LUNG CANCER

Lung cancer: investigation

and staging

Whats new?
C

David R Baldwin
C

Abstract
In the modern lung cancer service, the first visit to hospital is where the
initial investigation pathway is formulated to ensure that as much diagnostic and staging information is obtained with least risk and discomfort
for the patient. It is of over-riding importance to ensure that this is in line
with the patients wishes and appropriate to the fitness of the individual
as well as the potential treatment. To do this a contrast-enhanced
computed tomogram (CT) of the lower neck, chest and upper abdomen
should be available at the time of the first clinical assessment. At this
time, performance status is recorded, and blood tests and spirometry
obtained. The most effective next test (usually a biopsy) can then be
selected. Clear information should be given to the patient, who must
have access to support from a lung cancer nurse specialist. Clinical
assessment and spirometry will identify the need for further tests to
assess fitness. The exact sequence of investigations will vary according
to the clinical and CT findings, but to ensure the most accurate stage
and therefore most effective treatment, pathological confirmation of findings on imaging is usually sought, with samples provided that are
adequate for sub-classification of tumours.

named key-worker, usually a lung cancer nurse specialist as part

of the multidisciplinary team (MDT).

Clinical and CT assessment

Assessment at the first visit to the lung cancer clinic or ward
should allow the most rapid and efficient investigation(s) to be
planned. The emphasis should be on obtaining diagnostic and
staging information with least risk to the patient. A full history
and examination provides essential information about symptoms, diagnosis and stage, but having CT available greatly
improves the accuracy of the assessment. The update of the
guidelines on the management of lung cancer by NICE provides
a management algorithm based on clinical assessment and CT
(Figure 1; modified to include pleural disease).1 Spirometry, and
renal, liver and bone profiles, full blood count and coagulation
indices should also be requested. Performance status should be
recorded and the severity of any co-morbidities assessed.
Performance status is usually recorded on the World Health
Organization and Eastern Collaborative Oncology Group (WHO/
ECOG) scale of 0e5:
 full fitness e 0
 capable of light work, such as housework e 1
 up and about more than 50% of waking hours e 2
 confined to the chair or bed more than 50% e 3
 confined to chair or bed e 4
 deceased e 5.
An alternative, rather more detailed system is the Karnofsky
score (0e100).2
The first assessment may point to the presence of locally
advanced or metastatic disease that precludes treatment with
curative intent. In the National Lung Cancer Audit in 2009,
almost three out of every four patients had stage IIIB or IV
disease at presentation, too advanced for treatment with curative
intent. About 80% of patients with small cell lung cancer have
metastatic disease at presentation. Metastatic disease may be
indicated by weight loss (10%), fatigue, bone pain, headache
and nausea characteristic of raised intracranial pressure, other
neurological signs, liver capsular pain or the presence of skin
metastases. Blood tests may show a reduced haematocrit,
increased platelet and white cell counts, and disturbance of liver
and bone enzymes. If, at the clinical and CT assessment, there
are obvious features of advanced disease, only a diagnostic test is
needed, and in some even that may not be in the patients best
interest. In a few patients, clinical assessment alone with a chest

Keywords diagnosis; fitness assessment; imaging; investigations;

lung cancer; positron emission tomography; spirometry; staging

Principles
Investigation of patients with suspected lung cancer has three
main purposes:
 to confirm or refute the diagnosis
 to determine the stage of the cancer
 to verify the fitness of the individual.
All of these are necessary to establish what treatment can be
offered to the patient. Patients should be given sufficient information, sensitively and in terms that are easily understood, to
allow them to decide at any stage of their pathway what investigations they want. Most patients will want to go ahead with
diagnostic, staging and fitness assessment, but some will prefer
a supportive approach without further investigations. The latter
group should have their decision sensitively examined to ensure
they have made the right decision. Whatever approach is taken,
supportive care should always be offered, with an allocated

David R Baldwin MBChB MD FRCP is a Consultant Physician at the

Respiratory Medicine Unit, Nottingham University Hospitals, and
Honorary Associate Professor, Division of Epidemiology and Public
Health, University of Nottingham, Nottingham, UK. Competing
interests: none declared.

