The future in diagnosis and staging of lung cancer: surgical techniques

Surgical techniques remain central to the diagnosis and staging of lung cancer. Clinical situations which invoke the role of surgery include the diagnosis of solitary pulmonary masses, staging of the mediastinum, restaging of the mediastinum and the assessment of resectability. The techniques available include cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy and different procedures for intra-operative mediastinal lymph node assessment including systematic nodal dissection, lobe-specific nodal dissection and sentinel node mapping. The staging of lung cancer is continuously evolving as technological advances combine with clinical advances to better stratify patients into treatment and prognostic categories and alter pre-operative investigation algorithms. Although most of the surgical techniques have been around for many years, it is their application in future which is likely to change. The increasing use of positron emission tomography/computed tomography fusion imaging is raising the proportion of patients being shown to have additional lesions that could contraindicate surgical treatment but which require tissue confirmation to exclude a false-positive examination. Many such lesions are amenable to the expanding techniques available to the interventional endoscopist. The relationship between the surgeon and the endoscopist must become closer to ensure that the appropriate technique is used at each point in the patient's pathway. The future of surgical techniques will be driven by: (1) developments in screening and imaging, with a likelihood that more early stage cancers will present and may be amenable to minimally invasive surgical approaches with the possibility of a role for robotics and nanotechnology; (2) improvements in neoadjuvant therapies which will demand flawless mediastinal staging and restaging; (3) advances in molecular biology which, whilst currently requiring that surgery provide samples of tumour and lymph node tissue to fully characterize the disease, do hold the promise that ever smaller amounts of tissue will be required and that eventually the genetic fingerprint will provide a biological ultrastaging to perhaps supersede anatomical staging.     

Imaging techniques for diagnosis and staging of lung cancer

Noninvasive imaging modalities continue to offer opportunities in the diagnosis and staging of lung cancer. Positron emission tomography with fluorodeoxyglucose imaging in lung cancer represents an important, new, and accurate tool in the armamentarium of the radiologist. Computed tomography scanning, MR imaging, and PET play a significant role in the selection of patients for curative lung cancer surgery, decreasing the number of unnecessary thoracotomies. The imaging modalities also help to direct the choice of appropriate invasive and surgical procedures.     

The future in diagnosis and staging of lung cancer: positron emission tomography

Since its introduction in 1974, positron emission tomography (PET) has gained widespread use, especially in diagnosis and staging of lung cancer. In this respect, (18)F-fluorodeoxyglucose (FDG) is by far the most used PET tracer exploiting the increased glucose uptake and metabolism in malignant cells. A large number of studies have suggested that addition of FDG-PET to conventional workup can improve diagnosis and staging in patients with non-small cell lung cancer (NSCLC). In meta-analysis, the sensitivity and specificity of PET in diagnosing single pulmonary nodules and masses is found to be 96 and 78%, respectively. In mediastinal staging, the sensitivity and specificity of PET is estimated to be 83 and 92%. In order to achieve high diagnostic values from PET, it is necessary to pay attention to a number of pitfalls, e.g., the uptake of FDG by inflammatory cells causing false-positive results, as well as size and histology of the tumour in order to avoid false-negative results. In 2001, the first integrated PET/computed tomography (CT) was installed, and since then, the use of this modality has expanded steadily, thereby decreasing examination time and overcoming the lack of anatomical details on PET. Recently, PET and PET/CT have become increasingly integrated in therapy planning and evaluation: response evaluation during and after chemotherapy, restaging after neoadjuvant therapy, planning of radiotherapy and detection of recurrent disease are all examples of emerging indications for PET and PET/CT in managing patients with lung cancer.     

Bronchoscopy and needle biopsy techniques for diagnosis and staging of lung cancer

Lung cancer is the leading cause of cancer deaths in the United States. The individual therapeutic approach and prognosis depends on accurate diagnosis and staging. Flexible bronchoscopy (FB) and transthoracic needle biopsy (TNB) are the most widely used techniques for this purpose. This article provides a critical overview of indications, diagnostic yield, and limitations of bronchoscopy and TNB in the diagnosis of lung cancer.     

