Thoracic Imaging 2003 - Society of Thoracic Radiology

More documents

Recommendations

Info

Endoscopic Ultrasound Staging of Lung Cancer James Ravenel, M.D. Medical University of South Carolina Learning Objectives: 1) Discuss the role in EUS in the staging of lung cancer 2) Identify appropriate indications for EUS 3) Identify typical locations for performing EUS/FNA Endoscopic ultrasound (EUS) is a relatively recent technique that was initially utilized to evaluate gastrointestinal tumors. As the ultrasound probes and skills of endoscopists improved a wider array of applications have become available including evaluation of the liver, and mediastinum. At our institution EUS with fine needle aspiration (FNA) has become a vital tool in the staging of lung cancer, complementing CT, PET bronchoscopy and surgical staging. Technique Although a trained endoscopist is required, one of the great advantages of EUS/FNA is that it can be performed in an outpatient setting with conscious sedation. Using an echoendoscope, the procedure is similar to traditional endoscopy. Sonography is performed most frequently with a 5-10 MHz linear-array probe. Radial scanning may be used as well. Our endoscopists sample any lymph node greater than 1 cm seen, followed by nonenlarged lymph nodes (usually levels 5,7 and 8) as appropriate. Typically, three to four passes are made into each node evaluated with a 22-gauge needle. The entire procedure takes approximately 20-30 minutes. The complication rate is extremely low (0.03% for perforation of the cervical esophagus). The instances of perforation at the biopsy site and procedure induced bacteremia are likewise extremely rare. Results EUS Alone Initial reports utilizing EUS staging focused on morphologic and sonographic features of lymph nodes. Sonographic features suggestive of malignancy include size > 1cm, distinct margin, round shape and decreased echogenicity. Combining the first three criteria results in a specificity of 80%. Features favoring benignity include oval or triangular shape and a central echogenic region. The majority of lymph nodes, however, are uniformly hypoechoic. Overall, sonographic criteria alone have a sensitivity ranging from 45-75% for malignancy. EUS may also useful by confirming T4 disease. EUS can demonstrate direct invasion of the trachea, esophagus and vascular structures. EUS tends to overstage tumors when mediastinal invasion without organ or vascular involvement is suspected. EUS with FNA When coupled with FNA, morphologic and sonographic criteria need not be applied. While suspicious nodes by these criteria may be sampled first, any N2 lymph node visualized can usually be aspirated. Because a positive result is generally accepted as proof of mediastinal disease, specificity is usually quoted at 100% and based on this result no more invasive staging needs to be performed. False negative results in mediastinal staging may occur for two reasons. The first is due to sampling error; that is FNA fails to obtain malignant cells from a metastatic node. The second relates to regions not evaluated by EUS. Pre- and paratracheal lymph nodes are infrequently seen by EUS due to the inability of ultrasound to penetrate the air-filled trachea. Prevascular lymph nodes (level 6) can be seen by EUS but are usually not sampled due to major blood vessels (aorta, pulmonary artery) in the path of the needle. Even so, most reports show a sensitivity for EUS-FNA to range from 87-95%. The use of this technique is particularly helpful in limiting the number of mediastinoscopies by documenting N2 disease (up to 80% in some reports). Because level 2, 3, and 4 lymph nodes are generally not visualized, a negative EUS-FNA does not preclude mediastinoscopy prior to planned curative resection especially if enlarged, or PET positive lymph nodes are seen on cross sectional imaging. In most cases, the positive yield of EUS can be increased by selecting individuals with enlarged lymph nodes at levels 5, 7, and 8 at CT. In patients with no enlarged lymph nodes at CT, EUS still may find N2 disease in up to 1/3 of patients. Because level 5 requires either extended cervical medianstinoscopy or anterior mediastinotomy, EUS is particularly well suited for