Chest
Volume 132, Issue 3, Supplement, September 2007, Pages 131S-148S
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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Initial Diagnosis of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)

https://doi.org/10.1378/chest.07-1357Get rights and content

Background

Lung cancer is usually suspected in individuals who have an abnormal chest radiograph finding or have symptoms caused by either local or systemic effects of the tumor. The method of diagnosis of suspected lung cancer depends on the type of lung cancer (ie, small cell lung cancer [SCLC] or non-SCLC [NSCLC]), the size and location of the primary tumor, the presence of metastasis, and the overall clinical status of the patient.

Objectives

To determine the test performance characteristics of various modalities for the diagnosis of suspected lung cancer.

Methods

To update previous recommendations on the initial diagnosis of lung cancer, a systematic search of MEDLINE, Healthstar, and Cochrane Library databases to July 2004, and print bibliographies was performed to identify studies comparing the results of sputum cytology, bronchoscopy, transthoracic needle aspiration (TTNA), or biopsy with histologic reference standard diagnoses among at least 50 patients with suspected lung cancer. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the lung cancer panel prior to approval by the Thoracic Oncology Network, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physician.

Results

Sputum cytology is an acceptable method of establishing the diagnosis of lung cancer with a pooled sensitivity rate of 0.66 and specificity rate of 0.99. However, the sensitivity of sputum cytology varies by location of the lung cancer. For central, endobronchial lesions, the overall sensitivity of flexible bronchoscopy (FB) for diagnosing lung cancer is 0.88. The diagnostic yield of bronchoscopy decreases for peripheral lesions. Peripheral lesions smaller or larger than 2 cm in diameter showed a sensitivity of 0.34 and 0.63, respectively. In recent years, endobronchial ultrasound (EBUS) has shown potential in increasing the diagnostic yield of FB while dealing with peripheral lesions without adding to the risk of the procedure. In appropriate situations, its use can be considered before moving on to more invasive tests. The pooled sensitivity for TTNA for the diagnosis of lung cancer is 0.90. A trend toward lower sensitivity was noted for lesions < 2 cm in diameter. The accuracy in differentiating between SCLC and NSCLC cytology for the various diagnostic modalities was 0.98, with individual studies ranging from 0.94 to 1.0. The average false-positive rate and FN rate were 0.09 and 0.02, respectively.

Conclusions

The sensitivity of bronchoscopy is high for the detection of endobronchial disease and poor for peripheral lesions < 2 cm in diameter. Detection of the latter can be aided with the use of EBUS in the appropriate clinical setting. The sensitivity of TTNA is excellent for malignant disease. The distinction between SCLC and NSCLC by cytology appears to be accurate.

Section snippets

Recommendations

  • 1

    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

  • 2

    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

  • 7

    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

  • 8

    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

  • 9

    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

  • 10

    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

  • 11

    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

  • 12

    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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