eMedicine Specialties > Radiology > Chest

Lung Cancer, Non-Small Cell

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
Bruce Maycher, MD, Director of Pulmonary Radiology, St Boniface General Hospital; Associate Professor, Department of Radiology, University of Manitoba

Updated: May 31, 2009

Introduction

Background

Worldwide, bronchogenic carcinoma is the most common cause of cancer death in both men and women. In the US, approximately one third of cancer deaths occur as a consequence of lung cancer, and approximately 170,000 new cases of lung cancer occur annually. The 5-year survival rate is 14%, and it has largely remained unchanged for decades. Lung cancer kills more people than colorectal, breast, and prostate cancers combined. Approximately 45% of lung cancer cases occur in women, and in North America, the number of deaths resulting from lung cancer has surpassed the number of deaths resulting from breast cancer.

Non–small cell lung cancer. Bronchoscopy. A large central lesion was diagnosed as non–small cell carcinoma.

Non–small cell lung cancer. Left upper collapse is almost always secondary to endobronchial bronchogenic carcinoma.

Approximately 20% of malignant tumors of the lung are due to small cell carcinoma. At presentation, small cell lung cancer is almost always metastatic to the mediastinal lymph nodes or distantly; therefore, the treatment is combination chemotherapy.^1,2,3,4

Non–small cell cancer requires meticulous staging, because the treatment and prognosis vary widely depending on the stage. In non–small cell lung cancer, surgical resection offers patients the best chance for survival. Surgery may be curative for stage I and stage II disease; however, only a minority of patients (20-25%) have disease at these stages. Patients with stage IIIA disease may be candidates for surgical resection. In patients with stage IIIB disease, the tumors usually are considered unresectable. Patients with stage IV disease have distant metastases and are offered nonsurgical treatment, with the exception of rare cases of resectable solitary metastasis in a patient who also has a resectable primary lesion.

Most patients with stage I and stage II disease require preoperative or intraoperative mediastinal dissection for accurate staging prior to lung resection. The overall surgical mortality rate following lung resection is 3.7%. The mortality rate is higher (6-9%) in patients requiring pneumonectomy and in patients older than 70 years. The overall 5-five year survival rate may depend on whether the tumor is stage T1 or stage T2. The overall 5- and 10-year survival rates are 75% and 67%, respectively, in patients who undergo resection for stage I disease.

Patients with stage IA (T1 N0) disease have a significantly higher survival rate (82% at 5 y) compared with those with stage IB (T2 N0) disease (68% at 5 y and 60% at 10 y).⁵ Patients with stage IIA (T1 N1) tumors have a survival rate of approximately 50% at 5 years, whereas patients with stage IIB (T2 N1 and T3 N0) tumors have a 40% survival rate. Patients with stage IIIA (T1 or T2 N2) tumors have been reported to have a 5-year survival rate of 29%. The 5-year survival rate in patients with complete resection of stage IIIB tumors is 49% in T3 N0 disease, 27% in T3 N1 disease, and 15% in T3 N2 tumors. For patients with stage IV disease, the median survival is 8.5-21 weeks, and the 1-year survival rate is 10%.

The overall 5-year survival rate is grim because most patients with non–small cell lung cancer present with locally advanced or metastatic disease. Approximately 65-80% of patients present with unresectable disease. At present, the National Cancer Institute and other medical associations and regulatory bodies do not recommend early screening for lung cancer as part of a periodic health examination.

A number of studies are currently under way to find improved treatments for non-small cell lung cancer.^6,7,8

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education articles Lung Cancer, Bronchoscopy, Understanding Lung Cancer Medications, and Non-Small-Cell Lung Cancer.

Pathophysiology

Bronchogenic carcinoma is the most common cancer and the most common cause of cancer-related death in both men and women. Risk factors for lung cancer include the following:

• Cigarette smoking: Smoking increases the risk of bronchogenic carcinoma by 4-120 times. In some patients, the risk may return to normal levels 15 years after they stop smoking, but most patients continue to have a lifelong risk higher than that of individuals who do not smoke.
• Exposure to asbestos: Asbestos exposure increases the risk 4- or 5-fold, or as much as 100-fold if the exposed individual is also a smoker.
• History of interstitial lung disease: As many as 6-12% of patients with idiopathic pulmonary fibrosis develop bronchogenic carcinoma (adenocarcinoma).
• Exposure to toxic agents: Agents such as arsenic, nickel (squamous cell carcinoma), chromium, and chloromethyl ether (small cell carcinoma) increase the risk.
• Exposure to uranium or radon: Exposure to breakdown products of uranium increases the risk of non–small cell more than small-cell carcinoma of the lungs.
• Prior lung cancer: Approximately 10-32% of patients who survive resection for lung cancer may develop a second primary lung tumor.
• Lung disease: The presence of concomitant chronic obstructive pulmonary disease is a risk factor for lung cancer.
• HIV infection: In patients with HIV infection, the risk of non–small cell lung carcinoma is increased by 6.5 times. Patients with HIV infection and a history of smoking may develop bronchogenic carcinoma at a relatively young age (<50 y).

