- •Foreword
- •Preface
- •Contents
- •About the Editors
- •Contributors
- •1: Tracheobronchial Anatomy
- •Trachea
- •Introduction
- •External Morphology
- •Internal Morphology
- •Mucous Layer
- •Blood Supply
- •Anatomo-Clinical Relationships
- •Bronchi
- •Main Bronchi
- •Bronchial Division
- •Left Main Bronchus (LMB)
- •Right Main Bronchus (RMB)
- •Blood Supply
- •References
- •2: Flexible Bronchoscopy
- •Introduction
- •History
- •Description
- •Indications and Contraindications
- •Absolute Contraindications
- •Procedure Preparation
- •Technique of FB Procedure
- •Complications of FB Procedure
- •Basic Diagnostic Procedures
- •Bronchoalveolar Lavage (BAL)
- •Transbronchial Lung Biopsy (TBLB)
- •Transbronchial Needle Aspiration (TBNA)
- •Bronchial Brushings
- •Advanced Diagnostic Bronchoscopy
- •EBUS-TBNA
- •Ultrathin Bronchoscopy
- •Transbronchial Lung Cryobiobsy (TBLC)
- •Therapeutic Procedures Via FB
- •LASER Bronchoscopy
- •Electrocautery
- •Argon Plasma Coagulation (APC)
- •Cryotherapy
- •Photodynamic Therapy
- •Airway Stent Placement
- •Endobronchial Valve Placement
- •Conclusion
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Procedure Description
- •Procedure Planning
- •Target Approximation
- •Sampling
- •Complications
- •Future Directions
- •Summary and Recommendations
- •References
- •4: Rigid Broncoscopy
- •Innovations
- •Ancillary Equipment
- •Rigid Bronchoscopy Applications
- •Laser Bronchoscopy
- •Tracheobronchial Prosthesis
- •Transbronchial Needle Aspiration (TBNA)
- •Rigid Bronchoscope in Other Treatments for Bronchial Obstruction
- •Mechanical Debridement
- •Pediatric Rigid Bronchoscopy
- •Tracheobronchial Dilatation
- •Foreign Bodies Removal
- •Other Indications
- •Complications
- •The Procedure
- •Some Conclusions
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •Preprocedural Evaluation and Preparation
- •Physical Examination
- •Procedure-Related Indications
- •Application of the Technique
- •Topical Anesthesia
- •Anesthesia of the Nasal Mucosa and Nasopharynx
- •Anesthesia of the Mouth and Oropharynx
- •Superior Laryngeal Nerve Block
- •Recurrent Laryngeal Nerve Block (RLN)
- •Conscious Sedation
- •Monitored Anesthesia Care (MAC)
- •General Anesthesia
- •Monitoring the Depth of Anesthesia
- •Interventional Bronchoscopy Suites
- •Airway Devices
- •Laryngeal Mask Airway (LMA)
- •Endotracheal Tube (ETT)
- •Rigid Bronchoscope
- •Modes of Ventilation
- •Spontaneous Ventilation
- •Assisted Ventilation
- •Noninvasive Positive Pressure Ventilation (NIV)
- •Positive Pressure Controlled Mechanical Ventilation
- •Jet Ventilation
- •Electronic Mechanical Jet Ventilation
- •Postprocedure Care
- •Special Consideration
- •Anesthesia for Peripheral Diagnostic and Therapeutic Bronchoscopy
- •Anesthesia for Interventional Bronchoscopic Procedures During the COVID-19 Pandemic
- •Summary and Recommendations
- •Conclusion
- •References
- •Background
- •Curricular Structure and Delivery
- •What Is a Bronchoscopy Curriculum?