MEDICINE 40:4

CT is employed at the beginning of the pathway, to allow the

appropriate diagnostic/staging test
Minimally invasive techniques are used to stage patients
accurately, to ensure the maximum number are offered treatment with curative intent
Pathological samples must be adequate to allow tissue subtyping
In fitness assessment, ensure patients have co-morbidities
treated and are re-assessed for treatment with curative intent

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Figure 1

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X-ray will be enough to plan management; this scenario is more

likely in the very ill patient admitted as an emergency.

Chest CT delivers an effective radiation dose of 8 mSv (w2.7

years of background radiation), thought to confer a 1 in 2500 risk
of fatal cancer, although in suspected lung cancer the benefit
usually outweighs this small risk.

Sequence of investigations
Diagnosis and staging may be possible using a single investigation. The order of investigations may vary according to the
presentation, but the general sequence is shown in Figure 1,
based on clinical and CT assessment, whilst also taking into
account fitness. The MDT should be consulted if there is doubt
about the sequence of tests.

Other imaging and minimally invasive diagnostic and

staging investigations
Various investigations are used to establish diagnosis and stage
(Figure 1). Thus, some discretion may be employed according to
local resources, expertise and the patients wishes.
Positron emission tomography (PET): PET exploits the fact that
most malignant lung neoplasms have higher metabolic activity
than benign tissue. (See article on Imaging in Chest Disease on
pp. 177e185 of this issue.)
PET-CT is a combined scan that covers the skull vertex to mid
thigh. It allows the overlaying of CT and PET images to aid
accurate localization. For primary tumours, a negative PET-CT
scan may reduce the probability of malignancy sufficiently to
allow conservative follow-up (Table 1) although there are limitations of PET-CT (Table 2). Many benign conditions can be
positive on PET, and a positive scan should be followed by
histological confirmation, which may include definitive resection.
For nodes, a negative PET scan is encouraging but pre-operative
sampling is preferred for all nodes significantly enlarged on CT
(Figure 1). Where PET-CT is negative, resection can proceed
although intraoperative nodal sampling is recommended. If PET is
positive then sampling of nodes is recommended. PET sensitivity
is 93% and specificity 96% in detecting metastases, and is now
a mandatory investigation prior to treatment with curative intent.
PET is less useful in detecting cerebral metastases because the
brain is a high glucose consumer and therefore 182-fluoro-2-deoxy

Imaging
Chest X-ray
Whereas the chest X-ray is usually the first investigation performed in primary care or in the emergency setting, it is noncontributory where the CT is available in the rapid access lung
cancer clinic. NICE guidelines on referral for suspected lung
cancer include advice on when to request a chest X-ray.3 An
abnormal chest X-ray is strongly predictive of lung cancer but is
not specific, often being abnormal in benign disease. Moreover,
the chest X-ray is normal in 5e10% of patients with confirmed
lung cancer. It can identify pulmonary nodules or masses,
pulmonary collapse, mediastinal lymphadenopathy, a pleural
effusion or an area of consolidation.
Contrast-enhanced CT
A CT of the lower neck, thorax and upper abdomen forms the
basis on which further investigation is planned. The findings on
CT may make a diagnosis of malignancy very likely by identifying metastatic disease or local tumour invasion into the chest
wall or mediastinum. Whilst morphological features of solitary
pulmonary nodules (SPN) can be predictive of malignant or
benign disease, the management pathway is complex. Intravenous contrast may provide a further guide to diagnosis, but
should be used with caution where renal function is known
to be abnormal, to minimize the risk of contrast-induced
nephropathy.