Frequency

United States

In 2005, 20,129 men and 69,078 women in the United States died of lung cancer, and 107,416 men and 89,271 women were diagnosed with lung cancer. Nationally from 1991 to 2005, the incidence of lung cancer decreased 1.8% a year in men but increased 0.5% a year in women.^9,10

Lung cancer accounts for about 15% of all new cancers. During 2009, there will be about 219,440 new cases of lung cancer (116,090 among men and 103,350 among women).¹¹

International

Mortality for women in the US is one of the highest in the world. Compared to men in some other countries, mortality in men in the US is lower than that in men in other countries.⁹

Mortality/Morbidity

In 2005, 20,129 men and 69,078 women in the United States died of lung cancer, and 107,416 men and 89,271 men were diagnosed with lung cancer. From 1991 to 2005, the incidence of lung cancer nationally decreased 1.8% a year in men but increased 0.5% a year in women.^9,10,11

Race

Among men in the United States, lung cancer is the second most common cancer among white, black, Asian/Pacific Islander, American Indian/Alaska Native, and Hispanic men.⁹

Among women in the United States, lung cancer is the second most common cancer among white, black, and American Indian/Alaska Native women, and it is the third most common cancer among Asian/Pacific Islander and Hispanic women.⁹

Sex

Nationally, trends have shown a marked increase in cancer incidence among women.¹² From 1991 to 2005, the incidence of lung cancer decreased 1.8% a year in men but increased 0.5% a year in women.

Age

The percentage of men who will develop lung cancer on the basis of age over the next 10, 20, and 30 years, respectively, has been projected as follows: 30 years of age (0.03%; 0.21%; 1%); 40 years of age (0.19%; 0.99%; 3.15%); 50 years of age (0.83%; 3.07%; 6.22%); 60 years of age (2.43%; 5.84%; 7.72%); 70 years of age (4.08; 6.33; not determined).¹³

The percentage of women who will develop lung cancer on the basis of age over the next 10, 20, and 30 years, respectively, has been projected as follows: 30 years of age (0.03%; 0.21%; 0.83%); 40 years of age (0.18%; 0.81%; 2.47%); 50 years of age (0.64%; 2.33%; 4.70%); 60 years of age (1.78%; 4.26%; 5.69%); 70 years of age (2.80; 4.40; not determined).¹³

Anatomy

The relative frequency of lung cancer is 3:2 in the right lung, as compared with the left lung, and in the upper lobe, as compared with the lower lobe. Squamous cell carcinomas occur predominantly in a central location, whereas adenocarcinoma presents in approximately 50% of patients as a peripheral lesion. Tumors arising endobronchially are located in segmental or lobar bronchi. Fewer than 4% of cancers arise in the apex of the upper lobes, and fewer than 1% arise from the trachea.

TNM classification

• The primary tumor (T) is classified according to its size and local invasion.
  • T1 - A tumor less than or equal to 3 cm in its greatest dimension, surrounded by lung or visceral pleura, without involvement of the main bronchus
  • T2 - A tumor with any of the following features:
    • Larger than 3 cm in largest dimension
    • Involvement of the mainstem bronchus more than 2 cm from the carina
    • Invades the visceral pleura
    • Associated with atelectasis or postobstructive pneumonitis extending to the hilar region but not involving the entire lung
  • T3 - A tumor of any size with any of the following features:
    • Tumor (including superior sulcus tumors) directly invading the chest wall, diaphragm, mediastinal pleura, or parietal pericardium
    • Tumor in the main bronchus less than 2 cm distal to the carina (but without involvement of the carina)
    • Tumor associated with atelectasis or obstructive pneumonitis of the entire lung
  • T4 - A tumor of any size with any of the following features:
    • Tumor invading the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina
    • Any tumor with a malignant pleural or pericardial effusion
    • Any tumor with satellite tumor nodules within the ipsilateral primary tumor lobe of the lung
  • Additional T descriptions that rarely are used include the following:
    • TX - Inability to assess a primary tumor (presence of malignant cells in sputum or bronchial washings but not visualized by imaging studies or bronchoscopy)
    • T0 - No evidence of a primary tumor
    • TIS - Carcinoma in situ
• The regional lymph node status (N) is also used to classify the tumor.
  • N0 - No regional lymph node metastasis
  • N1 - Ipsilateral peribronchial or hilar nodal metastases or intrapulmonary nodes involved by direct extension of the primary tumor
  • N2 - Ipsilateral mediastinal and subcarinal, midline prevascular, and retrotracheal nodes
  • N3 - Contralateral mediastinal or contralateral hilar nodal metastases, ipsilateral or contralateral scalene or supraclavicular nodes
  • NX - Additional N description rarely used, means regional lymph nodes cannot be assessed
• Distant metastasis (M) descriptions classify the tumor according to location of metastases.
  • M0 - No distant metastasis
  • M1
    • Distant metastasis or separate tumor nodules in other lobes of same lung
    • Tumor nodules in the contralateral lung (considered M1 if of the same histologic cell type as the primary lesion; tumor of different cell type in contralateral lung is considered a synchronous primary lesion)
  • MX - Additional M description in which the presence of distant metastasis cannot be assessed

Staging classification

Clinical staging is shown in Image 10.

Non–small cell lung cancer. Comparative characteristics of the primary tumor are shown in the vertical columns. Horizontal columns refer to lymph node involvement. The different stages are color coded and can be found at the intersection of appropriately matched horizontal and vertical columns. Stages with unique characteristics, such as stages 0 and IV, are defined in separate boxes. Courtesy of Lababede et al (Chest 1999; 115(1): 233-5).

