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NEOPLASIE TORACICHEPOST‐IASLC: UPDATES DA SIDNEY
Lucca, 27‐28 Novembre 2013
Mesotelioma Pleurico Maligno
INTERVENTIONAL DIAGNOSTICSINTERVENTIONAL DIAGNOSTICS
FRANCESCO FACCIOLODepartment of Surgical Oncology
Division of Thoracic SurgeryNational Cancer Institute “Regina Elena”, Rome
MPM/ INTERVENTIONAL DIAGNOSTICS
WHAT IS THE GOAL?WHAT IS THE GOAL?
MPM/INTERVENTIONAL DIAGNOSTICS
• TO ADDRESS THE APPROPRIATE TREATMENT• TO ADDRESS THE APPROPRIATE TREATMENT
– SECURE / ACCURATE ANATOMOPATHOLOGICAL DIAGNOSIS
– STAGING / ASSESSMENT OF SURGICAL INDICATIONSS G G / SS SS O SU G C C O S
– COLLECTION OF ADEQUATE BIOLOGICAL TISSUE
MPM/ INTERVENTIONAL DIAGNOSTICS
WHAT ARE THE INSTRUMENTS?WHAT ARE THE INSTRUMENTS?
MPM/INTERVENTIONAL DIAGNOSTICS
• STAGING / COLLECTION OF BIOLOGICAL TISSUE
– MEDIASTINAL NODES/ EBUS; EUS; CERVICAL MEDIASTINOSCOPY; EXTENDED MEDIASTINOSCOPY; ANTERIOR MEDIASTINOTOMY
– PLEURAE/ VATS; EXTRAPLEURAL MINITHORACOTOMY U / S; U O CO O(BIOPSIES)
PERITONEAL CAVITY/ LAPAROSCOPY; PERITONEAL– PERITONEAL CAVITY/ LAPAROSCOPY; PERITONEAL LAVAGE AND CYTOLOGY
MPM/ INTERVENTIONAL DIAGNOSTICS
WHAT ARE THE RULES?WHAT ARE THE RULES?
MPM/ INTERVENTIONAL DIAGNOSTICS
UPDATED GUIDELINES FOR PATHOLOGICAL DIAGNOSIS OF MPM FROM IMIG (EXCERPT)DIAGNOSIS OF MPM FROM IMIG (EXCERPT):
•ADEQUATE BIOPSIES/ LESS COMMONLY: CYTOLOGY, EXFOLIATIVE AND FNA
•CYTOLOGY/ ADEQUATE FLUID AMOUNT FOR CELL-BLOCKS OR SMEARS
•MORPHOLOGIC FEATURES AND NUCLEAR GRADE TO PREDICT SURVIVAL/ CYTOLOGIC DIAGNOSIS OF “MPM EPITHELIOID TYPE”SURVIVAL/ CYTOLOGIC DIAGNOSIS OF “MPM EPITHELIOID TYPE” MIGHT BE NOT SUFFICIENT IN THE FUTURE
APART FROM DIAGNOSTIC DIFFICULTIES/ THE FREQUENT•APART FROM DIAGNOSTIC DIFFICULTIES/ THE FREQUENT PRACTICE OF LITIGATION IN CASES OF MM MAKES PATHOLOGISTS RELUCTANT TO DIAGNOSE MESOTHELIOMA WITHOUT HISTOLOGIC CONFIRMATORY EVIDENCEWITHOUT HISTOLOGIC CONFIRMATORY EVIDENCE
HUSAIN AN ET AL. - ARCH PATHOL LAB MED 2012
MPM/ INTERVENTIONAL DIAGNOSTICS
VATS – MINITHORACOTOMY/ INDICATIONS
•VATS/ PROCEDURE OF CHOICE WHEN POSSIBLE; DIRECT INSPECTION; MULTIPLE BIOPSIES MULTIPLE SITES; PALLIATIONINSPECTION; MULTIPLE BIOPSIES, MULTIPLE SITES; PALLIATION
•EXTRAPLEURAL MINITHORACOTOMY/ OBLITERATION OF THE PLEURAL SPACE; CONTRAINDICATION TO GENERAL ANESTHESIA;PLEURAL SPACE; CONTRAINDICATION TO GENERAL ANESTHESIA; PREDETERMINED INOPERABILITY
MPM/ INTERVENTIONAL DIAGNOSTICS
IS THERE ANYTHING MORE TO SAY?
