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KHDAK'de İndüksiyon Tedavisi Sonrası Yeniden Evrelemede Cerrahi Prof. Dr. Semih Halezeroğlu.

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... konulu sunumlar: "KHDAK'de İndüksiyon Tedavisi Sonrası Yeniden Evrelemede Cerrahi Prof. Dr. Semih Halezeroğlu."— Sunum transkripti:

1 KHDAK'de İndüksiyon Tedavisi Sonrası Yeniden Evrelemede Cerrahi Prof. Dr. Semih Halezeroğlu

2 In NSCLC patients with N2 disease identified preoperatively (IIIA3), induction therapy followed by surgery is not recommended except as part of a clinical trial.

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4 No statistically significant difference of survival in patients randomised to the chemo-radiotherapy and induction chemo- or chemo-radiotherapy followed by surgery European Organisation for Research and Treatment of Cancer-Lung Cancer Group. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-smallcell lung cancer. J Natl Cancer Inst 2007;99(March (6)):442—50. North American Lung Cancer Intergroup Phase III study of concurrent chemotherapy and radiotherapy (CT/RT) versus CT/RT followed by surgical resection for stage IIIA (pN2) nonsmall cell lung cancer (NSCLC): outcomes update of North American Intergroup 0139 (RTOG 9309). Oncologist 2006;11:43

5 Mediastinal Yeniden Evreleme Yöntemleri Non-invaziv  CT  MR  PET-CT Minimal invaziv  FNAB  TBNA  EBUS  EUS İnvaziv  Remediastinoskopi  VATS  Mediastinotomi

6 Vansteenkiste J, Fischer BM, Dooms C, et al:Positron-emission tomography in prognostic and therapeutic assessment of lung cancer: Systematic review. Lancet Oncol 5: , 2004 On the basis of these results, we could not recommend PET after induction therapy as a reliable indicator of surgical resection in patients with mediastinal clearance nor as a means of avoiding thoracotomy in those with persistent mediastinal LN disease. Yeniden evrelemede PET-CT

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8 De Leyn, P. et al. J Clin Oncol; 24: Fig 2. In this patient, the positron emission tomography scan shows moderate uptake of fluorodeoxyglucose in the mediastinum after induction chemotherapy

9 Restaging N status with PET-CT after chemotherapy PET-CT is more accurate than re- mediastinoscopy Accuracy  PET-CT: 83%  Re-mediastinsocopy:60% P<0.05

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11 The positive predictive value of PET-CT for persistent mediastinal LN metastasis and for the risk of an incomplete resection was high. Our study indicates that PET-CT may be useful in determining the operability after induction chemotherapy for N2 disease.

12 Mediastinoskopi Carlens E Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 1959; 36: 343–352.

13 Remediastinoskopi Endikasyonlar Rekürren akciğer kanseri Metakron ikinci primer akciğer kanseri Yetersiz ilk prosedür (örnekleme hatası) ‏ Lenfoma, sarkoidoz, tbc gibi hastalıklardan sonra ortaya çıkan akcieğr kanseri İndüksiyon tedavisi sonrası yeniden evreleme

14 Remediastinoskopi Teknik RT'den sonra 4 hafta içinde Klasik mediastinoskop Tüm göğüs hazırlığı Aynı servikal insizyon İnnominate arter trakeaya sıkı şekilde yapışmış Sol paratrakeal alandan künt disseksiyon Arkus aortanın altından subkarinal alana ulaşma

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16 Copyright ©2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved. De Waele M. et al.; Eur J Cardiothorac Surg 2008;33: Survival after remediastinoscopy divided into a true-positive, true- negative and false-negative subgroup

17 Copyright ©2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved. De Waele M. et al.; Eur J Cardiothorac Surg 2008;33: Survival after remediastinoscopy divided into a true-negative and combined true-positive and false-negative subgroup

18 Komplikasyonlar 104 Remediastinoskopi olgusunda Mortalite: %1 (innominate arter rüptürü) Morbidite:%4  VKS rüptürü – sağ torakotomi: 1  Bronkiyal arter rüptürü: 1  Akciğerden biyopsi: 1  Yara enfeksiyonu-drenaj: 1 M. De Waele et al. / European Journal of Cardio-thoracic Surgery 33 (2008) 824—828

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21 Editorial comment Mediastinal restaging: has the Holy Grail been found? Paul E. Van Schil *, Jeroen M.H. Hendriks, Michèle De Waele, Patrick Lauwers

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23 VATS ile Yeniden Evreleme

24 Copyright ©2006 The American Association for Thoracic Surgery Cerfolio R. J. et al.; J Thorac Cardiovasc Surg 2006;131: Staging algorithm for patients with suspected N2 disease

25 Copyright ©2006 The American Association for Thoracic Surgery Cerfolio R. J. et al.; J Thorac Cardiovasc Surg 2006;131: Outcomes of the 128 patients with biopsy-proven N2 disease eligible for this study

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27 When the maxSUV of a node that was involved initially with metastatic cancer decreased by 50% or more, it is highly likely that the node has been rendered benign by the neoadjuvant therapy. A persistently high maxSUV of an initially involved mediastinal node should not be perceived as evidence of residual disease, but rather only as an indication for a repeat biopsy of the node. Cerfolio R. J. et al.; J Thorac Cardiovasc Surg 2006;131:

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29 Mediastinotomi

30 In patients with suspected left upper lobe lung cancer and otherwise normal computed tomography scan results, anterior mediastinotomy does not significantly reduce the rate of preventable thoracotomy. Nechala P et al Ann Thorac Surg Dec;82(6): Retrospective analysis of the clinical performance of anterior mediastinotomy.

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32 Mediastinotomy Mediastinotomy may be necessary to obtain tissue diagnosis in inoperable cases or for the assessment of resectability of left upper lobe tumours

33 SONUÇ  Minimally invasive procedures, such as EBUS-TBNA and EUS-NA may be alternatively used for mediastinal staging,  but mediastinoscopy or remediastinoscopy should be preferably reserved for restaging De Leyn P, Lardinois D, Van Schil P, Rami-Porta R, Passlick B, Zielinski M, Waller D, Lerut T, Weder W, ESTS European trends in preoperative and intra-operative nodal staging: ESTS guidelines. J Thorac Oncol 2007;2: Detterbeck FC, Jantz MA, Wallace M, Vansteenkiste J, Silvestri GA. Invasive mediastinal staging of lung cancer. ACCP evidence-based clinical practice guidelines. Chest 2007;132:202S-220S. Surmont V, van Klaveren RJ, Goor C, Schramel F, Manegold C, Legrand C, Van Schil P, Van Meerbeeck JP. Lessons to learn from EORTC study 08981: a feasibility study of induction chemoradiotherapy followed by surgical resection for stage IIIB non-small cell lung cancer. Lung cancer 2007;55:95-99

34 İndüksiyon Tedavisi Sonrası Mediastinal Yeniden Evreleme Sorular  İT öncesi tüm hastalar sadece mediastinoskopi ile mi evrelenebilir?  İT sonrası PET-CT yeterli midir?  İT sonrası histolojik doğrulama her zaman gerekli midir?  Histolojik doğrulama için tek alternatif remediastinoskopi midir?  Remediastinoskopi komplikasyonları yüksek bir yöntem midir?  Remediastinoskopi standart yolla mı, TEMLA ile mi yapılmalıdır?

35 İndüksiyon Tedavisi Sonrası Mediastinal Yeniden Evreleme Yanıtlar  İT öncesi tüm hastalar sadece mediastinoskopi ile mi evrelenebilir? VATS, EBUS, EUS, Mediastinotomi  İT sonrası PET-CT yeterli midir? Kısmen  İT sonrası histolojik doğrulama her zaman gerekli midir? Hayır  Histolojik doğrulama için tek yöntem remediastinoskopi midir? VATS, EBUS, EUS, Mediastinotomi  Remediastinoskopi komplikasyonları yüksek bir yöntem midir? Hayır  Remediastinoskopi standart yolla mı, TEMLA ile mi yapılmalıdır? TEMLA daha iyi.

36 Mediastinal restaging: has the Holy Grail been found? Not yet But Almost!

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