Presentation

Squamous cell carcinoma

Squamous cell carcinoma accounts for 30-40% of cases of bronchogenic carcinoma, and it has a strong association with smoking. The lesion is usually located centrally, and among all bronchogenic carcinomas, it is most likely to cavitate. Squamous cell carcinomas grow intraluminally and are least likely to metastasize distantly (<20% of cases at presentation). The mode of spread is direct extension to the local lymph nodes. Squamous cell carcinomas are commonly associated with clubbing and hypertrophic osteoarthropathy. Hypercalcemia is also commonly observed secondary to a parathormone-like peptide created by the tumor. Tumors of squamous histology can sometimes elicit a sarcoid reaction in nodes, resulting in nodal enlargement without metastatic spread.

Adenocarcinoma

Adenocarcinoma occurs with a frequency of 30-40%, which has surpassed the incidence of squamous cell carcinoma. The lesion is located peripherally in approximately one half of cases, and it is associated with smoking. Adenocarcinoma may arise from a previous scar; it rarely cavitates; and an eccentric pattern of calcification may be evident. An early propensity is noted of metastases to the lymph nodes, pleura, adrenal glands, central nervous system (CNS), and bone.

Bronchoalveolar cell carcinoma

Bronchoalveolar cell carcinoma is a subtype of adenocarcinoma that accounts for as many as 5% of bronchogenic carcinomas. Although an association with smoking has not been established, a substantial percentage of patients have a significant smoking history. The incidence of bronchoalveolar cell carcinoma is increased in patients who have underlying interstitial lung disease, parenchymal scarring, and exogenous lipoid pneumonia.

Bronchoalveolar cell carcinoma is classified as mucinous and nonmucinous on the basis of histopathologic features. The mucinous variety is most common (80%) and arises from columnar mucus-containing cells. The mucinous variety is likely to be multicentric; it occasionally appears with bronchorrhea; and it has a worse prognosis. The nonmucinous form arises from type II pneumocytes or Clara cells; it is more likely to be localized; and it has a better prognosis. Bronchoalveolar carcinoma may spread to other sites or the other lung by means of transbronchial spread called aerogenous spread. These tumors can also demonstrate growth along the pulmonary interstitium without destroying lung architecture. This is called lepidic growth. In comparison, both types of growth are associated with a worse prognosis.

Bronchoalveolar carcinoma may appear in a variety of ways, including a solitary pulmonary nodule (45%), multiple nodules (25%), and consolidation (30%). Presentation as a solitary pulmonary nodule is associated with the best prognosis. Nodules can be sharp or poorly defined, and they may be cavitated. In 30% of patients, an associated pleural effusion is noted, as well as hilar or mediastinal lymphadenopathy.

Large cell carcinoma

Large cell carcinomas account for only 5-10% of bronchogenic carcinomas and are strongly associated with cigarette smoking. The lesion occurs peripherally and grows rapidly, with early metastases and a poor outcome. A subtype of large cell carcinoma is giant cell carcinoma. This is highly malignant and associated with a poor prognosis.

Clinical manifestations

The symptoms of non–small cell carcinoma can be secondary to the following:

• Local bronchopulmonary disease – Cough and hemoptysis
• Spread of tumor to adjacent structures – Chest pain
• Distant metastases - Bone pain, jaundice, seizures, or neurologic symptoms
• Constitutional effects – Fatigue, anorexia, and weight loss
• Paraneoplastic syndromes

Paraneoplastic syndromes associated with bronchogenic carcinoma

• Hypercalcemia
• Ectopic adrenocorticotropic hormone production
• Syndrome of inappropriate secretion of antidiuretic hormone
• Eaton-Lambert syndrome (peripheral neuropathy with myasthenia-like symptoms)
• Acanthosis nigricans
• Hypertrophic osteoarthropathy

Superior sulcus or Pancoast tumor may involve the subclavian vein, the phrenic or vagus nerve, the subclavian artery, the recurrent laryngeal nerve, and/or the sympathetic chain. The symptoms may depend on the structure involved and include arm pain, weakness of the shoulder and arm, arm swelling, and Horner syndrome. Constitutional symptoms can include malaise, weakness, fever, and weight loss.

International staging system for lung cancer

The international staging system for lung cancer provides a common framework for treatment options and prognostication in patients with bronchogenic carcinoma. The staging system is derived from the TNM classification scheme in which T indicates the primary tumor, N indicates the regional lymph nodes, and M indicates the distant metastasis; the 4 stage groups I-IV.

Table. Radiologic Findings by Tumor Histologic Type

Patients with limited chest wall invasion and no evidence of distant metastases are considered potentially curable (stage IIIA). MRI may be slightly more accurate than CT in determining the extent of chest wall invasion. The treatment of choice is radiation therapy followed by surgery or radiation therapy alone for patients with unresectable lesions. The following criteria usually indicate an unresectable lesion:

• Tumor invasion of the great vessels at the thoracic inlet (most commonly the subclavian artery because of its location)
• Phrenic or recurrent laryngeal nerve paralysis
• Invasion of the vertebral bodies, trachea, or esophagus

Preoperative radiation therapy is used to reduce tumor size 3-6 weeks prior to surgery. Surgery involves en bloc resection of the chest wall.

Preferred Examination

In a malignancy such as bronchogenic carcinoma, early detection can lead to surgical resection of the lesion and cure. Unfortunately, to date, the use of radiologic modalities has not proven successful in reducing mortality rates. For screening of non–small cell carcinoma of the lung, chest radiography may result in improved survival, although a mortality benefit cannot be demonstrated.