MPM/ INTERVENTIONAL DIAGNOSTICS
THOROUGH INVASIVE ASSESSMENT – 1/ EVIDENCE FOR
•NODAL STATUS – 1/ BETTER PROGNOSIS FOR N0 COMPARED TO N+ EXCLUSION OF N3 DISEASETO N+; EXCLUSION OF N3 DISEASE
•NODAL STATUS – 2/ EBUS AND EUS MAY YIELD UP TO 36%NODAL STATUS 2/ EBUS AND EUS MAY YIELD UP TO 36% MORE POSITIVE NODES IN CLINICAL N0 DISEASE
•PERITONEAL DISEASE/ UP TO 44% OF POSITIVE PERITONEAL LAVAGE REPORTED IN EXTENDED PREOPERATIVE ASSESSMENT PROTOCOLS
MPM/ INTERVENTIONAL DIAGNOSTICS
THOROUGH INVASIVE ASSESSMENT – 2/ CONCERNS
•NODAL STATUS – 1/ N+ BEHAVIOUR IN MPM DIFFERS FROM NSCLC:HOW TO INTERPRET POSITIVE RESULTS FROM MEDIASTINAL ASSESSMENT?
•NODAL STATUS – 2/ EBUS AND EUS RESULTS RELY ON NEEDLE ASPIRATION CYTOLOGY: NOT TO BE USED TO ACHIEVE AN INITIAL DIAGNOSIS OF MPM SHOULD BE PRECEDED BYINITIAL DIAGNOSIS OF MPM – SHOULD BE PRECEDED BY PLEURAL BIOPSIES
•NODAL STATUS – 3/ NEGATIVE EBUS AND EUS SHOULD BE FOLLOWED BY INVASIVE MEDIASTINAL ASSESSMENT
•PERITONEAL ASSESSMENT/ PATIENT’S COMPLIANCE??
MPM/ INTERVENTIONAL DIAGNOSTICS
SURGICAL CONSIDERATIONS – VATS/ 1
•ASSESSMENT OF OPERABILITY/ CARDIOPHRENIC ANGLE; PERICARDIAL INVOLVEMENT; MEDIASTINAL INFILTRATIONPERICARDIAL INVOLVEMENT; MEDIASTINAL INFILTRATION
•PLEURAL TALCAGE/ PRELIMINARY TO MAJOR SURGERY; RESOLUTION OF SYMPTOMSRESOLUTION OF SYMPTOMS
•PLEURAL BIOPSIES/ RESPECT ENDOTHORACIC FASCIA; MULTIPLE SITES ADEQUATE HISTOLOGIC SPECIMENSMULTIPLE SITES; ADEQUATE HISTOLOGIC SPECIMENS
MPM/ INTERVENTIONAL DIAGNOSTICS
SURGICAL CONSIDERATIONS – VATS/ 2
•VATS/ SHOULD BE PREFERABLY PERFORMED BY THE SAME SURGEON UNDERTAKING MAJOR SURGERY (WHEN NOTSURGEON UNDERTAKING MAJOR SURGERY (WHEN NOT EXCLUDED)
VATS/ THORACOPORTS ACCESSES SHOULD LIE ON THE LINE OF•VATS/ THORACOPORTS ACCESSES SHOULD LIE ON THE LINE OF FUTURE THORACOTOMY
MPM/ INTERVENTIONAL DIAGNOSTICS
FUTURE DIRECTIONS?
MPM/ INTERVENTIONAL DIAGNOSTICS
NEW PERSPECTIVES
•SURGERY IS NO MORE JUST A MATTER OF SURGERY – 1/INTERVENTIONAL DIAGNOSIS NEEDED TO OBTAIN ADEQUATE TISSUE FOR MOLECULAR ANALYSESTISSUE FOR MOLECULAR ANALYSES
•SURGERY IS NO MORE JUST A MATTER OF SURGERY – 2/ IN VITRO COLTURES OF NEOPLASTIC CELLS USEFUL TO PREDICTVITRO COLTURES OF NEOPLASTIC CELLS USEFUL TO PREDICT CHEMOSENSITIVITY*
SURGERY IS NO MORE JUST A MATTER OF SURGERY 3/ IN•SURGERY IS NO MORE JUST A MATTER OF SURGERY – 3/ IN VITRO COLTURES OF NEOPLASTIC STEM CELLS
•SURGERY IS NO MORE JUST A MATTER OF SURGERY – 4/ NEW TRENDS IN TRANSLATIONAL RESEARCH: IDENTIFICATION OF NEW GENOMIC MARKERS ISOLATED FROM THE PRIMARY TUMOR THAT CAN BE FOUND IN PERIPHERAL BLOOD
* our experience reported in Canino C, et al. Oncogene 2011
MPM/ INTERVENTIONAL DIAGNOSTICS
HARD TIMES?
