Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT.

Restaging of Bronchogenic Carcinoma Based on 7th Edition of
TNM Classification - Using Integerated PET CT

of 44
Restaging of bronchogenic carcinoma based on 7thedition
of TNM classification - using integerated PET CT.
Poster No.: C-0943
Congress: ECR 2011
Type: Educational Exhibit
Authors: B. RAGHAVAN
1
, G. SIVARAMALINGAM
2
;
1
CHENNAI, TA/IN,
2
CHENNAI, tamilnadu/IN
Keywords: PET-CT, Oncology
DOI: 10.1594/ecr2011/C-0943
Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to third-
party sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org

of 44
Learning objectives
1.To restage the recently diagnosed cases of bronchogenic carcinoma in our clinical
setup based on the 7th edition of TNM classification.
2.To assess the staging variation between the 6th and 7th editions using a combined
PET/CT scanner by evaluating the primary and metastatic lesions on both metabolic and
anatomic basis.
3.To assess the role of PET/CT in staging .
Background
In 2009, the seventh edition of the TNM staging system for lung cancer was published by
the International Union Against Cancer and the American Joint Committee on Cancer,
based on proposals from the International Staging Project of the International Association
for the Study of Lung Cancer (IASLC) using the 46 different data bases collected across
19 countries between 1990 and 2000, from 100,869 cases of newly diagnosed primary
lung cancer.(1)
The new 7th edition of the TNM classification system features a number of revisions,
including subdivision of tumor categories on the basis of size, differentiation between
local intra thoracic and distant metastatic disease, recategorization of malignant pleural or
pericardial disease etc, on the basis of evidence from a significantly larger worldwide data
base that has been subjected to extensive validation which attempts to better correlate
disease with prognostic value and treatment strategy.
Two primary methods of lung cancer staging are available clinical staging and pathologic
staging. Clinical staging includes minimally inasive & non invasive methods of which
imaging has a key role to play. Integrated PET CT with its depiction of anatomy & function
delineates the various TNM stages non-invasively.(2)
Images for this section:

of 44
Fig. 1: 7th Edition TNM Staging
Fig. 2: Lung cancer staging in 6th and 7th edition of TNM classification. The red box
indicates unresectable disease.

of 44
Imaging findings OR Procedure details
We retrospectively looked at the data of 115 patients with lung cancer, who reported to
our PET CT centre ( Apollo speciality hospitals, Chennai) from october 2009 to january
2011, out of which 60 untreated HPE proven cases were included in the study.
All paients fasted for at least six hours before the PET/CT examination, although
oral hydration with glucose- free water was allowed after ensuring a normal blood
glucose level in the peripheral blood, patients received an IV injection of 5 Mci of F-18
flurodeoxyglucose and then rested for approximately 45 minutes before scanning. Scans
were accquired using a PET/CT Scanner (Philips Gemini TF 64 Slice). Image accquisition
was done from the vertex of the skull to midthigh after IV administration of non-
ionic iodinated contrast agent (1ml/kg body weight with saline chasing) for attenuation
correction & diagnosis.
We compared and analysed the variation in individual T,N,M and the final staging, and
thereby the prognostic factors and survival differences in the patient data according to
the sixth and the seventh edition of the TNM system.

of 44
Fig. 1: Fig. 20: PET CT scanner.(Picture courtesy Philips Medical Systems)

of 44
Fig. 2: Well defined solitary pulmonary nodule of size 1.6 cms in left lower lobe
with no mediastinal lymph nodes or distal metastases.CT guided lung Bx was done
HPE was adenocarcinoma followed by surgery. 6th edition(T1N0M0)stage IA,7th
edition(T1aN0M0)stage IA - no stage variation.

of 44
Fig. 3: T1a - 1.3cms lesion more than 2cms from carina abutting right upper lobe
bronchus & no invasion proximal to lobar bronchus. The coronal image shows the
distance from the carina (3.1 cm). Final staging of 6th (III B) and 7th (III B) edition did not
alter in this case as the patient was N3 supraclavicular and lower cervical nodes.

of 44
Fig. 4: T1b - Peripherally located 2.5 cms sized lesion surrounded by lung. Final Staging
(stage IV by 6th edition and 7th edition) did not change due to vertebral metastases.

of 44
Fig. 5: T2a - 3.3 cms sized mass lesion (>3cms)with N2 lymphnodes (ipsilateral hilar &
subcarinal nodes ) and M1b rib metastases. Final staging (Stage IV)did not alter in 6th
& 7th edition because of rib metastases.