Approximate sensitivity and specificity of diagnostic

and staging investigationsa

Tumour stage: it is important to distinguish between T3 and T4

disease because the latter is generally not resectable, although
radical radiotherapy may still be an option. CT has a sensitivity
of 55% and specificity of 89% in this differentiation and can only
serve as a guide; where uncertainty exists, alternative imaging or
surgical exploration is indicated.
Nodal stage: CT is also the main initial investigation to determine nodal status, but should not be used as the definitive test
other than in the most obvious cases of nodal metastases. The
lower neck cuts can identify supraclavicular lymphadenopathy,
which is easily biopsied under ultrasound guidance for pivotal
diagnosis and staging. By convention, mediastinal nodes are
considered significantly enlarged if their shortest axis diameter is
10 mm or more. At this arbitrary but pragmatic cut off, there are
still significant false-positives and false-negatives. The variable,
but average sensitivity is 57% and specificity 82% (false-positives 44% and false-negatives 17%). This poor (and variable)
specificity necessitates nodal sampling to determine offers of
treatment with curative intent.

MEDICINE 40:4

Test

Sensitivity
(%)

Specificity
(%)

PET-CT
SPECT
Transthoracic needle
aspiration
EUS-FNA
EBUS-TBNA
Bronchoscopy  biopsy
Non-ultrasound guided TBNA
Neck US
Thoracoscopy
Mediastinoscopy

85e90
65e90
85e90

80e90
75e85
90e95

85e95
85e95
70e90
40e70
80e90
90e95
78e95

99
99
90e95
99
99
90e95
100

EBUS, endobronchial ultrasound; EUS, endoscopic ultrasound; FNA, fine needle aspiration; PET, positron emission tomography; SPECT, single photon
emission computed tomography; TBNA, transbronchial needle aspiration;
US, ultrasound.
a
These ranges are based on review of numerous studies and are estimated
on the basis that the tests are employed in the appropriate clinical and CT
circumstances as shown in Figure 1.

Table 1

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over-expressed in malignant lung neoplasms, so there is

a concentration of the label in lung tumours. Tc-99m decays by
emitting a single photon (single photon emission CT (SPECT)),
which can be detected by a gamma camera. Although studies
suggest that the accuracy of NeoSPECT approaches that of PETCT, the latter is now widely available and is much more widely
used than NeoSPECT.

Limitations of PET-CT
General

Relatively poor CT image quality (compared

with staging CT) and no contrast given

False-negatives

Low metabolic activity (some

adenocarcinomas including bronchoalveolar
carcinoma, carcinoid tumours)
Small lesion size (<8 mm diameter)
Mis-registration artefact
Uncontrolled diabetes mellitus
Inflammatory and infective conditions
(including rheumatoid nodules, Wegeners
granulomatosis, tuberculosis, progressive
massive fibrosis)

False-positives

Brain MRI and CT: all patients with symptoms suggestive of brain
metastases should undergo contrast-enhanced CT scan of head or
MRI scan of brain. MRI detects around a third more cerebral
metastases than CT. There is debate about whether CT or MRI
should be performed prior to treatment with curative intent in
asymptomatic patients. Some smaller studies have shown cerebral
metastases to be present in up to 10% of patients. The influence of
PET-CT on this is not known. NICE indicates that either CT or MRI
may be used, especially in later stage disease.

Table 2
D-glucose (FDG) avid. Despite this, PET-CT may detect up to 60%
of cerebral metastases. The effective radiation dose of PET-CT
depends on the specific settings but ranges from 14 to 25 mSv.

Bone scintigraphy: bone scintigraphy may be used to detect

bone metastases in symptomatic patients, but does not add
anything if PET-CT has already been done and is negative.

NeoSPECT: technetium-99m depreotide (NeoSPECT) is a radiolabelled analogue of somatostatin. Somatostatin receptors are

Body MRI: MRI is most commonly employed to clarify the

relationship of tumour tissue to other vital structures, for

Figure 2

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example, Pancoast tumours and the brachial plexus, stellate

ganglion, subclavian vessels and bones, or bone metastases to
the spinal cord.