the evaluation of the mediastinum in left upper lobe neoplasms. Similarly, EUS offers a more complete evaluation of the subcarinal lymph nodes compared to mediastinoscopy. Distant disease is also occasionally accessible by EUS-FNA. Pleural effusions, the left adrenal gland and selected liver lesions are sites outside the mediastinum that have been successfully biopsied during EUS. Conclusion EUS-FNA is a valuable adjunct for staging lung cancer. It is particularly useful for confirming mediastinal disease and therefore obviating the need for surgery. REFERENCES: Bhutani MS, Hawes RH, Hoffman BJ. A comparison of the accuracy of echo features during endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration for diagnosis of malignant lymph node invasion. Gastrointest Endosc. 1997; 45:474-479. Gress FG, Savides TJ, Sandler A., et. al. Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: A comparison study. Ann Intern Med. 1997; 127:604-612. Fritscher-Ravens A, Soehendra N, Schirrow L, et. al. Role of transesophageal endosonography-guided fine-needle aspiration in the diagnosis of lung cancer. Chest. 2000; 117:339-345. Larsen SS, Krasnik M, Vilmann P, et. al. Endoscopic ultrasound guided biopsy of mediastinal lesion has a major impact on patient management. Thorax. 2002; 57:98-103. Silvestri GA, Hoffman BJ, Bhutani MS, et. al. Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg. 1996; 61:1441-1446. Wallace MB, Silvestri GA, Sahai AV, et. al. Endoscopic ultrasound-guided fine needle aspiration for staging patients with carcinoma of the lung. Ann Thorac Surg. 2001; 72:1861-1867. Wiersema MJ, Vazquez-Sequeiros E, Wiersema LM. Evaluation of mediastinal lymphadenopathy with endoscopic US-guided fine-needle aspiration biopsy. Radiology. 2001; 219:252-257. Wiersema MJ, Vilmann P, Giovanni M, et. al. Endosonographyguided fine-needle aspiration biopsy: Diagnostic accuracy and complication assessment. Gastroenterology. 1997; 112:1087-1095. 225 WEDNESDAY
Metastatic Disease to Lung Gordon L. Weisbrod, M.D. Medical Imaging University Health Network Pulmonary Metastatic Disease Spread of Tumour to Lungs 1. Via pulmonary (or bronchial) arteries K interstitial nodules or lymphangitic spread. 2. Via pulmonary and pleural lymphatics K lymphangitic spread from mediastinal and hilar nodes. 3. Via thoracic duct into right side of heart. 4. Via the airways (BAC). 5. Via communicating lymphatic channels from upper abdominal nodes and peritoneal cavity (i.e. Ca ovary). Pulmonary Metastatic Disease: Radiological-Surgical Correlation 100 lungs – 84 patients – previously treated extrathoracic malignancies 237 nodules resected – 173 (73%) CT – 151 (82%) metastatic 207 (87%) metastatic 21 ( 9%) benign 9 ( 4%) bronch Ca nodules - +CT } 100% +CHX } Metastatic nodules: + CT } - CXR } 84% Metastatic 65 solitary nodules on CXR - 35 (54%) solitary at surgery 44 solitary nodules on CT - 35 (80%) solitary at surgery (Peuchot and Libshitz, Radiology 1987; 164:719-722.) Frequency of Pulmonary Metastases Autopsy 30-53% High frequency - rich vascular supply Renal cell - systemic venous drainage Chorio Bone sarcoma Incidence of Metastases Found at Initial Presentation versus Autopsy Choriocarcinoma (female) 60 70-100 Lung (unresectable) 34 20-40 Kidney 5-30 50-75 Rhabdomyosarcoma 21 25 Wilms’ 20 60 Ewing’s 18 77 Osteosarcoma 15 75 Testis 2-12 70-80 Bladder 5-10 25-30 Thyroid 4-10 65 Melanoma 5 66-80 Prostate 5 13-53 Head and Neck 5 13-40 Colon/Rectum
Page 1 and 2:
The Society of Thoracic Radiology T
Page 3 and 4:
Dear Friends, Welcome to Miami Beac
Page 5 and 6:
Continuing Medical Education Credit
Page 7 and 8:
Warren B. Gefter, MD University of
Page 9 and 10:
Ernest M. Scalzetti, MD SUNY Upstat
Page 11 and 12:
Registration Hours Saturday, March
Page 13 and 14:
Program Committee Ella A. Kazerooni
Page 15 and 16:
Small Airway Disease Americana 3 Mo
Page 17 and 18:
Benjamin Felson Memorial Lecture Am
Page 19 and 20:
Session 2-B Concurrent Session Clin
Page 21 and 22:
Workshops (choose 1) 1:00 - 1:45 D1
Page 23 and 24:
Sunday
Page 25 and 26:
March 2, 2003 General Session Sunda
Page 27 and 28:
SUNDAY 46 One type of direct-readou
Page 29 and 30:
CT-PET Imaging Suzanne Aquino, M.D.
Page 31 and 32:
