Aspiration And PET/CT For Mediastinal

bootlessbwakInternet και Εφαρμογές Web

12 Νοε 2013 (πριν από 3 χρόνια και 8 μήνες)

173 εμφανίσεις

Combined Transbronchial Needle
Aspiration And PET/CT For Mediastinal
Staging Of Lung Cancer

Şermin Börekçi
1
, Osman Elbek
1
, Nazan Bayram
1
,
Nevin Uysal
1
, Kemal Bakır
2

1
Department 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 datas

The 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 prognosis

Detterbeck 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

ƒ
General anesthesia

ƒ
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:

ƒ
Paratracheal lymph node sampling by TBNA


1979; Oho:


Using of flexible neddle with Fiberoptic bronchoscopy

9
1983; Wang:


Mapping and new kind of neddle for TBNA

1.INTRODUCTION AND AIM
-
VI

FACTORS FOR SUCCESS


Cell type of Cancer (small cell)

9
Right sided lesions

9
Large lymph nodes and masses

9
Localization of lesions
(paratracheal, subcarinal)

9
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

ƒ
I
f this approach can reduce to need for
m
ediastinoscopy.


2.
MATERIAL AND METHODS
-
I


Prospective, invasive, uncontrolled study


Department of Pulmonary Diseases, University of Gaziantep


From march 2006 to March 2008


The patients who suspected lung cancer


Enlarged mediastinal lymph nodes (

1 cm)
localized on CT


Underwent PET/CT scanning

ƒ
Consecutive 25 patients


2.
MATERIAL AND METHODS
-
II


TBNA sampling:


Flexible bronchoscopy

ƒ
Thorax CT and PET/CT combination


Acording to Wang’s map of lymph node

ƒ
22 Gauge aspiration needle


4 sampling from each lymph node station


Starting from the lymph node that the most advanced
stage

ƒ
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
-
IV


Statistical Analysis:


M
ediastinoscopy 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 patients

Symptoms (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
-
III

Histopathologic Diagnosis
2; 8%
23; 92%
SCCA
NSCCA
3.RESULTS
-
IV

NSCCA
6; 26%
4; 17%
10; 44%
3; 13%
NSCCA
Adenocarcinoma
Squamose cell CA
Malign epitelial CA
N
S
3.RESULTS
-
V


Total 43 enlarged mediastinal lymph
nodes were sampled from 25 patients

3.RESULTS
-
VI

Stations of Lymph Nodes
21; 49%
13; 30%
9; 21%
Right Paratracheal
Subcarinal
Right Hilar
3.RESULTS
-
VII

TB
İ
A ve
Mediastinoskopi
Sonu
ç
lar
ı
Lenf
Nodu
İ
stasyonu TB
İ
A Sonucu
Mediastinoskopi
Sonucu
1)
Sa
ğ
paratrakeal
negatif
negatif
2)
Sa
ğ
paratrakeal
pozitif
pozitif
3)
Subkarinal
pozitif pozitif
4)
Sa
ğ
hiler
negatif
negatif
5)
Sa
ğ
paratrakeal
yetersiz
negatif
6)
Subkarinal
yetersiz
negatif
7)
Sa
ğ
paratrakeal
negatif
negatif
8)
Sa
ğ
hiler
yetersiz
negatif
9)
Sa
ğ
paratrakeal
yetersiz
negatif
10)
Subkarinal
yetersiz
negatif
11)
Sa
ğ
paratrakeal
negatif
negatif
12)
Subkarinal
negatif pozitif
13)
Sa
ğ
paratrakeal
negatif
ö
rneklenmedi
14)
Subkarinal
negatif
pozitif
15)
Sa
ğ
hiler
negatif
ö
rneklenmedi
16)
Sa
ğ
paratrakeal
negatif
negatif
17)
Sa
ğ
paratrakeal
yetersiz
pozitif
18)
Sa
ğ
hiler
yetersiz
pozitif
19)
Sa
ğ
paratrakeal
negatif
negatif
20)
Sa
ğ
paratrakeal
negatif
negatif
21)
Sa
ğ
paratrakeal
negatif
negatif
22)
Subkarinal
negatif
negatif
23)
Sa
ğ
hiler
negatif
negatif
24)
Sa
ğ
paratrakeal
negatif
negatif
25)
Subkarinal
negatif
negatif
26)
Sa
ğ
hiler
negatif
negatif
27)
Subkarinal
negatif
negatif
28)
Sa
ğ
paratrakeal
yetersiz
pozitif
29)
Sa
ğ
paratrakeal
yetersiz
pozitif
30)
Subkarinal
yetersiz
pozitif
31)
Sa
ğ
paratrakeal
negatif
negatif
32)
Sa
ğ
paratrakeal
pozitif
yap
ı
lmad
ı
33)
Subkarinal
pozitif
yap
ı
lmad
ı
34)
Sa
ğ
paratrakeal
pozitif
yap
ı
lmad
ı
35)
Subkarinal
pozitif yap
ı
lmad
ı
36)
Sa
ğ
hiler
pozitif
yap
ı
lmad
ı
37)
Sa
ğ
paratrakeal
pozitif
yap
ı
lmad
ı
38)
Subkarinal
pozitif
yap
ı
lmad
ı
39)
Sa
ğ
hiler
pozitif
yap
ı
lmad
ı
40)
Sa
ğ
paratrakeal
pozitif
yap
ı
lmad
ı
41)
Sa
ğ
hiler
pozitif
yap
ı
lmad
ı
42)
Sa
ğ
paratrakeal
pozitif yap
ı
lmad
ı
43)
Subkarinal
pozitif
yap
ı
lmad
ı
3.RESULTS
-
VIII

