Lung Cancer staging Role of ENDOBRONCHIAL ULTRASOUND(Ebus) EBUS

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1 Lung Cancer staging Role of ENDOBRONCHIAL ULTRASOUND(Ebus) Arvind Perathur Winter Retreat Feb 13 th 2011 Mason City IA EBUS Tiger now offers a very economical and environmentally friendly all electric vehicle that can carry up to 14 passengers. With the standard 5.5 Kw motor and 48V battery pack (16 Trojan T145 6 volt batteries), the E Bus has a 60 mile range per charge.

2 Case 75 M 60 pack year smoker H/O moderately differentiated invasive squamous cell carcinoma of larynx s/p surgery and chem radiation 4 years ago.

3 Agenda Lung Cancer facts Staging brief update Survival Need for accurate staging Can we make a change? LUNG CANCER FACTS 200K newly diagnosed lung Ca in US yearly Lung Ca deaths 28% of all cancer deaths Lung Ca deaths 160K per year More than breast, prostate and colon cancers put to gather Only 16% of Lung Ca diagnosed before it has spread Breast 50% Prostate 90% 84% patients with lung cancer diagnosis die within 5 yrs Breast 11% Prostate <1% 85% of Lung Ca occurs in previous or current smokers 15% of 200K (30K) newly diagnosed NONSMOKER Lung Ca per year Radon exposure second leading cause Genetic predisposition

4 SADLY... Less money is spent on lung cancer research than on research on other cancers. In 2007, the National Cancer Institute estimated it spent $1,415 $13,991 per lung cancer death per breast cancer death $10,945 per prostate cancer death and $4,952 per colorectal cancer Significant disparity in the research and development Poor awareness and overall poorer outcome Lung cancer patients don t survive long enough to publicize American Cancer Society. Cancer Facts and Figures Atlanta: American Cancer Society; 2009 National Cancer Institute Snapshots: US CANCER DEATHS Female Male

5 Trends in cigarette smoking among persons 18 years old, by gender United States, STAGING & SURVIVAL

6 Stage groups according to TNM descriptor and subgroups. Detterbeck F C et al. Chest 2009;136: Detterbeck F C et al. Chest 2009;136:

7 Graphic illustration of stages IIIa and IIIb. Detterbeck F C et al. Chest 2009;136: Staging Clinical staging can markedly differ from pathologic staging 24% clinically overstaged 20% clinically understaged 190 cn2 patients: 38% pn0 / pn1, 6% pn3 199 cn2 negative patients: 28% with pn2 ATS/ERS: obtain pathologic evaluation in all patients thought to be a surgical candidate before thoracotomy Bülzebruck et al, Cancer 1992; 70: 1102 Watanabe et al, Ann Thorac Surg 1991; 51: 253 Am J Respir Crit Care Med 1997; 156: 320 Cerfolio et al Ann Thorac Surg 2005; 80: 1207 De Leyn et al, Eur J Cardiothorac Surg 2007; 32:

8 5 year overall survival by stage(%) Stage Clinical Pathologic AVG IA IB IIA IIB IIIA IIIB IV Stage grouping. Detterbeck F C et al. Chest 2009;136:

9 Staging Accuracy Staging Clinical staging can markedly differ from pathologic staging 24% clinically overstaged 20% clinically understaged 190 cn2 patients: 38% pn0 / pn1, 6% pn3 199 cn2 negative patients: 28% with pn2 ATS/ERS: obtain pathologic evaluation in all patients thought to be a surgical candidate before thoracotomy Bülzebruck et al, Cancer 1992; 70: 1102 Watanabe et al, Ann Thorac Surg 1991; 51: 253 Am J Respir Crit Care Med 1997; 156: 320 Cerfolio et al Ann Thorac Surg 2005; 80: 1207 De Leyn et al, Eur J Cardiothorac Surg 2007; 32:

10 Comparison of techniques for mediastinal lymph node staging NSCLCa Navani N et al. (2009) Mediastinal staging of NSCLC with endoscopic and endobronchial ultrasound Nat Rev Clin Oncol doi: /nrclinonc