- •Tradition, Teaching Styles, and Beliefs
- •Using Assessment Tools to Guide the Educational Process
- •The Ethics of Teaching
- •When Learners Teach: The Journey from Novice to Mastery and Back Again
- •The Future Is Now
- •References
- •Interventional Procedure
- •Assessment of Flow–Volume Curve
- •Dyspnea
- •Analysis of Pressure–Pressure Curve
- •Conclusions
- •References
- •Introduction
- •Adaptations of the IP Department
- •Environmental Control
- •Personal Protective Equipment
- •Procedure Performance
- •Bronchoscopy in Intubated Patients
- •Other Procedures in IP Unit
- •References
- •Introduction
- •Safety
- •Patient Safety
- •Provider Safety
- •Patient Selection and Screening
- •Lung Cancer Diagnosis and Staging
- •Inpatients
- •COVID-19 Clearance
- •COVID Clearance: A Role for Bronchoscopy
- •Long COVID: A Role for Bronchoscopy
- •Preparing for the Next Pandemic
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Clinical Presentation
- •Diagnosis
- •Treatment
- •History and Historical Perspectives
- •Indications and Contraindications
- •Benign and Malignant Tumors
- •Tumors with Uncertain Prognosis
- •Application of the Technique
- •Evidence Based Review
- •Summary and Recommendations
- •References
- •12: Cryotherapy and Cryospray
- •Introduction
- •Historical Perspective
- •Equipment
- •Cryoadhesion
- •Indications
- •Cryorecanalization
- •Cryoadhesion and Foreign Body Removal
- •Cryoadhesion and Mucus Plugs/Blood Clot Retrieval
- •Endobronchial Cryobiopsy
- •Transbronchial Cryobiopsy for Lung Cancer
- •Safety Concerns and Contraindications
- •Cryoablation
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Cryospray
- •Indications
- •Evidence
- •Safety Concerns and Contraindications
- •Advantages of Cryotherapy
- •Limitations
- •Future Research Directions
- •References
- •13: Brachytherapy
- •History and Historical Perspective
- •Indications and Contraindications
- •Application of the Technique
- •Evidence-Based Review
- •Adjuvant Treatment
- •Palliative Treatment
- •Complications
- •Summary and Recommendations
- •References
- •14: Photodynamic Therapy
- •Introduction
- •Photosensitizers
- •First-Generation Photosensitizers
- •M-Tetrahidroxofenil Cloro (mTHPC) (Foscan®)
- •PDT Reaction
- •Tumor Damage Process
- •Procedure
- •Indications
- •Curative PDT Indications
- •Palliative PDT Indications
- •Contraindications
- •Rationale for Use in Early-Stage Lung Cancer
- •Rationale
- •PDT in Combination with Other Techniques for Advanced-Stage Non-small Cell Lung Cancer
- •Commentary
- •Complementary Endoscopic Methods for PDT Applications
- •New Perspectives
- •Other PDT Applications
- •Conclusions
- •References
- •15: Benign Airways Stenosis
- •Etiology
- •Congenital Tracheal Stenosis
- •Iatrogenic
- •Infectious
- •Idiopathic Tracheal Stenosis
- •Distal Bronchial Stenosis
- •Diagnosis Methods
- •Patient History
- •Imaging Techniques
- •Bronchoscopy
- •Pulmonary Function Test
- •Treatment
- •Endoscopic Treatment
- •Dilatation
- •Laser Therapy
- •Stents
- •How to Proceed
- •Stent Placement
- •Placing a Montgomery T Tube
- •The Rule of Twos for Benign Tracheal Stenosis (Fig. 15.23)
- •Surgery
- •Summary and Recommendations
- •References
- •16: Endobronchial Prostheses
- •Introduction
- •Indications
- •Extrinsic Compression
- •Intraluminal Obstruction
- •Stump Fistulas
- •Esophago-respiratory Fistulas (ERF)
- •Expiratory Central Airway Collapse
- •Physiologic Rationale for Airway Stent Insertion
- •Stent Selection Criteria
- •Stent-Related Complications
- •Granulation Tissue
- •Stent Fracture
- •Migration
- •Contraindications
- •Follow-Up and Patient Education
- •References
- •Introduction
- •Overdiagnosis
- •False Positives
- •Radiation
- •Risk of Complications
- •Lung Cancer Screening Around the World
- •Incidental Lung Nodules
- •Management of Lung Nodules
- •References
- •Introduction
- •Minimally Invasive Procedures
- •Mediastinoscopy