The future of bronchoscopy in diagnosing, staging and treatment of lung cancer

Bronchoscopy is a central technique in diagnosing lung cancer, but also in different therapeutic approaches. A lot of techniques are available. The most common indication for bronchoscopy is for tissue sampling and determining the extent of lung cancer. Established diagnostic techniques are forceps biopsy, aspiration or brush cytology sampling, or needle aspiration. Laser therapy, electrocautery, cryotherapy and stenting are well-described techniques for the palliation of symptoms due to airway involvement in patients with advanced stages. Newer technologies, with an established role in clinical practice, are endobronchial ultrasound, autofluorescence bronchoscopy, and electromagnetic navigation. Other technologies, such as magnification, narrow-band imaging and confocal fluorescence microendoscopy, are in development for the use within the airways.     

The radiologic staging of lung cancer.

The radiographic evaluation and staging of bronchogenic carcinoma remains one of the greatest challenges to the thoracic radiologist and one of his or her most important responsibilities. With lung cancer now the most common malignant tumor in both men and women, there will be a continued need for radiologists to guide clinicians to the appropriate diagnostic and staging procedures, to help plan curative surgery, and to assess the response to therapy or progression of disease. The article reviews the radiographic approach to lung cancer diagnosis and staging with an emphasis on the use of computed tomography and magnetic resonance imaging for the evaluation of the primary tumor and mediastinal and hilar lymph node metastases.     

Bronchoscopy for the diagnosis and staging of lung cancer

Bronchoscopy is an invaluable tool utilized for the diagnosis, staging, and management of lung cancer. Advancements in computer technology and engineering have allowed for the emergence of newer modalities to evaluate endobronchial, parenchymal, and mediastinal pathology. Established techniques such as white light video bronchoscopy and its ancillary procedures (forceps biopsy, brush biopsy, bronchoalveolar lavage, bronchial washings, and transbronchial needle aspiration) are discussed here, with their accuracy described in relation to tumor location, size, and type. Newer technologies such as autofluorescence bronchoscopy, narrow band imaging, endoscopic ultrasound, endobronchial ultrasound, electromagnetic navigation, optical coherence tomography, and confocal fluorescent laser microscopy are introduced and put into perspective. Special emphasis has been placed on their role in the early detection and staging of lung cancer. Some technology requires further study to delineate its role in the disease, whereas other modalities are emerging as the new gold standard in evaluation of lung cancer. The future holds great promise with further miniaturization of equipment and improvements in computer processing power that may allow for in vivo pathological evaluation of abnormal tissue.     

Advances in lung cancer diagnosis and staging: endobronchial ultrasound

Background:  Endobronchial ultrasound (EBUS) is an accurate and relatively less invasive procedure for the diagnosis of lung lesions and mediastinal lymph node staging for lung cancer. We aimed to evaluate the clinical utility and safety of this new EBUS service established in our hospital.
Methods:  Consecutive patients who underwent EBUS–transbronchial lung biopsy (EBUS–TBLB) for biopsy of peripheral pulmonary lesions or for transbronchial needle aspiration (TBNA) of mediastinal lymph node enlargement were included in this audit. Demographic and clinical data were obtained prospectively. Diagnostic yield from the results of EBUS was compared to other clinical information obtained.
Results:  Thirty-eight patients underwent EBUS over a 10-month period. The yield from EBUS–TBLB was 62%. The average size of the lung lesions biopsied was 3.5 cm and 62% were located in the upper lobes. Malignancy was diagnosed in 14 cases and a benign aetiology in four. The yield from EBUS–TBNA was 88% and the average size of the lymph nodes was 2.3 cm. The lymph nodes were all located in the subcarinal station except for two that were in the lower paratracheal station. Malignancy was diagnosed in 10 cases on TBNA and 4 cases had benign pathology. There was one complication seen (small pneumothorax).
Conclusion:  EBUS is safe and an effective method for both, diagnosis of peripheral pulmonary lesions and staging for lung cancer.     

