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 viamediastinoscopy 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) Chapter 085. Neoplasms of the Lung (Part 9) Chest radiographs and CT scans are needed to evaluate tumor size andnodal involvement; old radiographs are useful for comparison. CT scans of thethorax and upper abdomen are of use in the preoperative staging of NSCLC todetect mediastinal nodes and pleural extension and occult abdominal disease (e.g.,liver, adrenal), and in planning curative radiation therapy. However, mediastinalnodal involvement should be documented histologically if the findings willinfluence therapeutic decisions. Thus, sampling of lymph nodes viamediastinoscopy or thoracotomy to establish the presence or absence of N2 or N3nodal involvement is crucial in considering a curative surgical approach forpatients with NSCLC with clinical stage I, II, or III disease, regardless of whetherthe PET is positive or negative. A preoperative mediastinoscopy may not need tobe done in patients with normal-size nodes (by CT) that are PET-negative, as thediscovery of micrometastases is unlikely to change the preoperative managementof the disease, although lymph node sampling should be done intraoperatively. Astandard nomenclature for referring to the location of lymph nodes involved withcancer has evolved (Fig. 85-1). Unless the CT-detected abnormalities areunequivocal, histology of suspicious extrathoracic lesions should be confirmed byprocedures such as fine-needle aspiration if the patient would otherwise beconsidered for curative treatment. In SCLC, CT scans are used in the planning ofchest radiation treatment and in the assessment of the response to chemotherapyand radiation therapy. Surgery or radiotherapy can make interpretation ofconventional chest x-rays difficult; after treatment, CT scans can provide goodevidence of tumor recurrence. Figure 85-1 Regional lymph node stations for lung cancer staging. (Used bypermission from CF Mountain, C Dresler: Chest 111:1718, 1997.) If signs or symptoms suggest involvement by tumor, brain CT or bonescans are performed, as well as radiography of any suspicious bony lesions. Anyaccessible lesions suspicious for cancer should be biopsied if involvement wouldinfluence treatment. In patients presenting with a mass lesion on chest x-ray or CT scan and noobvious contraindications to a curative approach after the initial evaluation, themediastinum must be investigated. Approaches vary among centers and includeperforming chest CT scan and mediastinoscopy (for right-sided tumors) ormediastinotomy (for left-sided lesions) on all patients and proceeding directly tothoracotomy for staging of the mediastinum. Patients who present with diseasethat is confined to the chest but not resectable, and who thus are candidates forneoadjuvant chemotherapy plus surgery or for curative radiotherapy with orwithout chemotherapy, should have additional tests done as indicated to evaluatespecific symptoms. In patients presenting with NSCLC that is not curable, all thegeneral staging procedures are done, plus fiberoptic bronchoscopy as indicated toevaluate hemoptysis, obstruction, or pneumonitis, as well as thoracentesis withcytologic examination (and chest tube drainage as indicated) if fluid is present. Asa rule, a radiographic finding of an isolated lesion (such as an enlarged adrenalgland) should be confirmed as cancer by fine-needle aspiration before a curativeattempt is rejected.