Role of Induction and Adjuvant Role of Induction and Adjuvant Therapy in Regionally Advanced / Therapy in Regionally Advanced /

Resectable NSCLCResectable NSCLC

Rodney J. Landreneau M.D.Professor of Surgery

Department of CardioThoracic SurgeryUniversity of Pittsburgh Medical Center

Pittsburgh, Pennsylvania

Stage IIIA Non Small Cell Lung Stage IIIA Non Small Cell Lung CancerCancer

A “heterogeneous” anatomic stage

classification with difficult to interpret responses to

therapy

Stage IIIa Non-Small Cell Lung Stage IIIa Non-Small Cell Lung Cancer HeterogeneityCancer Heterogeneity

• Microscopic mediastinal disease prognosis compared to macroscopic disease.

• Single station mediastinal node involvement compared to multiple station involvement

• Minimal clinical nodal involvement vs. Bulky mediastinal node involvement

Stage IIIa – “Bulky”Stage IIIa – “Bulky”

Stage IIIa – “Minimal Involvement”Stage IIIa – “Minimal Involvement”

Single Station IIIa DiseaseSingle Station IIIa Disease

Induction Chemo-radiotherapy for Stage III-a non-small cell

lung cancer

Standard of Care ???

Intergroup Trial 0139Chemo-radiation vs Chemo-radiation

followed by surgical resection of Stage

IIIa NSCLC

Kathy Albain et al.

Lancet. 2009 Aug 1;374:379-86

LUNG INTERGROUP TRIAL 0139 STUDY DESIGN IIIA(PN2)

STRATIFY

KPS 70-80 vs 90-100T1 vs T2 vs T3

RANDOMIZE

RE-EVALUATE RE-EVALUATE 2-4 weeks after 7 days before completion of RT completion of RT

Induction CT/RT

Cisplatin, 50 mg/m2 IV d1, 8, 29, 36Etoposide, 50 mg/m2 IV d1-5, 29-33

Thoracic RT, 45 Gy (1.8 Gy/d), begin d1

LUNG INTERGROUP TRIAL 0139 STUDY DESIGN

No progression at re-evaluation

Surgical Resection

Continue RT to 61 Gy without interruption

CONSOLIDATIONcisplatin plus etoposide

X 2 cycles

INTERGROUP 0139/RTOG 9309PROGRESSION-FREE SURVIVAL BY

TREATMENT ARMS

CT/RT/S 159/202 CT/RT 172/194

Logrank p = 0.017Hazard ratio = 0.77 (0.62, 0.96)%

Aliv

e w

ithou

t Pro

gres

sion

0

25

50

75

100

0 12 24 36 48 60

/

/ /// / // / / / // / // / / / / / / // / /

Months from Randomization

Failed/Total

Criteria for Patient Criteria for Patient Eligibility for O139 Eligibility for O139

Trial?Trial?

“Any mediastinal node positive status by any means? No systemic sampling/ recording” – Kathy

Albain - personal communication

Adjuvant ChemotherapyAdjuvant Chemotherapy in NSCLC: in NSCLC:

A new standard of care?A new standard of care?

N Engl J Med 2004;350:351-60N Engl J Med 2004;350:351-60

New Engl J Med 2004;350:351-60New Engl J Med 2004;350:351-60

4%

NEJM 2004;350:351-60

Chemotherapy better

935 775 619 520 447 372 282 208 125

932 780 650 550 487 399 300 208 133

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 years

chemotherapy: 578 deaths

- 495 deaths before 5 years

- 83 deaths after 5 years

control 590 deaths - 534 deaths before 5 years - 56 deaths after 5 years

HR: 0.91 (0.81-1.02, P = 0.10)

Le Chevalier T, et al. J Clin Oncol. 2008(May 20 suppl). Abstract 7507.

