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*[[Thoracotomy]]
*[[Thoracotomy]]
*[[Thoracoscopy]]
*[[Thoracoscopy]]
*[[Bronchoscopy]]: Bronchoscopy is used to obtain a specimen for histopathological subtyping and immunohistochemical staining by the following methods:
*[[Bronchoscopy]]: [[Bronchoscopy]] is used to obtain a specimen for [[Histopathology|histopathological]] subtyping and [[Immunohistochemistry|immunohistochemical staining]] by the following methods:
**Bronchial brush
**Bronchial brush
**Bronchial wash
**Bronchial wash
**[[Bronchoalveolar lavage|Bronchioloalveolar lavage]]
**[[Bronchoalveolar lavage|Bronchioloalveolar lavage]]
**Transbronchial fine-needle aspiration (FNA)
**[[Fine-needle aspiration|Transbronchial fine-needle aspiration (FNA)]]
**Core biopsy
**Core biopsy


*[[Mediastinoscopy]]
*[[Mediastinoscopy]]
**Chamberlain procedure
**[[Mediastinoscopy|Chamberlain procedure]]
**Left parasternal mediastinotomy  
**Left parasternal mediastinotomy  
**Anterior mediastinotomy  
**[[Mediastinoscopy|Anterior mediastinotomy]]
*Transthoracic percutaneous [[fine needle aspiration]]
*Transthoracic percutaneous [[fine needle aspiration]]
*Sputum [[cytology]]
*Sputum [[cytology]]
**The sensitivity of sputum [[cytology]] varies by location of the lung cancer   
**The sensitivity of sputum [[cytology]] varies by location of the [[lung cancer]]  


The table below summarizes the advantages and limitations of different types of diagnostic modalities in non-small cell lung cancer arranged from the most to the least invasive.<ref>name="AJCC4-L">AJCC Cancer Staging Manual 4th edition; Chapter 19; Lung - original pages 115-122</ref><ref>{{cite web |url=http://www.cancerstaging.org/products/csmanual4ed.pdf |title=Archived copy |accessdate=2011-05-23 |deadurl=yes |archiveurl=https://web.archive.org/web/20110928055151/http://www.cancerstaging.org/products/csmanual4ed.pdf |archivedate=2011-09-28 |df= }}</ref><ref name="AJCC4-L">AJCC Cancer Staging Manual 4th edition; Chapter 19; Lung - original pages 115-122
The table below summarizes the advantages and limitations of different types of diagnostic modalities in non-small cell lung cancer arranged from the most to the least invasive.<ref>name="AJCC4-L">AJCC Cancer Staging Manual 4th edition; Chapter 19; Lung - original pages 115-122</ref><ref>{{cite web |url=http://www.cancerstaging.org/products/csmanual4ed.pdf |title=Archived copy |accessdate=2011-05-23 |deadurl=yes |archiveurl=https://web.archive.org/web/20110928055151/http://www.cancerstaging.org/products/csmanual4ed.pdf |archivedate=2011-09-28 |df= }}</ref><ref name="AJCC4-L">AJCC Cancer Staging Manual 4th edition; Chapter 19; Lung - original pages 115-122
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | [[Thoracotomy]]  
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | [[Thoracotomy]]  
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Allows the most thorough inspection and sampling of lymph node stations
*Allows the most thorough inspection and sampling of [[Lymph node metastases|lymph node]] stations
*May be followed by resection of tumor, if feasible
*May be followed by resection of he tumor, if feasible
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*Invasive approach
*Invasive approach
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| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*Invasive
*Invasive
*Does not cover all mediastinal lymph node stations; particularly subcarinal lymph nodes (station 7), paraesophageal and pulmonary ligament lymph nodes (stations 8 and 9).
*Does not cover all [[mediastinal lymph node]] stations; particularly [[Mediastinal lymph node|subcarinal lymph nodes]] (station 7), paraesophageal and pulmonary ligament lymph nodes (stations 8 and 9).
*False-negative rate approximately 20%
*[[False-negative|False-negative rate]] approximately 20%
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | [[Thoracoscopy|Video-assisted thoracoscopy]]
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | [[Thoracoscopy|Video-assisted thoracoscopy]]
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Useful for the evaluation of inferior mediastinum, station 5 and 6 lymph nodes
*Useful for the evaluation of [[inferior mediastinum]], station 5 and 6 lymph nodes
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Invasive
*Invasive
*Does not cover superior anterior mediastinum
*Does not cover [[Superior mediastinum|superior anterior mediastinum]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Transthoracic percutaneous [[fine needle aspiration]] under CT guidance
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" | Transthoracic percutaneous [[fine needle aspiration]] under CT guidance

Revision as of 15:38, 16 January 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Trusha Tank, M.D.[2],Maria Fernanda Villarreal, M.D. [3]

Overview

Diagnosis of non-small cell lung cancer can be confirmed by histopathological evaluation and immunohistochemical staining of the tumor specimen obtained from biopsy. Different types of lung tissue biopsy for non-small cell lung cancer include transthoracic needle biopsy, open biopsy, and video-assisted thoracoscopic surgery (VATS). Specimen for histopathological evaluation and immunohistochemical staining can also be obtained by bronchoscopy, mediastinoscopy, transthoracic percutaneous fine needle aspiration or sputum cytology.

