Workup/Staging

Question 1

What is the initial workup for a pt suspected of having lung cancer?

Answer 1

Lung cancer initial workup: H&P + focus on weight loss >5% over prior 3 mos, KPS, tobacco Hx, neck exam for N3 Dz, CBC, CMP, CT chest to include adrenals, PET/CT scan, MRI brain for presumed stages II–III, MRI for paraspinal/sup sulcus tumors, Dx of lung cancer rendered by Bx via transbronchial endoscopic or transthoracic FNA (intraop preferred), mediastinoscopy or EBUS for suspected hilar or N2 nodes, PFTs prior to Tx, and smoking cessation counseling

Question 2

What is the most cost effective 1st step in a pt presenting with a new lung lesion on CXR or CT?

Answer 2

Obtain prior imaging for comparison.

Question 3

What are the 3 most common presenting Sx of NSCLC?

Answer 3

Dyspnea, cough, and weight loss (others include chest pain and hemoptysis)

Question 4

What is the sensitivity and specificity of sputum cytology for Dx of lung cancer?

Answer 4

Sensitivity <70%, specificity >90%. Accuracy increases with increasing # of specimens analyzed. At least 3 sputum specimens are recommended for the best accuracy.

Question 5

What is the sensitivity and specificity of FDG-PET compared to CT for the staging of lung cancers?

Answer 5

PET: sensitivity 83%, specificity 91%

CT: sensitivity 64%, specificity 74%

Question 6

What is the estimated % of pts who will have false+ N2 nodes based on PET/CT?

Answer 6

10%–20%. PPV >80%. +N2 nodes by PET/CT need pathologic confirmation before deferring to potentially curative Sg.

Question 7

What is the estimated % of pts who will have false– N2 nodes based on PET/CT?

Answer 7

5%–16%. NPV >95%. –N2 nodes by PET/CT for clinical T1 lesions may not need mediastinoscopic evaluation (this is controversial).

Question 8

What is the rate of occult mets from lung cancer detected by FDG-PET?

Answer 8

In many series, the range is ∼6%–18%.

Question 9

If a PET scan is being ordered, should a bone scan be obtained to evaluate for bone mets as well?

Answer 9

No. In NSCLC, PET is just as sensitive as bone scan but more specific. However, consider pathologic confirmation for solitary PET+ lesions given the risk of a false+.

Question 10

What clinical characteristics are important to focus on to determine the nature of a solitary pulmonary nodule?

Answer 10

Nodule size (and whether there are changes in size in the past 2 yrs), Hx of smoking, age, and nodule margin on CT (i.e., spiculation)

Question 11

Stage for stage, does adenocarcinoma or SCC has a worse prognosis? Why?

Answer 11

Adenocarcinoma. It has a greater propensity to metastasize, particularly to the brain.

Question 12

Does large cell carcinoma have a natural Hx and prognosis more similar to SCC or adenocarcinoma?

Answer 12

Large cell carcinoma has a natural Hx and prognosis more similar to adenocarcinoma.

Question 13

Describe the T staging of NSCLC using the AJCC 8th edition (2017).

Answer 13

T1: ≤3 cm, surrounded by lung parenchyma (T1a ≤1 cm; T1b 1.1–1.9 cm; T1c 2.0–2.9 cm)

T2: >3 but ≤5 cm, + visceral pleura, main bronchus (not carina), +atelectasis of lobe (T2a 3.1–3.9 cm; T2b 4.0–4.9 cm)

T3: >5 but ≤7 cm, tumor invading invasion to CW, pericardium, phrenic nerve or separate tumor nodule in same lobe

T4: >7 cm any size, invading mediastinum, diaphragm, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, or with separate tumor nodules in a different ipsi lung lobe

Question 14

Describe the N staging of NSCLC using AJCC 8th edition (2017).

Answer 14

N1: ipsi hilar or pulmonary nodes

N2: ipsi mediastinal or subcarinal nodes

N3: any SCV/scalene nodes or contralat mediastinal/hilar nodes

Question 15

What is the AJCC 8th edition (2017) of the TNM stage for malignant pleural/pericardial nodules/effusion or opposite lung tumor nodules in NSCLC?