- •CT-Guided Transthoracic Biopsy
- •Fluoroscopy-Guided Transthoracic Biopsies
- •US-Guided Transthoracic Biopsy
- •Thoracentesis and Pleural Biopsy
- •Thoracentesis
- •Pleural Biopsy
- •Surgical or Medical Thoracoscopy
- •Image-Guided Pleural Biopsy
- •Closed Pleural Biopsy
- •Image-Guided Biopsies for Extrathoracic Metastases
- •Tissue Acquisition, Handling and Processing
- •Implications of Tissue Acquisition
- •Guideline Recommendations for Tissue Acquisition in Mediastinal Staging
- •Methods to Overcome Challenges in Tissue Acquisition and Genotyping
- •Rapid on-Site Evaluation (ROSE)
- •Sensitive Genotyping Assays
- •Liquid Biopsy
- •Summary, Recommendations and Highlights
- •References
- •History
- •Data Source and Methodology
- •Tumor Size
- •Involvement of the Main Bronchus
- •Atelectasis/Pneumonitis
- •Nodal Staging
- •Proposal for the Revision of Stage Groupings
- •Small Cell Lung Cancer (SCLC)
- •Discussion
- •Methodology
- •T Descriptors
- •N Descriptors
- •M Descriptors
- •Summary
- •References
- •Introduction
- •Historical Perspective
- •Fluoroscopy
- •Radial EBUS Mini Probe (rEBUS)
- •Ultrasound Bronchoscope (EBUS)
- •Virtual Bronchoscopy
- •Trans-Parenchymal Access
- •Cone Beam CT (CBCT)
- •Lung Vision
- •Sampling Instruments
- •Conclusions
- •References
- •History and Historical Perspective
- •Narrow Band Imaging (NBI)
- •Dual Red Imaging (DRI)
- •Endobronchial Ultrasound (EBUS)
- •Optical Coherence Tomography (OCT)
- •Indications and Contraindications
- •Confocal Laser Endomicroscopy and Endocytoscopy
- •Raman Spectrophotometry
- •Application of the Technique
- •Supplemental Technology for Diagnostic Bronchoscopy
- •Evidence-Based Review
- •Summary and Recommendations, Highlight of the Developments During the Last Three Years (2013 on)
- •References
- •Introduction
- •History and Historical Perspective
- •Endoscopic AF-OCT System
- •Preclinical Studies
- •Clinical Studies
- •Lung Cancer
- •Asthma
- •Airway and Lumen Calibration
- •Obstructive Sleep Apnea
- •Future Applications
- •Summary
- •References
- •23: Endobronchial Ultrasound
- •History and Historical Perspective
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •Convex Probe Ultrasound
- •Equipment
- •Technique
- •Indication, Application, and Evidence
- •CP-EBUS for Malignant Mediastinal or Hilar Adenopathy
- •CP-EBUS for the Staging of Non-small Cell Lung Cancer
- •CP-EBUS for Restaging NSCLC After Neoadjuvant Chemotherapy
- •Complications
- •Summary
- •References
- •Introduction
- •What Is Electromagnetic Navigation?
- •SuperDimension Navigation System (EMN-SD)
- •Computerized Tomography
- •Computer Interphase
- •The Edge Catheter: Extended Working Channel (EWC)
- •Procedural Steps
- •Planning
- •Detecting Anatomical Landmarks
- •Pathway Planning
- •Saving the Plan and Exiting
- •Registration
- •Real-Time Navigation
- •SPiN System Veran Medical Technologies (EMN-VM)
- •Procedure
- •Planning
- •Navigation
- •Biopsy
- •Complications
- •Limitations
- •Summary
- •References
- •Introduction
- •Image Acquisition
- •Hardware
- •Practical Considerations
- •Radiation Dose
- •Mobile CT Studies
- •Future Directions
- •Conclusion
- •References
- •26: Robotic Assisted Bronchoscopy
- •Historical Perspective
- •Evidence-Based Review
- •Diagnostic Yield
- •Monarch RAB
- •Ion Endoluminal Robotic System
- •Summary
- •References
- •History and Historical Perspective
- •Indications and Contraindications
- •General
- •Application of the Technique
- •Preoperative Care
- •Patient’s Position and Operative Field
- •Incision and Initial Dissection
- •Palpation
- •Biopsy
- •Control of Haemostasis and Closure
- •Postoperative Care
- •Complications
- •Technical Variants
- •Extended Cervical Mediastinoscopy
- •Mediastinoscopic Biopsy of Scalene Lymph Nodes
- •Inferior Mediastinoscopy
- •Mediastino-Thoracoscopy
- •Video-Assisted Mediastinoscopic Lymphadenectomy
