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

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Restaging of bronchogenic carcinoma based on 7theditionof TNM classification - using integerated PET CT.

Poster No.: C-0943

Congress: ECR 2011

Type: Educational Exhibit

Authors: B. RAGHAVAN1, G. SIVARAMALINGAM2; 1CHENNAI, TA/IN,2CHENNAI, tamilnadu/IN

Keywords: PET-CT, Oncology

DOI: 10.1594/ecr2011/C-0943

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Learning objectives

1.To restage the recently diagnosed cases of bronchogenic carcinoma in our clinicalsetup based on the 7th edition of TNM classification.

2.To assess the staging variation between the 6th and 7th editions using a combinedPET/CT scanner by evaluating the primary and metastatic lesions on both metabolic andanatomic 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 bythe International Union Against Cancer and the American Joint Committee on Cancer,based on proposals from the International Staging Project of the International Associationfor the Study of Lung Cancer (IASLC) using the 46 different data bases collected across19 countries between 1990 and 2000, from 100,869 cases of newly diagnosed primarylung 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 betweenlocal intra thoracic and distant metastatic disease, recategorization of malignant pleural orpericardial disease etc, on the basis of evidence from a significantly larger worldwide database that has been subjected to extensive validation which attempts to better correlatedisease with prognostic value and treatment strategy.

Two primary methods of lung cancer staging are available clinical staging and pathologicstaging. Clinical staging includes minimally inasive & non invasive methods of whichimaging has a key role to play. Integrated PET CT with its depiction of anatomy & functiondelineates the various TNM stages non-invasively.(2)

Images for this section:

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Fig. 1: 7th Edition TNM Staging

Fig. 2: Lung cancer staging in 6th and 7th edition of TNM classification. The red boxindicates unresectable disease.

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Fig. 3

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Imaging findings OR Procedure details

We retrospectively looked at the data of 115 patients with lung cancer, who reported toour PET CT centre ( Apollo speciality hospitals, Chennai) from october 2009 to january2011, 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, althoughoral hydration with glucose- free water was allowed after ensuring a normal bloodglucose level in the peripheral blood, patients received an IV injection of 5 Mci of F-18flurodeoxyglucose and then rested for approximately 45 minutes before scanning. Scanswere accquired using a PET/CT Scanner (Philips Gemini TF 64 Slice). Image accquisitionwas 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 attenuationcorrection & diagnosis.

We compared and analysed the variation in individual T,N,M and the final staging, andthereby the prognostic factors and survival differences in the patient data according tothe sixth and the seventh edition of the TNM system.

Images for this section:

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

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

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Fig. 3: T1a - 1.3cms lesion more than 2cms from carina abutting right upper lobebronchus & no invasion proximal to lobar bronchus. The coronal image shows thedistance from the carina (3.1 cm). Final staging of 6th (III B) and 7th (III B) edition did notalter in this case as the patient was N3 supraclavicular and lower cervical nodes.

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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.

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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.

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

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Fig. 7: T3 -6.6 cms sized mass with areas of necrosis in left upper lobe with mediastinaland chest wall pleural invasion. Final Stage IIIA did not change in 6th and 7th editionbecause of N2 nodes (ipsilateral hilar, lower paratracheal, and subcarinal nodes ). *Thedelineation of the hyper-metabolic area facilitated proper targeting of the area to bebiopsied.

Fig. 8: T4-right upper lobe mass lesion with right main bronchus, carina and Superiorvenacava (arrow) invasion. In both editions the Final stage is T4N0M0 but it is downstaged from IIIB to IIIA in 7th edition.

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

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

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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. Nosignificant mediastinal adenopathy. 6th edition it is T4N0M0 - STAGE IIIB, 7th editionT3N0M1a - STAGE IV and the lesion has been upstaged.

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Fig. 12: M1b - Left upper lobe mass with renal & bony metastases. Stage IV in botheditions.

Fig. 13: Serial pre-operative X-rays show a right upper lobe mass which showedprogression. PET scan (PET images are in Fig 14 )was performed for staging after theCT guided biopsy showed bronchoalveolar carcinoma.Patient underwent surgery. Postop X-ray of the same patient(right bottom image). Post-op HPE findings confirmed thehistopathology with node -ve disease.

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Fig. 14: Same patient as in fig. 13 shows a 6.3 cms sized broncho alveolar type ofadenocarcinoma 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 ofsize criteria.

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

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

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Fig. 17: 7. 3 cms sized mass in right upper lobe with no mediastinal lymph nodes orintrathoracic/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 7thedition).

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Fig. 18: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partialatelectasis of anterior segment of right upper lobe. The lesion was T2 in 6th edition andremained T2a in 7th edition due to the size criteria and metabolically inactive partialcollapse of right upper lobe.

Fig. 19: Small cell carcinoma in right hilar region with great vessels (right pulmonaryartery and vein), pericardium and bronchus intermedius invasion.Right supraclavicularand contralateral hilar lymph nodes are also seen.(arrows) 6th edition-(T4N3M0)STAGEIIIB,7th edition-(T4N3M1a) STAGE IV;the lesion is upstaged from IIIB to IV due topericardial invasion.

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Conclusion

Re-staging of bronchogenic carcinoma based on 7th edition and assessment of variationbetween 6th and 7th edition:

• In our series the overall change in final Stage was seen in only 11 % ( Fig1) 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 thecurrent indications of therapy, nearly one-fifth (17%) of the patients could beoffered different treatment options because of the rearrangement of someTNM subsets in different stages.

• Our case load consisted of more than 50 % of stage IV disease & we didnot have any N1 in our series & hence there was a limitation to predict theimpact of 7th edition in early T & N staging [4].

• In our series maximum change was seen in M category (Fig 2) due to thesub-categorisation as local or distant metastatic disease to subdivision of M1a & 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 indeciding various treatment options like surgery, chemotherapy, radiotherapyincluding 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 haveany 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 maximumwere skeletal metastases(fig.5)

• PET did not have a bearing on T staging however it is able to accuratelydelineate the tumor load & boundaries (fig 9) & differentiate it fromassociated collapse / consolidation(fig.10) or area of necrosis,guidingtargeted biopsy from the metabolically representative area.

• PET/CT has a definite role in assessing recurrent disease based onmetabolic 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 andconfirm by histopathological evaluation using minimally invasive techniqueslike CT guided biopsy, mediastinoscopy and VATS.

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Images for this section:

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

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Fig. 2: Distribution of the change based on TNM descriptors.

Fig. 3: Distribution of cases changed in Final Staging.

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Fig. 4

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

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

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Fig. 7: CT and PET/CT images of the same patient showed in figure 6: Brain lesions werenot hyper metabolic in comparison to the normal brain parenchyma in PET CT,contrastenhanced CT images helped in diagnosis of metastatic lesion.This illustrates the poorsensitivity of PET in identifying brain metastases.

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Fig. 8: Mass lesion with SVC obstruction shows response to Cyber knife therapy.Topimage shows the mass with fiducials in the planning CT,post treatment response seenin the bottom 2 images.

Fig. 9: 43 year old male with Pan coast tumor - non-small cell lung carcinoma showstumor regression in the post chemotherapy follow-up scan.

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Fig. 10: FDG avid 3.1 cms sized right hilar mass lesion with non FDG avid distal partialatelectasis of anterior segment of right upper lobe. The lesion was T2 in 6th edition andremained T2a in 7th edition due to the size criteria and metabolically inactive partialcollapse of right upper lobe.

Fig. 11: case of non small cell carcinoma right upper lobe, underwent right upperlobectomy, patient received post surgery radiotherapy also.Follow up PET/CT after 2year showed a recurrent FDG avid focus (top right image)in right upper lobe abutting theright side of trachea. PET/CT helped in identifying and localising this local recurrencewhich with CT alone will be difficult to detect in post operative scenario.

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

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Fig. 13: Hyper metabolic spiculated mass lesion in left upper lobe with a non FDG avidsubcentimeter nodule in same lobe. Subcentimeter lesions are beyond the resolution ofPET acquisition.

Fig. 14: Hyper metabolic lesion in the left lower lobe in a 30 year old patient whohad hemoptysis. The contrast enhanced CT showed a separate arterial branches fromthe descending thoracic aorta and the venous drainage is into the hemiazygos veinsuggestive of sequestration. Histopathology confirmed the same with super addedinfection.

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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

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3. Strand TE, Rostad H, Wentzel-Larsen T, et al. A population - basedevaluation of the seventh edition of the TNM system for lung cancer. EurRespir J 2010; 36: 401-407.

4. R. Rami-Porta* and P. Goldstraw#:Strength and weakness of the new TNMclassification for lung cancer,Eur Respir J 2010; 36: 237-239.

5. Makoto Suzuki .et.al: Applicability of the revised International Associationfor the Study of Lung Cancer staging system to operable non-small-cell lungcancers, European Journal of Cardio-thoracic Surgery 36 (2009);1036.

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9. Takayuki Fukui et al.Prognostic evaluation based on a new TNM stagingsystem proposed by the International Association for the Study of LungCancer for resected non-small cell lung cancers, The Journal of Thoracicand Cardiovascular SurgeryNovember 2008 (Vol. 136, Issue 5, Pages 1343-1348), 15 August 2008

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2009; 4:300-31011. Hage R, de la Riviere AB, Seldenrijk CA, van den Bosch JM. Update in

pulmonary carcinoid tumors:a review article. Ann Surg Oncol 2003;10:697-70412. Goldstraw P, Crowley J, Chansky K, et al. TheIASLC LungCancer Staging

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