Chapter 085. Neoplasms of the Lung (Part 9)

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Chest radiographs and CT scans are needed to evaluate tumor size and nodal involvement; old radiographs are useful for comparison. CT scans of the thorax and upper abdomen are of use in the preoperative staging of NSCLC to detect mediastinal nodes and pleural extension and occult abdominal disease (e.g., liver, adrenal), and in planning curative radiation therapy. However, mediastinal nodal involvement should be documented histologically if the findings will influence therapeutic decisions. Thus, sampling of lymph nodes via mediastinoscopy or thoracotomy to establish the presence or absence of N2 or N3 nodal involvement is crucial in considering a curative surgical...

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Chapter 085. Neoplasms of the Lung (Part 9) Chest radiographs and CT scans are needed to evaluate tumor size and nodal involvement; old radiographs are useful for comparison. CT scans of the thorax and upper abdomen are of use in the preoperative staging of NSCLC to detect mediastinal nodes and pleural extension and occult abdominal disease (e.g., liver, adrenal), and in planning curative radiation therapy. However, mediastinal nodal involvement should be documented histologically if the findings will influence therapeutic decisions. Thus, sampling of lymph nodes via mediastinoscopy or thoracotomy to establish the presence or absence of N2 or N3 nodal involvement is crucial in considering a curative surgical approach for patients with NSCLC with clinical stage I, II, or III disease, regardless of whether the PET is positive or negative. A preoperative mediastinoscopy may not need to be done in patients with normal-size nodes (by CT) that are PET-negative, as the discovery of micrometastases is unlikely to change the preoperative management of the disease, although lymph node sampling should be done intraoperatively. A
standard nomenclature for referring to the location of lymph nodes involved with cancer has evolved (Fig. 85-1). Unless the CT-detected abnormalities are unequivocal, histology of suspicious extrathoracic lesions should be confirmed by procedures such as fine-needle aspiration if the patient would otherwise be considered for curative treatment. In SCLC, CT scans are used in the planning of chest radiation treatment and in the assessment of the response to chemotherapy and radiation therapy. Surgery or radiotherapy can make interpretation of conventional chest x-rays difficult; after treatment, CT scans can provide good evidence of tumor recurrence. Figure 85-1
Regional lymph node stations for lung cancer staging. (Used by permission from CF Mountain, C Dresler: Chest 111:1718, 1997.)
If signs or symptoms suggest involvement by tumor, brain CT or bone scans are performed, as well as radiography of any suspicious bony lesions. Any accessible lesions suspicious for cancer should be biopsied if involvement would influence treatment. In patients presenting with a mass lesion on chest x-ray or CT scan and no obvious contraindications to a curative approach after the initial evaluation, the mediastinum must be investigated. Approaches vary among centers and include performing chest CT scan and mediastinoscopy (for right-sided tumors) or mediastinotomy (for left-sided lesions) on all patients and proceeding directly to thoracotomy for staging of the mediastinum. Patients who present with disease that is confined to the chest but not resectable, and who thus are candidates for neoadjuvant chemotherapy plus surgery or for curative radiotherapy with or without chemotherapy, should have additional tests done as indicated to evaluate specific symptoms. In patients presenting with NSCLC that is not curable, all the general staging procedures are done, plus fiberoptic bronchoscopy as indicated to evaluate hemoptysis, obstruction, or pneumonitis, as well as thoracentesis with cytologic examination (and chest tube drainage as indicated) if fluid is present. As a rule, a radiographic finding of an isolated lesion (such as an enlarged adrenal gland) should be confirmed as cancer by fine-needle aspiration before a curative attempt is rejected.