What is the next step for a patient with a positive lung cancer screening computed tomography (CT) scan showing new opacification of the right lower lobe segmental airways?

From the Guidelines

The next step for a patient with a positive lung cancer screening computed tomography (CT) scan showing new opacification of the right lower lobe segmental airways should be a bronchoscopy, as this is the preferred diagnostic strategy for patients with central masses and suspected endobronchial involvement. This approach is supported by the guidelines for non-small cell lung cancer, which emphasize the importance of choosing a diagnostic step based on factors such as anticipated diagnostic yield, diagnostic accuracy, and invasiveness of the procedure 1.

When considering the optimal diagnostic steps, it is crucial to involve thoracic radiologists, interventional radiologists, and board-certified thoracic surgeons who devote a significant portion of their practice to thoracic oncology. Multidisciplinary evaluation may also benefit from the involvement of a pulmonologist with experience in advanced bronchoscopic techniques for diagnosis. The guidelines suggest that the least invasive biopsy with the highest yield is preferred as the first diagnostic study, and for patients with central masses, bronchoscopy is the recommended initial approach 1.

Some key points to consider in the diagnostic workup include:

• The patient's symptoms and medical history, including any risk factors for lung cancer such as smoking history
• The size and location of the tumor, as well as the presence of mediastinal or distant disease
• The need for concomitant staging to avoid additional biopsies or procedures
• The importance of obtaining adequate tissue specimen for diagnosis and molecular testing

Given the potential for the opacification to represent malignancy, timely evaluation is essential for optimal outcomes. The patient should be scheduled for follow-up tests, such as bronchoscopy with biopsy, within 1-2 weeks if possible, and should be advised to report any new or worsening symptoms while awaiting further evaluation.

From the Research

Next Steps for Lung Cancer Screening

The next step for a patient with a positive lung cancer screening computed tomography (CT) scan showing new opacification of the right lower lobe segmental airways involves further diagnostic procedures to confirm the presence of lung cancer.

• The patient may undergo electromagnetic navigational bronchoscopy (ENB) with transbronchial biopsy, which has emerged as a technology that improves the diagnostic sensitivity of conventional bronchoscopic biopsy 2.
• If ENB biopsy is non-diagnostic, computed tomography (CT)-guided biopsy may be performed, which has a high diagnostic yield even following non-diagnostic ENB biopsies 2.
• For peripheral lesions, such as ground-glass opacity nodules (GGNs), bronchoscopic brush cytology with manual mapping navigation may be used to increase the sensitivity of conventional bronchoscopic brushing for the diagnosis of peripheral pulmonary lesions 3.
• For central pulmonary lesions, CT-guided percutaneous transthoracic needle biopsy (PTNB) and electronic bronchoscopy-guided transbronchial lung biopsy (TBLB) may be compared in terms of diagnostic accuracy, complication rates, and predictive values 4.
• If lung cancer is confirmed, treatment options may include lobectomy, which is the treatment of choice for primary non-small cell lung cancer (NSCLC) provided that the patient is fit enough to undergo surgery 5.
• Image-guided EBUS bronchoscopy systems may be used for lung-cancer staging, which can facilitate optimal EBUS scanning and nodal biopsy 6.

Diagnostic Considerations

When considering the next steps for a patient with a positive lung cancer screening CT scan, it is essential to evaluate the characteristics of the lesion, including size, location, and distribution.

• Lesions <21.5 mm, in the outer 2/3 of the lung, and in the lower lung have the lowest likelihood of a diagnostic yield with ENB biopsies 2.
• CT-guided biopsy may be more suitable for these lesions due to its high diagnostic yield 2.
• The choice of diagnostic procedure should be based on the individual patient's characteristics and the specific lesion being evaluated.