required to guide treatment (Figure 1). Sampling of intermediate

(10e20 mm) and larger (>20 mm) nodes can also provide critical
staging as well as diagnostic information, but most centres prefer
to use non-US-guided TBNA for larger nodes and ultrasonographic techniques for intermediate.
For peripheral lesions (those surrounded by normal lung
parenchyma without any evidence of endobronchial abnormalities), the sensitivity of bronchoscopy is lower (brushings 55%,
transbronchial biopsy 46% and washings or bronchoalveolar
lavage (BAL) 43%). Thus, bronchoscopy is not the preferred first
test for peripheral lesions in the UK. Ultrathin bronchoscopy,
radial ultrasound and electromagnetic navigation have all been
employed to improve sensitivity, but they are time-consuming
and not widely used in the UK.4

Minimally invasive tissue sampling

Except where a patient declines or will not benefit from a tissue
diagnosis, pathological confirmation of stage should follow the
most efficient pathway (Figure 1). Sputum cytology is now
considered of little value in diagnosis but may be useful in a few
patients unfit for more invasive investigations.
Fibreoptic bronchoscopy: most patients are fit for flexible
fibreoptic bronchoscopy performed under conscious sedation. In
centrally located tumours, it not only has a high diagnostic yield
but also allows other procedures to be performed. Bronchoscopy is
a safe procedure with a mortality of 0.04% and has a low major
complication rate (respiratory depression, pneumonia) of 0.12%.
Non-ultrasound (US)-guided transbronchial needle aspiration
(TBNA) is performed via bronchoscopy by inserting a 1e1.5 cm
fine needle (18e22 G) through a main airway wall following
careful review of the CT scan. This enables tumours that do not
penetrate the mucosa to be sampled as well as enlarged lymph
nodes. TBNA alone has a sensitivity of 67%, but combining
endobronchial biopsy, brushings, washings and TBNA achieves
a sensitivity of 88%. Bronchoscopy and TBNA is the preferred
option for centrally located tumours or where nodal staging is not

Endoscopic ultrasound (EUS) and endobronchial ultrasound

(EBUS): EUS and EBUS employ a specially modified endoscope
or bronchoscope with a linear ultrasound transducer at the tip
and an angulated channel through which a needle is passed that
can be seen on ultrasound and guided directly into the node.
EBUS is able to sample most of the mediastinal nodal stations
and EUS most of the posterior mediastinal nodes.5 EUS can also
be used to sample the left adrenal gland. In experienced hands,
combined EBUS and EUS have a staging accuracy equivalent to
mediastinoscopy.6 Figure 2 shows the mediastinal node stations
and indicates those that can be sampled by each technique.

Summary of surgical sampling techniques used in the diagnostic work-up or performed at the same time as curative
surgery
Technique

Method

Application

Open biopsy

Either small thoracotomy or video-assisted

approach to identify a lesion and obtain large
sample. General anaesthetic

Rigid bronchoscopy

Rigid bronchoscope inserted under general

anaesthetic. Much larger biopsies can be taken
Small incision in suprasternal notch under
general anaesthetic. Plane developed in
anterior mediastinum and rigid telescope
inserted

Biopsy of a lesion where other techniques

unsuccessful. Alternatively, can be used for a
frozen section immediately before curative
surgery as first tissue diagnosis
Where other techniques have failed in the
context of a visible endobronchial lesion
Mediastinoscopy gives access to the pretracheal and para-tracheal lymph nodes, as
well as lymph nodes between the left and right
main bronchus. Provides accurate staging
information. False-negative rate of 10% in
studies may reflect inaccessible nodes
Small series have shown sensitivity and
specificity similar to anterior mediastinoscopy
(below)
Staging of left upper lobe carcinoma and for
diagnosis of some mediastinal masses. Allows
access to the aorto-pulmonary (A/P) window
Used for diagnosis and therapy of pleural
disease. Can help to define pleural
involvement by tumour (T-stage), provide
access to nodal stations including the A/P
window and confirm the presence of pleural
metastases. Used for lung biopsy and some
resections

Cervical mediastinoscopy

Extended mediastinoscopy

Exploration extended to include assessment

of left upper lobe tumours

Anterior mediastinotomy

Incision made in left anterior chest wall,

second or third intercostal space

Video-assisted thoracoscopic surgery (VATS)