On the basis of results from the Mayo Lung Project and a Czechoslovakian study, the American Cancer Society does not recommend routine mass screening for the detection of lung cancer. However, early stage detection, resectability, and survival improve with chest radiographic screening in high-risk populations. Studies have shown that low-dose helical CT scan of the thorax may detect lesions at an earlier stage and, therefore, may potentially improve resectability, survival, and mortality rates.

Radiologic manifestations of bronchogenic carcinoma include obstructive pneumonitis or atelectasis, lung nodule or mass, apical mass, cavitated mass, or nodule or mass associated with lymphadenopathy. Chest radiography is a readily available, inexpensive, and useful imaging modality in the workup of patients with non–small cell carcinoma. Therefore, chest radiography is used most often as an initial investigation.

Invariably, other investigations such as CT scanning are required for better delineation of the abnormality detected on plain radiographs. CT can also be helpful in excluding a benign lesion and in preoperative staging. CT of the chest is an important informative tool that helps in detailed imaging of the primary tumor and its anatomic relationship to other structures, and it provides information with respect to the size of mediastinal lymph nodes and the status of the pleural space. However, CT criteria for adenopathy are based on size alone and do not always accurately reflect the presence or absence of tumor metastases. CT can best be thought of as a technique that provides a roadmap for more accurate surgical staging.

The roles of MRI and positron emission tomography (PET) scan are not as well defined. MRI may be superior to CT in the assessment of the chest wall invasion by apical tumors. The use of PET scanning is expanding rapidly.

PET scanning may be useful in the assessment of solitary pulmonary lung nodules. Several studies indicate that PET scanning appears to be valuable in deciding whether a nodule is benign or malignant, as well as in staging locoregional and distant metastatic disease. In some centers, PET/CT scanners are available to allow more precise anatomic localization.

Limitations of Techniques

Chest radiography remains the primary means of radiographic assessment of lung carcinoma. However, 12-30% of lung cancers are missed on chest radiographs.¹⁴ A nodule smaller than 2-3 mm may not be detected by using chest radiographs, and overlapping soft tissue opacities may hide small endobronchial lesions. Chest radiographs depict indirect signs of endobronchial lesions such as obstructive pneumonia or atelectasis. These signs may well be secondary to benign tumors or mucus plugging or a foreign body. In a solitary lung nodule, probability of malignancy is approximately 40% overall; therefore, a nodule identified on a chest x-ray requires further diagnostic workup to exclude lung cancer.

The advantage of CT scanning in non–small cell lung cancer is that it can be used to distinguish tumor from surrounding atelectatic lung. CT scans may be helpful in demonstrating superior vena cava compression, pericardial effusion, and lymphangitic dissemination in several other conditions. A major limitation of CT scanning is the inability to distinguish invasion from simple approximation to adjacent structures.

In staging of non–small cell carcinoma, CT has several limitations. Normal-sized mediastinal lymph nodes may contain microscopic metastatic deposits that are subsequently identified on thoracotomy in as many as 20% of patients. Similarly, enlarged inflammatory nodes may be falsely characterized as metastases in as many as 20% of patients.

The sensitivity and specificity of CT in detecting metastatic mediastinal lymph node involvement is in the range of 70-80%. CT scanning may have further limitations in distinguishing stage IIIA disease from stage IIIB disease. In a peripheral TI lesion, CT probably does not contribute, because chest radiography appears to be sufficient. CT is also limited in evaluating the extent of endobronchial abnormalities. CT may also be limited in evaluating and staging apical lung tumors.

Differential Diagnoses

Other Problems to Be Considered

Lung abscess

Radiography

Non–small cell lung cancer. Bronchoscopy. A large central lesion was diagnosed as non–small cell carcinoma.

Non–small cell lung cancer. Left pleural effusion and volume loss secondary to non–small cell carcinoma of the left lower lobe. The pleural effusion was sampled and found to be malignant; therefore, the lesion is inoperable.

Non–small cell lung cancer. Left upper collapse is almost always secondary to endobronchial bronchogenic carcinoma.

Non–small cell lung cancer. Complete left lung collapse secondary to bronchogenic carcinoma of left mainstem bronchus.

Non–small cell lung cancer. A cavitating right lower lobe squamous cell carcinoma.

Non–small cell lung cancer. Patient has right lower lobe opacity. This is not well circumscribed and was found to be a squamous cell carcinoma.

Non–small cell lung cancer. Right upper lobe lesion diagnosed as adenocarcinoma on percutaneous biopsy.

Non–small cell lung cancer. Right upper lobe collapse with the S sign of Golden secondary to underlying non–small cell carcinoma of the bronchus.

Findings

On chest radiography, the findings of non–small cell lung carcinomas are varied and considered in the differential diagnosis of many disorders. The most common findings are described below.

