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Lung Cancer Imaging Guidance
 

Diagnosis and Staging

The lung cancer diagnosis and staging guidance document provides imaging professionals and cancer care providers with relevant and current evidence-based recommendations for the imaging of lung cancer patients throughout the diagnosis and staging portion of the cancer journey. 

We reviewed the Lung Cancer Diagnosis Pathway to identify all decision points related to diagnostic imaging for which clinical guidance was sought from existing guidelines.  The results are presented in the table below.

Our endorsement ensures relevant guidance

The Cancer Imaging Program has reviewed and endorsed these recommendations for use by physicians involved in lung cancer care. For more details, including information about the endorsement process, download the full Lung Cancer Imaging Guidelines: Diagnosis and Staging document.

Lung Cancer Diagnosis and Staging Recommendation Table
Clinical Pathway Scenario CIP Recommendations Source Description of Guidance
Initial presentation
Clinical Suspicion Chest x-ray CCO 2011
Ref 3
A person should have a chest X-ray within two working days if they present with any of the following:
  • Hemoptysis
  • new finger clubbing
  • suspicious lymphadenopathy
  • Dysphagia
  • Features suggestive of lung cancer that has metastasized elsewhere or other cancers that have metastasized to the lung
  • Features suggestive of paraneoplastic syndromes
OR
Any of the following unexplained signs or symptoms lasting more than three weeks (patients with known risk factors may be considered sooner):
  • Cough
  • Weight loss/loss of appetite
  • Shortness of breath
  • chest and/or shoulder pain
  • abnormal chest signs
  • Hoarseness
Patients with underlying chronic respiratory problems should have a chest X-ray within three weeks if they have unexplained changes in existing symptoms.
Chest x-ray negative but high level of suspicion CT scan of thorax and upper abdomen NICE 2011 1.1.4
Ref 4
If the chest X-ray is normal but there is a high suspicion of lung cancer, patients should be offered urgent referral to a member of the lung cancer MDT, usually the chest physician.
Chest x-ray SPN Review previous images
If no previous - CT scan of thorax and upper abdomen
NICE 2011 1.3.2
Ref 4
Patients with known or suspected lung cancer should be offered a contrast-enhanced chest CT scan to further the diagnosis and stage the disease. The scan should also include the liver and adrenals.
Chest x-ray Mass CT scan of thorax and upper abdomen NICE 2011 1.3.2
Ref 4
Patients with known or suspected lung cancer should be offered a contrast-enhanced chest CT scan to further the diagnosis and stage the disease. The scan should also include the liver and adrenals.

Diagnosis - Positive CT scan
Peripheral Mass or suspicious lung nodule Needle biopsy – fine or core NICE 2011 1.3.14
Ref 4
Offer CT- or ultrasound-guided transthoracic needle biopsy to patients with peripheral lung lesions when treatments can be planned on the basis of this test.
Peripheral Mass or suspicious lung nodule PET/CT if needle biopsy not possible or inconclusive CCO 2007
Ref 5
PET should be reserved for those situations in which a biopsy is inconclusive or contraindicated
Central Mass Needle biopsy – fine or core if failed endoscopic biopsy
If both not possible - PET/CT
NICE 2011 1.3.16
Ref 4
Offer fibreoptic bronchoscopy to patients with central lesions on CT where nodal staging does not influence treatment. Enlarged lymph nodes (≥ 10 mm maximum short axis on CT) may be simultaneously sampled with TBNA (non-ultrasound-guided) if required for diagnosis.
Central Mass PET/CT if both fine/core and endoscopic biopsy not possible CCO 2007
Ref 5
PET should be reserved for those situations in which a biopsy is inconclusive or contraindicated
Suspected stage 4 Tissue biopsy from easiest site NICE 2011 1.3.25
Ref 4
Confirm the presence of isolated distant metastases/synchronous tumours by biopsy or further imaging (for example, MRI or PET-CT) in patients being considered for treatment with curative intent.
Pleural effusion Thoracocenthesis - ultrasound guided if necessary ACCP
Ref 6
In patients suspected of having lung cancer who have an accessible pleural effusion, thoracentesis is recommended to diagnose the cause of the pleural effusion.
Chest wall involvement Consider US NICE 2011 1.3.3
Ref 4
In the assessment of mediastinal and chest wall invasion:

