Ca Lung : Work-Up And DiagnosisBySyed Ali Raza

History & Examination History :

The work up starts right from taking an accurate history.Symptoms may be referable to Primary dis. In chestMetastatic diseaseOr Paraneoplastic manifestations Or Patient may be entirely asymptomatic and present as an incidental radiologic finding.History of smoking is most important.

Examination :Physical examination should be directed at determining whether there is metastatic disease which would provide staging information as well as in case of superficial cutanous lymph node involvement allow for easier biopsy.Particular attention toHead and neck for concomitant cancersLymph nodes in supraclavicular fossa,neck and axillaAbdomen for hepatomegaly.

Chest Radiographs Chest X-ray P.A view and lateral view

are the most important first modality towards diagnosis.If mass is present old x ray films should be obtained for comparison.Persistent infiltrates are suggestive of cancers.

CT Scan Of The Chest And Abdomen : Through the level of Adrenal glands.

Ct scan has overall accuracy of 70 % .It provides information regarding extent of invasion of primary tumor,presence of pleural effusion,and Lymph node status.

Mediastinal Nodes are generaly considered abnormal when larger than 1.5 cm in diameter and normal when smaller than 1.0 cm : between these two limits are indeterminate.

Adrenal masses :Unsuspected adrenal masses are common in NSCLC . Non-malignant masses are also common (adrenal adenomas) .These can be distinguished on density characteristics on CT or MRI. If diagnosis is unclear and adrenal is the only site of metastasis then biopsy is indicated.

Also advised is CT scan of The brain and Abdomen for staging purpose.

If the probability of lung cancer is high (e.g., >80%), it is generally more efficient to proceed with evaluation of the stage than confirmation of the diagnosis.Frequently, this will identify a necessary procedure that will serve both to confirm the stage as well as the diagnosis. For example, biopsy of a potential solitary metastasis or of a suspicious mediastinal node can confirm both the stage and diagnosis.

When the probability of cancer is intermediate (i.e., about 5% to 65%), PET imaging can be helpful in defining a management algorithm.PET does not definitively establish the diagnosis; therefore, it is only helpful when it alters the probability of lung cancer sufficiently to justify either proceeding with a biopsy or observation.

There are also situations in which the reliability of the clinical diagnosis is less certain; this occurs most frequently in the case of a localized, solitary pulmonary nodule (SPN). A SPN is defined as a solitary lesion <3 cm in diameter, surrounded by normal lung, and not associated with other abnormalities in the thorax, such as lymphadenopathy or pleural effusion. These nodules are usually found as incidental findings on imaging studies done for other reasons.

Histology : Before proceeding further diagnosis of

cancer must be obtained histologically.Start from least invasive procedure always.Sputum Cytology :Repeated sputum cytology is positive in only 60% to 80 % of centrally located NSCLC and 15% to 20% of peripheral NSCLC.3 samples should be taken with intervals.

Indication :If patient is symptomatic or radiologic evidence indicates a central and accesible cancer or nodal disease.It also rules out endobronchial lesions from a second bronchogenic Ca.Bronchoscopy is unnecessary if histologic or cytologic diagnosis of metastatic lung ca has already been made.

Percutanous Lung biopsy

Indication and Uses Widely used for a peripheral located

lesion not approachable by bronchoscopy to establish histological diagnosis.(a lesion in 1/3 lateral portion of a lung is called as peripheral lesion)

Lymph Nodes: Enlarged,hard,peripheral lymph nodes

represent potential site for biopsy.Blind biopsies of suprclavicular lymph nodes are positive for cancers in less than 5 % cases.

STAGING : Clinical stage (identified by a “c” prior to the

stage group) is determined by all information available before any definitive treatment. This may involve merely a simple history and physical examination, may include imaging studies, or may involve invasive biopsies or surgical procedures with sampling the primary tumor, intrathoracic lymph nodes, pleural fluid, or extrathoracic sites. Pathologic staging (identified by a “p” prior to the stage group) is determined only if surgical resection with intent to cure is performed.

Staging Work Up The Staging work up includes

Ct-ScanPositron Emission Tomography (PET) ScanMediastinoscopyPercutanous and transbronchial biopsyBone Scan

PET Scan : Superior to Ct-Scan and is complimentary to

mediastinoscopy in the evaluation of mediastinal nodes.Most useful in excluding distant occult metastasis.In re-staging after a pre-operative therapy I.e. Chemotherapy or radiotherapy or in follow up. Currently PET-CT Scans are becoming available and can accurately stage patients.

CT-Brain Ct-brain should be obtained as part of

the routine staging for Any patient showing clinical signsAll patients with SCLC (associated with 10% incidence of Brain mets).And for stage III or IV NSCLC who are under consideration for aggressive multimodaity thearpy or chemotherapy.

-For routine pre-operative staging of NSCLC.-In Patients with mediastinal masses ,negative sputum cytology and negative bronchoscopy.-To evaluate mediastinal lymphadenopathy.-Re-staging after preoperative chemotherapy or CCRT in patients with stage III NSCLC based on pathologic documentation of N2 positive lymph nodes.

Bone scan has largely suplemented by PET Scan.It’s a less expensive modality and is advised in cases where PET scan is too costly for the non-affording patient.Also provide information in a patient with know metastatic disease in whom new bone involvement is suspected.

NCCN GuidelinesFor Lung BIOPSY : Patients with a strong clinical suspicious of stage I or II

don’t require a biopsy before surgery.

A pre-operative biopsy may be appropriate- if a non-lung cancer diagnosis is suspected-if intraoperative diagnosis is very dificult or risky.

If a pre-operative diagnosis is not made then an intraopertaive diagnosis is must before lobectomy,bilobectomy or pneumonectomy .

FOR BRONCHOSCOPY : Bronchoscopy should be performed during a

planned surgical procedure then as a separate procedure.Bronchoscopy is required before a surgical resection.A pre-opertaive bronchoscopy is appropriate-if a central tumor requires a pre-resection evaluation for biopsy-for surgical planing(potential resection)-for pre-operative airway preparation.

FOR Mediastinoscopy: Invasive mediastinal staging is

recommended before surgical resection for most patients with clinical stage I or II.It should be done in the planned resection as initial step rather than as a separate procedure.Pre-operative invasive mediastinoscopy is appropriate for clinical suspicion of N2 or N3 or when intraoperative cytology or frozen section is not available.