• Bronchial stenosis
  • Bronchial stenosis and poststenotic changes are common because most non–small cell carcinomas demonstrate intraluminal growth. Narrowing of the main bronchi or a complete cutoff can be identified on chest radiographs.
  • An endobronchial lesion commonly leads to partial or complete atelectasis and is the most common sign of bronchogenic carcinoma. Complete endobronchial obstruction can sometimes produce distal mucoid impaction, which may be visible on plain radiographs as a tubular or branching opacity.
    • Atelectasis of a segment, a lobe, or an entire lung may occur.
    • Radiographic signs include patchy irregular or homogeneous opacities in a lobar or segmental distribution.
    • A loss of lung volume may be seen, as well as displacement of interlobar fissures, the mediastinum, the diaphragm, and the ribs.
    • Postobstructive pneumonia may be identified in a segmental or lobar distribution. In patients with recurrent pneumonia, bronchogenic carcinoma is suggested unless proven otherwise.
• Regional hyperlucency
  • An endobronchial lesion reduces the ventilation despite normal or increased air volume.
  • As a result, hypoxic vasoconstriction reduces perfusion, and attenuation is seen as hyperlucency on chest radiography. In partially atelectatic areas of the lung, hyperlucency rather than opacity may be evident.
• Hilar mass
  • Central bronchogenic carcinomas manifest added opacity in the hilar region.
  • In the early stage, the tumor may fill the lateral concavity of the hilar shadow, and in the advanced stage, all hilar structures are obliterated.
  • Infiltration of lymphatics with bronchogenic carcinomas may be demonstrated as linear opacities radiating from the hilar mass into the lung periphery.
• Solitary pulmonary nodule
  • A solitary pulmonary nodule may be relatively well marginated and appears as a rounded lung opacity.
  • Reportedly, a solitary pulmonary nodule is benign in as many as 60% of patients in some series. All patterns of calcification except eccentric or scattered punctate (stippled) calcification are associated with a benign lesion.
  • Procuring and identifying the lesion on previous chest radiographs is extremely important. This may help establish the doubling time interval for the nodule. A doubling time of 30-365 days commonly is associated with a malignancy.
  • Other possible signs of malignancy include the following:
    • Diameter more than 3 cm
    • Ill-defined or spiculated margin
    • Rigler notch sign (a notch on the nodule corresponding to the vascular supply)
    • Radial striated markings at the nodular margin (termed corona radiata)
    • Thick-walled cavity
    • Eccentric calcification
• Nonresolving pneumonia
  • An ill-defined homogeneous or patchy consolidation in a segmental or nonsegmental distribution may be an indication of bronchogenic carcinoma. Patients with these findings often are treated initially for pneumonia; the lack of response to antibiotic therapy suggests the diagnosis of a malignancy.
  • The opacity may contain air bronchograms and air alveolograms. This presentation is often seen with adenocarcinoma and bronchoalveolar carcinoma.
• Indirect signs of involvement of contiguous structures also may be found. Bronchogenic carcinoma may involve the surrounding thoracic structures, which often indicates that the tumor is not resectable. Findings include the following:
  • Osteolytic lesions and pathologic fractures of rib and vertebra
  • Phrenic nerve involvement causing diaphragmatic paralysis and exhibiting ipsilateral elevation of involved diaphragm
  • Pleural effusion secondary to visceral pleural involvement or lymphatic obstruction (confirm the presence of a malignant effusion using thoracentesis)
• Mediastinal lymph node enlargement: Metastases to paratracheal, tracheobronchial, peribronchial, aortopulmonary, and subcarinal lymph nodes may be identified on chest radiographs. The radiographic signs include a widened mediastinum, an increase in the right paratracheal stripe, a convex margin of the mediastinum, an absence of concavity in the aortopulmonary window, and splaying of carina.

Degree of Confidence

Lung cancer screening with chest radiographs has improved the 5-year survival rates, but a mortality benefit has not been demonstrated.

Computed Tomography

Non–small cell lung cancer. CT scan shows cavitation and air-fluid level (same patient as in Image 5 in Multimedia).

Findings

CT scanning of the thorax plays multiple roles in evaluation of patients with bronchogenic carcinoma. These include lung cancer screening, evaluation of a solitary pulmonary nodule, and staging.

Using CT to detect lung cancer

A few trials have used low-dose helical CT to screen patients at risk for lung cancer. CT has depicted noncalcified nodules, although a small number have been found to be malignant.

• Solitary pulmonary nodule: CT plays a significant role in workup of solitary pulmonary nodules.
  • CT scans may help establish a specific diagnosis in some patients.
  • CT densitometry may help in differentiating between benign and malignant lesions.
  • CT scans may help in the diagnosis of arteriovenous fistulas, rounded atelectasis, fungus balls, mucoid impaction, and lung infarcts. CT scans may also help in identifying a fungus ball that is not well delineated on a chest radiograph.
  • A peripheral nodule with ill-defined, irregular, and spiculated border is malignant in more than 90% of patients.
  • Air bronchogram findings and pseudocavitation (focal lucency) are seen more commonly in malignant nodules.
  • Cavitation may be a feature of both malignant and benign lesions.
  • The thickness of the wall cavity may be helpful in distinguishing between benign and malignant lesions. A wall of less than 1 mm indicates a benign lesion in 95% of patients, and a wall thickness of more than 15 mm indicates a malignant lesion in more than 80% of patients.
• CT densitometry: CT densitometry is useful in detecting the presence and distribution of calcification and fat within solitary nodules.
  • CT scan is more sensitive than chest radiography for detecting the presence of calcification. Approximately one third of indeterminate nodules found on chest radiography can be demonstrated to have calcium on CT scans. CT numbers can be obtained by placing a cursor over the lesion; a value of more than 200 HU indicates calcification.
  • The presence of fat, detected either from direct visualization or from CT numbers ranging from –40 to –120 HU, is diagnostic of hamartoma.
• Contrast-enhanced CT: Enhanced scans may help in distinguishing between malignant and benign lesions.
  • Malignant lesions enhance to a greater degree than do benign lesions after the administration of a contrast material; however, active granulomas or other infectious lesions can also enhance.
  • A measurement of CT numbers during enhancement is useful. An increase of 20 HU or more indicates a sensitivity for lung cancer of 98% and a specificity of 73%.¹⁵ Contrast enhancement may be used in patients who do not have characteristic findings of either malignant or benign lesions. The nonenhancing nodules may be monitored as long as other features suggesting malignancy are not present.

