Chest
DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)Initial Diagnosis of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)
Section snippets
Recommendations
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In patients suspected of having SCLC based on the radiographic and clinical findings, it is recommended that the diagnosis be confirmed by the easiest method (eg, sputum cytology, thoracentesis, FNA, bronchoscopy including TBNA, endobronchial ultrasound [EBUS]-needle aspiration [NA], and esophageal ultrasound [EUS]-NA), as dictated by the patient's presentation. Grade of recommendation, 1C
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In patients suspected of having lung cancer who have an accessible pleural effusion, thoracentesis is
Diagnosis of Primary Tumor
A variety of techniques (eg, sputum cytology, flexible bronchoscopy [FB], and TTNA) are available as methods of achieving a definitive diagnosis. Positron emission tomography (PET) scanning has emerged as a helpful adjunct in both the diagnosis and staging of lung cancer.
The main goals in selecting a specific diagnostic modality are to (1) maximize the yield of the selected procedure for both diagnosis and staging and (2) to avoid unnecessary invasive tests for the patient, with special
Sputum Cytology
Key Question 1: What are the performance characteristics of sputum cytology for the diagnosis of lung cancer with special consideration for the location of the tumor?
Sputum cytology is the least invasive means of obtaining a diagnosis in a patient who is suspected of having lung cancer. The diagnostic accuracy of sputum cytology, however, is dependent on rigorous specimen sampling (at least three specimens) and preservation techniques, as well as on the location (central vs peripheral) and size
Recommendation
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In patients suspected of having lung cancer, who present with a central lesion with or without radiographic evidence of metastatic disease, in whom a semi-invasive procedure such as bronchoscopy or TTNA might pose a higher risk, sputum cytology is recommended as an acceptable method of establishing the diagnosis. However, the sensitivity of sputum cytology varies by the location of the lung cancer. It is recommended that further testing be performed with a nondiagnostic sputum cytology test if
FB
Key Question 2: What are the performance characteristics of FB and its ancillary procedures for the diagnosis of central (endobronchial) as opposed to peripheral tumors and to peripheral tumors < 2 cm and > 2 cm in size?
FB with its attendant procedures is a valuable diagnostic procedure in the workup of a patient suspected of having lung cancer. A comprehensive literature search on studies published from 1970 to 2001 was performed24 to determine the sensitivity of FB for the diagnosis of
Recommendations
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In patients suspected of having lung cancer who have a central lesion, bronchoscopy is recommended to confirm the diagnosis. However, it is recommended that further testing be performed if bronchoscopy results are nondiagnostic and suspicion of lung cancer remains. Grade of recommendation, 1C
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In expert hands, a radial probe US device can increase the diagnostic yield of FB while dealing with peripheral lesions of < 20 mm in size. Its use can be considered prior to referring the patient for TTNA.
TTNA
Key Question 3: What are the performance characteristics for TTNA as a diagnostic modality with particular emphasis on the size and location of the suspected cancer?
In the previously published lung cancer guidelines, Schreiber and McCrory24 analyzed data from a metaanalysis106 of 46 studies and an additional 19 studies107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125 that focused on the performance characteristics of TBNA or biopsy for the diagnosis
Recommendation
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In patients suspected of having lung cancer who have a small (< 2 cm) peripheral lesion, and who require tissue diagnosis before further management can be planned, TTNA is recommended. However, it is recommended that further testing be performed if TTNA results are nondiagnostic and suspicion of lung cancer remains. Grade of recommendation, 1B
Cell Type Accuracy
Key Question 4: What is the diagnostic error when differentiating between NSCLC and SCLC generated by various diagnostic techniques (eg, bronchoscopy, TTNA, and sputum cytology)?
In a patient with lung cancer, distinguishing between SCLC and NSCLC is of paramount importance as each of these cancers is treated in a radically different manner. The distinction between SCLC and NSCLC on sputum cytology, TTNA cytology, and bronchoscopic washings, brushings, and BAL cytology is quite reliable. Table 7
Recommendations
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In patients suspected of having lung cancer, the diagnosis of NSCLC made on cytology results (eg, sputum, TTNA, or bronchoscopic specimens) is highly reliable and can be accepted with a high degree of certainty. Grade of recommendation, 1B
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The possibility of an erroneous diagnosis of SCLC on a cytology specimen must be kept in mind if the clinical presentation or clinical course is not consistent with that of SCLC. In such a case, it is recommended that further testing (biopsy for histologic
Conclusion
A variety of techniques is available to assist the clinician in achieving a definitive diagnosis of lung cancer. Selection of the most appropriate test is best done in a multidisciplinary fashion with input from a pulmonologist, chest radiologist, and thoracic surgeon. Furthermore, the most appropriate test is usually determined by the type of lung cancer (SCLC or NSCLC), the size and location of the tumor, and the presumed stage of the cancer.
A diagnosis should be obtained by whatever method
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