- •Transcervical Extended Mediastinal Lymphadenectomy
- •Evidence-Based Review
- •Summary and Recommendations
- •References
- •Introduction
- •Case 1
- •Adrenal and Hepatic Metastases
- •Brain
- •Bone
- •Case 1 Continued
- •Biomarkers
- •Case 1 Concluded
- •Case 2
- •Chest X-Ray
- •Computerized Tomography
- •Positive Emission Tomography
- •Magnetic Resonance Imaging
- •Endobronchial Ultrasound with Transbronchial Needle Aspiration
- •Transthoracic Needle Aspiration
- •Transbronchial Needle Aspiration
- •Endoscopic Ultrasound with Needle Aspiration
- •Combined EUS-FNA and EBUS-TBNA
- •Case 2 Concluded
- •Case 3
- •Standard Cervical Mediastinoscopy
- •Extended Cervical Mediastinoscopy
- •Anterior Mediastinoscopy
- •Video-Assisted Thoracic Surgery
- •Case 3 Concluded
- •Case 4
- •Summary
- •References
- •29: Pleural Anatomy
- •Pleural Embryonic Development
- •Pleural Histology
- •Cytological Characteristics
- •Mesothelial Cells Functions
- •Pleural Space Defense Mechanism
- •Pleura Macroscopic Anatomy
- •Visceral Pleura (Pleura Visceralis or Pulmonalis)
- •Parietal Pleura (Pleura Parietalis)
- •Costal Parietal Pleura (Costalis)
- •Pleural Cavity (Cavitas Thoracis)
- •Pleural Apex or Superior Pleural Sinus [12–15]
- •Anterior Costal-Phrenic Sinus or Cardio-Phrenic Sinus
- •Posterior Costal-Phrenic Sinus
- •Cost-Diaphragmatic Sinus or Lateral Cost-Phrenic Sinus
- •Fissures18
- •Pleural Vascularization
- •Parietal Pleura Lymphatic Drainage
- •Visceral Pleura Lymphatic Drainage
- •Pleural Innervation
- •References
- •30: Chest Ultrasound
- •Introduction
- •The Technique
- •The Normal Thorax
- •Chest Wall Pathology
- •Pleural Pathology
- •Pleural Thickening
- •Pneumothorax
- •Pulmonary Pathology
- •Extrathoracic Lymph Nodes
- •COVID and Chest Ultrasound
- •Conclusions
- •References
- •Introduction
- •History of Chest Tubes
- •Overview of Chest Tubes
- •Contraindications for Chest Tube Placement
- •Chest Tube Procedural Technique
- •Special Considerations
- •Pneumothorax
- •Empyema
- •Hemothorax
- •Chest Tube Size Considerations
- •Pleural Drainage Systems
- •History of and Introduction to Indwelling Pleural Catheters
- •Indications and Contraindications for IPC Placement
- •Special Considerations
- •Non-expandable Lung
- •Chylothorax
- •Pleurodesis
- •Follow-Up and IPC Removal
- •IPC-Related Complications and Management
- •Competency and Training
- •Summary
- •References
- •32: Empyema Thoracis
- •Historical Perspectives
- •Incidence
- •Epidemiology
- •Pathogenesis
- •Clinical Presentation
- •Radiologic Evaluation
- •Biochemical Analysis
- •Microbiology
- •Non-operative Management
- •Prognostication
- •Surgical Management
- •Survivorship
- •Summary and Recommendations
- •References
- •Evaluation
- •Initial Intervention
- •Pleural Interventions for Recurrent Symptomatic MPE
- •Especial Circumstances
- •References
- •34: Medical Thoracoscopy
- •Introduction
- •Diagnostic Indications for Medical Thoracoscopy
- •Lung Cancer
- •Mesothelioma
- •Other Tumors
- •Tuberculosis
- •Therapeutic Indications
- •Pleurodesis of Pneumothorax
- •Thoracoscopic Drainage
- •Drug Delivery
- •Procedural Safety and Contraindications
- •Equipment
- •Procedure
- •Pre-procedural Preparations and Considerations
- •Procedural Technique [32]
- •Medical Thoracoscopy Versus VATS
- •Conclusion
- •References
- •Historical Perspective
- •Indications and Contraindications
- •Evidence-Based Review
- •Endobronchial Valves
- •Airway Bypass Tracts
- •Coils
- •Other Methods of ELVR
- •Summary and Recommendations
- •References
- •36: Bronchial Thermoplasty
- •Introduction
- •Mechanism of Action
- •Trials
- •Long Term: Ten-Year Study
- •Patient Selection
- •Bronchial Thermoplasty Procedure
- •Equipment
- •Pre-procedure
- •Bronchoscopy
- •Post-procedure
- •Conclusion
- •References
- •Introduction
- •Bronchoalveolar Lavage (BAL)
- •Technical Aspects of BAL Procedure
- •ILD Cell Patterns and Diagnosis from BAL