Using CT to stage lung cancer

• Primary tumors: CT scans may be useful in evaluating primary tumors. Although the size of the tumor, whether the lesion is T1 or T2, may not change the surgical approach, the site of the tumor is important to identify.
• CT scans may be helpful in determining tumor extension across the major fissure.
• CT scans are useful in assessing local invasion of the chest wall, mediastinum, mainstem bronchus, central veins, and arteries.
  • Signs of chest wall invasion include bone destruction, tumor extension into the chest wall, pleural thickening, and loss of extrapleural fat plane.
  • Identification of mediastinal invasion with CT usually is unreliable. In addition, minimal mediastinal fat invasion may be resectable in many cases.
  • Tumor invasion of the central arteries and veins may be identified by using CT, which indicates that a pneumonectomy is required.
  • Tumor invasion of the mainstem bronchus can also be visualized on CT scans. This is a useful finding for planning the surgical procedure.
• Hilar and mediastinal lymph node metastases: CT is a useful radiologic modality for noninvasive anatomic evaluation of the hila and mediastinum.
  • The indication of metastasis primarily is based on size criteria. A lymph node with a short-axis diameter of more than 1 cm is defined as enlarged.
  • Although the probability of metastasis increases with increasing lymph node size, CT scanning is not helpful in differentiating a metastasis from a benign lesion.
• Microscopic metastasis: CT may be useful in assessing metastases.
  • Normal-sized lymph nodes have been reported in 7-33% of patients undergoing CT staging. In addition, controversy exists over whether the short-axis or the long-axis diameters should be used in imaging. Another limitation may be interobserver variability in the interpretation of imaging studies.
  • Despite the limitations, CT provides useful staging information to the surgeon. Noting enlargement in a specific location may help surgeons in planning procedures, including mediastinoscopy, mediastinotomy, or percutaneous needle aspiration biopsy.
  • CT is useful in demonstrating extrathoracic metastases. Distant metastases demonstrated with CT include metastases to the adrenal glands, brain, bones, liver, and soft tissues.
  • Chest CT should include the upper abdomen to assess the liver, upper abdominal lymph nodes, and adrenal glands. However, on needle biopsy, most adrenal masses are shown to be adenomas rather than metastases.

Degree of Confidence

On contrast-enhanced CT scans, increased attenuation of 20 HU or more is 98% sensitive and 73% specific for lung cancer.¹⁵

Magnetic Resonance Imaging

Findings

MRI is an imaging modality with several advantages, including a lack of ionizing radiation, the ability to image vascular structures without contrast media, the ability to image in any plane, and superior contrast resolution. MRI is not useful as an initial imaging tool, but it may be superior to CT in the evaluation of local invasion and detection of hilar lymphadenopathy.

In particular, MRI is useful in the evaluation of superior sulcus tumors. Invasion of the brachial plexus, subclavian vessels, and adjacent vertebral bodies can be demonstrated with MRI. Compared with other techniques, MRI may be slightly more accurate in detecting extranodal tumor extension into the mediastinum.

The multiplanar capability of MRI enables a more accurate evaluation of hilar lymph nodes, aortopulmonary window lymph nodes, and subcarinal region lymph nodes, compared with that of CT.

Degree of Confidence

MRI depends on size criteria for the detection of mediastinal metastases. MRI is limited in detecting small lymph nodes containing microscopic deposits. MRI can be used as an imaging modality for apical or superior sulcus lung tumors. MRI is superior in detecting invasion of the chest wall, vertebral body, subclavian vessels, and brachial plexus. For the detection of chest wall invasion, a sensitivity of approximately 90% and a specificity of 96-100% has been reported.

Nuclear Imaging

Findings

Bone scanning

In patients who have biochemical or physical evidence of bone metastasis, a bone scan is required as part of the preoperative workup. A routine bone scan is usually not recommended in asymptomatic patients.

Positron emission tomography

PET can be used to determine the metabolic activity rather than the morphologic features of the lesions. Bronchogenic carcinoma is associated with an increased rate of glucose metabolism. PET uses deoxyglucose linked to fluorine 18 (a positron emitter). The agent, 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG), competes with glucose for transport into the cells and after phosphorylation accumulates in tumor cells. Lung tumor cells have increased glucose metabolism; however, this is not specific for tumors and may occur in infectious or inflammatory processes.

FDG-PET scan has been used to differentiate benign from malignant pulmonary nodules. PET scans also may be useful in detecting distant metastases when whole-body imaging is performed. Because of the false-positive rate, invasive staging procedures may still be required before potentially curative surgical management is denied.¹⁶

Degree of Confidence

PET imaging has higher sensitivity, specificity, and accuracy than CT in staging mediastinal disease. Published studies have demonstrated a sensitivity of 80%, an overall specificity of 92%, and an accuracy of 92%, with a positive predictive value of 90% and a negative predictive value of 93%.

False Positives/Negatives

False-negative studies can occur in patients with carcinoid syndrome, bronchoalveolar carcinomas, and bronchogenic carcinoma measuring less than 10 mm. False-positive findings are known to occur in infectious or inflammatory disorders such as tuberculosis, histoplasmosis, and rheumatoid nodules.

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.

