The Bottom Line:
“The National Comprehensive Cancer Network (NCCN), the American College of Chest Physicians (ACCP, and the American Society of Clinical Oncology (ASCO)) have created guidelines for the diagnosis and treatment of lung cancer. They advise the following recommendations:
- Patients with a strong clinical suspicion of stage 1 or 2 lung cancer (based on risk factors and radiologic appearance) do not require a biopsy before surgery. A biopsy adds time, costs, and procedural risk and may not be needed for treatment decisions.
- A preoperative biopsy may be appropriate if a non-lung cancer diagnosis is strongly suspected that can be diagnosed by core biopsy or fine needle aspiration.
- A preoperative biopsy may be appropriate if an intraoperative diagnosis appears difficult or very risky. If a preoperative tissue diagnosis has not been obtained, then an intraoperative diagnosis (ie, wedge resection, needle biopsy) is necessary before lobectomy or pneumonectomy.
- Invasive mediastinal imaging is recommended before surgical resection for most patients with clinical stage 1 or 2 lung cancer.
- The preferred diagnostic strategy for an individual patient depends on the size and location of the tumor, the presence of mediastinal or distant disease, patient characteristics (such as pulmonary pathology and/or other significant comorbidities), and local experience and expertise.
- The least invasive biopsy with the highest yield is preferred as the first diagnostic study.
- Anatomic pulmonary resection is preferred for the majority of patients with NSCLC.
- Patients suspected of having the metastatic disease should have confirmation from one of the metastatic sites if feasible but should have a biopsy of the primary lung lesion or mediastinal lymph nodes if it is technically difficult or very risky to biopsy a metastatic site.
- Patients with metastatic disease should have the histologic subtype established with adequate tissue for molecular testing (including consideration for re-biopsy or plasma biopsy) to enable the best guidance for chemotherapy options.
- Decisions about the optimal diagnostic steps for suspected stage 1 to 3 lung cancer should be made by thoracic radiologists, interventional radiologists, interventional pulmonologists, and thoracic surgeons who devote a significant portion of their practice to thoracic oncology.
- A joint decision among a radiologist, a pulmonologist, and a medical or radiation oncologist is the desirable approach.
- In patients suspected of having small cell lung cancer (SCLC) based on radiographic and clinical findings, it is recommended that a pathologic diagnosis be confirmed by the least invasive method (sputum cytology, thoracentesis, fine needle aspiration (FNA), or transbronchial aspiration, as dictated by the patient’s presentation (Grade 1C).
- In patients suspected of having lung cancer who have a solitary extrathoracic site suspicious of metastasis, it is recommended that tissue confirmation of the metastatic site be obtained if an FNA or biopsy of the site is feasible (Grade 1C).
- In patients suspected of having lung cancer who have lesions in multiple distant sites suspected of metastases but in whom biopsy of a metastatic site would be technically difficult, it is recommended that diagnosis of the primary lung lesion be obtained by the least invasive method (Grade 1C).
- In patients suspected of having lung cancer with a peripheral lung nodule, when tissue diagnosis is required due to the uncertainty of diagnosis or poor surgical candidacy, radial EBUS is recommended as an adjunct imaging modality (Grade 1C). If radial EBUS is thought to be unlikely to achieve a diagnosis, then electromagnetic navigation guidance is recommended if the equipment and the expertise are available (Grade 1C). Remark: If electromagnetic navigation is not available, then percutaneous lung lesion biopsy is recommended.
- If specimens obtained initially are not adequate for histologic and molecular characterization, then pursuing a second biopsy is acceptable, given the importance of accurate tumor characterization.
- In the case of a small (less than 3 cm), solitary, peripheral lung lesion that is suspicious for lung cancer in a patient who appears to have early-stage disease and is a surgical candidate, the diagnostic dilemma generally centers around whether it is necessary to obtain a biopsy specimen to confirm the diagnosis of cancer before surgical resection is carried out. When the lesion is moderate to highly suspicious for lung cancer, surgical excision performed via thoracoscopy is the most definitive method of establishing a diagnosis and determining treatment. In nodules with an indeterminate likelihood of malignancy, sampling via percutaneous lung lesion biopsy or bronchoscopy with or without guidance technology (radial EBUS or electromagnetic navigation) may be considered.” (Young)
The Bottom Line 