SUNDAY 58 an accompanying decreased
Page 33 and 34:
SUNDAY 60 Radiofrequency Ablation i
Page 35 and 36:
SUNDAY 62 17. Sewell PE, Vance RB.
Page 37 and 38:
SUNDAY 64 cal ventilation will be r
Page 39 and 40:
SUNDAY 66 radiologic, and histopath
Page 41 and 42:
SUNDAY 68 application. The untreate
Page 43 and 44:
SUNDAY 70 The Expanded Spectrum of
Page 45 and 46:
SUNDAY 72 Hypersensitivity Pneumoni
Page 47 and 48:
SUNDAY 74 Small Airway Diseases Mic
Page 49 and 50:
SUNDAY 76 The “Head-cheese Sign
Page 51 and 52:
SUNDAY 78 “Holes” in the Lung:
Page 53 and 54:
SUNDAY 80 Pleural Effusions Gerald
Page 55 and 56:
SUNDAY 82 Asbestos Related Pleural
Page 57 and 58:
SUNDAY 84 Other Pleural Neoplasms S
Page 59 and 60:
SUNDAY 86 Image-Guided Therapy of M
Page 61 and 62:
Notes 88
Page 63 and 64:
March 3, 2003 General Session 7:00
Page 65 and 66:
Cardiac MRI: Established Indication
Page 67 and 68:
Cardiac MRI: New Developments Gauth
Page 69 and 70:
5. The volume of contrast medium re
Page 71 and 72:
Acute Aortic Syndrome Ernest M. Sca
Page 73 and 74:
as well as separation of the cusps
Page 75 and 76:
Pulmonary Veins: Imaging for Radiof
Page 77 and 78:
Imaging of Cardiopulmonary Support
Page 79 and 80:
plied to the hollow fibers by an ex
Page 81 and 82:
swelling of the entire leg, calf sw
Page 83 and 84:
Multi-channel Pulmonary CTA: New Te
Page 85 and 86:
terminate scintigrams, CT correctly
Page 87 and 88:
CT Strucural and Functional Imaging
Page 89 and 90:
curves (TDCs) are generated by manu
Page 91 and 92:
7. Crawford T, Yoon C, Wolfson K, e
Page 93 and 94:
80. Fleischmann D, Rubin GD, Bankie
Page 95 and 96:
127 MONDAY
Page 97 and 98:
129 MONDAY
Page 99 and 100:
REFERENCES Bergin CJ, Rios G, King
Page 101 and 102:
Notes 134
Page 103 and 104:
March 4, 2003 General Session 7:00
Page 105 and 106:
Adult Manifestations of Congenital
Page 107 and 108:
will usually display the limbs of t
Page 109 and 110:
Imaging of the Pericardium Paul L.
Page 111 and 112:
Cardiomyopathy Martin J. Lipton, M.
Page 113 and 114:
TUESDAY 150 Nuclear Cardiology Upda
Page 115 and 116:
TUESDAY 152 ties. The predominant 1
Page 117 and 118: TUESDAY 154 Imaging protocols: Util
Page 119 and 120: Manpower Shortage in Radiology: Sol
Page 121 and 122: 159 TUESDAY
Page 127 and 128: NIBIB Update for Thoracic Radiology
Page 129 and 130: vertically along the right atrium t
Page 131 and 132: Multidetector Pediatric Chest CT: P
Page 133 and 134: The Spectrum of Pulmonary Infection
Page 135 and 136: Immune deficiency occurs frequently
Page 137 and 138: TUESDAY 180 The Internet and the Pr
Page 139 and 140: TUESDAY 182 Workshop A1: Lymphoma:
Page 141 and 142: TUESDAY 184 Digital Images: Camera
Page 143 and 144: TUESDAY 186 Analysis of Mediastinal
Page 145 and 146: Unusual Manifestations of Lung Canc
Page 147 and 148: Wednesday
Page 149 and 150: March 5, 2003 General Session Wedne
Page 151 and 152: WEDNESDAY 208 principle is that “
Page 153 and 154: WEDNESDAY 210 years and a current o
Page 155 and 156: WEDNESDAY 212 lesions generally mim
Page 157 and 158: WEDNESDAY 214 capable of studying t
Page 159 and 160: WEDNESDAY 216 Small T1 Lung Cancer:
Page 161 and 162: WEDNESDAY 218 REFERENCES Seely JM,
Page 163 and 164: WEDNESDAY 220 Therefore, radiologis
Page 165 and 166: WEDNESDAY 222 sectional area varies
Page 167: WEDNESDAY 224 Lung Cancer Staging A
Page 171 and 172: Thoracic Metastates from Osteosarco
Page 173 and 174: STR tutorial: Use of MD CT reconstr
Page 175 and 176: ogenic edema, fat embolism, heroin
Page 177 and 178: WEDNESDAY 236 Pulmonary Arterial Hy
Page 179 and 180: WEDNESDAY 238 pathological process,
Page 181 and 182: Thursday
Page 183 and 184: THURSDAY 250 Pulmonary Tuberculosis
Page 185 and 186: THURSDAY 252 1. Clinical criteria:
Page 187 and 188: THURSDAY 254 AIDS patients are also
Page 189 and 190: THURSDAY 256 Viral Infection on HRC
Page 191 and 192: THURSDAY 258 Imaging of Coccidioido
Page 193 and 194: THURSDAY 260 from the laryngeal sur
Page 195 and 196: THURSDAY 262 Inflammatory Diseases
Page 197 and 198: Virtual Endoscopy in the Thorax: Pr
Page 199 and 200: Notes 269 THURSDAY
Page 201: SECOND LEVEL THIRD LEVEL
show all

Thoracic Imaging 2003 - Society of Thoracic Radiology

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?