Diagnosis and Staging of Advanced Non-Small-Cell Lung Cancer (NSCLC): ESMO Guidelines
Download PDF: ESMO guidelines on lung cancer
Incidence/Epidemiology
- Screening with low-dose CT reduces lung cancer-related mortality. The most efficient and cost effective way to do it still need to be determined before large-scale implementation.
- Screening with low-dose CT should not be offered on an individual basis. It can, however, be considered for current or former heavy smokers (≥30 pack years
- or ≤15 years since smoking cessation) aged 55-74 years. These would need to be informed about potential benefits and risks, and referred to a dedicated screening programme in an experienced multidisciplinary team.
- Other screening methods, including chest X-ray, sputum analysis or biomarkers, are not recommended for clinical use.
Diagnosis
- The recommended method for obtaining a pathological diagnosis of centrally located tumours is bronchoscopy.
- The diagnostic approach to non-calcified pulmonary nodules should be based on existing guidelines.
- A pre-treatment pathological diagnosis, preferably obtained by biopsy, is recommended. In some patients with clinical stage I/II lesions where this may not be feasible, a high likelihood of malignancy based on assessment of clinical and imaging findings in an experienced multidisciplinary group may be considered sufficient.
Staging and risk assessment
- In NSCLC where distant metastases have been ruled out, a more detailed locoregional staging is required to distinguish early stages (I/II) from potentially resectable stage IIIA and from unresectable stage III, according to the seventh TNM staging system. This is a multidisciplinary process involving imaging, endoscopic and surgical techniques.
- Patients without suspect mediastinal lymph node (LN) metastasis on both CT and positron emission tomography (PET) can in general proceed to surgery, except in the case of a centrally located tumour or hilar LNs (see algorithm).
- For patients with suspect mediastinal lymph node metastasis on CT or PET scan (unless bulky) pathological confirmation of nodal disease is recommended (see algorithm):
- The preferred first technique to confirm lymph node disease is needle aspiration under endobronchial (EBUS) or oesophageal ultrasound (EUS) guidance.
- For patients with suspect lymph nodes on imaging and negative EBUS/EUS results, an additional mediastinoscopy is recommended.
- The risk of postoperative morbidity and mortality should be estimated using validated risk-specific models.
- Formal lung function testing should be undertaken to estimate postoperative lung function. Surgical resection is recommended in patients with FEV1 and DLCO >80% and no other major co-morbidities. For others, additional ergospirometry, echocardiography, coronary tests etc. may be warranted.
- Co-morbidities should be evaluated and optimised before surgery.
See also: Suggested Algorithm for Lung Cancer Staging
Reference: Vansteenkiste J et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann Oncol. 2013 Oct;24 Suppl 6:vi89-98.
