosis

2; 8%

23; 92%

SCCA

NSCCA

3.RESULTS-IVNSCCA

6; 26%

4; 17%10; 44%

3; 13%

NSCCA

Adenocarcinoma

Squamose cell CA

Malign epitelial CA

NS

3.RESULTS-V

Total 43 enlarged mediastinal

lymph nodes were sampled from

25 patients

3.RESULTS-VIStations of Lymph Nodes

21; 49%

13; 30%

9; 21%

Right Paratracheal

Subcarinal

Right Hilar

3.RESULTS-VIITBİA ve Mediastinoskopi Sonuçları

Lenf Nodu İstasyonu TBİA Sonucu Mediastinoskopi Sonucu1) Sağ paratrakeal negatif negatif2) Sağ paratrakeal pozitif pozitif3) Subkarinal pozitif pozitif4) Sağ hiler negatif negatif5) Sağ paratrakeal yetersiz negatif6) Subkarinal yetersiz negatif7) Sağ paratrakeal negatif negatif8) Sağ hiler yetersiz negatif9) Sağ paratrakeal yetersiz negatif10) Subkarinal yetersiz negatif11) Sağ paratrakeal negatif negatif12) Subkarinal negatif pozitif13) Sağ paratrakeal negatif örneklenmedi14) Subkarinal negatif pozitif15) Sağ hiler negatif örneklenmedi16) Sağ paratrakeal negatif negatif 17) Sağ paratrakeal yetersiz pozitif18) Sağ hiler yetersiz pozitif19) Sağ paratrakeal negatif negatif20) Sağ paratrakeal negatif negatif21) Sağ paratrakeal negatif negatif22) Subkarinal negatif negatif23) Sağ hiler negatif negatif24) Sağ paratrakeal negatif negatif25) Subkarinal negatif negatif26) Sağ hiler negatif negatif27) Subkarinal negatif negatif28) Sağparatrakeal yetersiz pozitif 29) Sağparatrakeal yetersiz pozitif30) Subkarinal yetersiz pozitif31) Sağ paratrakeal negatif negatif 32) Sağ paratrakeal pozitif yapılmadı33) Subkarinal pozitif yapılmadı34) Sağparatrakeal pozitif yapılmadı35) Subkarinal pozitif yapılmadı36) Sağ hiler pozitif yapılmadı37) Sağ paratrakeal pozitif yapılmadı38) Subkarinal pozitif yapılmadı39) Sağ hiler pozitif yapılmadı40) Sağ paratrakeal pozitif yapılmadı41) Sağ hiler pozitif yapılmadı42) Sağparatrakeal pozitif yapılmadı43) Subkarinal pozitif yapılmadı

3.RESULTS-VIIIAdequacy of sampling

33; 77%

10; 23%

Inadequate sampling

Adequate sampling

3.RESULTS-IXResults of Malignity ( positive or negative )

19; 58%

14; 42%Malignity positive

Malignity negative

3.RESULTS-XStations of lymph nodes with adequate sampling

15; 46%

10; 30%

8; 24%

Right paratracheal

Subcarinal

Right hilar

p > 0.05

3.RESULTS-XIStations of lymph nodes with malign results

6; 42%

4; 29%

4; 29%

Right paratracheal

Subcarinal

Right hilar

p > 0.05

3.RESULTS-XIIMediastinocopy

Malign Mediastinoscopy Benign

TBNA Malign 14 0 14

TBNA Benign 2 17 19

Total 16 17 33

TBNA Sensitivity %87

TBİA Specificity %100

Positive predictive value %100

Negative predictive value %89

TBNA false positivity %0

TBNA false negativity %12

3.RESULTS-XIIIThe clinical factors that might effect positive TBNA result Factor p

Lymph node location 0.18LAP on CT 0.33PET SUV Max ≥5 <0.05*Broncoscopic properties ( precence of direct or indirect findings) 0.10Adequate or inadequate TBNA sampling 0.09Tumor tissue group 0.37

* The PET SUV max≥5 was 11 times increased positive TBNA results [OR=10.68 (1.91-59.62), P<0.01

3.RESULTS-XIVThe Procedures For Diagnosis

11; 44%

10; 40%

3; 12%1; 4%

Toracotomy

Broncus mucosa biopsy

TTNAB

TBB

3.RESULTS-XVTissue diagnosis could done by TBNA for all 14 lymph node (%100) stations with malign result

The Cases With Tissue Diagnosis By TBNA

12; 86%

2; 14%

KHDAK

KHAK

3.RESULTS-XVI

The staging was completed with TBNA in 5/19 (%26) patients without mediastinoscopy.

