eMedicine Specialties > Radiology > Chest

Lung Cancer, Non-Small Cell: Follow-up

Author: Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Coauthor(s): Bruce Maycher, MD, Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor, Department of Radiology, University of Manitoba
Contributor Information and Disclosures

Updated: May 31, 2009

Intervention

Percutaneous transthoracic needle biopsy (PTNA) is used for the diagnosis of lung cancer.

Technique

The patient is prepared for percutaneous transthoracic needle biopsy prior to the procedure, and informed consent is obtained. Prothrombin time and platelet count tests are performed within the 2 weeks prior to the procedure. The relative contraindications for PTNA include patient inability to hold breath, patient inability to maintain certain body positions, underlying coagulopathy (internal normalized ratio >1.3, platelet count <50,000/cm3), severe chronic obstructive pulmonary disease, required mechanical ventilation, vascular lesion, pulmonary arterial hypertension, and bullae near the lesion.

The biopsy room should be equipped with oxygen, suction and oral and nasal airway machines, an AmbuBag, a Pleurovac, and a crash cart. An intravenous line is inserted in the patient, and blood pressure monitors (during and after the procedure), electrocardiogram leads, and an oxygen saturation monitor are attached. After localization of the lesion, the biopsy needle is introduced over the rib, and the specimen is obtained while the patient holds his or her breath. A core biopsy may also be performed with a cutting needle through the same puncture site.

Results

Expert support from a cytopathologist is essential for the preparation of samples and the interpretation of findings. The diagnostic yield is increased if quick on-site pathologic analysis is available at the time of biopsy to confirm the adequacy of the sample. Many investigators have reported a sensitivity of 90-95% with PTNA for the diagnosis of cancer. The accuracy is 100% in differentiating non–small cell carcinoma from small cell carcinoma. The yield for accurate diagnosis is lower for smaller and deeply situated lesions.

A negative result is unsatisfactory unless a specific benign diagnosis is established. Benign diagnoses include hamartoma, granuloma, an infectious organism, or fibrogranulation tissue. Patients who receive a benign diagnosis usually require periodic follow-up monitoring. Unfortunately, fewer than 40% of needle biopsies indicate a specific benign diagnosis.

Complications

The incidence of pneumothorax after needle biopsy has been reported to be 15-30%. Most pneumothoraces occur within the first hour after biopsy; however, a 4-hour chest radiograph must be obtained. Chest tube drainage is required in a minority (<15%) of patients.

Hemorrhage may occur in patients in 1-10% of transthoracic needle biopsy procedures. Hemorrhage is almost always self-limiting. Patients are cautioned to lay on the side of the hemorrhage to avoid spilling blood into the unaffected lung.

Systemic air embolism is an extremely rare complication of needle biopsy that occurs when air enters the pulmonary vein directly from the open needle. Rarely, placement of the needle may create a fistula between the alveolus and the vein. This is an extremely rare complication (0.012%) of transthoracic needle biopsy.

Postbiopsy management

Chest radiographs are recommended at 1- and 4-hour intervals after the biopsy is performed, unless the patient appears to be hypoxemic or unstable, in which case chest radiography should be performed immediately.

A small or asymptomatic pneumothorax may be followed at an interval of 2-4 hours with repeat chest radiography. If the pneumothorax remains stable and patient is asymptomatic, chest tube drainage is not required. In an enlarging pneumothorax (15-30% pneumothorax) or a symptomatic patient, a pneumothorax drainage catheter should be placed and connected to a Heimlich valve or Pleurovac system.

Medicolegal Pitfalls

  • The role of chest radiography in screening for lung cancer remains unanswered. Three large randomized trials demonstrated a decreased lung cancer mortality rate in the screening group, but none of these 3 centers had an untested control group.
  • The decision whether to observe the lesion, perform biopsy, or resect an indeterminate nodule remains unclear. Contrast-enhanced CT and PET scanning with FDG may improve the sensitivity and specificity in identifying malignant nodules.
  • CT scans are used extensively for staging non–small cell lung cancer; however, CT staging leads to either overestimated or underestimated staging in approximately 40% of patients. MRI can be helpful in identifying the relationship of the tumor to the central pulmonary artery, aorta, carina, and main bronchi.
  • MRI can better delineate invasion or abutment of the superior vena cava, central pulmonary arteries, pericardium, and heart.
  • Variability in interpretation is common, even among experienced radiologists.
  • Advantages of MRI over CT are such that it may be easier to distinguish lymph nodes from blood vessels due to their different signal intensities or attenuations, respectively. Enlargement of aortopulmonary window and subcarinal nodes may be better detected by using MRI scanning.
  • MRI is not able to depict calcification. Blood vessels with low flow may be misdiagnosed as lymph nodes or masses. Respiratory or other motion may cause blurring of images, leading to a missed diagnosis of lymphadenopathy.
  • Prevalence of mediastinal lymph node involvement with T1 lesion is 22% or less.

