Non-small cell lung cancer (staging)

Population Covered By The Guidance

This pathway provides guidance on imaging patients with confirmed non-small cell lung carcinoma on histology. This staging process will determine further definitive treatment.

Lead Researcher: Dr Arjun Shivananda

Experts & Contributors: Dr Ravinder Dhillon, Dr Teck Siew, Dr Mark Teh, Dr Yuranga Weerakkody

Editorial Panel: Core Membership

Date reviewed: April 2017

Date Published: May 2018

Image 1a (Chest radiograph: Left hilar mass causing collapse of the left upper lobe and elevation of the left main bronchus.

Lung Carcinoma

Images 1b, 1c, and 1d (Computed Tomography): CT of the same patient reveals a large, relatively homogenous mass within the left upper lobe measuring 95mm and extending from the apex to the hilum. Central areas of low attenuation are compatible with tissue necrosis. There is also encasement of the left upper lobe bronchus and pulmonary artery with extensive background emphysema

Lung Carcinoma

Images 1b, 1c, and 1d (Computed Tomography): CT of the same patient reveals a large, relatively homogenous mass within the left upper lobe measuring 95mm and extending from the apex to the hilum. Central areas of low attenuation are compatible with tissue necrosis. There is also encasement of the left upper lobe bronchus and pulmonary artery with extensive background emphysema

Lung Carcinoma

Images 1b, 1c, and 1d (Computed Tomography): CT of the same patient reveals a large, relatively homogenous mass within the left upper lobe measuring 95mm and extending from the apex to the hilum. Central areas of low attenuation are compatible with tissue necrosis. There is also encasement of the left upper lobe bronchus and pulmonary artery with extensive background emphysema

Lung Carcinoma

Image 2a: Lobectomy showing a large non-small cell lung carcinoma arising from the proximal bronchus and invading into the surrounding parenchyma. Note the patchy central necrosis and punctate areas of haemorrhage.

Lung Carcinoma

Images 2b and 2c: Post-mortem specimens showing infiltration of lung parenchyma by bronchoalveolar carcinoma.

Lung Carcinoma

Images 2b and 2c: Post-mortem specimens showing infiltration of lung parenchyma by bronchoalveolar carcinoma.

Lung Carcinoma

Images 2d (H&E, x2.5) and 2e (H&E, x20): Histological sections of a moderately well differentiated squamous cell carcinoma of the lung showing infiltrating sheets and tongues of malignant squamous cells with whorls of keratin (blue arrows). At higher power, the malignant cells demonstrate marked nuclear atypia with abundant glassy eosinophilic cytoplasm

Lung Carcinoma

Images 2d (H&E, x2.5) and 2e (H&E, x20): Histological sections of a moderately well differentiated squamous cell carcinoma of the lung showing infiltrating sheets and tongues of malignant squamous cells with whorls of keratin (blue arrows). At higher power, the malignant cells demonstrate marked nuclear atypia with abundant glassy eosinophilic cytoplasm

Lung Carcinoma

  • It is important to accurately stage NSCLC, as stages I to III are potentially resectable and in some instances curable. Accurately staging NSCLC can result in a higher quality of life in those with the disease as a result of more targeted and appropriate treatment
  • Chest radiography is indicated in all patients but has low sensitivity for detecting lesion spread
  • A CT of the chest and upper abdomen is indicated in all patients, as it allows for the evaluation of the size and extent of the primary tumour and metastatic spread to the mediastinum/upper abdomen
  • A PET scan is indicated in all patients with NSCLC who DO NOT have evidence of stage IV (non-curative) disease on CT scans
  • Increasingly, NSCLC is staged with combined PET-CT which is as accurate or superior to PET alone or CT alone
  • Site specific symptoms warrant directed evaluation of that site with the most appropriate study
  • Palliative care for NSCLC may include non-curative chemotherapy, radiation and/or surgery

Date of literature search: January 2017

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

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Pathway User Guide

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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE
No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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