11 Staging Non Invasive Staging: Radiology Standard CT: using > 10 mm as abnormal sensitivity: ~ 60% specificity: ~ 80% Integrated PET CT: improved staging and anatomic accuracy sensitivity: ~ 84 90% specificity: ~ 85 94% Perhaps even less accurate for: early stage disease re staging Cerfolio et al Ann Thorac Surg 2005; 80: 1207 Tourney KG et al, Thorax 2007;62: Dwamena et al, Radiology 1999; 213: 530 Lardinois et al, N Engl J Med 2003; 348: 2500 Antoch et al, Radiology 2003; 329:526 Chest 2003; 123: 137s BETTER WAY OF STAGING EBUS

12 EBUS in Normal Mediastenum 100 patients with NSCLC and CT with no mediastinal LN > 10mm EBUS TBNA of all identifiable nodes surgical staging with med (15) or thoracotomy (85) mean LN diameter: 8.1mm 2 aspirates / node CA seen in 19by EBUS, missed in 2 N0 N1 = 3, N2 = 13, N3 = 3 Sens 92.3%, Spec 100%, NPV 96.3% could avoid surgery in 17% Herth et al, Eur Respir J 2006; 28: 910 EBUS PET negative Mediastenum 97 patients with known / suspected NSCLC and neg PET CT in the mediastinum EBUS TBNA f/b surgical staging mean diameter 7.9mm + in 8 patients: N3 in 1, N2 in 5, N1 in 2 1 additional patient found with N1 disease on surgical staging Herth et al, Chest 2008; 133:887

13 1 mm size difference between the bronchoscope and ebus scope EBUS mouth Bronch-nose or mouth CTSNet)

14 CTSNet ( Right paratracheal node (4R) between truncus anterior of R PA (red arrow) and azygos vein (blue arrow). Biopsy needle is advanced through the node (white arrow) CTSNet (

15 Can we make a change? Accurate Mediastinal Staging If lymph nodes are not looked at EVERY case has stage 1 disease Surgery v/s No Surgery Avoid unnecessary treatment options Cure v/s Palliation Restaging after induction chemotherapy

16 Historical Data Graphic illustration of stages IIIa and IIIb. Stage IIIA means the cancer is confined to the lung itself and the lymph nodes around the windpipe or in the mediastinum (place behind the chest bone and in front of the heart) on the same side as the cancerous lung. Detterbeck F C et al. Chest 2009;136:

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18 Induction CT+/ RT with Surgery in IIIa NSCLCa More treatment related deaths in the surgically treated arm Overall survival not significantly different Further Insights from Europe 579 pts No definite difference in progression free survival More pts underwent pneumonectomy Rx for Stage III NSCLCa Wide range of approaches, but the data suggest that we may do a better job by individualizing our patient populations in terms of tumor bulk, number of nodal stations involved, patient tolerance of aggressive therapy, sterilization of mediastinal lymph nodes post-induction therapy, and potential need for pneumonectomy

19 Algorithm for patients with suspected NSCLCa after CT Navani N et al. (2009)

20 Case 75 M 60 pack year smoker H/O moderately differentiated invasive squamous cell carcinoma of larynx s/p surgery and chem radiation 4 years ago.

21 EBUS: Subcarinal (#7) & Left Paratracheal (#4L) Poorly differentiated Squamous cell carcinoma 40 yr old male with h/o renal cancer s/p nephrectomy 5 yrs ago

22 45 yr female with h/o cervical Ca 10 yrs ago Services at Mercy and Statistics N = 60 First procedure mid August 09 Main contributors: Lisa Baltierra, Cancer Center Lung Case Manager, Jim Koppin, Manager of CV &P Carol Flaherty, Surgical Services Director, with support from Mitch Morrison, Director, Mercy Heart Center, and Kandice Nedved, Interim Director, Mercy Cancer Center

23 Need for the project Better staging and appropriate management keeping with the guidelines of the major societies Improve customer service/patient satisfaction keep patients closer to home rather than refer elsewhere ie Mayo Clinic or University of Iowa. Improve the financial bottom line each patient referred out was a potential loss of revenue at $21,970 per case. Lisa Baltierra Lung Cancer Co ordinator Financially Desirable Outcomes to support return on investment 1. Increase bronchoscopies from the baseline of 25 per year to 50 per year. First year, the bronchoscopies/ebus performed was 81 (30 patients over our goal). 2. Retain patients to our facility that previously had to be sent elsewhere for this procedure which averaged 12 patients per year. In the first year, zero patients have been sent elsewhere for an EBUs procedure. By keeping those 12 patients here, we have realized a potential positive impact of $263,640. Other disease processes diagnosis SARCOIDOSIS LYPHOMA HISTOPLASMOSIS

24 Thank you