Multimedia

Media file 1: Non–small cell lung cancer. Bronchoscopy. A large central lesion was diagnosed as non–small cell carcinoma.

Media file 2: Non–small cell lung cancer. Left pleural effusion and volume loss secondary to non–small cell carcinoma of the left lower lobe. The pleural effusion was sampled and found to be malignant; therefore, the lesion is inoperable.

Media file 3: Non–small cell lung cancer. Left upper collapse is almost always secondary to endobronchial bronchogenic carcinoma.

Media file 4: Non–small cell lung cancer. Complete left lung collapse secondary to bronchogenic carcinoma of left mainstem bronchus.

Media file 5: Non–small cell lung cancer. A cavitating right lower lobe squamous cell carcinoma.

Media file 6: Non–small cell lung cancer. CT scan shows cavitation and air-fluid level (same patient as in Image 5 in Multimedia).

Media file 7: Non–small cell lung cancer. Patient has right lower lobe opacity. This is not well circumscribed and was found to be a squamous cell carcinoma.

Media file 8: Non–small cell lung cancer. Right upper lobe lesion diagnosed as adenocarcinoma on percutaneous biopsy.

Media file 9: Non–small cell lung cancer. Right upper lobe collapse with the S sign of Golden secondary to underlying non–small cell carcinoma of the bronchus.

Media file 10: Non–small cell lung cancer. Comparative characteristics of the primary tumor are shown in the vertical columns. Horizontal columns refer to lymph node involvement. The different stages are color coded and can be found at the intersection of appropriately matched horizontal and vertical columns. Stages with unique characteristics, such as stages 0 and IV, are defined in separate boxes. Courtesy of Lababede et al (Chest 1999; 115(1): 233-5).

References

1. Ravaioli A, Papi M, Pasquini E, Marangolo M, Rudnas B, Fantini M, et al. Lipoplatin monotherapy: A phase II trial of second-line treatment of metastatic non-small-cell lung cancer. J Chemother. Feb 2009;21(1):86-90. [Medline].

2. Ohba T, Yamasaki T, Endo Y, Furuie M, Ohtani Y, Inase N, et al. A phase I study of TS-1 plus carboplatin in patients with advanced non-small-cell lung cancer. J Chemother. Feb 2009;21(1):80-5. [Medline].

3. Ricciardi S, Tomao S, de Marinis F. Toxicity of targeted therapy in non-small-cell lung cancer management. Clin Lung Cancer. Jan 2009;10(1):28-35. [Medline].

4. Herbst RS, Lynch TJ, Sandler AB. Beyond doublet chemotherapy for advanced non-small-cell lung cancer: combination of targeted agents with first-line chemotherapy. Clin Lung Cancer. Jan 2009;10(1):20-7. [Medline].

5. Martini N, Bains MS, Burt ME, et al. Incidence of local recurrence and second primary tumors in resected stage I lung cancer. J Thorac Cardiovasc Surg. Jan 1995;109(1):120-9. [Medline].

6. [Best Evidence] Reck M, von Pawel J, Zatloukal P, Ramlau R, Gorbounova V, Hirsh V, et al. Phase III trial of cisplatin plus gemcitabine with either placebo or bevacizumab as first-line therapy for nonsquamous non-small-cell lung cancer: AVAil. J Clin Oncol. Mar 10 2009;27(8):1227-34. [Medline].

7. [Best Evidence] Fidias PM, Dakhil SR, Lyss AP, Loesch DM, Waterhouse DM, Bromund JL, et al. Phase III study of immediate compared with delayed docetaxel after front-line therapy with gemcitabine plus carboplatin in advanced non-small-cell lung cancer. J Clin Oncol. Feb 1 2009;27(4):591-8. [Medline].

8. [Best Evidence] Hanna N, Neubauer M, Yiannoutsos C, McGarry R, Arseneau J, Ansari R, et al. Phase III study of cisplatin, etoposide, and concurrent chest radiation with or without consolidation docetaxel in patients with inoperable stage III non-small-cell lung cancer: the Hoosier Oncology Group and U.S. Oncology. J Clin Oncol. Dec 10 2008;26(35):5755-60. [Medline].

9. Lung Cancer Initiatives. Centers for Disease Control and Prevention. Department of Health and Human Services. Available at http://www.cdc.gov/cancer/lung/pdf/0809_lung_fs.pdf. Accessed May 30, 2009.

10. US Cancer Statistics Working Group. United States Cancer Statistics: 1999–2005 Incidence and Mortality Web-based Report. Atlanta (GA). Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2009. Available at http://www.cdc.gov/uscs. Accessed May 30, 2009.

11. Detailed Guide: Lung Cancer - Non-Small Cell What Are the Key Statistics About Lung Cancer?. American Cancer Society. Available at http://www.cancer.org/docroot/CRI/content/CRI_2_4_1x_What_Are_the_Key_Statistics_About_Lung_Cancer_15.asp?sitearea=. Accessed May 30, 2009.

12. Hsu LH, Chu NM, Liu CC, Tsai SY, You DL, Ko JS, et al. Sex-associated differences in non-small cell lung cancer in the new era: Is gender an independent prognostic factor?. Lung Cancer. Mar 17 2009;[Medline].

13. Ries LAG, Melbert D, Krapcho M, Stinchcomb DG, Howlader N, Horner MJ, et al. SEER Cancer Statistics Review, 1975–2005, National Cancer Institute. Bethesda, MD, based on November 2007 SEER data submission, posted to the SEER Web site, 2008. SEER Web Site. Available at http://seer.cancer.gov/csr/1975_2005/. Accessed May 30, 2009.