"Fading" Benefit ?"Fading" Benefit ?IALT: 7.5-Year Median Follow-UpIALT: 7.5-Year Median Follow-Up

ASCO 2004ASCO 2004

CALGB 9633CALGB 9633

0 20 40 60 80

Survival Time (Months)

0.0

0.2

0.4

0.6

0.8

1.0

Pro

bab

ility

Chemotherapy

Observation

71%59% HR 0.62

p=0.028

SUMMARY STATISTICS:Log-Rank test for equality of groups: p=0.0164Wilcoxon test for equality of groups: p=0.0100Survival rate at 5 years for Observation: 54% - % C.I. ( 48%, 61%)Survival rate at 5 years for Vinorelbine: 69% - % C.I. ( 62%, 75%)

Observation Vinorelbine

Perc

enta

ge

0

20

40

60

80

100

Time (years) # At Risk(Observation) # At Risk(Vinorelbine)

0.0239243

2.0182193

4.094

121

6.04751

8.01310

10.000

NCIC BR 10

Chemotherapy

Observation

69%54%

HR 0.7p=0.012

YRS

5yrs 4yrs

ChemotherapyChemotherapy ObservationObservation

MOSMOS 95 months95 months 78 months78 months

P valueP value 0.100.10

HR (90% CI)HR (90% CI) 0.80 (0.60-1.07)0.80 (0.60-1.07)

0 2 4 6 8

Survival Time (Years)

0.0

0.2

0.4

0.6

0.8

1.0

Pro

bab

ility

ObservationChemo

0 1 2 3 4 5 6 7 8 9

ASCO 2006 (137/155 of Total Events) ASCO 2006 (137/155 of Total Events) ABSTR #7007ABSTR #7007

CALGB 9633CALGB 9633 - - OVERALL SURVIVALOVERALL SURVIVAL

ASCO 2005 ANITA : OSASCO 2005 ANITA : OS

months

Su

rviv

al D

istr

ibu

tion

Fu

nct

ion

1.00

0.75

0.50

0.25

00 20 40 60 80 100 120

0.79 [0.66 - 0.95]0.79 [0.66 - 0.95]Hazard RatioHazard Ratio

0.0130.013P-valueP-value

65.865.843.843.8Median monthsMedian months

NVB + CDDPNVB + CDDPOBS.OBS.

Obs

NVB + CDDP

Review of Adjuvant Review of Adjuvant ChemotherapyChemotherapy

Adjuvant Platinum-Based Adjuvant Platinum-Based ChemotherapyChemotherapy

Study Design Stage N Chemo

ALPI RCT I-III 1209 Cis / Mito / Vindesine

IALT RCT I-III 1867Cis / Vinca or

Etoposide

BLT RCT I-IIIA 488* Cis regimen (1 of 4)

JBR.10 RCT IB-II 482 Cis / Vinorelbine

CALGB RCT IB 344* Carbo / Paclitaxel

ANITA RCT I-IIIA 840 Cis / Vinorelbine

*Failed to complete goal enrollment.Negative trial resultPositive trial resultInitial positive result, later follow-up negative

Perception or Reality???

Adjuvant Chemotherapy for NSCLCAdjuvant Chemotherapy for NSCLCLung Adjuvant Cisplatin Evaluation (LACE)Lung Adjuvant Cisplatin Evaluation (LACE)

• Meta-analysis of adjuvant cisplatin trials performed since 1995

• BLT, ALPI, IALT, JBR.10, ANITA

• Pooled individual patient data

• 4584 resected patients, 5 randomized trials– 7% Stage IA

– 30% Stage IB

– 36% Stage II

– 27% Stage III

Pignon JP, et al. J Clin Oncol. 2008;26:3552-3559.

Adjuvant Chemotherapy for NSCLCAdjuvant Chemotherapy for NSCLCLACE: Overall SurvivalLACE: Overall Survival

No Deaths Hazard Ratio

ALPI 569 / 1088 0.95 [0.81;1.12]

ANITA 458 / 840 0.82 [0.68;0.98]

BLT 186 / 307 [0.71;1.27]

IALT 980 / 1867 0.91 [0.80;1.04]

JBR10 197 / 482 0.71 [0.54;0.94]

Total 2390 / 4584

Trial / No Entered HR [95% CI]

P = 0.005

0.89 [0.82;0.96]

Chemotherapy better | Control better0.0 0.5 1.0 1.5 2.0

569 / 1088 0.95 [0.81;1.12]

458 / 840 0.82 [0.68;0.98]

0.95

980 / 1867 0.91

197 / 482 0.71 [0.54;0.94]

Total

Trial Entered (Chemotherapy / Control) (95% CI)

Chemotherapy effect

0.89 (0.82;0.96]

0.0 0.5 1.0 1.5 2.0

Pignon JP, et al. J Clin Oncol. 2008;26:3552-3559.

Adjuvant Chemotherapy for NSCLCAdjuvant Chemotherapy for NSCLCLACE: Pooled Data Overall SurvivalLACE: Pooled Data Overall Survival

5.4% survival advantage at 5 years

HR = 0.89

95% CI 0.82-0.96

P = 0.005

Su

rviv

al (

%)

0

20

40

60

80

100

Time from Randomization (Years)0 1 2 3 4 5

61.0

48.857.1

43.5

ChemotherapyNo chemotherapy

Su

rviv

al (

%)

0

20

40

60

80

100

0 1 2 3 4 5 ≥ 6

61.0

48.857.1

43.5

Pignon JP, et al. J Clin Oncol. 2008;26:3552-3559.

Adjuvant Chemotherapy for NSCLCAdjuvant Chemotherapy for NSCLCLACE Analysis by StageLACE Analysis by Stage

Adjuvant chemo has greatest benefit for stage II

and III and may be detrimental for stage IA

Stage IA 104 / 347 1.41 [0.96;2.09]

Stage IB 515 / 1371 0.92 [0.78;1.10]

Stage II 893 / 1616 0.83 [0.73;0.95]

Stage III 878 / 1247 0.83 [0.73;0.95]

CategoryNo. Deaths

/ No. EnteredHazard Ratio

(Chemotherapy / Control) HR [95% CI]

0.5 1.0 1.5 2.0 2.5

Stage IA 1.41 [0.96;2.09]

Stage IB 0.92 [0.78;1.10]

Stage II 0.83 [0.73;0.95]

Stage III 0.83 [0.73;0.95]

CategoryNo Deaths

/ No EnteredHazard

(Chemotherapy / Control) HR [95% CI]

Test for trend: P = 0.051Chemotherapy better Control better

0.5 1.0 1.5 2.0 2.5

Pignon JP, et al. J Clin Oncol. 2008;26:3552-3559.

Based on HR from LACE meta-analysis and 5YS from ANITA trialChemotherapy = 4 months of cisplatin + vinorelbine

Stage IB

Stage II

Stage III

Adjuvant Chemo for Stage IB – III NSCLCAdjuvant Chemo for Stage IB – III NSCLCAbsolute Benefit in 5-Year SurvivalAbsolute Benefit in 5-Year Survival

Alive dueto surgery

Alive dueto chemo

Die despitechemo

Pignon JP et al. J Clin Oncol. 2006;24(18S). Abstract 7008; Douillard JY et al. Lancet Oncol. 2006:7;719-727.

““NATCH” TrialNATCH” Trial

Induction Chemotherapy for NSCLCInduction Chemotherapy for NSCLCOngoing TrialOngoing Trial

“(Neo)adjuvant Taxol Carboplatin Hope” (NATCH) “(Neo)adjuvant Taxol Carboplatin Hope” (NATCH)

Stages I and II (T3N1) NSCLCGoal = 600 patients

Accrual complete - 624

Randomize

Surgery

Surgery - 211

Carboplatin/Paclitaxel x 3 (65%)

Surgery - 212Carboplatin/

Paclitaxel x 3 - 201 (93%)

Rosell R, et al. Lung Cancer. 2001;34(suppl 3):S63-S74.

““No” Differences 5 yr No” Differences 5 yr Disease Free SurvivalDisease Free Survival

Surgery – 39%Induction/Surgery – 41%

Surgery/ Adjuvant – 39%

Felip E., et al. - ASC0 (abst #7500) -2009

Adjuvant ChemotherapyAdjuvant Chemotherapy in NSCLC: in NSCLC:

A new standard of care?A new standard of care?

Breaking the Sound Barrier

Adjuvant ChemotherapyAdjuvant Chemotherapy

Standard of CareStandard of Care

Good performanceGood performance status patients with status patients with “R0” Anatomic Resection “R0” Anatomic Resection

– Stages IIA-BStages IIA-B

– IIIA NSCLCIIIA NSCLC

– Maybe Larger IBMaybe Larger IB ??????

Future Directions

0102030405060708090

100

1 2 3 4 5 6 7 8 9 10

YEARS

PE

RC

EN

T S

UR

VIV

AL

AD ChemotxEmperic ChemotxObservation

Patients with micrometastisisResponders to Chemotx

STD

Empiric therapy

Assay directed?

? Study Concept ?? Study Concept ?““Single Station IIIa NSCLC”Single Station IIIa NSCLC”

Is There a Role for Surgery for N2 NSCLC?Is There a Role for Surgery for N2 NSCLC?

““Surprise” N2 DiseaseSurprise” N2 Disease

Specific Clinical Frequency of Specific Clinical Frequency of ““Single StationSingle Station” IIIa NSCLC” IIIa NSCLC

Historically – 33% to 50% of patients in “IIIa” surgical series

Mithos P - Ann Thor Surg 2008

Rae F – Lung Cancer 2004

Kang HC – Ann Thor Surg 2008

““Single Station” Stage IIIa ProposalSingle Station” Stage IIIa Proposal

• Randomized trial: Induction Chemotherapy followed by anatomic resection “less than” pneumonectomy compared to anatomic resection “less than” pneumonectomy with Adjuvant Chemotherapy [mediastinal staging accuracy evaluation]

Small T1 Right Upper Lobe Small T1 Right Upper Lobe CancerCancer

Small T1 Right Upper Lobe Cancer- Small T1 Right Upper Lobe Cancer- Paratracheal Nodes Clinical NegativeParatracheal Nodes Clinical Negative

Small T1 Right Upper Lobe Cancer- Small T1 Right Upper Lobe Cancer- PET Positive Single Station PET Positive Single Station

Paratracheal Nodes Paratracheal Nodes

Phase III Randomized Study DesignPhase III Randomized Study Design

SINGLE

STATION

N2

R

A

N

D

O

M

I

Z

E

Platinum based Chemotherapy

x3 cycles

SURGERY

SURGERY Platinum based chemotherapy

x3 cycles

●Clinical Stage T1-3, N2 Single Station

● Staging Procedures: Mediastinoscopy, EBUS, EUS, PET

●RO anatomic resection (segmentectomy or lobectomy)

●Mediastinal node dissection (including 4R, 10, 7 pockets on right and 5, 6, 10L, 7 on left)

●Tissue acquisition for correlative studies

Surgical ManagementSurgical Management

Single Station IIIa ProposalSingle Station IIIa Proposal

Study ObjectivesStudy Objectives

• The primary endpoint – evaluation of the progression-free survival and overall survival surgery with induction vs adjuvant therapy single station IIIa disease

• Secondary endpoints

Response rate

Relative toxicity and complications.• To evaluate the utility of modern staging techniques of

mediastinoscopy, PET imaging and endoscopic ultrasound guided biopsy techniques in accurately identifying single station IIIa disease.

Correlative StudiesCorrelative Studies

Collaborative StudiesCollaborative Studies

• Chemoresponse assay analysis – observational study – tissues at mediastinoscopy and also at time of resections.