of 44
Fig. 6: T2b - 5.8 cms (>5 cms )sized mass lesion.Fusion images show the FDG avid
peripheral component with the central area of necrosis. Final Stage III A did not alter in
both editions because of N2 lymph nodes ( not shown in image ).

of 44
Fig. 7: T3 -6.6 cms sized mass with areas of necrosis in left upper lobe with mediastinal
and chest wall pleural invasion. Final Stage IIIA did not change in 6th and 7th edition
because of N2 nodes (ipsilateral hilar, lower paratracheal, and subcarinal nodes ). *The
delineation of the hyper-metabolic area facilitated proper targeting of the area to be
biopsied.
Fig. 8: T4-right upper lobe mass lesion with right main bronchus, carina and Superior
venacava (arrow) invasion. In both editions the Final stage is T4N0M0 but it is down
staged from IIIB to IIIA in 7th edition.

of 44
Fig. 9: N stage Two different cases of right upper lobe mass lesion with sub carinal
lymphadenopathy (N2). Additionally the lower image shows FDG avid ipsilateral hilar

of 44
node (Presence of ipsilateral hilar adenopathy alone would indicate N1 disease) in
addition to the subcarinal node however the presence of rib metastases has upstaged
the disease to Stage IV.

of 44
Fig. 10: N3 left upper lobe mass lesion with CONTRALATERAL lower paratracheal &
supra clavicular lymph nodes
Fig. 11: M1a - Adeno carcinoma right upper lobe with diffuse pleural dissemination. No
significant mediastinal adenopathy. 6th edition it is T4N0M0 - STAGE IIIB, 7th edition
T3N0M1a - STAGE IV and the lesion has been upstaged.

of 44
Fig. 12: M1b - Left upper lobe mass with renal & bony metastases. Stage IV in both
editions.
Fig. 13: Serial pre-operative X-rays show a right upper lobe mass which showed
progression. PET scan (PET images are in Fig 14 )was performed for staging after the
CT guided biopsy showed bronchoalveolar carcinoma.Patient underwent surgery. Post
op X-ray of the same patient(right bottom image). Post-op HPE findings confirmed the
histopathology with node -ve disease.

of 44
Fig. 14: Same patient as in fig. 13 shows a 6.3 cms sized broncho alveolar type of
adenocarcinoma in right upper lobe. Non FDG avid right lower para tracheal lymph node .
6th edition(T2N0M0)STAGE IB, 7th edition(T2bN0M0)STAGE IIA- upstaged because of
size criteria.

of 44
Fig. 15: Mass lesion in right lower lobe with carina, mediastinal and great
vessel (right pulmonary artery) invasion.Ipsilateral para tracheal and para aortic
lymphadenopathy,pericardial dissemination and non FDG avid right sided pleural
effusion are seen. 6th edition (T4N3M0)-STAGE IIIB, 7th edition(T4N3M1a) - STAGE IV;
lesion upstaged because of pericardial dissemination.

of 44
Fig. 16: Non small cell ca in right upper lobe with mediastinal invasion & non FDG avid
spiculated nodule measuring (0.8 cms ) in superior basal segment of right lower lobe and
FDG avid necrotic right subpectoral lymph node . 6th edition (T4N3M1)-STAGE IV, 7th
edition (T4N3M0)- STAGE IIIB , the presence of satellite nodule in the same lung but
different lobe down staged the disease. PET is not sensitive in sub-centimeter nodules
and CT morphology was used in deciding the stage.

of 44
Fig. 17: 7. 3 cms sized mass in right upper lobe with no mediastinal lymph nodes or
intrathoracic/distant metastasis. 6th edition (T2N0M0)-STAGE IB,7th edition (T3N0M0)
- STAGE IIB, the lesion is upstaged according to the size criteria (>7 cms - T3 in 7th
edition).

of 44
Fig. 18: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partial
atelectasis of anterior segment of right upper lobe. The lesion was T2 in 6th edition and
remained T2a in 7th edition due to the size criteria and metabolically inactive partial
collapse of right upper lobe.
Fig. 19: Small cell carcinoma in right hilar region with great vessels (right pulmonary
artery and vein), pericardium and bronchus intermedius invasion.Right supraclavicular
and contralateral hilar lymph nodes are also seen.(arrows) 6th edition-(T4N3M0)STAGE
IIIB,7th edition-(T4N3M1a) STAGE IV;the lesion is upstaged from IIIB to IV due to
pericardial invasion.