The clinical nodal staging of patients before and after TBNA, and final surgical nodal staging after mediastinoscopy

PatientNo

Before TBNA # After TBNA After mediastinoscopy

1& T2N2M0 N2 (negative) N2 (negative)2 T4N2M0 N2 (positive) N2 (poszitive)ϯ

3& T2N2M0 N2 (negative) N2 (negative)5& T2N2M0 N2 (negative) N2 (negative)8& T2N2M0 N2 (negative) N2 (negative)9&* T2N2M0 N2 (negative) N2 (positive)

10&* T2N2M0 N2 (negative) N2 (positive) 11& T3N2M0 N2 (negative) N2 (negative)13& T2N2M0 N2 (negative) N2 (negative)14& T3N1M0 N2 (negative) N2 (negative)15& T3N2M0 N2 (negative) N2 (negative)16& T4N1M0 N2 (negative) N2 (negative)17& T4N2M0 N2 (negative) N2 (negative)20& T2N2M0 N2 (negative) N2 (negative)21 T2N2M0 N2 (positive) Initial staging was

changed after TBNA in 13/19 (%69)The correct diagnosis was done in 17/19 (%89) with TBNA

22 T3N2M0 N2 (positive)

23 T3N2M0 N2 (positive)

24 T2N2M0 N2 (positive)

25 T2N2M0 N2 (positive)

Treatments

PatientNo Treatment

1 Operation

2 Neoadjuvant chemoradiotherapy 3 Operation

4 Operation

5 Operation

6 Operation7 Operation8 Operation9 Neoadjuvant chemoradiotherapy10 Neoadjuvant chemoradiotherapy11 Operation12 CT

13 Operation14 Operation15 Operation16 Operation17 Operation18 Neoadjuvant chemoradiotherapy19 Neoadjuvant chemoradiotherapy20 Operation21 Neoadjuvant chemoradiotherapy22 CT+RT23 CT 24 Neoadjuvant chemoradiotherapy25 CT

Treatments

11; 44%

7; 28%

4; 16%

3; 12%

Operation

NeoadjuvantChemoradiotherapy

Chemoradiotherapy

Chemotherapy

4. DISCUSSION-I

TBNA could done during first broncoscopic procedure with

local anestezia, could decrease to need adding procedure

for staging so good for patient’s comfort and cost effective.

In our study staging of 5 (%26) in 19 patients were done

without mediastinoscopy and TBNA decreased the need of

mediastinoscopy.

4. DISCUSSION-IIAcording to literatures lymph node location can effect

TBNA result . Patelli and collagues showed that, TBNA sensitivity was %52 for left paratracheal, %84 for right paratracheal and %84 for subcarinal lymph node (Patelli M, et al. Ann Thoracic Surg, 2002).

In our study there is no statistical differance between

lymph node location and TBNA positivity (p>0.05).

4. DISCUSSION-III If combination of PET with TBNA increase the succes of

diagnosis is unknown. There is limited study to show that this combination is increase the succes of diagnosis (Bernasconi, et al. Eur Respir J, 2006 ve Hsu LH, et al. Respirology, 2007).

In our study the sencitivity, spesificity, PPV, NPV of the procedure that combined PET/CT with TBNA were found very high like Bernasconi’s and Hsu’s study (respectively %87, %100, %100, %89).

4.DISCUSSION-IVThe clinical factors that might effect positive TBNA result Factor p

Lymph node location 0.18LAP on CT 0.33PET SUV Max ≥5 <0.05*Broncoscopic properties ( precence of direct or indirect findings) 0.10Adequate or inadequate TBNA sampling 0.09Tumor tissue group 0.37

* The PET SUV max≥5 was 11 times increased positive TBNA results [OR=10.68 (1.91-59.62), P<0.01

4. DISCUSSION-V

In previous study tahat we done in our clinic we found that sencitivity of TBNA combined with CT were %58 (Bayram N, et al. Indian J Chest Dis Allied Sci, 2008). And also now, we found that sensitivity of of TBNA combined with PET/CT is incresed to %87. This positive result may be due to increase of TBNA experience and olso due to PET/BT that shows details.

4. DISCUSSION-VIIt is showed that TBNA combined with PET can reduce

the %57 of mediastinoscopy need (Bernasconi, et al. Eur Respir J, 2006).

In our study this ratio was %26. This lower ratio than Bernasconi’s is may be due to most of our patients were operable and toracotomy was carried out after mediastinoscopy in the same operation session.

5. LIMITATIONSThere is no control group

The distribution of lymph node station were right

There were no rapid on-site cytological examination.

6. RESULTS-I

TBNA is less invasive and has less complication than mediastinoscopy and can be used for correct staging of lung cancer.

6. RESULTS-IICombination of TBNA with PET/CT can increase sensitivity

Increse of TBNA positivity is meningfull on lymph nodes with SUV Max ≥ 5

TBNA decreased the need of mediastinoscopy

SUGGESTION

Our experience suggest that TBNA should

be routinly performed during the standart

diagnostic bronchoscopy for staging of lung

cancer to all patients with mediastinal

lympadenopathy on CT and/or PET/CT.

THANKS