• Genotypic / mutational analysis of “excision / repair enzyme” profiles to assess such biomarker utility in determining individual response to platinum agents.

• Quality of life determinations related to induction therapy and adjuvant therapy for “single station” IIIa disease.

Companion / Integrated Companion / Integrated StudiesStudies

?Induction Radiation Therapy with Chemotherapy for multistation disease ( low volume (less 3cm dia

nodes) ?

?Adjuvant PORT with Chemotherapy for multi-station microscopic disease found at resection?

Nothing happens unless you try!Nothing happens unless you try!

City of PittsburghCity of PittsburghPennsylvaniaPennsylvania

Thank Thank YouYou

Case PresentationCase Presentation““Sublobar Resection” vs. Sublobar Resection” vs. “Lobectomy” for Stage I “Lobectomy” for Stage I

NSCLCNSCLC

Case Study Case Study

• An asymptomatic, well nourished, 77 year old man, 80 pk/year active cigarette smoker participating in the National Lung Screening Trial (NLST) is found to have a 1.4 cm non-calcified lung nodule in the posterior segment of his right upper lobe without mediastinal or hilar lymph node enlargement on first “incidence” scan in 2005.

Case StudyCase Study

• No history of previous cancer and no complaints of urinary or bowel problems. Screening colonoscopy performed 7 years ago normal without any polpys.

• Chest pain 4 years ago was evaluated with coronary angiography and ventriculogram demonstrating diffuse mild (less than 30%) narrowing and a left ventricular ejection fraction of 55%.

• No complaint of dyspnea on exertion. – Walks the 2 miles a day through the hills around home in Pittsburgh.

Case StudyCase Study

• PET/CT performed which demonstrated solitary nodule in Right upper lobe with SUV – 3. No other abnormal activity noted on fusion scan.

• Pulmonary function studies were performed demonstrating:– FEV-1 = 70% of predicted– FVC = 85% of predicted – FEF 25-75 = 55% of predicted– DLCO% = 60% of predicted– Normal ABG

Question #1Question #1• What diagnostic / therapeutic decisions would you make for this

patient?– A) percutaneous CT directed biopsy. If negative for malignant cells, further

follow-up scan in 6 months

– B) posterolateral thoracotomy and lobectomy with lymph node dissection

– C) VATS lobectomy with full nodal sampling

– D) Anatomic Segmentectomy with full nodal sampling

– E) VATS wedge resection with clear surgical margins

– F) B,C, or D

Question #1 answerQuestion #1 answer• What diagnostic / therapeutic decisions would you make for this patient?

– A) percutaneous CT directed biopsy. False negatives important issue. ? Influence of “lead time bias” and “over diagnosis” but generally not accepted.

– B) posterolateral thoracotomy and lobectomy with lymph node dissection – C) VATS lobectomy with full nodal sampling – D) Anatomic Segmentectomy with full nodal sampling – E) VATS wedge resection with clear surgical margins. Local recurrence (~20%) and

overall survival major negative influence on using this for primary therapy– F) B,C or D

Question #2Question #2• Which statement / statements are false regarding the clinical

outcome following sublobar resection?– A) wedge resection of stage I lung cancer has equivalent clinical success to that of anatomic

resection.– B) Anatomic segmentectomy has comparable survival to lobectomy for stage 1a nsclc – C) Pulmonary function is preserved relative to lobectomy

following anatomic segmentectomy for stage I nsclc– D) Visceral pleural involvement does affect survival for clinical 1a, node negative lung cancers

undergoing segmentectomy – E) VATS segmentectomy as equivalent clinical results to open segmentectomy for stage 1a nsclc

Question #2 answerQuestion #2 answer• Which statement / statements are false regarding the clinical

outcome following sublobar resection?– A) wedge resection of stage I lung cancer has equivalent clinical success to that of anatomic

resection.– B) Anatomic segmentectomy has comparable survival to lobectomy for stage 1a nsclc – C) Pulmonary function is preserved relative to lobectomy

following anatomic segmentectomy for stage I nsclc– D) Visceral pleural involvement does affect survival for clinical 1a, node negative lung cancers

undergoing segmentectomy – E) VATS segmentectomy as equivalent clinical results to open segmentectomy for stage 1a nsclc

Case StudyCase Study• VATS anatomic posterior segmentectomy of the right upper lobe

with comprehensive mediastinal nodal sampling (4R, 3,10,11, 7) in 2005. Uneventful 4 day hospital course.