- •Technical Advises for Conventional TLB and TLB-C in ILD
- •Future Directions
- •References
- •Introduction
- •The Pediatric Airway
- •Advanced Diagnostic Procedures
- •Endobronchial Ultrasound
- •Virtual Navigational Bronchoscopy
- •Cryobiopsy
- •Therapeutic Procedures
- •Dilation Procedures
- •Thermal Techniques
- •Mechanical Debridement
- •Endobronchial Airway Stents
- •Metallic Stents
- •Silastic Stents
- •Novel Stents
- •Endobronchial Valves
- •Bronchial Thermoplasty
- •Discussion
- •References
- •Introduction
- •Etiology
- •Congenital ADF
- •Malignant ADF
- •Cancer Treatment-Related ADF
- •Benign ADF
- •Iatrogenic ADF
- •Diagnosis
- •Treatment Options
- •Endoscopic Techniques
- •Stents
- •Clinical Results
- •Stent Complications
- •Other Available Stents
- •Other Endoscopic Methods
- •References
- •Introduction
- •Anatomy and Physiology of Swallowing
- •Functional Physiology of Swallowing
- •Epidemiology and Risk Factors
- •Types of Foreign Bodies
- •Organic
- •Inorganic
- •Mineral
- •Miscellaneous
- •Clinical Presentation
- •Acute FB
- •Retained FB
- •Radiologic Findings
- •Bronchoscopy
- •Airway Management
- •Rigid Vs. Flexible Bronchoscopy
- •Retrieval Procedure
- •Instruments
- •Grasping Forceps
- •Baskets
- •Balloons
- •Suction Instruments
- •Ablative Therapies
- •Cryotherapy
- •Laser Therapy
- •Electrocautery and APC
- •Surgical Management
- •Complications
- •Bleeding and Hemoptysis
- •Distal Airway Impaction
- •Iron Pill Aspiration
- •Follow-Up and Sequelae
- •Conclusion
- •References
- •Vascular Origin of Hemoptysis
- •History and Historical Perspective
- •Diagnostic Bronchoscopy
- •Therapeutic Bronchoscopy
- •General Measures
- •Therapeutic Bronchoscopy
- •Evidence-Based Review
- •Summary
- •Recommendations
- •References
- •History
- •“The Glottiscope” (1807)
- •“The Esophagoscope” (1895)
- •The Rigid Bronchoscope (1897–)
- •The Flexible Bronchoscope (1968–)
- •Transbronchial Lung Biopsy (1972) (Fig. 42.7)
- •Laser Therapy (1981–)
- •Endobronchial Stents (1990–)
- •Electromagnetic Navigation (2003–)
- •Bronchial Thermoplasty (2006–)
- •Endobronchial Microwave Therapy (2004–)
- •American Association for Bronchology and Interventional Pulmonology (AABIP) and Journal of Bronchology and Interventional Pulmonology (JOBIP) (1992–)
- •References
- •Index
28 Lung Cancer Staging Methods: A Practical Approach |
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who received targeted therapy at some time during their treatment had a median overall survival of 31.8 months compared to 12.7 months for cytotoxic chemotherapy and 5.1 months for supportive care only [30]. Biomarkers are classi-ed as actionable or prognostic. Actionable biomarkers are the mutations for which treatments have been developed compared to prognostic biomarkers which are indicative of a patient’s survival independent of the treatment received. The NCCN guidelines recommend testing for ALK rearrangements, BRAF mutations, EGFR mutations, METex14 skipping mutations, NTRK1/2/3 gene fusions, RET rearrangements, and ROS1 rearrangements for individuals with advanced NSCLC [7]. Biomarker status should be documented prior to initiation of therapy as patients may be able to receive targeted therapy or immunotherapy with or without chemotherapy. If mutational analysis cannot be performed on a biopsy sample, the patient may need to a repeat procedure/biopsy to obtain tissue solely for molecular analysis. Some patients may not be able to undergo another procedure for molecular analysis. In these instances, a liquid biopsy drawn from a blood sample searching for circulating tumor cell free DNA can be obtained to assess for actionable mutations. If a patient has both a
Fig. 28.4 PET-CT showing a RUL 2.4 cm hypermetabolic nodule with an SUV of 10.1
molecular biomarker and high PD-L1 expression, targeted therapy is usually recommended rst prior to consideration of immunotherapy [7].