of 44
Conclusion
Re-staging of bronchogenic carcinoma based on 7th edition and assessment of variation
between 6th and 7th edition:
• In our series the overall change in final Stage was seen in only 11 % ( Fig
1) of cases and in all the cases there was change in the management.
Population based case study by strand et al [3] revealed that based on the
current indications of therapy, nearly one-fifth (17%) of the patients could be
offered different treatment options because of the rearrangement of some
TNM subsets in different stages.
• Our case load consisted of more than 50 % of stage IV disease & we did
not have any N1 in our series & hence there was a limitation to predict the
impact of 7th edition in early T & N staging [4].
• In our series maximum change was seen in M category (Fig 2) due to the
sub-categorisation as local or distant metastatic disease to subdivision of M1
a & M1b.
• TNM staging applies to Small cell carcinoma (fig 6)& Carcinoid.[10],[11].
• The 7th edition clinical staging by imaging, helped in sub classification of the
various TNM stages and to arrive at the final Staging. And it also helped in
deciding various treatment options like surgery, chemotherapy, radiotherapy
including targeted therapies like cyber knife (fig.8), for better survival rates
(fig.4).
ROLE OF INTEGRATED PET/ CT:
• PET helped in nodal & metastatic staging work-up however it did not have
any impact in any of our cases which altered in the final staging.[7]
• PET/CT detected metastases in 39 out of the 60 cases of which maximum
were skeletal metastases(fig.5)
• PET did not have a bearing on T staging however it is able to accurately
delineate the tumor load & boundaries (fig 9) & differentiate it from
associated collapse / consolidation(fig.10) or area of necrosis,guiding
targeted biopsy from the metabolically representative area.
• PET/CT has a definite role in assessing recurrent disease based on
metabolic activity (fig.11).
• PET has limitation in brain metastases (fig.7), bronchoalveolar carcinoma
(fig.12) and in subcentimeter satellite nodules (fig.13).
• Hyper metabolism can also be seen in cases of infective lung lesions (fig.14)
and in reactive lymphadenopathy causing false positivity in PET imaging.
In these instances we use Contrast MDCT characteristics for diagnosis and
confirm by histopathological evaluation using minimally invasive techniques
like CT guided biopsy, mediastinoscopy and VATS.

of 44
Fig. 1: The application of 7th edition criteria altered the overall staging in 11% of cases
in our study.

of 44
Fig. 2: Distribution of the change based on TNM descriptors.
Fig. 3: Distribution of cases changed in Final Staging.

of 44
Fig. 4
Fig. 5: Organ wise distribution of metastases in 39 cases.

of 44
Fig. 6: Case of small cell carcinoma presented with hyper metabolic mass lesion in right
upper lobe with right adrenal and brain metastases (top three images).Post radiotherapy
follow up images (bottom three images) showed regression in metabolic activity as well
as size of the lesions.

of 44
Fig. 7: CT and PET/CT images of the same patient showed in figure 6: Brain lesions were
not hyper metabolic in comparison to the normal brain parenchyma in PET CT,contrast
enhanced CT images helped in diagnosis of metastatic lesion.This illustrates the poor
sensitivity of PET in identifying brain metastases.

of 44
Fig. 8: Mass lesion with SVC obstruction shows response to Cyber knife therapy.Top
image shows the mass with fiducials in the planning CT,post treatment response seen
in the bottom 2 images.
Fig. 9: 43 year old male with Pan coast tumor - non-small cell lung carcinoma shows
tumor regression in the post chemotherapy follow-up scan.

of 44
Fig. 10: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partial
atelectasis of anterior segment of right upper lobe. The lesion was T2 in 6th edition and
remained T2a in 7th edition due to the size criteria and metabolically inactive partial
collapse of right upper lobe.
Fig. 11: case of non small cell carcinoma right upper lobe, underwent right upper
lobectomy, patient received post surgery radiotherapy also.Follow up PET/CT after 2
year showed a recurrent FDG avid focus (top right image)in right upper lobe abutting the
right side of trachea. PET/CT helped in identifying and localising this local recurrence
which with CT alone will be difficult to detect in post operative scenario.

of 44
Fig. 12: Well defined non FDG avid mass lesion in left upper lobe. Histo pathology is
proved to be broncho alveolar carcinoma and PET has poor sensitivity for brochoalveolar
type of adenocarcinoma.