• Typical adenocarcinoma (T1N0) – 1.5 cm dia. with 2.3 cm surgical margins. No evidence of neurovascular invasion or visceral pleural invasion.

• No evidence of local or systemic recurrence now 6 years from surgical resection.

Breaking the Sound BarrierBreaking the Sound Barrier

“Tragedies of Emperic Therapy”

SophoclesGreek Tragedian

497-405 BC

SophoclesGreek Tragedian

497-405 BC

Cancer – “The Crab” Cancer – “The Crab”

NSCLC StagingNSCLC Staging

Importance of Surgical StagingImportance of Surgical StagingImportance of Surgical StagingImportance of Surgical Staging

Lopez-Encuentra A et al. Ann Thorac Surg 2005; 79: 974-9

* Poor concordance between clinical and pathologic staging

"Fading" Benefit ?"Fading" Benefit ?IALT: Cisplatin + a Vinca or EtoposideIALT: Cisplatin + a Vinca or Etoposide

Arriagada R, et al. N Engl J Med. 2004;350:351-360.

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5

Surgery

Surgery + chemo

Pro

po

rtio

n S

urv

ivin

g

Years

HR = 0.86; 95% CI 0.76-0.98; P < 0.03

N = 1867

935 775 619 520 447 372 282 208 125

932 780 650 550 487 399 300 208 133

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 years

chemotherapy: 578 deaths

- 495 deaths before 5 years

- 83 deaths after 5 years

control 590 deaths - 534 deaths before 5 years - 56 deaths after 5 years

HR: 0.91 (0.81-1.02, P = 0.10)

Le Chevalier T, et al. J Clin Oncol. 2008(May 20 suppl). Abstract 7507.

"Fading" Benefit ?"Fading" Benefit ?IALT: 7.5-Year Median Follow-UpIALT: 7.5-Year Median Follow-Up

Multimodality therapy of Multimodality therapy of Stage IIIa NSCLC ?Stage IIIa NSCLC ?

The Evolution of Treatment Outcomes for Resected Stage IIIA Non-Small Cell

Lung Cancer Over 15 Years at a Single Institution

Linda Martin, Arlene Correa, Wayne Hofstetter, Waun Ki Linda Martin, Arlene Correa, Wayne Hofstetter, Waun Ki Hong, Ritsuko Komaki, Joe Putnam, Jr., David Rice, Roy Hong, Ritsuko Komaki, Joe Putnam, Jr., David Rice, Roy

Smythe, Stephen Swisher, Ara Vaporciyan, Garrett Walsh, and Smythe, Stephen Swisher, Ara Vaporciyan, Garrett Walsh, and Jack RothJack Roth

The Department of Thoracic and Cardiovascular SurgeryThe Department of Thoracic and Cardiovascular Surgery

MD Anderson Cancer CenterMD Anderson Cancer Center

Houston, TexasHouston, Texas

MethodsMethods

• 1986-2001 – retrospectively 1986-2001 – retrospectively reviewed all NSCLC patients who reviewed all NSCLC patients who had surgery at UT MDACC (n= had surgery at UT MDACC (n= 2861, 2861, 353 IIIa patients353 IIIa patients))• identified pathologically confirmed N2 identified pathologically confirmed N2