Special Concerns

  • Postpneumonectomy complications
    • After pneumonectomy, accumulation of pleural fluid gradually replaces the air in the surgical bed over time. Most of the air is reabsorbed within 2 weeks after pneumonectomy; residual air may persist for months or occasionally years.
    • Multiple air-fluid levels may also be seen within a few days following pneumonectomy and reflect loculation of fluid. Over time, ipsilateral shift of the mediastinum occurs, with elevation of the diaphragm, and the space is filled with fluid as well as some degree of fibrothorax. If shift occurs too rapidly, compromise of vascular or bronchial structures can lead to respiratory or circulatory instability.
    • Contralateral mediastinal shift may occur secondary to accumulation of air or fluid and may suggest one of several diagnoses, depending on the postpneumonectomy interval. Absence of a continuous rise in the air-fluid level in postpneumonectomy space suggests bronchial stump air leak. A decrease in the air-fluid level after an initial rise may indicate thoracentesis, chest tube drainage, leakage of fluid through dehiscence of thoracic incision, bronchial stump leak, or leak into the abdominal cavity through a diaphragmatic tear.
    • Pneumonectomy has a high mortality rate (5-10%). The causes of death include pneumonia, respiratory failure, pulmonary embolism, myocardial infarction, bronchopleural fistula, and empyema. The incidence of postpneumonectomy empyema varies from 2-5% and is often associated with bronchopleural fistula. Early postoperative empyema may be caused either by a preoperative pleural sepsis or by intraoperative contamination, while delayed onset of empyema connotes bronchopleural or bronchoesophageal pleural fistula.
  • Pancoast tumor
    • A Pancoast tumor (superior sulcus tumor) is a rare form (1%) of bronchogenic carcinoma that arises in the superior sulcus of the lung apex.
    • The most common tissue type is squamous cell carcinoma, but adenocarcinoma also may occur at this site.
    • These tumors often lead to invasion of the pleura and rib, producing shoulder pain that is often treated as musculoskeletal pain.
    • Involvement of the lower roots of brachial plexus cause arm pain and paresthesias in ulnar nerve distribution.
    • The tumor may spread to the sympathetic ganglion, leading to Horner syndrome, which manifests as ipsilateral enophthalmos, miosis, partial ptosis, and anhidrosis.
 


More on Lung Cancer, Non-Small Cell

Overview: Lung Cancer, Non-Small Cell
Imaging: Lung Cancer, Non-Small Cell
Follow-up: Lung Cancer, Non-Small Cell
Multimedia: Lung Cancer, Non-Small Cell
References
Further Reading
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Further Reading

Clinical guidelines
Cancer Care Ontario and American Society of Clinical Oncology adjuvant chemotherapy and adjuvant radiation therapy for stages I-IIIA resectable non-small-cell lung cancer guideline. American Society of Clinical Oncology - Medical Specialty Society
Cancer Care Ontario - State/Local Government Agency [Non-U.S.].  2007 Dec.  13 pages.  NGC:006052

Postoperative adjuvant radiation therapy in stage II or IIIA completely resected non-small cell lung cancer.
Program in Evidence-based Care - State/Local Government Agency [Non-U.S.].  1997 Sep 15 (revised 2005 Feb).  16 pages.  NGC:004124

Treatment of non-small cell lung cancer-stage IIIA: ACCP evidence-based clinical practice guidelines. (2nd Edition)
American College of Chest Physicians - Medical Specialty Society.  2003 Jan (revised 2007 Sep).  23 pages.  NGC:005935

Clinical trials

 Phase I Study of IV DOTAP: Cholesterol-Fus1 in Non-Small-Cell Lung Cancer

Gene-Expression Profiles in CNS-Metastatic Non-Small Cell Lung Cancer

Elderly Dependent Patients With Non Small Cell Lung Cancer (NSCLC)


Related eMedicine topics
Lung Cancer, Small Cell

Lung Cancer, Staging

Lung, Carcinoid

Lung, Metastases

Pancoast Syndrome



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Keywords

lung cancer, bronchogenic carcinoma, primary lung malignancy, small cell lung cancer, SCLC, non–small cell lung cancer, non–small-cell lung cancer, NSCLC, lung carcinoma, lung tumor, asbestos, smoking

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Contributor Information and Disclosures

Author

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Bruce Maycher, MD, Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor, Department of Radiology, University of Manitoba
Bruce Maycher, MD is a member of the following medical societies: American Roentgen Ray Society, Canadian Medical Association, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

Medical Editor

Kitt Shaffer, MD, PhD, Director of Undergraduate Medical Education, Associate Professor, Department of Radiology, Cambridge Health Alliance
Kitt Shaffer, MD, PhD is a member of the following medical societies: American Roentgen Ray Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

W Richard Webb, MD, Professor, Department of Radiology, University of California at San Francisco
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Barry H Gross, MD, Professor, Department of Radiology, University of Michigan Medical School; Professor, University of Michigan Cancer Center
Barry H Gross, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Michigan State Medical Society, Physicians for Social Responsibility, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

 
 
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