Case 1 Concluded
Patient underwent CT-guided biopsy of the adrenal lesion which was diagnostic for adenocarcinoma of the lung and Stage IVB was confrmed. Molecular analysis documented an EGFR mutation and he was referred to Oncology for targeted therapy.
Case 2
A 64-year-old female with a previous smoking history is evaluated in clinic with a 1.8 cm RUL nodule. Due to patient preference, a follow-up CT scan obtained 6 months later showed that the nodule had grown in size. PET-CT was performed (Figs. 28.4 and 28.5) and revealed the nodule was hypermetabolic along with a hypermetabolic right hilar lymph node.
The rst step in deciding which invasive approach to stage the mediastinum is to perform initial radiographic staging (Table 28.1).
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Fig. 28.5 PET-CT showed a hypermetabolic right hilar lymph node measuring 2.1 cm with an SUV of 10
Table 28.1 De nition of intrathoracic radiographic categories of lung cancer
Group |
Description |
De nition (by chest CT scan) |
A |
Mediastinal |
Tumor mass within the |
|
in ltration |
mediastinum such that |
|
|
discrete lymph nodes cannot |
|
|
be distinguished or measured |
|
|
|
B |
Enlarged |
Discrete mediastinal nodes |
|
discrete |
≥1 cm in short axis diameter |
|
mediastinal |
on a transverse CT image |
|
nodes |
|
|
|
|
C |
Clinical stage |
Normal mediastinal nodes |
|
II or central |
(<1 cm) but enlarged N1 |
|
stage I tumor |
nodes (>1 cm) or a central |
|
|
tumor (within proximal |
|
|
one-third of the hemithorax) |
D |
Peripheral |
Normal mediastinal and N1 |
|
clinical stage I |
nodes (<1 cm) and a |
|
tumor |
peripheral tumor (within |
|
|
outer two-thirds of |
|
|
hemithorax) |
|
|
|
Chest X-Ray
Although CXR is a good tool in providing preliminary information such as obvious chest wall and mediastinal invasion in large tumors, it has limited sensitivity to predict T3/T4 disease or metastases to the mediastinum. The patient will
need further imaging for better delineation of the extent of disease prior to consideration of treatment options.
Computerized Tomography
Computerized tomography scan of the chest is the cornerstone of lung cancer imaging on which further management is decided. Ideally, it should be extended to include the liver and adrenal glands to assess for metastatic disease. Based on the intra-thoracic radiographic characteristics (including both the primary tumor and the mediastinum), patients with lung cancer can be separated into four groups, A to D (Table 28.1 and Fig. 28.6). Radiographic group A involves patients with mediastinal in ltration that encircles the vessels and airways, so that the discrete lymph nodes can no longer be discerned or measured. Group B involves patients with enlarged mediastinal node (≥1 cm in short axis diameter) in whom the size of the discrete nodes can be measured. The last two groups involve patients with normal mediastinal nodes. In radiographic group C, the presence of a central tumor or sus-
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28 Lung Cancer Staging Methods: A Practical Approach |
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a |
b |
c |
d |
Fig. 28.6 American College of Chest Physicians intrathoracic radiographic (CT) categories for lung cancer. (a) Mediastinal in ltration by tumor. (b) Enlarged discrete
N2,3 nodes. (c) A central tumor or a tumor with enlarged N1 nodes, but a normal mediastinum. (d) A peripheral small tumor with normal sized lymph nodes
pected N1 disease makes the chance of N2 or N3 nodal involvement relatively high, 20–25%. Despite normal-sized mediastinal lymph nodes, further con rmation is needed. In group D, those with a clinical stage I tumor, the chance of either distant metastases or mediastinal involvement is quite low [12]. The advantage of CT is that it provides accurate anatomic de nition of the tumor within the thorax. For example, it helps us accurately identify T3 or T4 lesions and enlarged lymph nodes which directs tissue biopsy for histopathologic diagnosis and staging.