metastasesmetastases• Included all T1-3, N2 casesIncluded all T1-3, N2 cases

1 30 2

Hazard Ratios - SurvivalHazard Ratios - Survival

Male vs. Female

Low/Mid vs. Upper Lobe

Multimodality Rx vs. Surgery

R1/R2 vs. R0

2 N2 Stations

>2 N2 Stations

Protective Increased Risk

0.003

<0.001

0.002

<0.001

<0.001

0.007

p-value

Survival by Lymph Node Survival by Lymph Node Stations InvolvedStations Involved

Cu

mu

lati

ve S

urv

ival

Pro

bab

ility

Cu

mu

lati

ve S

urv

ival

Pro

bab

ility

0 10 20 30 40 50 60

0.0

0.2

0.4

0.6

0.8

1.0

1 Station1 Station

2 Stations2 Stations

>2 Stations>2 StationsP<0.001P<0.001

Time (months)Time (months)

Median SurvivalMedian Survival

25.325.3

16.816.8

15.515.5

Survival -Treatment GroupSurvival -Treatment GroupC

um

ula

tive

Su

rviv

al P

rob

abili

tyC

um

ula

tive

Su

rviv

al P

rob

abili

ty

Time (months)Time (months)0 10 20 30 40 50 60

0.0

0.2

0.4

0.6

0.8

1.0

P=0.004P=0.004

Multimodality Multimodality TreatmentTreatment

Surgery Surgery AloneAlone

Median survivalMedian survival

15.9 months15.9 months

25.3 months25.3 months

ConclusionsConclusions

• Survival for pIIIA (N2) NSCLC has significantly Survival for pIIIA (N2) NSCLC has significantly improved over timeimproved over time

• Use of multimodality treatment has increased over Use of multimodality treatment has increased over timetime

• Prognostic factors associated improved survival:Prognostic factors associated improved survival: Female genderFemale gender Upper lobe tumor locationUpper lobe tumor location Single N2 station involvementSingle N2 station involvement R0 resectionR0 resection

• Multimodality therapy is a modifiable factor Multimodality therapy is a modifiable factor significantly associated with improved survivalsignificantly associated with improved survival

?? Accuracy of Preoperative ?? Accuracy of Preoperative Staging in Identifying Staging in Identifying

“Single Station” IIIa Non-“Single Station” IIIa Non-Small Cell Lung Cancer ??Small Cell Lung Cancer ??

NSCLC StagingNSCLC Staging

Radiographic AssessmentRadiographic AssessmentRadiographic AssessmentRadiographic Assessment

• CT Scan

• PET Scan

- Good at primary tumor assessment - LN sensitivity and specificity: 65-80%

NSCLC StagingNSCLC Staging

Radiographic AssessmentRadiographic AssessmentRadiographic AssessmentRadiographic Assessment

• CT Scan

• PET Scan

- Superior to CT in detecting mediastinal LN involvement (90%) and mets

- Good NPV, poor PPV- Unclear whether cost-effective

NSCLC StagingNSCLC Staging

PET/CT

- Excellent sensitivity- Limited PPV- False positives common- Better than CT or PET alone in detecting LN involvement or mets

Gonzalez-Stawinsky GV et al. JTCVS 2003; 126: 1900-5

- n=202 with CA

- PET neither confirms or excludes involvement of the mediastinum- Cervical mediastinoscopy with biopsy remains the gold standard

NSCLC StagingNSCLC Staging

Invasive Staging TechniquesInvasive Staging TechniquesInvasive Staging TechniquesInvasive Staging Techniques

• Cervical Mediastinoscopy

• Chamberlain Procedure

• Thoracoscopy

• EBUS/EUS

EBUS for Station 7EBUS for Station 7

Herth FJ et al. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration. J Bronchol 2006; 13(2): 84-91

Surgical Resection Associated Surgical Resection Associated with “with “InductionInduction” or “” or “AdjuvantAdjuvant” ” Systemic Therapy for “Single Systemic Therapy for “Single

Station” IIIa NSCLCStation” IIIa NSCLC