Estudiante

Lung Cancer
Multidisciplinary Approach to Tissue Sampling
Andrew C. Chang, MDa, Baskaran Sundaram, MBBS, MRCP, FRCRb, Douglas A. Arenberg, MDc,*
KEYWORDS
 Lung  Nodule  Biopsy  Bronchoscopy  Computed tomography  Surgery  Multidisciplinary

KEY POINTS
 Patients with lung nodules suspicious for malignancy should not have a biopsy (as opposed to surgery) if it won’t change thetreatment.  Whenever possible, any biopsy done for suspected cancer should provide both a diagnosis, and an unambiguous stage, as well as tissue for molecular analysis.  The choice of biopsy approach should balance certainty (accuracy), safety, the patients’ preferences, and account for local expertise.

With the spreading use of computed tomography (CT) imaging for ever-widening indications and thepotential for widespread screening for lung cancer among those perceived to be at risk, lung nodules that raise varying degrees of suspicion for cancer are an increasingly relevant problem in radiology practice. The care of patients with known or suspected lung cancer has become increasingly complex. As management of lung cancer evolves, the majority of patients now receive, at some time duringthe course of their disease, multiple modes of treatment, for example, surgery, chemotherapy, radiotherapy, and/or palliative treatment. In line with this, evidence-based guidelines from the American College of Chest Physicians (ACCP)1 and the National Comprehensive Cancer Network (NCCN)2 advocate that patient care and treatment planning be managed by multidisciplinary teams.1 The termmultidisciplinary implies that teams combining individuals with diverse expertise in surgical, medical, and radiologic subspecialties provide efficient, evidence-based care and achieve optimal outcomes of complex diseases. Individuals with

at least a special interest, if not a career focus, in thoracic malignancies should comprise such teams. In the context of tissue sampling, the goal of multidisciplinarycare should be to establish a seamless, efficient, and coordinated approach to diagnosis, staging, and treatment of patients with suspected lung cancer. The goal should be to first determine which patients require a biopsy, then to select the one biopsy approach that provides both a diagnosis and an accurate stage, balancing certainty for treating physicians and safety for the patient. Accuratestaging of patients with lung cancer is of paramount importance because of the prognostic importance of disease stage, as well as the fact that treatment of lung cancer varies widely across stages (Table 1). Finally, it is increasingly important that tissue be obtained for both pathologic diagnosis and selected molecular analyses to guide treatment decisions. The greatest impact of themultidisciplinary team may be the coordinated efforts of multiple specialists to stage the patient’s lung cancer accurately, to provide reliable prognostic

a Section of Thoracic Surgery, University of Michigan, 2120 Taubman Center, SPC 5344, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; b Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive,Cardiovascular Center-Room 5481, Ann Arbor, MI 48109, USA; c Pulmonary & Critical Care Medicine, 6301 MSRB III, SPC 5642, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA * Corresponding author. E-mail address: darenber@umich.edu

Radiol Clin N Am 50 (2012) 951–960 http://dx.doi.org/10.1016/j.rcl.2012.05.001 0033-8389/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.radiologic.theclinics.com

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Table 1 Variation in the treatment options for lung cancer according to stage Anatomic Stage I

Acceptable Physiologic Reserve Surgery (certain patients with stage IB may be candidates for adjuvant chemotherapy) Surgery and adjuvant chemotherapy

Poor Physiologic Reserve Biopsya EBRT SBRT RFA Other (cryotherapy, wedge resection, or brachytherapy)...