of 44
Fig. 13: Hyper metabolic spiculated mass lesion in left upper lobe with a non FDG avid
subcentimeter nodule in same lobe. Subcentimeter lesions are beyond the resolution of
PET acquisition.
Fig. 14: Hyper metabolic lesion in the left lower lobe in a 30 year old patient who
had hemoptysis. The contrast enhanced CT showed a separate arterial branches from
the descending thoracic aorta and the venous drainage is into the hemiazygos vein
suggestive of sequestration. Histopathology confirmed the same with super added
infection.

of 44
Personal Information
Dr.Bagyam Raghavan, Senior consultant radiologist, Apollo speciality hospitals,Chennai,
Tamil nadu, India.
Dr.Geethapriya Sivaramalingam, Senior resident, Apollo speciality hospitals, Chennai,
Tamil nadu, India.
References
References
1. Stacy J.UyBico et.al: Lung Cancer Staging Essentials: The New TNM
Staging System and Potential Imaging pitfalls, RadioGraphics,10.1148/
rg.305095166 September 2010; 30, 1163-1181.
2. Seth Kligerman and Subba Digumarthy: Staging of Non-Small Cell Lung
Cancer - Using Integrated PET/CT, American Journal of Radiology 2009;
193:1203-1211.
3. Strand TE, Rostad H, Wentzel-Larsen T, et al. A population - based
evaluation of the seventh edition of the TNM system for lung cancer. Eur
Respir J 2010; 36: 401-407.
4. R. Rami-Porta* and P. Goldstraw#:Strength and weakness of the new TNM
classification for lung cancer,Eur Respir J 2010; 36: 237-239.
5. Makoto Suzuki .et.al: Applicability of the revised International Association
for the Study of Lung Cancer staging system to operable non-small-cell lung
cancers, European Journal of Cardio-thoracic Surgery 36 (2009);1036.
6. Blodgett et al.speciality imaging. PET/CT oncologic imaging with correlative
diagnostic CT;1st ed.
7. Erasmus JJ, Rohren E, Swisher SG. Prognosis and reevaluation of lung
cancer by positron emission tomography imaging. Proc Am Thorac Soc
2009;6:171-179
8. Seth Kligerman and Gerald Abbott: a radiologic review of the new TNM
classification for lung cancer, American Journal of Radiology 2010;
194:562-573
9. Takayuki Fukui et al.Prognostic evaluation based on a new TNM staging
system proposed by the International Association for the Study of Lung
Cancer for resected non-small cell lung cancers, The Journal of Thoracic
and Cardiovascular Surgery
November 2008 (Vol. 136, Issue 5, Pages 1343-1348), 15 August 2008
10. Ignatius Ou SH, Zell JA. The applicability of the proposed IASLC staging
revisions to small cell lung cancer (SCLC) with comparison to the current UICC
6th TNM edition. J Thorac Oncol

of 44
2009; 4:300-310
11. Hage R, de la Riviere AB, Seldenrijk CA, van den Bosch JM. Update in
pulmonary carcinoid tumors:a review article. Ann Surg Oncol 2003;10:697-704
12. Goldstraw P, Crowley J, Chansky K, et al. TheIASLC LungCancer Staging
Project: proposals for the revision of the TNM stage groupings in the
forthcoming (seventh) edition of the TNM Classification of Malignant
Tumours. J Thorac Oncol2007; 2: 706-714
13. Behnaz Goudarzi and Richard Wahl, PET/CT evaluation of
bronchioloalveolar carcinoma: Correlation with CT and FDG/PET findings
Nucl Med. 2007; 48 (Supplement 2):122P

Apollohospitals:http://www.apollohospitals.com/
Twitter:https://twitter.com/HospitalsApollo
Youtube:http://www.youtube.com/apollohospitalsindia
Facebook:http://www.facebook.com/TheApolloHospitals
Slideshare:http://www.slideshare.net/Apollo_Hospitals
Linkedin:http://www.linkedin.com/company/apollo-hospitals
Blog:Blog:http://www.letstalkhealth.in/

Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT.

Recomendados

Recomendados

Más contenido relacionado

La actualidad más candente

La actualidad más candente (20)

Similar a Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT.

Similar a Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT. (20)

Más de Apollo Hospitals

Más de Apollo Hospitals (20)

Último

Último (20)

Restaging of Bronchogenic Carcinoma Based on 7th Edition of TNM Classification - Using Integerated PET CT.