Answer 15

Malignant pleural/pericardial nodules/effusion or opposite lung tumor nodules in NSCLC is characterized as M1a.

Question 16

According to AJCC 8th edition (2017), is a single brain mets to the brain stage the same as a brain mets and a bone mets? What about 2 brain mets?

Answer 16

A single extrathoracic mets (1 brain met) is M1b, while multiple extrathoracic mets (in 1 organ or >1 organ) is M1c. A brain and bone met or 2 brain mets would both be M1c.

Question 17

According to AJCC 8th edition (2017), what is the nodal subclassification?

Answer 17

N1: N1a-Single station N1 involvement, N1b-Multiple station N1 involvement; N2a1-single station N2 without N1 involvement (skip), N2a2-single station N2 with N1 involvement, N2b-multiple station N2 involvement; N3-N3 LN involvement

Question 18

What is considered early-stage NSCLC? Categorize the appropriate TNM stratification according to AJCC 8th edition.

Answer 18

Stages I and II are considered early-stage NSCLC.

Stage IA1: T1aN0

Stage IA2: T1bN0

Stage IA3: T1cN0

Stage IB: T2aN0

Stage IIA: T2bN0

Stage IIB: T1N1, T2N1 or T3N0

Question 19

What procedures prior to thoracotomy can be used to evaluate the following nodal stations: (1) left and right stations 2, 4, and 7; (2) stations 5–6?

Answer 19

1. Mediastinoscopy to evaluate left and right stations 2, 4, and 7 or EBUS to evaluate left and right stations 2, 3, 4, 7, and 10
2. VATS or ant mediastinotomy (Chamberlain procedure) for stations 5–6

Question 20

When should pre-Tx mediastinal nodal assessment be done?

Answer 20

As per NCCN 2018, bronchoscopy and pathologic mediastinal staging should be done for stage IB (peripheral T2a, N0), stage I (central T1ab–2a, N0), stage II (T1ab–2ab, N1; T2b, N0) or T3N0.

To confirm PET or CT + nodes
All sup sulcus tumors
If T3 or central T1–T2 lesions

Question 21

What routine PFT results (FEV1 and DLCO) indicate that the pt needs further testing prior to undergoing resection?

Answer 21

If the FEV1 is <80% predicted for the age and size of the pt or the DLCO is <80% predicted, then the pt may need quantitative lung scans/exercise testing to carefully predict postop pulmonary function.

Question 22

What is the min absolute FEV1 necessary for pneumonectomy and lobectomy?

Answer 22

Pneumonectomy: >2 L

Lobectomy: Postop >1.0 L

Any patient with <1.5L capacity may be a candidate for wedge resection. The marginal % FEV1 for Sg is 40% of the predicted value.

Question 23

Which subsets of lung cancer pts are at high risk for surgical morbidity?

Answer 23

Subsets at high risk for surgical morbidity:

pCO2 >45 mm Hg (hypercapnia controversial)
pO2 <50 mm Hg
Preop FEV1 <40% of predicted value
Poor exercise tolerance
DLCO <40% of predicted value (desired >60%)
Postop FEV1 <0.71 or <30% of predicted value
Cardiac problems (left ventricle ejection fx <40%, MI within 6 mos, arrhythmias)
Obesity

Question 24

What are some factors that predict for postop complications (i.e., mortality, infection)?

Answer 24

Active smoking (6 times higher), poor nutrition, advanced age, and poor lung function. It is advised that pts should quit smoking for at least 4 wks prior to resection and have a nutrition evaluation.

Question 25

What % of lung cancer pts clinically at stage I are upstaged at Sg?

Answer 25

5%–25% of stage I lung cancer pts are upstaged at Sg.

Question 26

In addition to stage, name 3 other poor prognostic factors in lung cancer pts.

Answer 26

Poor prognostic factors in lung cancer:

1. KPS <80%
2. Weight loss >5% in 3 mos (10% in 6 mos)
3. Age >60 yrs