Adequacy of sampling
33; 77%
10; 23%
Inadequate sampling
Adequate sampling
3.RESULTS
-
IX

Results of Malignity ( positive or negative )
19; 58%
14; 42%
Malignity positive
Malignity negative
3.RESULTS
-
X

Stations of lymph nodes with adequate sampling
15; 46%
10; 30%
8; 24%
Right paratracheal
Subcarinal
Right hilar
p > 0.05

3.RESULTS
-
XI

Stations of lymph nodes with malign results
6; 42%
4; 29%
4; 29%
Right paratracheal
Subcarinal
Right hilar
p > 0.05

3.RESULTS
-
XII

Mediastinocopy

Malign

Mediastinoscopy Benign

TBNA

Malign

14

0

14

TBNA

Benign

2

17

19

Total

1
6

17

3
3

TBNA Sensitivity



%87

TBİA Specificity




%100

Positive predictive value


%100

Negative predictive value


%89

TBNA false positivity



%0

TBNA false negativity



%12

3.RESULTS
-
XIII

The clinical factors that might effect positive TBNA result


Factor






p



Lymph node location






0.18

LAP on CT







0.33

PET SUV Max ≥5







<0.05*

Broncoscopic properties ( precence of direct or indirect findings) 0.10

Adequate or inadequate TBNA sampling




0.09

Tumor 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
-
XIV

The Procedures For Diagnosis
11; 44%
10; 40%
3; 12%
1; 4%
Toracotomy
Broncus mucosa biopsy
TTNAB
TBB
3.RESULTS
-
XV


Tissue 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
m
ediastinoscopy.

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

Patient

No

Before TBNA
#

After TBNA

After mediastinoscopy

1
&

T2N2M0

N
2
(negative)

N
2
(negative)

2

T4N2M0

N
2
(positive)

N
2
(poszitive)
ϯ

3
&

T2N2M0

N
2
(negative)

N
2
(negative)

5
&

T2N2M0

N
2
(negative)

N
2
(negative)

8
&

T2N2M0

N
2
(negative)

N
2
(negative)

9
&
*

T2N2M0

N
2
(negative)

N
2
(positive)

10
&
*


T2N2M0

N
2
(negative)

N
2
(positive)


11
&

T3N2M0

N
2
(negative)

N
2
(negative)

13
&

T2N2M0

N
2
(negative)

N
2
(negative)

14
&

T3N1M0

N
2
(negative)

N
2
(negative)

15
&

T3N2M0

N
2
(negative)

N
2
(negative)

16
&

T4N1M0

N
2
(negative)

N
2
(negative)

17
&

T4N2M0

N
2
(negative)

N
2
(negative)

20
&

T2N2M0

N
2
(negative)

N
2
(negative)

21

T2N2M0

N
2
(positive)


Initial staging was
changed after TBNA in
13/19 (%69)


The correct diagnosis
was done in 17/19 (%89)
with TBNA

22

T3N2M
0

N
2
(positive)

23

T3N2M0

N
2
(positive)

24

T2N2M0

N
2
(positive)

25

T2N2M
0

N
2
(positive)

Treatments

Patient

N
o

T
reatment

1

Opera
tion

2

Neoadjuvant

chemoradiotherapy


3

Opera
tion

4

Opera
tion

5

Opera
tion

6

Opera
tion

7

Opera
tion

8

Opera
tion

9

Neoadjuvant chemoradiotherapy

10

Neoadjuvant chemoradiotherapy

11

Opera
tion

12

CT

13

Opera
tion

14

Opera
tion

15

Opera
tion

16

Opera
tion

17

Opera
tion

18

Neoadjuvant chemoradiotherapy

19

Neoadjuvant chemoradiotherapy

20

Opera
tion

21

Neoadjuvant chemoradiotherapy

22

CT+RT

23

CT


24

Neoadjuvant

chemoradiotherapy

25

CT

Treatments
11; 44%
7; 28%
4; 16%
3; 12%
Operation
Neoadjuvant
Chemoradiotherapy
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
-
II


Acording 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).

9
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
-
IV

The clinical factors that might effect positive TBNA result


Factor






p



Lymph node location






0.18

LAP on CT







0.33

PET SUV Max ≥5







<0.05*

Broncoscopic properties ( precence of direct or indirect findings) 0.10

Adequate or inadequate TBNA sampling




0.09

Tumor 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
-
VI


It 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. LIMITATIONS


There 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
-
II


Combination 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