14. Miller WT. Value of clinical history. AJR Am J Roentgenol. Sep 1990;155(3):653-4. [Medline].

15. Swensen SJ, Brown LR, Colby TV. Lung nodule enhancement at CT: prospective findings. Radiology. Nov 1996;201(2):447-55. [Medline].

16. Hellwig D, Baum RP, Kirsch C. FDG-PET, PET/CT and conventional nuclear medicine procedures in the evaluation of lung cancer: A systematic review. Nuklearmedizin. Jan 14 2009;48(1):[Medline].

17. ATS and ERS. Pretreatment evaluation of non-small-cell lung cancer. The American Thoracic Society and The European Respiratory Society. Am J Respir Crit Care Med. Jul 1997;156(1):320-32. [Medline].

18. Botta DM, Head HD. Non-small cell lung cancer: an update. Curr Surg. Sep-Oct 2003;60(5):492-8. [Medline].

19. Boulikas T, Vougiouka M. Recent clinical trials using cisplatin, carboplatin and their combination chemotherapy drugs (Review). Oncol Rep. Mar 2004;11(3):559-95. [Medline].

20. Dales RE, Stark RM, Raman S. Computed tomography to stage lung cancer. Approaching a controversy using meta-analysis. Am Rev Respir Dis. May 1990;141(5 Pt 1):1096-101. [Medline].

21. Hatter J, Kohman LJ, Mosca RS, et al. Preoperative evaluation of stage I and stage II non-small cell lung cancer. Ann Thorac Surg. Dec 1994;58(6):1738-41. [Medline].

22. Henschke CI, Naidich DP, Yankelevitz DF, et al. Early lung cancer action project: initial findings on repeat screenings. Cancer. Jul 1 2001;92(1):153-9. [Medline].

23. Hillers TK, Sauve MD, Guyatt GH. Analysis of published studies on the detection of extrathoracic metastases in patients presumed to have operable non-small cell lung cancer. Thorax. Jan 1994;49(1):14-9. [Medline].

24. Lababede O, Meziane MA, Rice TW. TNM staging of lung cancer: a quick reference chart. Chest. Jan 1999;115(1):233-5. [Medline].

25. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA Cancer J Clin. Jan-Feb 1999;49(1):8-31, 1. [Medline].

26. Lowe VJ, Naunheim KS. Positron emission tomography in lung cancer. Ann Thorac Surg. Jun 1998;65(6):1821-9. [Medline].

27. Mac Manus MP, Hicks RJ, Ball DL, et al. F-18 fluorodeoxyglucose positron emission tomography staging in radical radiotherapy candidates with nonsmall cell lung carcinoma: powerful correlation with survival and high impact on treatment. Cancer. Aug 15 2001;92(4):886-95. [Medline].

28. McLoud TC, Bourgouin PM, Greenberg RW, et al. Bronchogenic carcinoma: analysis of staging in the mediastinum with CT by correlative lymph node mapping and sampling. Radiology. Feb 1992;182(2):319-23. [Medline].

29. Michel F, Soler M, Imhof E, Perruchoud AP. Initial staging of non-small cell lung cancer: value of routine radioisotope bone scanning. Thorax. Jul 1991;46(7):469-73. [Medline].

30. Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest. Jun 1997;111(6):1710-7. [Medline].

31. Parkin DM, Pisani P, Ferlay J. Estimates of the worldwide incidence of eighteen major cancers in 1985. Int J Cancer. Jun 19 1993;54(4):594-606. [Medline].

32. Patz EF Jr, Erasmus JJ, McAdams HP, et al. Lung cancer staging and management: comparison of contrast-enhanced and nonenhanced helical CT of the thorax. Radiology. Jul 1999;212(1):56-60. [Medline].

33. Reilly JJ. Preparing for pulmonary resection: preoperative evaluation of patients. Chest. Oct 1997;112(4 Suppl):206S-208S. [Medline].

34. Roberts JR, Blum MG, Arildsen R, et al. Prospective comparison of radiologic, thoracoscopic, and pathologic staging in patients with early non-small cell lung cancer. Ann Thorac Surg. Oct 1999;68(4):1154-8. [Medline].

35. Scott WJ, Shepherd J, Gambhir SS. Cost-effectiveness of FDG-PET for staging non-small cell lung cancer: a decision analysis. Ann Thorac Surg. Dec 1998;66(6):1876-83; discussion 1883-5. [Medline].

36. Shaffer K. Radiologic evaluation in lung cancer: diagnosis and staging. Chest. Oct 1997;112(4 Suppl):235S-238S. [Medline].

37. Silvestri GA, Hoffman BJ, Bhutani MS, et al. Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg. May 1996;61(5):1441-5; discussion 1445-6. [Medline].

38. Travis WD, Lubin J, Ries L, Devesa S. United States lung carcinoma incidence trends: declining for most histologic types among males, increasing among females. Cancer. Jun 15 1996;77(12):2464-70. [Medline].

39. Vansteenkiste JF, Stroobants SG. The role of positron emission tomography with 18F-fluoro-2-deoxy-D- glucose in respiratory oncology. Eur Respir J. Apr 2001;17(4):802-20. [Medline].

40. White CS, Templeton PA, Belani CP. Imaging in lung cancer. Semin Oncol. Apr 1993;20(2):142-52. [Medline].

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

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.

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

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)