1. Jaime Palomino, MD Pulmonary, Critical Care Medicine Tulane University

2. Lung Cancer - Staging Objectives/Content 7 th Edition staging system NSCLC LN anatomy TNM classification SCLC Staging work up Staging of mediastinum Pleural mesothelioma

3. TNM Staging – Lung CA Initial proposal by Dr. Clifton Mountain AJCC 1973, UICC 1974 2155 patients from MD Anderson Last revision 1997 5319 patients

4. Lung Cancer – Staging 6 th ed. Lababede O et al. CHEST 1999;115:233-35

5. Lung Cancer Staging. 7 th Edition. TNM Classification Staging Manual In Thoracic Oncology. IASLC. 2009

6. Lung Cancer – Staging 7th ed. Goldstraw P et al. J Thorac Oncol 2007;2:706-714

7. Lung Cancer Staging. 7 th Edition. Nodal Chart Staging Manual In Thoracic Oncology IASLC. 2009

8. Staging Manual In Thoracic Oncology IASLC. 2009

9. Staging Manual In Thoracic Oncology IASLC. 2009

10. Staging Manual In Thoracic Oncology IASLC. 2009

11. Staging Manual In Thoracic Oncology IASLC. 2009

12. Staging Manual In Thoracic Oncology IASLC. 2009

13. Staging Manual In Thoracic Oncology IASLC. 2009

14. Lung Cancer Staging. 7 th Edition. T1 Staging Manual In Thoracic Oncology IASLC. 2009

15. Lung Cancer Staging. 7 th Edition. T2 Staging Manual In Thoracic Oncology IASLC. 2009

16. Lung Cancer Staging. 7 th Edition. T3 Staging Manual In Thoracic Oncology IASLC. 2009

17. Lung Cancer Staging. 7 th Edition. T4 Staging Manual In Thoracic Oncology IASLC. 2009

18. Lung Cancer Staging. 7 th Edition. N0, N1 Staging Manual In Thoracic Oncology IASLC. 2009

19. Lung Cancer Staging. 7 th Edition. N2 Staging Manual In Thoracic Oncology IASLC. 2009

20. Lung Cancer Staging. 7 th Edition. N3 Staging Manual In Thoracic Oncology IASLC. 2009

21. Lung Cancer Staging. 7 th Edition. M1a Staging Manual In Thoracic Oncology IASLC. 2009

22. Lung Cancer Staging. 7 th Edition. M1b Staging Manual In Thoracic Oncology IASLC. 2009

23. Lung Cancer Staging. 7 th Edition. TNM Classification Clinical StagePathologic Stage Detterbeck et al. CHEST 2009;136:260-271

24. Lung Cancer Staging. 7 th Edition. Stage 0, I Detterbeck et al. CHEST 2009;136:260-271

25. Lung Cancer Staging. 7 th Edition. Stage II Detterbeck et al. CHEST 2009;136:260-271

26. Lung Cancer Staging. 7 th Edition. Stage III Detterbeck et al. CHEST 2009;136:260-271

27. Lung Cancer Staging. 7 th Edition. Stage IV Detterbeck et al. CHEST 2009;136:260-271

28. Lung Cancer Staging. 7 th Edition. TNM Classification Staging Manual In Thoracic Oncology. IASLC. 2009

29. Lung Cancer Staging. 7 th Edition. TNM Classification Detterbeck et al. CHEST 2009;136:260-271

30. Lung Cancer – Staging 7 th ed. Goldstraw P et al. J Thorac Oncol 2007;2:706-714

31. 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

32. Lung Cancer Staging. 7 th Edition. SCLC Shepherd et al. J Thorac Oncol. 2007;2:1067-1077

33. Lung Cancer Staging. 7 th Edition. SCLC Vallieres et al. J Thorac Oncol. 2009;4:1049-1059

34. 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)

35. 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 2007;132:202S-220S

36. Sampling Of The Mediastinum  Mediastinoscopy  Gold standard  Minimally Invasive  TBNA  EBUS – FNA  EUS - FNA

37. Gomez et al. Proc Am Thorac Soc 2009;6:180-186

38. 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 2008;29:261-270 Haponik et al. CHEST 1997;112:251-253 Rafanan et al. SRCC 2000;21:405-420

39. EUS/FNA – Sampling Of The Mediastinum

40.  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 2008;29:261-270

41. EBUS – Linear (Convex) Probe El Bayoumi et al. SRCCM 2008;29:261-270

42. EBUS – Linear (Convex) Probe Yasufuku et al. CHEST 2004;126:122-128

43. EBUS – Linear Probe Gomez et al. Proc Am Thorac Soc 2009;6:180-186

44. 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 2006;28:910-914 Lee et al. CHEST 2008;134:368-374

45. EBUS/TBNA – Sampling Of The Mediastinum Shulman et al. Curr Opin Pulm Med 2007;13:271-277

46. Gomez et al. Proc Am Thorac Soc 2009;6:180-186

47. EBUS + EUS LN FNA Wallace et al. JAMA 2008;299:540-546

48. Gomez et al. Proc Am Thorac Soc 2009;6:180-186

49. Pleural Mesothelioma Staging. 7 th Edition. TNM Classification Staging Manual In Thoracic Oncology. IASLC. 2009

50. Pleural Mesothelioma Staging. 7 th Edition. TNM Classification Staging Manual In Thoracic Oncology. IASLC. 2009