Selection of modality for diagnosis and staging of patients with suspected non-small cell lung cancer
- Karl W Thomas, MD
Karl W Thomas, MD
- Professor of Medicine - Pulmonary, Critical Care, Allergy and Immunology
- Wake Forest School of Medicine
- Michael K Gould, MD, MS
Michael K Gould, MD, MS
- Senior Research Scientist
- Director for Health Services Research
- Department of Research and Evaluation
- Kaiser Permanente Southern California
- Section Editor
- David E Midthun, MD
David E Midthun, MD
- Section Editor — Lung Cancer
- Professor of Medicine, Mayo Clinic College of Medicine
- Deputy Editors
- Geraldine Finlay, MD
Geraldine Finlay, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Pulmonary, Critical Care, and Sleep Medicine
- Associate Professor
- Tufts University School of Medicine
- Susanna I Lee, MD, PhD
Susanna I Lee, MD, PhD
- Deputy Editor — Radiology
- Associate Professor of Radiology
- Harvard Medical School
- Massachusetts General Hospital
Non-small cell lung cancer (NSCLC) accounts for approximately 85 percent of all lung cancers . The two most common histopathologic subtypes are adenocarcinoma and squamous carcinoma. Tissue biopsy is necessary for the diagnosis and staging of NSCLC so that appropriate therapies can be administered in a timely fashion. (See "Personalized, genotype-directed therapy for advanced non-small cell lung cancer".)
This topic will discuss the general approach to selecting a modality to obtain tissue from a target biopsy site (primary tumor, lymph node, distant metastasis) in patients with suspected NSCLC. The approach to patients with a solitary pulmonary nodule, overview of the initial evaluation and imaging of NSCLC, procedures used for tissue biopsy of NSCLC, and the Tumor Node Metastasis staging system for NSCLC are discussed in detail separately. (See "Diagnostic evaluation of the incidental pulmonary nodule" and "Overview of the risk factors, pathology, and clinical manifestations of lung cancer" and "Overview of the initial evaluation, treatment and prognosis of lung cancer" and "Overview of the initial evaluation, diagnosis, and staging of patients with suspected lung cancer" and "Procedures for tissue biopsy in patients with suspected non-small cell lung cancer" and "Tumor, Node, Metastasis (TNM) staging system for lung cancer".)
The acquisition of tissue from the primary lung lesion or suspected metastases (eg, lymph nodes or distant organs) should ideally provide enough material for a timely and accurate histopathologic diagnosis with molecular characterization. Computed tomographic (CT), positron emission tomographic (PET) scanning, and/or other imaging modalities (eg, magnetic resonance imaging [MRI]) guide the clinician in choosing the optimal site(s) for tissue sampling. The goals must be balanced with minimizing patient risk and accommodating patient preferences. The goals do not necessarily change for patients with significant comorbid disease or those with suspected advanced-stage disease. However, the risks and potential complications of biopsy in these patients may limit the preferred options. (See 'Assessing patient risk' below.)
Efficient diagnosis and procedures — The preferred initial site for tissue biopsy is one that could simultaneously establish the histopathologic diagnosis and disease stage. However, if the initial selected diagnostic procedure does not establish the diagnosis or stage, additional procedures are necessary. Exceptions to this general approach may occur in patients with multiple limiting comorbidities or those with unambiguous clinical and radiographic evidence of metastasis.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- BIOPSY GOALS
- Efficient diagnosis and procedures
- Adequate biopsy size
- ASSESSING PATIENT RISK
- APPROACH TO THE PATIENT
- General principles
- Assessing radiographic stage
- Low risk N2/N3 mediastinal disease (localized peripheral lung cancer)
- Intermediate and high risk N2/N3 mediastinal disease
- - Intermediate risk N2 and N3 nodal involvement
- - High risk N2 or N3 nodal involvement
- - Modality choice - mediastinal sampling
- EBUS/EUS needle aspiration
- Alternative modalities
- Suspected advanced disease
- - Pleural (T2, T3, M1a)
- - Lung (T3, T4, M1a)
- - Pericardium (T3, M1a)
- - Liver, adrenal gland, brain, bone
- - Supraclavicular or scalene lymph node (N3)
- INDIVIDUALIZING THE APPROACH
- Role of multidisciplinary teams
- TNM STAGING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS