Chest
Volume 143, Issue 5, Supplement, May 2013, Pages e211S-e250S
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Methods for Staging Non-small Cell Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.12-2355Get rights and content

Background

Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.

Methods

Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

Results

The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.

Conclusions

Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.

Section snippets

General Approach

2.1.1. For patients with either a known or suspected lung cancer who are eligible for treatment, a CT scan of the chest with contrast is recommended (Grade 1B).

Remark: If PET scan is unavailable for staging, the CT of the chest should be extended to include the liver and adrenal glands to assess for metastatic disease.

2.1.2. For patients with either a known or suspected lung cancer, it is recommended that a thorough clinical evaluation be performed to provide an initial definition of tumor stage

Methods

The authors updated a systematic review of the diagnostic accuracy of different staging methods for patients with NSCLC. A more complete description of the methods can be found in the first edition of the ACCP guidelines.3, 4, 9, 10 Briefly, computerized searches of MEDLINE covering January 1991 to May 2006 for the previous guidelines and January 2006 to June 2012 for this iteration were performed. In addition, we searched the reference lists of included studies, practice guidelines, systematic

General Approach to Patients

The general approach to patients suspected of having lung cancer begins with a thorough history and physical examination. It is important to pay attention to both organ-specific (bone, brain) and nonspecific (fatigue, anorexia, weight loss) signs and symptoms of potential metastatic disease (Fig 1). The details of the clinical evaluation are discussed later, and were elucidated in detail in previous editions of the lung cancer guidelines.

Essentially, every patient suspected of having lung

Extrathoracic Staging

The work-up of patients with newly diagnosed lung cancer should begin with a thorough clinical evaluation focusing on history, physical examination, and laboratory testing germane to patients with cancer. The current preferred “expanded” clinical evaluation includes organ-specific and constitutional signs and symptoms, along with simple laboratory tests, as shown in Figure 1.36 It is well established that abnormal symptoms, physical findings, and routine blood tests in the initial clinical

General Concepts

Staging is a critical part of the evaluation of every patient with lung cancer. Defining malignant involvement of the mediastinal lymph nodes is particularly important, because in many cases, the status of these nodes determines whether there is surgically resectable disease. Clinical staging of lung cancer is usually directed by noninvasive imaging modalities. On the basis of such tests, physicians determine the likelihood of the presence or absence of tumor involvement in regional lymph nodes.

Summary

CT scanning of the chest is useful in providing anatomic detail that better identifies the location of the tumor and its proximity to local structures and determines whether lymph nodes in the mediastinum are enlarged. Unfortunately, the accuracy of chest CT scans in differentiating benign from malignant lymph nodes in the mediastinum is unacceptably low. PET scanning provides functional information of tissue activity and has much better sensitivity and specificity than chest CT scanning for

Acknowledgments

Author contributions: Dr Silvestri had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Silvestri: contributed to the literature review with review of abstracts and construction of evidence tables, the interpretation of evidence tables and the formulation of recommendations, and the writing of the manuscript.

Dr Gonzalez: contributed to the literature review with review of abstracts and construction of

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    Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

    COI Grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

    Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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