Telescope and instruments inserted through

one or more ports into the pleural space

Table 3

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7th edition of the TNM system for lung cancer (changes from 6th in bold type). Applies to non-small cell, small cell and
carcinoid lung cancer
Primary tumour (T)
TX Primary tumour cannot be assessed, or tumour proven by the presence of malignant cells in sputum or bronchial washings but not visualized by
imaging or bronchoscopy
T0 No evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal
than the lobar bronchus T1a <2 cm; T1b 2e3 cm
T2 Tumour with any of the following features of size or extent:
T2a 3e5 cm in greatest dimension; T2b >5e7 cm
Involving main bronchus, 2 cm or more distal to the carina
C
Invading the visceral pleura
C
Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung
T3 Tumour of any size that:
C
C

C
C
C
C
C

directly invades the chest wall (including superior sulcus tumours), diaphragm, mediastinal pleura, or parietal pericardium
is located in the main bronchus less than 2 cm distal to the carina but without involvement of the carina
is associated with atelectasis or obstructive pneumonitis of the entire lung
is associated with separate nodule(s) in the same lobe
is >7 cm in greatest dimension

T4 Tumour of any size that:

C
C

invades the mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, or carina
is associated with separate nodule(s) in a different ipsilateral lobe

Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed
N0 No regional lymph nodes metastasis
N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, including direct extension
N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene or supraclavicular lymph node(s)
Distant metastases (M)
MX Presence of distant metastasis cannot be assessed
M1a
Separate tumour nodule(s) in a contralateral lobe
malignant pleural or pericardial effusion (was T4)
C
pleural nodules
M1b Distant metastasis
C
C

Surgical stage groupings in 7th TNM classification

Stage
Stage
Stage
Stage
Stage

group
0
IA
IB
IIA

Stage IIB
Stage IIIA

Stage IIIB
Stage IV

T
Tis
T1a, b
T2a
T1a, b
T2a
T2b
T2b
T3
T1, T2
T3
T4
T4
Any T
Any T

N
N0
N0
N0
N1
N1
N0
N1
N0
N2
N1, N2
N0, N1
N2
N3
Any N

M
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1a, b

Note: Mx has been deleted from the entire TNM staging system for all tumours.

Table 4

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Percutaneous transthoracic needle aspiration/biopsy (PTNB):

it is the preferred test for peripheral lung lesions with no associated
mediastinal lymphadenopathy on CT. This may be preceded by
PET-CT if treatment with curative intent is considered (Figure 1).
Fluoroscopy, CT or US is used to guide a needle into the lesion.
Core biopsy needles that yield larger samples are most often used.
Lesions abutting the chest wall can usually be detected on US and
biopsied without complication. Lesions that are deeper in the lung,
or small, require CT guidance and biopsy is more frequently
associated with complications. The most important complication
is pneumothorax, occurring in 20e30% of biopsies with the need
for a chest drain in 7e10%. Haemoptysis occurs in 3.6% and the
mortality is 0.1%. As a staging investigation, PTNB may be used to
confirm mediastinal involvement where TBNA, EUS and EBUS are
not possible.

with a diagnosis of lung cancer and 20% with mesothelioma.

Contrast-enhanced CT scan may reveal pleural thickening alone
or pleural nodules with or without an effusion. Where there is no
diagnosis on initial pleural tap then image-guided pleural biopsy
(CT or US) or thoracoscopy may be indicated. Image-guided
pleural biopsy is safer and more sensitive than blind techniques, such as Abrams needle biopsy, and the latter are now
less often used.
Thoracoscopy: it is performed using a rigid or flexible telescope, via
one or more ports, inserted into the lateral chest. Where performed
by physicians it is termed medical thoracoscopy rather that videoassisted thoracoscopic surgery (VATS) (see Table 3). Medical
thoracoscopy may be performed under local or general anaesthetic
and allows accurate diagnosis of most pleural effusions or pleural
thickening, and treatment of malignant pleural effusions by talc
poudrage. It is often a day-case procedure. Both diagnostic and
therapeutic thoracoscopy can be done at the same time provided the
macroscopic appearances are characteristic.

