MD Conference Express ATS 2013 - (Page 32)
SELECTED UPDATES ON LUNG CANCER
Treating Stage I to III Non-Small-Cell Lung
Cancer With Limited Evidence
Written by Lori Alexander
The treatment of non-small cell lung cancer (NSCLC)
presents several challenges. Practice guidelines are based
on limited evidence, and are often unclear and subject to
multiple interpretations. Determining when mediastinal
lymph nodes should be sampled, and how to best treat
stage III disease, presents a particular challenge. Better
treatment outcomes are needed.
Figure 1. Four Main Patterns of Node Involvement
MEDIASTINAL SAMPLING
Anil Vachani, MD, Abramson Cancer Center,
Philadelphia, Pennsylvania, USA indicated that positron
emission tomography (PET) is the preferred imaging
method for mediastinal staging since it provides more
accuracy than computed tomography (CT). However,
a biopsy is still needed to confirm PET findings.
Endobronchial ultrasound-guided transbronchial needle
aspiration (EBUS-TBNA) is a minimally invasive technique
for obtaining tissue for staging, with results equivalent to
those for surgical staging. The 3rd edition of the American
College of Chest Physicians Evidence-Based Clinical
Practice Guidelines on Lung Cancer (LCIII guidelines)
indicate that surgical biopsy should be done if the
findings of a needle biopsy are negative [Silvestri GA et al.
Chest 2013].
Due to variation in the patterns of lymph node
involvement, it is difficult to know when mediastinal
sampling is necessary. There are four main patterns of
mediastinal lymph node involvement (Figure 1):
■ Massive mediastinal infiltration
■ Discrete node involvement
■ Central tumor with enlarged N1 lymph nodes
■ Peripheral tumor with no mediastinal or hilar
node enlargement
The risk of node involvement is high in the first two
patterns, so the LCIII guidelines recommend that the nodes
be sampled using the easiest method available (Table 1).
Dr. Vachani added that the EBUS-TBNA technique allows
for the assessment of contralateral hilar disease.
The last two patterns are often classified as a “normal
mediastinum” and present greater challenges in staging.
For a central lung cancer with enlarged N1 lymph nodes,
the risk of mediastinal node involvement is estimated
to be 20% to 25%. Dr. Vachani noted that even if PET
findings are negative, that risk is high enough to warrant
sampling. However, PET is still useful, as it provides a
“roadmap” for sampling.
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July 2013
(A) massive mediastinal Infiltration, (B) discrete node involvement, (C) central tumor with
enlarged N1 lymph nodes, and (D) peripheral tumor with no mediastinal or hilar node
enlargement.
Reproduced from Silvestri GA et al. Methods for Staging Non-small Cell Lung Cancer. Chest
2013;145(5)Suppl. With permission from the American College of Chest Physicians.
For a peripheral tumor with radiographic evidence of
mediastinal or hilar node enlargement, the percentage
of N2 or N3 disease ranges from 2% to 9%. When the
findings of both CT and PET are negative, the prevalence
of N2 or N3 disease decreases to ~4%. The prevalence of
node involvement increases with the size of the tumor;
the prevalence of N2 or N3 disease increases to 13% for
T2 lesions.
Dr. Vachani also noted that the LCIII recommendation
addresses lesions that are either T1a or T1b, and does not
provide specific guidance for larger primary lesions with a
normal mediastinum. He added that mediastinal sampling
should be considered when the prevalence of mediastinal
disease is >10%.
OPTIMAL TREATMENT OF STAGE III DISEASE
One of the greatest challenges in determining the best
treatment for stage III NSCLC is that the population of
patients is highly heterogeneous, said Douglas Arenberg,
MD, University of Michigan, Ann Arbor, Michigan,
USA. Stage III NSCLC represents the largest proportion
of available stages, with 25 TNM combinations being
classified as stage III in the 7th edition of the American Joint
Committee on Cancer Staging Manual.
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Table of Contents for the Digital Edition of MD Conference Express ATS 2013
MD Conference Express ATS 2013
Contents
Prevention and Early Treatment of Acute Lung Injury
Nocturnal Noninvasive Ventilation Improves Outcomes in Multiple Disorders
Hospital Readmissions: Challenges and Opportunities
EBUS-TBNA: Accurate and Safe for Detecting Sarcoidosis
Data Link Obstructive Sleep Apnea and Type 2 Diabetes
Statin Use Improves Respiratory-Related Mortality in Patients With COPD
Addition of Spironolactone to Ambrisentan May Be a Novel Treatment Strategy to Improve Outcome in Patients With PAH
Haloperidol Does Not Prevent Delirium in Ventilated ICU Patients
Beraprost Plus Sildenafil Effective in Pulmonary Arterial Hypertension
Dupilumab Is Safe and Effective for Controlling Asthma Attacks
Once-Daily QVA149 Improves Breathlessness in COPD Patients
CPAP in CVD and OSA Does Not Significantly Improve Cardiovascular Biomarkers
CPAP Reduces BP in Patients With Resistant Hypertension and Obstructive Sleep Apnea
Effects of Obesity on COPD
Pulmonary Embolism
Ventilator-Associated Pneumonia
Lung Cancer Screening
Idiopathic Pulmonary Fibrosis
Non-Small-Cell Lung Cancer
MD Conference Express ATS 2013
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