  • CT alone may not be reliable
  • Other techniques such as ultrasound should be considered where there is doubt
  • Surgical assessment may be necessary if there are no contraindications to resection

Staging Non-Small Cell Lung Cancer
MRI Brain To rule out metastasis NICE 2011 1.3.27
Ref 4

Offer patients with features suggestive of intracranial pathology, CT of the head followed by MRI if normal, or MRI as an initial test.
CT Brain If MRI not possible NICE 2011 1.3.27
Ref 4

Offer patients with features suggestive of intracranial pathology, CT of the head followed by MRI if normal, or MRI as an initial test.
CT Thorax and upper abdomen If previous inadequate or outdated ACR
Ref 7

Indicated CT chest with or without contrast through adrenal glands.
MRI Thorax Not Indicated routinely NICE 2011 1.3.6
Ref 4
Magnetic resonance imaging (MRI) should not routinely be performed to assess the stage of the primary tumour (T-stage) in NSCLC.
MRI Thorax For patients with superior sulcus tumors or chest wall invasion NICE 2011 1.3.7
Ref 4

MRI should be performed, where necessary to assess the extent of disease, for patients with superior sulcus tumours.
PET/CT Where curative resection is being considered CCO 2007
Ref 5
Prospective studies have found that PET detects unexpected distant metastases in up to 15% of patients, which may lead to changes in patient management
Bone scan If suspected metastasis NICE 2011 1.3.28
Ref 4
An X-ray should be performed in the first instance for patients with localized signs or symptoms of bone metastasis. If the results are negative or inconclusive, either a bone scan or an MRI scan should be offered.
X-ray bone Stage M1b disease NICE 2011 1.3.28
Ref 4
An X-ray should be performed in the first instance for patients with localized signs or symptoms of bone metastasis. If the results are negative or inconclusive, either a bone scan or an MRI scan should be offered.

Staging Small Cell Lung Cancer
MRI Brain For Staging NICE 2011 1.3.27
Ref 4
Offer patients with features suggestive of intracranial pathology, CT of the head followed by MRI if normal, or MRI as an initial test.
CT Brain If MRI not possible NICE 2011 1.3.27
Ref 4
Offer patients with features suggestive of intracranial pathology, CT of the head followed by MRI if normal, or MRI as an initial test.
CT Thorax and upper abdomen If previous inadequate or outdated ACR
Ref 7
CT chest with or without contrast (through adrenal glands).
CT of the abdomen with contrast
MRI Thorax Not Indicated routinely NICE 2011 1.3.6
Ref 4
Magnetic resonance imaging (MRI) should not routinely be performed to assess the stage of the primary tumour (T-stage) in NSCLC.
PET/CT For limited disease SCLC CCO 2009
Ref 8
PET is recommended for staging in patients with SCLC who are potential candidates for the addition of thoracic radiotherapy to chemotherapy
Bone scan Not indicated if PET/CT negative ACR
Ref 7
Not necessary if PET has been done.

References

Note: references 1 and 2 have been omitted as they are not referenced in the table above:

  1. Del Giudice L, Young S, Vella E, Ash M, Bansal P, Robinson A, et al. Referral of suspected lung cancer by family physicians and other primary care providers. Toronto (ON): Cancer Care Ontario; 2011 Aug 29. Program in Evidence-based Care Evidence-Based Series No.: 24-2.
  2. National Institute for Health and Clinical Excellence, Lung Cancer: The Diagnosis and Treatment of Lung Cancer. NICE Clinical guideline 121. April 2011
  3. Ung YC, Maziak DE, Vanderveen JA, Smith CA, Gulenchyn K, Evans WK,et al. 18-Fluorodeoxyglucose positron emission tomography in the diagnosis and staging of lung cancer. Toronto (ON): Cancer Care Ontario; 2007 Apr 27 [In review 2011 Sep]. Program in Evidence-based Care Evidence-based Series No.: 7-20
  4. M. P Rivera and A C. Mehta. Initial Diagnosis of Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition). Chest 2007;132; 131S-148S
  5. American College of Radiology, ACR Appropriateness Criteria. Clinical Condition: Non-invasive Clinical Staging of Bronchogenic Carcinoma. 2005, review 2010.
  6. Y Ung and C Walker-Dilks PET Imaging in Small Cell Lung Cancer: Recommendations A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO) Report Date: January 19, 2009
Last modified: Mon, Mar 03, 2014
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