What is the recommended workup and treatment approach for a patient with suspected lung malignancy?

Lung Malignancy Workup and Treatment Approach

The recommended workup for suspected lung cancer includes chest imaging with CT scan, tissue diagnosis via the least invasive method appropriate for the lesion location, and comprehensive staging with PET-CT for patients being considered for curative treatment.

Initial Diagnostic Evaluation

Imaging

• First-line imaging: Chest X-ray (AP and lateral with high kilovoltage technique) 1
  • Even with a normal chest X-ray, if lung cancer is suspected, proceed to CT scan 1
• Second-line imaging: Thoracic CT scan with contrast 1, 2
  • Spiral CT preferred when available for best image quality 1
  • CT scan alone is not sufficiently specific to confirm diagnosis 1

Tissue Diagnosis

Selection of biopsy method should be based on lesion location:

1. Central/endobronchial lesions:

   • Bronchoscopy with biopsy, brushing, lavage, or TBNA 2
   • For proximal tumors, multiple samples using different methods should be taken 1

2. Peripheral lesions:

   • Transthoracic needle aspiration (TTNA) 1, 2
   • Bronchoscopy with electromagnetic navigation or radial ultrasound 2
   • For distal tumors, at least one fine needle aspirate for cytology 1

3. Mediastinal involvement:

   • EBUS-guided needle aspiration
   • EUS-guided needle aspiration
   • Mediastinoscopy if other methods fail 2

4. Pleural effusion:

   • Ultrasound-guided thoracentesis (two negative aspirations needed to consider cytology negative) 1, 2

Important: Sputum cytology alone is not specific for lung cancer and requires histological confirmation 1

Staging Evaluation

Non-Small Cell Lung Cancer (NSCLC)

1. Local and regional staging:

   • Complete thoracic CT scan including upper abdomen, liver and adrenal glands 1

2. Distant metastasis evaluation:

   • PET-CT scan for patients being considered for curative treatment 1, 2
     • Reduces unnecessary thoracotomies by detecting occult metastases 3
     • Not recommended for nodules <10mm with no FDG uptake 1
   • Brain imaging:
     • CT with contrast or preferably MRI for patients with neurological symptoms 1, 2
   • Bone evaluation:
     • For patients with bone pain: MRI, serum calcium and alkaline phosphatase 1, 2

Small Cell Lung Cancer (SCLC)

• More extensive initial staging due to high likelihood of metastatic disease 1
• Brain CT/MRI should be considered before starting treatment 1
• PET-CT can help detect extensive disease that may change treatment approach 3

Treatment Approach

Non-Small Cell Lung Cancer

1. Operable disease (Stages I-IIIA):

   • Surgical resection (lobectomy or pneumonectomy with ipsilateral mediastinal node dissection) is the standard of care 1, 2
   • Target operative mortality: <2% for lobectomy, <6% for pneumonectomy 1
   • For patients who cannot tolerate standard surgery: conformal radiotherapy or limited resection 2

2. Locally advanced disease:

   • Multimodality approach with chemotherapy and radiation 2
   • Neoadjuvant therapy options:
     • For resectable tumors ≥4cm or node positive: platinum-doublet chemotherapy 4

3. Metastatic disease:

   • Treatment based on molecular profiling:
     • For EGFR mutations: tyrosine kinase inhibitors as first-line 2
     • For PD-L1 expression ≥1%: immunotherapy options 4
   • For patients without driver mutations: platinum-based chemotherapy combined with immunotherapy 4
   • For elderly or poor performance status: single-agent chemotherapy 2

Small Cell Lung Cancer

1. Limited disease:

   • Etoposide/cisplatin (4-6 cycles) with concurrent early thoracic radiotherapy 1
   • Prophylactic cranial irradiation for patients with major response 1

2. Extensive disease:

   • Chemotherapy with palliative intent 1
   • No benefit from maintenance chemotherapy 1

Management of Complications

• Brain metastases:

  • 1-3 metastases: stereotactic radiosurgery 2
  • ≥5 metastases: whole-brain radiotherapy 2
  • Large metastases (>3cm): surgical resection if candidate 2

• Malignant pleural effusion:

  • With re-expandable lung: tunneled pleural catheter or chemical pleurodesis 2
  • With lung entrapment: tunneled catheter for symptom relief 2

Common Pitfalls and Caveats

1. Diagnostic pitfalls:

   • CT scan alone is insufficient for diagnosis; histological confirmation is essential 1
   • PET scan can yield false positives with inflammatory conditions like granulomas and pneumonia 3
   • Confirmation of PET findings is critical to avoid erroneously directing patients away from potentially curative surgery 1

2. Treatment considerations:

   • Exploratory surgery can be considered for patients with strongly suggestive CT findings when biopsy is contraindicated 1
   • For solitary extrathoracic metastasis, histological confirmation is required before excluding patients from curative treatment 2
   • Maintenance chemotherapy has not shown benefit in SCLC 1

3. Prevention:

   • Smoking cessation remains the most effective prevention strategy 1
   • Chemopreventive agents have not shown efficacy and should not be offered to smokers with lung cancer 1