Accuracy of lung cancer staging in the multidisciplinary team setting

Accurate staging of lung cancer is of utmost importance in determining the stage-appropriate treatment and prognosis. Imaging tests which include contrast-enhanced computed tomography (CT) examination of the chest to include the liver and adrenal glands and 18-fluoro-2 deoxyglucose positron emission tomography (PET)/CT scan facilitate the initial tumor node metastasis (TNM) staging of the disease and provide guidance on the optimal biopsy site and biopsy method. The diagnostic and staging approach should be tailored to the individual patient according to risk, benefit, patient preferences, and available expertise. Diagnosis and staging should preferably be accomplished with a single procedure or the least number of invasive procedures if more than one is needed. Ideally, centers managing lung cancer patients should have a multidisciplinary thoracic oncology board prescribing personalized evidence-based management tailored to each individual patient. Multidisciplinary team (MDT) meetings provide a platform for key experts from various disciplines to contribute specific advice on the management of each individual patient. As assessment of mediastinal lymph node involvement is an important component of lung cancer staging, optimal mediastinal staging can be achieved with a variety of techniques that can be discussed and performed by the various specialists in the MDT. Despite a relative paucity of quality evidence that MDT contributes to improvements in lung cancer survival outcomes, this approach has evolved to become the standard of care in many centers around the world. Thoracic MDT has resulted in more focused and timely investigations for histopathologic diagnosis and disease staging which translate into earlier treatment initiation. Moreover, there is increasing evidence that MDT care facilitates and allows access to investigations that lead to improved accuracy of tumor and nodal staging. However, there is still a paucity of evidence on the accuracy of lung cancer staging in the MDT setting.

Utility of PET for Radiotherapy Treatment Planning

PET imaging has contributed substantially in oncology by allowing improved clinical staging and guiding appropriate cancer management. Integration with radiotherapy planning via PET/computed tomography (CT) simulation enables improved target delineation, which is paramount for conformal radiotherapy techniques. This article reviews the present literature regarding implications of PET/CT for radiotherapy planning and management.

Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.

METHODS

Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

RESULTS

The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.

CONCLUSIONS

Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.