Lung Cancer.pdf

14 J.B. Putnam, Jr., F.V. Fossella, and R. Komaki
out lung cancer in patients who are unable to undergo surgery. TTNA
biopsy is not recommended in patients with good physiologic reserve
who are considered appropriate candidates for surgery (e.g., patients with
clinical stage I or II disease).
In patients with hard palpable lymph nodes in the cervical or supraclavicular
area, fine-needle aspiration may provide an accurate diagnosis
of metastatic (N3) involvement. Otherwise, a superficial lymph node
biopsy or a scalene node biopsy can be performed to obtain tissue for further
evaluation. If cervical or supraclavicular lymph nodes are positive,
the disease is clinical stage IIIB, and surgery is not recommended.
Sputum Cytology
Sputum cytology may be an appropriate diagnostic procedure if the patient
is unable to undergo surgery, has symptoms suggestive of cancer,
and has severe emphysema and thus is not a candidate for TTNA biopsy
because of the increased risk of pneumothorax.
Transesophageal Sonography
Transesophageal sonography may assist the clinician in evaluating lung
cancer that may abut the esophagus, heart, or aorta. Directed transesophageal
biopsies of subcarinal lymph nodes may also be performed.
Bone Scanning, Computed Tomography, and Magnetic Resonance Imaging
In patients with resectable lung cancer (stage I or II disease), bone scanning
and CT of the brain are not recommended in the absence of related
symptoms. A bone scan should be performed only if the patient complains
of bone pain. Plain radiographic films of the affected area should be obtained
to supplement the bone scan. If questions still exist after the studies
are completed, magnetic resonance (MR) imaging of the painful area may
also be performed. Finally, biopsy of the involved bony area may be required.
Similarly, CT or MR imaging of the brain should be performed
only if the patient has neurological symptoms or if the diagnosis of SCLC
is suspected. It is not cost-effective to perform CT of the brain in an otherwise
asymptomatic patient with lung cancer who has no neurological
symptoms and is physiologically fit and stage-appropriate for surgery.
In patients with more advanced disease, bone scanning and CT or MR
imaging of the brain may have a higher yield in revealing occult metastatic
disease. MR imaging is frequently used to complement CT in evaluating
the location of these tumors within the chest. Specifically, MR imaging is
helpful for evaluating bony invasion of the chest wall or other mediastinal
structures. In patients with superior sulcus tumors and patients with tumors
involving the first and second or third ribs, MR imaging may provide
additional information beyond that obtainable with CT regarding the extent
of the tumor’s involvement of the brachial plexus, thoracic inlet, great
vessels, or other mediastinal structures (Komaki et al, 1990).