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. Contrast-enhanced computed tomography of the chest, neck and abdomen is the best next step in diagnosing 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 is used to confirm the diagnosis of non small cell lung cancer and identify the histopathological subtype to plan for the treatment.

Diagnostic Study of Choice

Diagnostic approach to the non small cell lung cancer

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 (CT).
• 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 (GGO)
  • Air bronchogram
  • Pleural or pericardial effusion
• When the imaging study suggests lung cancer, diagnosis must be confirmed by performing a transthoracic, bronchoscopic or an image-guided biopsy depending upon the location of the tumor.

Gold standard

• Lung biopsy is the gold standard test for the diagnosis of non-small cell lung cancer.
• The diagnostic result of lung biopsy is confirmatory of non-small cell lung cancer and depends on the histopathological 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

Diagnostic modality for staging

Staging of cancer and extent of metastasis can be diagnosed by various methods.

• Endoscopic ultrasound:
  • First-line diagnostic modality for mediastinal staging.
  • For more information on ultrasound findings of non small cell lung cancer, click here.
• CT scan:
  • Contrast-enhanced CT scan is used to diagnose distant metastasis to liver, adrenal gland, brain or other organs.
  • For more information on CT scan findings of non small cell lung cancer, click here.
• PET/CT scan:
  • PET scan is used to detect non small cell lung cancer in the early stage, look for possible metastasis to liver, adrenal gland or other organs.
  • PET scan cannot be used to diagnose metastasis to the brain because brain cells are normally illuminated in PET scan due to high glucose uptake.
  • For more information on PET scan findings of non small cell lung cancer, click here.
• MRI scan:
  • MRI scan is most often used to look for possible metastasis to the brain or spinal cord.
  • For more information on MRI findings of non small cell lung cancer, click here.

Staging

• Staging system classifications for non-small cell lung cancer include:
  • American Joint Committee on Cancer (AJCC) staging system
  • International Union Against Cancer (UICC) staging system

American Joint Committee on Cancer (AJCC) Staging

• The table below summarizes the TNM staging system for the diagnosis of non-small cell lung cancer.

TNM	Description
TX	The primary tumour cannot be assessed, or there are malignant cells in the sputum or bronchoalveolar lavage but not seen on imaging or bronchoscopy
T0	No evidence of primary tumor
Tis	Carcinoma in situ
T1	Tumour less than 3 cm in its greatest dimension, surrounded by lung or visceral pleura and without bronchoscopic invasion into the main bronchus.
T2	A tumour with any of: More than 3 cm in greatest dimension; Extending into the main bronchus, but more than 2 cm distal to the carina; Obstructive pneumonitis, but not involving the entire lung
T3	A tumour with any of: Invasion of the chest wall, diaphragm, mediastinal pleura, or parietal pericardium; Extending into the main bronchus, within 2 cm of the carina, but not involving the carina; Obstructive pneumonitis of the entire lung
T4	A tumour with any of: Invasion of the mediastinum, heart, great vessels, trachea, oesophagus, vertebra, or carina; Separate tumour nodules in the same lobe; Malignant pleural effusion
Regional Lymph Nodes
NX	Lymph nodes cannot be assessed
N0	No lymph nodes involved
N1	Metastasis to ipsilateral peribronchial or ipsilateral hilar lymph nodes
N2	Metastasis to ipsilateral mediastinal or subcarinal lymph nodes
N3	Metastasis to any of: Ipsilateral supraclavicular lymph nodes; Ipsilateral scalene lymph nodes; Contralateral lymph nodes.
Distant Metastasis
MX	Distant metastasis cannot be assessed
M0	No distant metastasis
M1	Distant metastasis is present

International Union Against Cancer (UICC) Staging System

• The table below summarizes the TNM staging system for the diagnosis of non-small cell lung cancer.

Stage	T	N	M
Occult carcinoma	TX	N0	M0
Stage 0	Tis	N0	M0
Stage IA	T1	N0	M0
Stage IB	T2	N0	M0
Stage IIA	T1	N1	M0
Stage IIB	T2	N1	M0
	T3	N0	M0
Stage IIIA	T1	N2	M0
	T2	N2	M0
	T3	N1	M0
	T3	N2	M0
Stage IIIB	Any T	N3	M0
	T4	Any N	M0
Stage IV	Any T	Any N	M1