Non small cell lung cancer diagnostic study of choice

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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],Furqan M M. M.B.B.S[3]

Overview

Chest X-Ray is the initial study performed when non-small cell lung cancer is suspected. Lung CT scan is the diagnostic study of choice for the diagnosis of non-small cell lung cancer. Endobronchial ultrasound is a first-line diagnostic modality for the mediastinal staging of the non-small cell lung cancer. The lung biopsy is the gold standard for the diagnosis of the non-small cell lung cancer. The lung biopsy helps to differentiate between the various subtypes of lung cancer.

Diagnostic Study of Choice

Study of choice

Non small cell cancer of the lung is diagnosed by the following approach:

• Chest X-Ray is the initial study performed when non-small cell lung cancer is suspected.
• The next step in diagnosing non small cell carcinoma of the lung is contrast-enhanced computed tomography.
• On CT, characteristic findings of non-small cell lung cancer include:
  • Centrally located tumors, invading the mediastinal structures
  • Peripherally located tumors, invading the pleura and chest wall
  • Tumor margins: Smooth, lobulated, irregular and spiculated
  • Tumor density: Uniformly solid; central necrosis; cavitation (squamous histology)
  • Area of consolidation in the pulmonary field
  • Ground-glass opacity
  • Air bronchogram
• When the imaging study suggests lung cancer, diagnosis must be confirmed by performing a bronchoscopic or an image-guided biopsy.

Diagnostic modality for staging

Endobronchial ultrasound is a first-line diagnostic modality for mediastinal staging.

• The sensitivity of endobronchial ultrasound is 90% and specificity is 97%.

• On ultrasound (endobronchial ultrasound), characteristic findings of non-small cell lung cancer include:
  • Enlarged lymph nodes
  • Local invasion of adjacent bronchial structures and mediastinum

• Indications for the endobronchial ultrasound:
  • Evaluation of lymph nodes and other structures in the mediastinum
  • Mediastinal invasion staging
  • Determination of management strategy
  • Real-time evaluation of structures

Gold standard

• Lung biopsy is the gold standard test for the diagnosis of non-small cell lung cancer.

Diagnostic results

The diagnostic result of lung biopsy is confirmatory of non-small cell lung cancer and depends on the type of cancer. Click here to view the biopsy findings of the subtypes.

Evaluation Algorithm for Suspected Non-Small Cell Lung Cancer

The algorithm below summarizes the initial imaging approach for patients with suspected non-small cell lung cancer.

Imaging approach ❑ Suspected lung cancer

Chest X Ray normal?

No

Yes

Enhanced Computed Tomography (ECT), includes: ❑ Thorax ❑ Upper Abdomen ❑ Low Neck

Manage and observe

Imaging evaluation

Location ❑ Central ❑ Peripheral ❑ Pleural lesion Size Lesion characteristics ❑ Margins (irregular/regular) ❑ Shape (spiculated/rounded) Presence of cavitation ❑ Yes ❑ No Type of adenopathy ❑ Hiliar ❑ Mediastinal

Diagnosis and Staging Assessment

Other Imaging or Diagnostic Modalities ❑ Sputum cytology ❑ Endobronchial ultrasound ❑ Endoscopic ultrasound ❑ Bronchoscopy ❑ Mediastinoscopy ❑ PET/CT

Biopsy