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Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Online Only Articles |

Methods for Staging Non-small Cell Lung CancerStaging Methods for NSCLC: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines FREE TO VIEW

Gerard A. Silvestri, MD, FCCP; Anne V. Gonzalez, MD; Michael A. Jantz, MD, FCCP; Mitchell L. Margolis, MD, FCCP; Michael K. Gould, MD, FCCP; Lynn T. Tanoue, MD, FCCP; Loren J. Harris, MD, FCCP; Frank C. Detterbeck, MD, FCCP
Author and Funding Information

From Medical University of South Carolina (Dr Silvestri), Charleston, SC; Montreal Chest Institute (Dr Gonzalez), McGill University Health Centre, Montreal, QC, Canada; the Division of Pulmonary, Critical Care, and Sleep Medicine (Dr Jantz), University of Florida, Gainesville, FL; the Pulmonary Section (Dr Margolis), Philadelphia VAMC, Philadelphia, PA; the Department of Research and Evaluation (Dr Gould), Kaiser Permanente Southern California, Pasadena, CA; the Section of Pulmonary and Critical Care Medicine (Dr Tanoue), and Yale University School of Medicine (Dr Detterbeck), New Haven, CT; and Maimonides Medical Center (Dr Harris), Brooklyn, NY.

Correspondence to: Gerard A. Silvestri, MD, FCCP, Medical University of South Carolina, 171 Ashley Ave, Room 812-CSB, Charleston, SC 29425; e-mail: silvestri@musc.edu


Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

COI Grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(5_suppl):e211S-e250S. doi:10.1378/chest.12-2355
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Background:  Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage. Several noninvasive imaging studies and invasive tests are available. Understanding the accuracy, advantages, and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making.

Methods:  Test accuracies for the available staging studies were updated from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines. Systematic searches of the MEDLINE database were performed up to June 2012 with the inclusion of selected meta-analyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

Results:  The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55% and 81%, respectively, confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis. For PET scanning, estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77% and 86%, respectively. These findings demonstrate that PET scanning is more accurate than CT scanning, but tissue biopsy is still required to confirm PET scan findings. The needle techniques endobronchial ultrasound-needle aspiration, endoscopic ultrasound-needle aspiration, and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89%, 89%, and 91%, respectively. In direct comparison with surgical staging, needle techniques have emerged as the best first diagnostic tools to obtain tissue. Based on randomized controlled trials, PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections.

Conclusions:  Since the last iteration of the staging guidelines, PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease. Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations. If negative, these needle techniques should be followed by surgical biopsy. All abnormal scans should be confirmed by tissue biopsy (by whatever method is available) to ensure accurate staging. Evidence suggests that more complete staging improves patient outcomes.

General Approach

2.1.1. For patients with either a known or suspected lung cancer who are eligible for treatment, a CT scan of the chest with contrast is recommended (Grade 1B).

Remark: If PET scan is unavailable for staging, the CT of the chest should be extended to include the liver and adrenal glands to assess for metastatic disease.

2.1.2. For patients with either a known or suspected lung cancer, it is recommended that a thorough clinical evaluation be performed to provide an initial definition of tumor stage (Grade 1B).

2.1.3. In patients with either a known or suspected lung cancer who have an abnormal clinical evaluation and no suspicious extrathoracic abnormalities on chest CT, additional imaging for metastases is recommended (Grade 1B).

Remark: Site specific symptoms warrant directed evaluation of that site with the most appropriate study.

Extrathoracic Staging

3.1.1. In patients with a normal clinical evaluation and no suspicious extrathoracic abnormalities on chest CT being considered for curative-intent treatment, PET imaging (where available) is recommended to evaluate for metastases (except the brain) (Grade 1B).

Remark: Ground glass opacities and an otherwise normal chest CT do not require a PET scan for staging.

Remark: In patients with peripheral stage cIA tumors a PET scan is not required.

Remark: If PET is unavailable, bone scan and abdominal CT are reasonable alternatives to evaluate for extrathoracic disease.

3.1.2. In patients with an imaging finding (eg, by PET) suggestive of a metastasis, further evaluation of the abnormality with tissue sampling to pathologically confirm the clinical stage is recommended prior to choosing treatment (Grade 1B).

Remark: Tissue sampling of the abnormal site is imperative so that the patient is not excluded from potentially curative treatment.

Remark: Tissue sampling of a distant metastatic site is not necessary if there is overwhelming radiographic evidence of metastatic disease in multiple sites.

Remark: Tissue sampling of the mediastinal lymph nodes does not necessarily need to be performed if there is overwhelming radiographic evidence of metastatic disease in multiple distant sites.

3.4.1. In patients with clinical stage III or IV non-small cell lung cancer (NSCLC) it is suggested that routine imaging of the brain with head MRI (or CT if MRI is not available) should be performed, even if they have a negative clinical evaluation (Grade 2C).

Mediastinal Staging

4.4.2.1. For patients with extensive mediastinal infiltration of tumor and no distant metastases, it is suggested that radiographic (CT) assessment of the mediastinal stage is usually sufficient without invasive confirmation (Grade 2C).

4.4.4.1. In patients with discrete mediastinal lymph node enlargement (and no distant metastases) with or without PET uptake in mediastinal nodes, invasive staging of the mediastinum is recommended over staging by imaging alone (Grade 1C).

4.4.4.2. In patients with PET activity in a mediastinal lymph node and normal appearing nodes by CT (and no distant metastases), invasive staging of the mediastinum is recommended over staging by imaging alone (Grade 1C).

4.4.4.3. In patients with high suspicion of N2,3 involvement, either by discrete mediastinal lymph node enlargement or PET uptake (and no distant metastases), a needle technique (endobronchial ultrasound [EBUS]-needle aspiration [NA], EUS-NA or combined EBUS/EUS-NA) is recommended over surgical staging as a best first test (Grade 1B).

Remark: This recommendation is based on the availability of these technologies (EBUS-NA, EUS-NA or combined EBUS/EUS-NA) and the appropriate experience and skill of the operator.

Remark: In cases where the clinical suspicion of mediastinal node involvement remains high after a negative result using a needle technique, surgical staging (eg, mediastinoscopy, video-assisted thoracic surgery [VATS], etc) should be performed.

Remark: The reliability of mediastinal staging may be more dependent on the thoroughness with which the procedure is performed than by which test is used.

4.4.6.1. In patients with an intermediate suspicion of N2,3 involvement, ie, a radiographically normal mediastinum (by CT and PET) and a central tumor or N1 lymph node enlargement (and no distant metastases), invasive staging of the mediastinum is recommended over staging by imaging alone (Grade 1C).

4.4.6.2. In patients with an intermediate suspicion of N2,3 involvement, ie, a radiographically normal mediastinum (by CT and PET) and a central tumor or N1 lymph node enlargement (and no distant metastases), a needle technique (EBUS-NA, EUS-NA or combined EBUS/EUS-NA) is suggested over surgical staging as a best first test (Grade 2B).

Remark: This recommendation is based on the availability of these technologies (EBUS-NA, EUS-NA or combined EBUS/EUS-NA) and the appropriate experience and skill of the operator.

Remark: In cases where the clinical suspicion of mediastinal node involvement remains high after a negative result using a needle technique, surgical staging (eg, mediastinoscopy, VATS, etc) should be performed.

Remark: The reliability of mediastinal staging may be more dependent on the thoroughness with which the procedure is performed than by which test is used.

4.4.8.1. For patients with a peripheral clinical stage IA tumor (negative nodal involvement by CT and PET), it is suggested that invasive preoperative evaluation of the mediastinal nodes is not required (Grade 2B).