Ultrasound of the neck and supraclavicular nodes: where CT

demonstrates bulky mediastinal nodes, about a third of patients
will have nodes visible on neck ultrasound. If these are positive
on needle aspiration biopsy then radical treatment is not possible
(N3). The test is carried out under local anaesthetic and has a low
morbidity.7

Staging systems:9,10
TNM staging and stage groupings e The American Joint
Committee on Cancer (AJCC) originally proposed a scheme for
lung cancer staging based on the TNM system in 1973. The latest
revision was published in 2010 (Table 4). The mediastinal node
stations are shown in Figure 2. The International Association for
the Study of Lung Cancer has proposed nodal zones that may be
relevant to prognosis in surgery (Figure 2). In addition to the
TNM system, stage grouping groups those TNM stages that
have a similar prognosis and potential for surgery (Figure 3).
For small cell lung cancer, a system of limited and extensive
disease was first proposed by the Veterans Administration Lung
Cancer Study Group (VALG) (Table 5). TNM staging is now recommended for all lung small cell cancer staging, although clinically,
the limited and extensive classification is still used to plan treatment. The systems are summarized in Tables 4 and 5 and Figure 3.

Biopsy of distant metastases: the common sites of distant

metastases in lung cancer are the bones, liver, adrenals and
brain. These may be detected by any of the investigations performed in the diagnostic pathway or by other tests warranted by
suspicion of metastases (e.g. MRI scan of brain for neurological
symptoms). Biopsy of distant metastases is often safer and easier
than biopsy of the primary.
Surgical biopsy
Surgical techniques are sometimes necessary where minimally
invasive techniques have failed and confirmation of staging is
required. Curative surgery will sometimes provide the first histological specimen where non-biopsy investigations have suggested a high
probability of malignancy and the possibility of cure, for example in
the case of a peripheral lesion and PET-CT negative for mediastinal or
distant metastases (Figure 1). Commonly employed techniques are
open or video-assisted surgical biopsy, mediastinoscopy, anterior
mediastinotomy and rigid bronchoscopy (Table 3).

Assessment of fitness:11,12 fitness is assessed clinically by

recording performance status and exercise tolerance, and
measuring spirometry. Additional investigations may be necessary depending on the options for treatment. If treatment with
curative intent is a possibility, patients with borderline fitness
require careful assessment of their lung function, and cardiac and
other co-morbidity. If there is cardiac co-morbidity, this should be
medically optimized and assessed by echocardiography and
exercise ECG. Patients with coronary stents should be assessed by
a cardiologist. Patients with abnormal spirometry should have

Investigation of suspected malignant pleural effusion and

pleural thickening8
Pleural effusion is usually confirmed by chest X-ray and the first
investigation is often a diagnostic pleural tap. The latter will
confirm whether the effusion is an exudate and establish the
diagnosis of malignancy from cytology in about 60% of patients

Stage Groupings: TNM stages with similar prognosis

T1a,b

T2a

T2b

T3

T4

N0

IA

IB

IIA

IIB

IIIA

N1

IIA

IIA

IIB

IIIA

IIIA

N2

IIIA

IIIA

IIIA

IIIA

IIIB

N3

IIIB

IIIB

IIIB

IIIB

IIIB

Patients should be
offered surgery if fitness
is adequate
Surgery may be suitable
for some patients,
based on clinical
judgment
Not suitable for surgery

