Chapter 085. Neoplasms of the Lung (Part 9) ppsx

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.