非小细胞肺癌规范化的诊断和分期治疗

据报道,非小细胞肺癌(NSCLC)约占所有肺癌的85%～88%,约85%肺癌死亡可归因于NSCLC.对NSCLC进行正确的诊断分期和针对性治疗十分必要.     

Transbronchial needle aspiration in the diagnosis and staging of lung cancer

OBJECTIVES: This study was aimed to determine effects of transbronchial needle aspiration (TBNA) in diagnosis and staging of lung cancer. METHODS: Records of 55 patients who underwent TBNA in our Chest Department from February 2002 to December 2004 were reviewed retrospectively. RESULTS: Out of 55 patients who had undergone TBNA, 30 were diagnosed to have lung cancer after complete work up. Transbronchial needle aspiration was positive for malignant cells in 12 out of 20 lung cancer patients with mediastinal lymphadenopathy on computed tomographic scan (CT scan) of the thorax. Mediastinoscopy was positive for malignancy in three cases and the remaining five had bulky lymph node enlargement which was considered malignant, given the histologic diagnosis established by other methods. Transbronchial needle aspiration was also positive for two other patients who had lymph nodes less than 1 cm size. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of TBNA in the diagnosis of lung cancer patients were 58%, 100%, 100%, 37% and 66%, respectively. CONCLUSIONS: The study demonstrates that TBNA is an efficient procedure in the diagnosis and staging of lung cancer. The diagnostic yield is increased when there is lymph node enlargement on CT scan of the thorax and reduces the need for mediastinoscopy.     

Radiologic staging of lung cancer.

Preoperative tumor staging in patients with known or suspected non-small cell lung cancer is generally performed using contrast enhanced chest computed tomography (CT) (including the adrenal glands). Abdominal CT is generally unnecessary, given the low frequency of isolated liver metastases. The role of MRI is limited, and it is used mainly as a problem solving tool in certain specific situations. A CT showing no mediastinal lymph node enlargement usually oviates preoperative mediastinal lymph node sampling, with certain exceptions. If enlarged mediastinal lymph nodes are demonstrated at CT, then CT may be used to direct preoperative lymph node sampling via transbronchoscopic Wang needle biopsy, mediastinoscopy, mediastinotomy, or video assisted thoracoscopy.     

正电子发射体层成像在肺癌诊断和分期中的价值

目的了解正电子发射体层成像(PET)在肺癌诊断和分期中的价值。方法收集1998年9月至2003年4月间行PET和CT检查,且诊断明确的肺部疾病患者的临床资料,对PET和CT检查结果与病理检查结果进行对比分析。结果在此期间共收集104例患者,其中肺癌64例(60%),肺部良性疾病40例(40%)。肺癌患者PET的标准摄取比值(SUV值)中位值为4.5(1.2～11.7),明显高于良性患者的1.0(0～7.7);且肺癌患者的SUV值与肺癌组织学类型、分化程度、临床分期和病灶大小均无关(P>0.05)。PET诊断肺癌的敏感性、特异性和准确性分别为88%、85%和87%;CT的敏感性、特异性和准确性分别为73%、28%、57%,PET的特异性和准确性显著高于CT(P<0.05)。对于胸腔淋巴结转移诊断的敏感性、特异性和准确性CT:N1期分别为33%、73%、59%,N2期分别为80%、79%、79%,N3期特异性及准确性均为97%;PET:N1期分别为33%、82%、65%,N2期分别为60%、83%、85%,N3期特异性及准确性均为85%;两者差异无统计学意义(P>0.05)。结论PET在鉴别肺内病灶良恶性质上有优势,对胸腔内淋巴结转移的诊断要结合CT结果综合判断。     

Case studies in the diagnosis and staging of non-small cell lung cancer

Lung cancer is the most common cause of cancer death in men and women. While overall survival rates remain dismal, survival for early stage disease approaches 70%. Expedient, accurate staging is vital to ensure timely resection of all potentially curable disease. Conversely, accurate staging is important in preventing unnecessary surgery. While a negative clinical evaluation has a high negative predictive value, many clinicians routinely order conventional imaging to exclude distant metastases. In this article, five case vignettes are presented to demonstrate the international system for staging lung cancer, including the most recent modifications. Various tumor characteristics and patterns of lymph node involvement are explored to demonstrate the subtleties of staging. The accuracy of various diagnostic modalities in the evaluation for mediastinal and distant metastasis is discussed.     

