From the Guidelines
The appropriate workup for a patient with suspected lung adenocarcinoma begins with a thorough history and physical examination, followed by imaging studies including a chest X-ray and contrast-enhanced CT scan of the chest and upper abdomen, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1.
Initial Evaluation
The initial evaluation should include a thorough clinical evaluation to provide an initial definition of tumor stage, as well as a CT scan of the chest with contrast to assess for metastatic disease 1.
- A thorough history and physical examination should be performed to identify any symptoms or signs that may indicate the presence of lung cancer.
- Imaging studies, including a chest X-ray and contrast-enhanced CT scan of the chest and upper abdomen, should be performed to evaluate the extent of the disease.
Tissue Diagnosis
Tissue diagnosis is essential and can be obtained through various methods, including:
- CT-guided needle biopsy
- Bronchoscopy with transbronchial biopsy
- Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)
- Surgical biopsy, depending on the location of the lesion 1 The choice of diagnostic method depends on the location and size of the tumor, as well as the patient's overall health status.
Staging Workup
Once adenocarcinoma is confirmed, staging workup should include:
- PET-CT scan to evaluate for distant metastases
- Brain MRI with contrast to assess for brain metastases, as adenocarcinoma has a predilection for brain involvement
- Pulmonary function tests to evaluate lung capacity for potential surgical candidates 1 These studies help to determine the extent of the disease and guide treatment decisions.
Molecular Testing
Molecular testing of the tumor tissue is crucial and should include assessment for:
- EGFR, ALK, ROS1, BRAF, NTRK, MET, RET, and KRAS mutations
- PD-L1 expression, as these findings guide targeted therapy options 1 This information helps to identify potential therapeutic targets and guide personalized treatment decisions.
Additional Studies
Complete blood count, comprehensive metabolic panel, and coagulation studies should also be performed to assess overall health status and fitness for treatment 1. These studies help to identify any underlying health issues that may impact treatment decisions. The most recent and highest quality study, published in 2024, recommends a multidisciplinary team approach to the diagnosis and management of lung cancer, including the use of advanced diagnostic techniques such as EBUS and robotic bronchoscopy 1.
From the Research
Lung Adenocarcinoma Workup
The workup for a patient with suspected lung adenocarcinoma involves several steps, including:
- A thorough history and physical examination to identify signs and symptoms of the disease, as well as to assess the patient's overall health and potential risk factors for lung cancer 2
- Imaging studies, such as chest computed tomography (CT) scans, to provide anatomic detail and identify potential lymph node involvement or metastases 3
- Positron emission tomography (PET) scans to provide functional information on tissue activity and help identify potential metastases 3, 4
- Tissue diagnosis, which may be obtained through various methods, including sputum cytology, thoracentesis, accessible lymph node biopsy, bronchoscopy, transthoracic needle aspiration, video-assisted thoracoscopy, or thoracotomy 2
- Evaluation of metastatic disease, which may involve laboratory tests, imaging studies, and tissue confirmation of mediastinal involvement 3, 2
Staging and Evaluation
The staging of lung adenocarcinoma is critical in determining treatment options and prognosis. The evaluation of metastatic disease is an important part of the staging process, and may involve:
- Clinical evaluation, including history and physical examination, to identify potential signs and symptoms of metastatic disease 3
- Imaging studies, such as CT scans and PET scans, to identify potential metastases 3, 4
- Tissue confirmation of mediastinal involvement or metastases, which may be obtained through various methods, including biopsy or fine-needle aspiration 3, 2
Molecular Diagnostics
Molecular diagnostics, including comprehensive molecular testing for genetic mutations, such as EGFR, ALK, and ROS1, may also be an important part of the workup for lung adenocarcinoma, particularly in patients with advanced disease or those who are candidates for targeted therapy 5, 4
- EGFR mutation testing, which may be predictive of response to certain targeted therapies, such as erlotinib or crizotinib 4
- ROS1 rearrangement testing, which may be predictive of response to certain targeted therapies, such as crizotinib 5
Follow-up and Surveillance
After treatment for lung adenocarcinoma, follow-up and surveillance are critical in monitoring for recurrence or metastatic disease. A suggested approach may include: