Initial evaluation of the nonsmall cell lung cancer patient: diagnosis and staging.
ABSTRACT The initial diagnosis and staging of nonsmall cell lung cancer patients is complex and involves multiple technologies. This review evaluates the recent literature and integrates it into a systematic method for evaluating patients.
The goal of the initial diagnosis and staging of nonsmall cell lung cancer is to provide sufficient information to allow definitive treatment. Initial steps should include a history and physical, basic laboratory tests, pulmonary functions, and PET-computed tomography (CT) imaging. If there is evidence of metastatic disease, then biopsy of the most advanced lesion is warranted. If there is no evidence of metastatic disease, the evaluation should focus on evaluation of the mediastinal lymph nodes. If there is evidence of nodal involvement by PET-CT, then endobronchial ultrasound-guided transbronchial needle aspiration is warranted. If there is no evidence of nodal involvement on PET-CT, then either surgery or CT-guided fine needle aspiration is warranted. Other factors that should be kept in mind when selecting a diagnostic strategy include whether or not the patient is a surgical candidate, the impact of comorbidities, the type of cancer, the need for predictive biomarker analysis, and the range of possible treatment options.
Integrating new technologies such as PET-CT and endobronchial ultrasound into the initial evaluation of patients can save unnecessary diagnostic procedures and lead to more rapid and accurate staging.
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ABSTRACT: ABSTRACT BACKGROUND: Evidence-based guidelines recommend mediastinal sampling as the first invasive test in patients with suspected lung cancer and mediastinal adenopathy. The goal of this study was to assess practice patterns and outcomes of diagnostic strategies in this patient population. METHODS: We conducted a retrospective analysis of all patients in 2009 that had mediastinal adenopathy without distant metastatic disease to determine whether or not guideline consistent care was delivered. Guideline consistent care was defined as mediastinal lymph node sampling being performed as part of the first invasive procedure. RESULTS: 137 patients were included. Guideline consistent care was provided in 30 (22%) cases. Patients receiving guideline consistent care had fewer invasive tests than patients with guideline inconsistent care (1.3 ± 0.5 vs. 2.3 ± 0.5 tests/patient respectively, p<0.0001) and fewer complications (0 of 30, 0% vs. 18 of 108, 17%; p=0.01). Most of the complications (16 of 18) were related to CT guided needle biopsy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was sufficient to guide treatment decisions without any other invasive tests in 88 (64%) patients. While not all of the complications and costs due to CT guided biopsies could have been avoided, roughly two thirds could have been eliminated by just changing the testing sequence. CONCLUSION: Quality gaps in lung cancer staging in patients with mediastinal adenopathy are common and lead to unnecessary testing and increased complications. In patients with suspected lung cancer without distant metastatic disease with mediastinal adenopathy, EBUS-TBNA should be the first test.Chest 05/2013; 144(6). DOI:10.1378/chest.12-3046 · 7.13 Impact Factor
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ABSTRACT: Guidelines recommend mediastinal lymph node sampling as the first invasive diagnostic procedure in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases. Retrospective cohort of 15,316 patients with lung cancer with regional spread without metastatic disease in the SEER or Texas Cancer Registry Medicare-linked databases. Patients were categorized based on the sequencing of invasive diagnostic tests performed: A) Evaluation consistent with guidelines, mediastinal sampling done first; B) Evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling performed but not as part of the first invasive test; C) Evaluation inconsistent with guidelines, NSCLC present, mediastinal sampling never done; and D) Evaluation inconsistent with guidelines, small cell lung cancer. The primary outcome was whether guideline consistent care was delivered. Secondary outcomes included whether patients with NSCLC ever had mediastinal sampling and use of TBNA among pulmonologists. Only 21% of patients had a diagnostic evaluation consistent with guidelines. Only 56% of NSCLC patients had mediastinal sampling prior to treatment. There was significant regional variability in guideline consistent care (range 12%-29%). Guideline consistent care was associated with lower patient age, metropolitan areas, and if the physician ordering or performing the test was male, U.S. trained, had seen more lung cancer patients, and was a pulmonologist or thoracic surgeon who had graduated more recently. More recent pulmonary graduates were also more likely to perform transbronchial needle aspiration (p<0.001). Guideline consistent care varied regionally and was associated with physician level factors, suggesting that a lack of effective physician training may be contributing to the quality gaps observed.Chest 11/2013; 145(5). DOI:10.1378/chest.13-1628 · 7.13 Impact Factor
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ABSTRACT: Guidelines recommend mediastinal lymph node sampling as the first invasive test in patients with suspected lung cancer with mediastinal lymphadenopathy without distant metastases, but there are no comparative effectiveness studies on how test sequencing impacts outcomes. Our objective was to compare practice patterns and outcomes of diagnostic strategies in patients with lung cancer. Retrospective cohort of 15,316 lung cancer patients with regional spread without distant metastases in the SEER or Texas Cancer Registry Medicare-linked databases. If the first invasive test involved mediastinal sampling patients were classified as guideline consistent, otherwise they were classified as inconsistent. We used propensity matching to compare the number of tests performed and multivariate logistic regression to compare the frequency of complications. 21% of patients had guideline consistent diagnostic evaluations. Among patients with NSCLC, 44% never had mediastinal sampling. Patients that had guideline consistent care required fewer tests than patients with guideline inconsistent care (p<0.0001), including thoracotomies (49% vs. 80%, p<0.001) and CT-guided biopsies (9% vs. 63%, p<0.001), although they had more transbronchial needle aspirations (37% vs. 4%, p<0.001). The consequence was that patients with guideline consistent care had fewer pneumothoraxes (4.8% vs. 25.6%, p<0.0001), chest tubes (0.7% vs. 4.9%, p<0.001), hemorrhages (5.4% vs. 10.6%, p<0.001) and respiratory failure events (5.3% vs. 10.5%, p<0.001). Guideline consistent care with mediastinal sampling first resulted in fewer tests and complications. We found three quality gaps: failure to sample the mediastinum first, failure to sample the mediastinum at all in NSCLC patients, and overuse of thoracotomy.Chest 10/2013; 145(2). DOI:10.1378/chest.13-1599 · 7.13 Impact Factor