氟脱氧葡萄糖F18正电子发射体层摄影术在肺癌诊断及分期中的价值

目的　探讨氟脱氧葡萄糖F18正电子发射体层摄影术(18FFDGPET)在肺癌诊断及分期中的价值。方法　94例疑诊为肺部肿瘤的患者进行了CT、18FFDGPET全身或局部检查,并对这些患者手术切除及活检的组织标本及痰液、胸腔积液的细胞标本进行了病理学检查。18FFDGPET图像分析采取单纯标准摄取值(SUV)法及目测与SUV值结合两种方法进行。SUV值法判定标准为:SUV值>25为恶性病灶,SUV值≤25为良性病灶;目测与SUV值结合法:根据病灶18FFDG摄取量与纵隔血池结构相比,并考虑SUV值、病变大小、形态及病史资料做出诊断。以病理及试验性治疗结果为确诊标准,分别计算18FFDGPET及CT在病变的定性、纵隔淋巴结转移、全身远端转移方面的敏感性、特异性、准确性、阳性预测值及阴性预测值,同时对18FFDGPETSUV值法与目测结合SUV值法的诊断效能进行比较。结果　(1)确诊情况:本组58例患者肺部病灶经组织病理学或细胞病理学检查证实为恶性;36例经病理检查或试验治疗证实为良性。(2)定性诊断:CT对肺部肿块定性诊断的敏感性、特异性、准确性、阳性及阴性预测值分别为:69%、65%、68%、82%、49%;18FFDGPET单纯SUV法分别为91%、89%、90%、93%和87%,目测+SUV值法分别为95%、94%、95%、97%和92%。(3)纵隔淋巴结转移:34例病理证实有纵隔淋巴结转移     

针型胸腔镜在晚期肺癌病理学诊断和分期中的价值

目的 探讨针型胸腔镜活检术在晚期肺癌病理学诊断和分期中的临床应用价值。方法 对经胸部螺旋CT和磁共振(MRI)检查临床诊断为Ⅲa～Ⅳ期肺癌，行痰、胸液细胞学和纤维支气管镜等检查，未能获得病理诊断的94例患，施行针型胸腔镜肺内原发病灶、纵隔淋巴结、肺内和胸壁转移病灶组织活检术。结果 94例患中89例经针型胸腔镜取得病理学标本，成功率为95％；术后病理均诊断为肺癌，其中腺癌47例，鳞癌23例，腺鳞癌12例，小细胞肺癌7例。经胸腔镜活检病理检查后，15例(17％)肺癌患病理分期得到更正；4例发生气胸，11例出现轻度皮下气肿，2例出现少量咯血；89例患术后8～18个月均获随访并行螺旋CT检查，无胸壁针道的肺癌种植性转移。结论 对常规检查方法不能明确病理诊断和病理分期的晚期肺癌患，针型胸腔镜活检术可作为一种有效的确诊手段。     

Diagnosis and staging of lung cancer

Lung cancer is the biggest cancer killer among men and women in the United States. Lung cancer can present in a myriad of ways and the goal of prompt diagnosis and staging requires that the clinician be able to knowledgeably choose from a variety of tools available for such purpose. Review of some of these tools and general strategies with regard to staging is provided. Many new technologies are becoming available and much evaluation needs to be done before their proper roles become well defined. Little has changed with regard to staging of small cell lung cancer in recent years. The International System for Staging Non-Small-Cell Lung Cancer was revised for a second time in 1997. Although the revisions have largely corrected the shortcomings of the 1985 version, some controversies persist. Whenever possible, a multidisciplinary approach to diagnosis, staging, and therapy should be utilized. This should include incorporating the services of the pulmonologist, the thoracic surgeon, the medical oncologist, the radiologist, the radiation therapist, the pathologist, the respiratory therapist, and the social worker.