MPM/ INTERVENTIONAL DIAGNOSTICS
WALLS SHRINKING?
•RECENT TRENDS IN LITERATURE/ WILLING TO REDUCE THE FIELD OF INDICATIONS FOR RADICAL SURGERY IN MPM (ESPECIALLY FOROF INDICATIONS FOR RADICAL SURGERY IN MPM (ESPECIALLY FOR EPP) – M.A.R.S., M.A.R.S. 2 AND OTHER RECENTS SERIES (E.G.: LANDZUDSKY’S)
•CHAIN EFFECT/ THESE WORKS ARE DESTINED TO AFFECT THE INDICATIONS TO INTERVENTIONAL DIAGNOSTICS AS WELL
•WHAT SHOULD BE THE SURGEON’S ATTITUDE TOWARDS PATIENTS WITH MPM?/ PROPOSING A HEAVY BURDEN OF INVASIVE DIAGNOSTICS BUT EXCLUDING MAJOR SURGERY?
MPM/ INTERVENTIONAL DIAGNOSTICS
DIAGNOSTIC PATH
resulting therapeutic options
MPM/ INTERVENTIONAL DIAGNOSTICS
MORE SURGERY! LESS SURGERY!MORE SURGERY!
•HISTOLOGIC DIAGNOSISMORE TISSUE!
LESS SURGERY!
•EPPPOSSIBLY HARMFUL!MORE TISSUE!
•DETERMINATION OF SUBTYPESMORE TISSUE!
POSSIBLY HARMFUL!
•EXTENDED P/DMAYBE NOT RADICAL!MORE TISSUE!
•MOLECULAR ANALYSESMORE TISSUE!
MAYBE NOT RADICAL!
•MAJORITY OF SUBTYPESMAYBE NOT AFFECTED BYMORE TISSUE!
•STAGINGMULTIPLE BIOPSIES,
MAYBE NOT AFFECTED BY SURGERY!
•LEGAL LITIGATIONS!,DIRECT EXPLORATION,
MEDIASTINAL ASSESSMENT!
MPM/ INTERVENTIONAL DIAGNOSTICS
WHAT TO DO?
MPM/ INTERVENTIONAL DIAGNOSTICS
CONCLUSIONS/ 1
•INVASIVE DIAGNOSTICS/ ARE MANDATORY IN A DISEASE AS COMPLEX AS MALIGNANT PLEURAL MESOTHELIOMACOMPLEX AS MALIGNANT PLEURAL MESOTHELIOMA
•COST-BENEFIT EVALUATION/ MUST BE MADE BETWEEN DIAGNOSTIC AGGRESSIVENESS AND INTENSITY OF FOLLOWINGDIAGNOSTIC AGGRESSIVENESS AND INTENSITY OF FOLLOWING TREATMENT
NEW PERSPECTIVES/ RELY ON WIDE AVALAIBILITY OF•NEW PERSPECTIVES/ RELY ON WIDE AVALAIBILITY OF BIOLOGICAL SAMPLES, THUS INVOLVING SURGEONS, RATHER THAN SUPERSEDING THEM
MPM/ INTERVENTIONAL DIAGNOSTICS
CONCLUSIONS/ 2
•SURGERY FOR MPM/DEFINITIVE POSITIONS ON MAJOR SURGERY (EPP) SHOULD BE TAKEN CAUTIOUSLY: MORE ACCURATE (= INVASIVE?) DIAGNOSTICS SHOULD LEAD TO MORE ACCURATE PATIENTS’ SELECTION, RATHER THAN TO EXCLUSION OF SURGERY.
•KEYWORDS TO MAJOR SURGERY FOR MPM/•KEYWORDS TO MAJOR SURGERY FOR MPM/• SELECTION• SELECTION• SELECTION
AND…• SELECTION
MPM/ INTERVENTIONAL DIAGNOSTICS
THANK YOUTHANK YOU
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