Figure 3

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3 National Collaborating Centre for Primary Care. Referral guidelines of

suspected cancer in adults and children. London: National Institute
for Health and Clinical Excellence, 2005.
4 Du Rand IA, Barber PV, Goldring J, et al. BTS Interventional bronchoscopy guideline group. Summary of the British Thoracic Society
guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax 2011 Nov; 66: 1014e5.
5 Invasive mediastinal staging of lung cancer: ACCP evidence-based
clinical practice guidelines. Chest 2007; 132: 202e20.
6 Annema JT, Meerbeck JPv, Rintoul RC, et al. Mediastinoscopy vs
endosonography for mediastinal nodal staging of lung cancer:
a randomized trial. J Am Med Assoc 2010; 304: 2245e52.
7 Hoosein MM, Barnes D, Khan AN, et al. The importance of ultrasound
in staging and gaining a pathological diagnosis in patients with
lung cancerda two year single centre experience. Thorax 2011; 66:
414e7.
8 Hooper C, Lee G, Maskell Non behalf of the BTS Pleural Guideline
Group. Investigation of a unilateral pleural effusion in adults: British
Thoracic Society pleural disease guideline 2010. Thorax 2010;
65(suppl 2): ii4e17. doi:10.1136/thx.2010.136978.
9 Rami-Porta R, Crowley JJ, Goldstraw P. The revised TNM staging
system for lung cancer. Ann Cardiovasc Surg 2009; 15: 4e9.
10 Union of International Cancer Control. http://www.uicc.org/resources/tnm.
11 Lim E, Baldwin DR, Beckles M, et al. British Thoracic Society and the
Society for Cardiothoracic Surgery in Great Britain and Ireland
guidelines on the radical management of patients with lung cancer.
Thorax 2010; 65(suppl III): iii1e27.
12 Brunelli A, Charloux A, Bolliger CT, et al. The European
Respiratory Society and European Society of Thoracic Surgeons
clinical guidelines for evaluating fitness for radical treatment(surgery
and chemoradiotherapy) in patients with lung cancer. Eur Resp J
2009.

Previous staging of small cell lung cancer

Limited stage disease
Defined according to the possibility of encompassing all detectable
tumour within a tolerable radiotherapy port. This includes patients
with:
C
disease confined to one hemithorax
C
ipsilateral hilar lymph nodes
C
ipsilateral and contralateral supraclavicular lymph nodes
C
ipsilateral and contralateral mediastinal lymph nodes with or
without ipsilateral pleural effusions independent of cytology
Extensive stage disease
Defined as disease at sites beyond the definition of limited disease.
This includes patients with:
C
metastatic lesions in contralateral lung
C
distant metastatic involvement (such as brain, bone, liver or
adrenals)
Table 5

carbon monoxide transfer factor (TLCO) measured and predicted

postoperative forced expiratory volume in 1 second (FEV1) estimated. Where CT suggests that regions of the lung may contribute
different amounts of ventilation and perfusion, a quantitative
ventilation or perfusion scan may enable better prediction of the
likely impact of surgery on lung function.
To further assess fitness a shuttle walk test may be used e the
ability to walk more than 400 m indicates the patient is fit for
surgery. Some centres prefer to perform cardio-pulmonary
exercise tests. However, there is still debate about the lower
limit of exercise test measurements below which a patient is
deemed unsuitable for surgery. Assessment of fitness for surgery
is can be complex and should always be discussed with the
surgeon and anaesthetist.

Practice points
Summary
C

Investigation and staging of lung cancer is complex and involves

interpretation of tests results individualized to the patient. The
fastest, safest and most efficient route should be taken, ensuring
the patients and carers views are prioritized. Where the next
step is not clear, early discussion of the issues at the MDT
meeting for lung cancer is helpful.
A

REFERENCES
1 National Institute for Health and Clinical Excellence. The diagnosis
and treatment of lung cancer (update). (Clinical guideline 121), 2011.
http://guidance.nice.org.uk/CG121.
2 Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, ed. Evaluation of chemotherapeutic agents. Columbia University Press, 1949; 196.

MEDICINE 40:4

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Investigations in lung cancer are to establish diagnosis, stage

and fitness
Where knowledge of stage is important to plan treatment,
choose investigations that provide the most information about
diagnosis and stage with least risk to the patient
A clinical and CT assessment is the starting point for optimal
selection of further investigation
Detailed fitness assessment is required for borderline patients
to ensure they have the best chance of receiving treatment
with curative intent
The wishes of the patients are of over-riding importance and
they should be provided with detailed information in a format
that they can understand

2012 Elsevier Ltd. All rights reserved.