This document provides guidance on evaluating and diagnosing lung cancer through history, physical examination, imaging, and biopsy. It discusses using chest x-rays, CT scans of the chest and abdomen, PET scans, and biopsies via sputum cytology, bronchoscopy, or percutaneous lung biopsy to establish a diagnosis and stage the cancer. Proper staging involves determining if the cancer has spread to lymph nodes, organs like the brain or bone. The document recommends following NCCN guidelines for determining when biopsies, bronchoscopy, or mediastinoscopy are needed before or as part of surgery.

1. Ca Lung :
Work-Up And
Diagnosis
By
Syed Ali Raza

2. History & Examination
 History :
The work up starts right from taking an
accurate history.
Symptoms may be referable to
Primary dis. In chest
Metastatic disease
Or Paraneoplastic manifestations
Or Patient may be entirely asymptomatic and
present as an incidental radiologic finding.
History of smoking is most important.

3.  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 to
Head and neck for concomitant cancers
Lymph nodes in supraclavicular fossa,neck and
axilla
Abdomen for hepatomegaly.

4. 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.

7. 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.

8.  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.

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

11.  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.

12.  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.

13.  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.

15. 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.

19.  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.

20. Percutanous Lung biopsy

21. 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)

22. 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.

23. 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.

24. Staging Work Up
 The Staging work up includes
Ct-Scan
Positron Emission Tomography (PET) Scan
Mediastinoscopy
Percutanous and transbronchial biopsy
Bone Scan

25. 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.

26. CT-Brain
 Ct-brain should be obtained as part of
the routine staging for
Any patient showing clinical signs
All 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.

28.  -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.

30.  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.

32. NCCN Guidelines
For 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 .

33. 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.

34. 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.