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

The following is 2017 TNM classification of lung cancer.

T: Primary Tumor

T	Description
TX	Primary tumor cannot be assessed. OR Tumor is demonstrated by the presence of malignant cells in bronchial washings or sputum, but is not visualized by imaging or bronchoscopy.
T0	There is no evidence of primary tumor.
Tis	Carcinoma in situ
T1	The tumor has the following characteristics: T1a: tumor ≤1 cm in the largest diameter. T1b: tumor> 1 cm, but ≤2 cm in the largest diameter. T1c: tumor> 2 cm, but ≤3 cm in the largest diameter. AND The tumor is surrounded by lung or visceral pleura AND The tumor does not extend to the main bronchus as demonstrated by the absence of bronchoscopic evidence of invasion more proximal than the lobar bronchus.
T2	The tumor has the following characteristics: T2a: tumor> 3 cm, but ≤4 cm in the largest diameter. T2b: Tumor> 4 cm, but ≤5 cm in the largest diameter. The tumor involves the main bronchus, 2 cm or more distal to the carina. OR The tumor invades the visceral pleura. OR There is evidence of atelectasis or obstructive pneumonitis that extends to the hilar region without the involvement of the entire lung.
T3	Tumor > 5 cm, but ≤ 7 cm in size. AND It directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium. OR The tumor is localized in the main bronchus at a distance less than 2 cm distal to the carina but without the involvement of the carina. OR There is evidence of associated atelectasis or obstructive pneumonitis of the entire lung.
T4	Tumor > 7 cm in size. The tumor invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina OR There is/are separate tumor nodule(s) in the same lobe. OR The tumor is associated with malignant pleural effusion.

N:Regional Lymph Nodes

T	Description
NX	the regional lymph nodes cannot be assessed.
N0	There is no evidence of regional lymph node metastasis.
N1	Metastasis in ipsilateral peribronchial and/or ipsilateral hilum or intrapulmonary lymph nodes N1a - A lymph node invasion. N1b - > 1 lymph node affected.
N2	There is metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s). N2a1 - One lymph node infested without lymph node involvement of an N1-defined lymph node station. N2a2 - One lymph node infested with a lymph node of an N1-defined lymph node station N2b - > 1 lymph node affected
N3	There is metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s).

M: Distant Metastasis

T	Description
MX	Distant metastasis cannot be assessed.
M0	There is no evidence of distant metastasis.
M1	There is evidence of distant metastasis which includes the presence of separate tumor nodule(s) in a different lobe (ipsilateral or contralateral). M1a - Tumor foci separated from the primary tumor in a contralateral lung lobe; Tumor with pleural metastases or malignant pleural or pericardial effusion M1b - Simple metastases in an organ M1c - Multiple metastases in one organ or one or more metastases in more than one organ

Classification of Lung Cancer by Staging

Stage	T	N	M
Occult carcinoma	TX	N0	M0
Stage 0	Tis	N0	M0
Stage IA1	T1(mi)/T1a	N0	M0
Stage IA2	T1b	N0	M0
Stage IA3	T1c	N0	M0
Stage IB	T2a	N0	M0
Stage IIA	T2b	N0	M0
Stage IIB	T1a	N1	M0
	T1c	N1	M0
	T2a	N1	M0
	T2b	N1	M0
	T3	N0	M0
Stage IIIA	T1a	N2	M0
	T1b	N2	M0
	T1c	N2	M0
	T2a	N2	M0
	T2b	N2	M0
	T1a	N2	M0
	T1b	N2	M0
	T1c	N2	M0
	T2a	N2	M0
	T2b	N2	M0
	T3	N1	M0
	T4	N0	M0
	T4	N1	M0
Stage IIIB	T1a	N3	M0
	T1b	N3	M0
	T1c	N3	M0
	T2a	N3	M0
	T2b	N3	M0
	T1a	N3	M0
	T1b	N3	M0
	T1c	N3	M0
	T2a	N3	M0
	T2b	N3	M0
	T3	N2	M0
	T4	N2	M0
Stage IIIC	T3	N3	M0
	T4	N3	M0
Stage IVA	Any T	Any N	M1a
	Any T	Any N	M1b
Stage IVB	Any T	Any N	M1c