Other Diagnostic Studies

Other diagnostic studies for non-small cell lung cancer include:[1]

The table below summarizes the advantages and limitations of different types of diagnostic modalities in non-small cell lung cancer arranged from the most to the least invasive.[2][3][4][5][6][7][8][9][9]

Procedure Advantages Limitations
Thoracotomy
  • Allows the most thorough inspection and sampling of lymph node stations
  • May be followed by resection of he tumor, if feasible
  • Invasive approach
  • Not indicated for staging alone
  • Significant risk of procedure-related morbidity
Left parasternal mediastinotomy
  • Allows evaluation of the aortopulmonary window lymph nodes
  • More invasive
  • False-negative rate approximately 10%
Chamberlain procedure
  • Limited applications, invasive
Cervical mediastinoscopy
  • Considered the gold standard (usual comparitor)
  • Excellent for 2RL 4RL
Video-assisted thoracoscopy
Transthoracic percutaneous fine needle aspiration under CT guidance
  • Widely available than some other methods
  • Traverses a lot of lung tissue
  • High pneumothorax risk
  • Some lymph node stations inaccessible
Bronchoscopy with blind transbronchial Wang needle
  • Less invasive than above methods
  • Relatively low yield
  • Not widely practiced
  • Bleeding risk

Biopsy

Common types of lung tissue biopsy include:[10][11]

Indications for lung tissue biopsy in suspected non-small cell lung cancer include:[11]

  • Determination of tumor histologic subtype
  • Characterization of genetic mutations
  • Determination of intra or extra-thoracic metastatic disease

Biopsy Findings

  • The table below summarizes the common types of non-small cell lung cancer biopsy findings.[11]
Type of tumor Biopsy findings
Lung adenocarcinoma
Squamous cell lung carcinoma
  • Central nucleus
  • Dense appearing cytoplasm, usually eosinophilic
  • Small nucleolus
  • Intracellular bridges - classic
Large cell lung carcinoma
  • Large polygonal cells and anaplastic cells
  • Solid nests without obvious squamous or glandular differentiation
  • Moderately abundant cytoplasm
  • Well defined cell borders
  • Vesicular nuclei, prominent nucleoli
Adenosquamous carcinoma
  • Substantial amounts of squamous and glandular differentiation
  • Positive stains for TTF1 and p63 in squamous component
Sarcomatoid carcinoma
  • Sarcoma-like differentiation
  • Spindle cells vary morphologically from epithelioid to strikingly spindled and are arranged in haphazard fascicles or storiform pattern
  • Moderate to abundant, dense, eosinophilic cytoplasm
Carcinoid tumor
  • Medium sized polygonal cells with lightly eosinophilic cytoplasm
  • Low nuclear grade, round to oval finely granular nuclei; may have rosettes or small acinar structures with variable mucin
  • Scanty vascular stroma, occasionally amyloid stroma with bone
Salivary gland tumor
  • Organized in round and sometimes confluent islands, rich in matrix and with dispersed condrocyte-type cells

Immunohistochemistry Stain

On immunohistochemistry, the findings depend on the histological type of non-small cell lung cancer.[12]

  • Common immunohistochemistry markers used for non-small cell carcinoma subtyping, include:
  • TTF-1 for adenocarcinoma
  • p63 and high-molecular-weight keratins for squamous cell carcinoma
  • Lack of staining with neuroendocrine markers (chromogranin A, synaptophysin, and CD56)


References

  1. ↑ Kinsey CM, Arenberg DA (2014). "Endobronchial ultrasound-guided transbronchial needle aspiration for non-small cell lung cancer staging". Am. J. Respir. Crit. Care Med. 189 (6): 640–9. doi:10.1164/rccm.201311-2007CI. PMID 24484269.
  2. ↑ name="AJCC4-L">AJCC Cancer Staging Manual 4th edition; Chapter 19; Lung - original pages 115-122
  3. ↑ "Archived copy" (PDF). Archived from the original (PDF) on 2011-09-28. Retrieved 2011-05-23.
  4. ↑ AJCC Cancer Staging Manual 4th edition; Chapter 19; Lung - original pages 115-122 "Archived copy" (PDF). Archived from the original (PDF) on 2011-09-28. Retrieved 2011-05-23.
  5. ↑ Feinstein AR, Sosin DM, Wells CK (June 1985). "The Will Rogers phenomenon. Stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer". N. Engl. J. Med. 312 (25): 1604–8. doi:10.1056/NEJM198506203122504. PMID 4000199.
  6. ↑ Chee KG, Nguyen DV, Brown M, Gandara DR, Wun T, Lara PN (July 2008). "Positron emission tomography and improved survival in patients with lung cancer: the Will Rogers phenomenon revisited". Arch. Intern. Med. 168 (14): 1541–9. doi:10.1001/archinte.168.14.1541. PMID 18663166.
  7. ↑ Mountain, Clifton F; Herman I Libshitz; Kay E Hermes. A Handbook for Staging, Imaging, and Lymph Node Classification. Charles P Young Company.
  8. ↑ Mountain CF (June 1997). "Revisions in the International System for Staging Lung Cancer". Chest. 111 (6): 1710–7. doi:10.1378/chest.111.6.1710. PMID 9187198. Archived from the original on 2003-09-05.
  9. ↑ 9.0 9.1 Micames CG, McCrory DC, Pavey DA, Jowell PS, Gress FG (February 2007). "Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging: A systematic review and metaanalysis". Chest. 131 (2): 539–48. doi:10.1378/chest.06-1437. PMID 17296659.
  10. ↑ Yung RC (2003). "Tissue diagnosis of suspected lung cancer: selecting between bronchoscopy, transthoracic needle aspiration, and resectional biopsy". Respir Care Clin N Am. 9 (1): 51–76. PMID 12820712.
  11. ↑ 11.0 11.1 11.2 Squamous cell carcinoma of the lung. Libre Pathology http://librepathology.org/wiki/Squamous_cell_carcinoma_of_the_lung Accessed on March 1, 2016
  12. ↑ Capelozzi VL (2009). "Role of immunohistochemistry in the diagnosis of lung cancer". J Bras Pneumol. 35 (4): 375–82. PMID 19466276.


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