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Selection of modality for diagnosis and staging of patients with suspected non-small cell lung cancer

Karl W Thomas, MD
Michael K Gould, MD, MS
Section Editor
David E Midthun, MD
Deputy Editors
Geraldine Finlay, MD
Susanna I Lee, MD, PhD


Non-small cell lung cancer (NSCLC) accounts for approximately 85 percent of all lung cancers [1]. 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.

Typical examples of utilizing the same procedure to acquire tissue for simultaneous diagnosis and staging of suspected NSCLC (table 1 and table 2) [2,3] include the following:

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Literature review current through: Nov 2017. | This topic last updated: Jul 06, 2017.
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