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

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

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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 4

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

Yeniden evrelemede PET-CT 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. Vansteenkiste J, Fischer BM, Dooms C, et al:Positron-emission tomography in prognostic and therapeutic assessment of lung cancer: Systematic review. Lancet Oncol 5:531-540, 2004 6

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Fig 2. In this patient, the positron emission tomography scan shows moderate uptake of fluorodeoxyglucose in the mediastinum after induction chemotherapy De Leyn, P. et al. J Clin Oncol; 24:3333-3339 2006 8

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 9

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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. 11

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

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 13

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 14

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De Waele M. et al.; Eur J Cardiothorac Surg 2008;33:824-828 Survival after remediastinoscopy divided into a true-positive, true-negative and false-negative subgroup De Waele M. et al.; Eur J Cardiothorac Surg 2008;33:824-828 Copyright ©2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved. 16

De Waele M. et al.; Eur J Cardiothorac Surg 2008;33:824-828 Survival after remediastinoscopy divided into a true-negative and combined true-positive and false-negative subgroup De Waele M. et al.; Eur J Cardiothorac Surg 2008;33:824-828 Copyright ©2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved. 17

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 18

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

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VATS ile Yeniden Evreleme 23

Staging algorithm for patients with suspected N2 disease Cerfolio R. J. et al.; J Thorac Cardiovasc Surg 2006;131:1229-1235 Copyright ©2006 The American Association for Thoracic Surgery 24

Cerfolio R. J. et al.; J Thorac Cardiovasc Surg 2006;131:1229-1235 Outcomes of the 128 patients with biopsy-proven N2 disease eligible for this study Cerfolio R. J. et al.; J Thorac Cardiovasc Surg 2006;131:1229-1235 Copyright ©2006 The American Association for Thoracic Surgery

Cerfolio R. J. et al.; J Thorac Cardiovasc Surg 2006;131:1229-1235 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;131:1229-1235

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Mediastinotomi

Ann Thorac Surg. 2006 Dec;82(6):2004-9. Mediastinotomi 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. 2006 Dec;82(6):2004-9. Retrospective analysis of the clinical performance of anterior mediastinotomy.

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

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;2:357-361 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

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?

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.

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