The major limitation of CT is its low accuracy in the identi cation of mediastinal metastases. The ACCP guidelines published the performance characteristics of CT for staging the mediastinum which involved 35 studies in a meta-analysis. The analysis showed a pooled sensitivity of 51%
(95% CI 47–54%) and a pooled speci city of 86% (95% CI 84–88%) [31]. This limitation is more evident in 5–15% of patients with clinical T1N0 lesions that will be found to have positive lymph node involvement by surgical sampling [32]. It is usually inappropriate to rely solely on chest CT to determine the mediastinal lymph node status; regardless, CT continues to play an important role in the evaluation of patients with either a known or suspected lung cancer who are eligible for treatment [12].
Positive Emission Tomography
The advent of the PET scan has been the single most notable addition to lung cancer staging in recent history. Cancer cells demonstrate increased
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cellular uptake of glucose when compared with normal cells. PET scan uses 18-FDG, a radio- labeled glucose analogue which undergoes the same cellular uptake as glucose. After phosphorylation, is not further metabolized and becomes trapped in cells. This accumulation of isotope is identi ed by a PET detector [33]. There are no standardized criteria de ning what constitutes a positive PET result and no ideal cutoff point for the standardized uptake value (SUV). However, lymph nodes with FDG uptake greater than that observed in the mediastinal blood pool are highly suspicious for metastatic disease [34].
Whole body PET imaging in preoperative staging of lung cancer has been shown to increase identi cation of patients with mediastinal and extrathoracic disease compared to conventional staging by 20% [35–38]. In addition, PET improves discrimination between N0-1 and N2-3 disease [39]. One systematic review of 45 studies which included 4105 patients reported sensitivity, speci city, positive predictive value (PPV) and negative predictive value (NPV) of 80%, 88%, 75%, and 91%, respectively for mediastinal staging [12]. One limitation of PET scan is the poor anatomic de nition of suspicious lesions. Integrated PET-CT enables the direct correlation of FDG-accumulating lesions with morphological structures. There is an improvement in the number of patients correctly staged with this modality over CT or PET alone, but that has not been shown to improve mortality [40, 41].
There have been 5 randomized controlled trials (RCTs) evaluating the role of PET scan in lung cancer patients all with varying results. While two studies suggest a reduction in the rate of futile thoracotomies with the use of PET as a staging modality [36, 38], three studies suggest no difference in a similar population [35, 37, 42]. This variation was likely due to the signi cant differences among the patients enrolled, their evaluation prior to PET, and the risk for advanced disease. Population-based studies suggest that the use of PET has had increased stage migration from stage III to stage IV, but adds little to the staging of patients with clinical stage I cancer [43]. One of the downsides to increasing sensitivity in detecting occult metastases is incorrectly
upstaging patients and potentially withholding possible curative management [12].
When staging the mediastinum with PET or PET-CT, benign FDG-avid lesions such as infections, infammation, and granulomatous disease can present as false positives. Additionally, lymph nodes <10 mm have a lower chance of detection from PET scan compared to enlarged lymph nodes [44]. In patients without mediastinal lymphadenopathy, a negative PET-CT is highly valid and patients may proceed to surgery unless they have a central tumor. However, the false negative rate is considerable in enlarged lymph nodes without FDG uptake (30%) [39].
Despite its widespread use, there is no consensus regarding the routine use of PET as a staging modality for patients with suspected NSCLC. Con rmation of PET ndings is essential because it also carries a signi cant rate of incorrect upstaging. Needle techniques to assess the mediastinum are the most rational next step. Nevertheless, there are enough data (including RCTs, prospective studies, and population studies) which suggest that the PET-CT is of more bene t than harm [12].
Magnetic Resonance Imaging
Historically, MRI of lung was thought not to be ideal due to low signal-to-noise ratio, which includes susceptibility artifacts caused by multiple air-tissue interfaces and motion artifacts [45]. Currently, MRI is indicated for superior sulcus tumors, such as a Pancoast tumor, and assessment of possible invasion of the spinal cord [46]. Recent improvements in MRI techniques such as short echo times, ultrafast turbo- spin-echo acquisitions, projection reconstruction technique, breath-hold imaging, electrocardiogram triggering, and oxygen enhancement have widened the potential for investigations of pulmonary parenchymal disease [45]. Once radiographic staging has been completed, the physician can select the proper invasive test depending on the location of the target and the performance characteristics of the test selected (Table 28.2) [12].
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