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Guidelines on the Diagnosis and Treatment of Primary Lung Cancer (2011)

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Guidelines on the Diagnosis and Treatment of Primary Lung Cancer (2011) G U I D E L I N E S Chinese guidelines on the diagnosis and treatment of primary lung cancer (2011) Xiu-yi Zhi1*, Yi-long Wu2*, Hong Bu3, Gang Cheng4, Ying Cheng5, Xiang Du6, Bao-hui Han7, Ge-ning Jiang8, Shun- chang Jiao9, De-ruo Liu10, Lun-xu Liu3, You Lu3, Sheng-lin Ma11, Yuan-kai Shi12, Chang-li Wang13, Jie Wang14, Tian- you Wang1, Yue Yang14, Qing-hua Zhou15, Lung Cancer Diagnosis and Treatment Expert Panel of the Chinese Ministry of Health 1Beijing Lung Cancer Center, Capital Medical University, Beijing; 2Guangdong Lung Cancer Institute, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou; 3West China Medical School, West China Hospital, Sichuan University, Chengdu; 4Beijing Hospital, Beijing; 5Cancer Hospital of Jilin Province, Changchun; 6Cancer Hospital of Fudan University, Shanghai; 7Shanghai Chest Hospital, Jiaotong University, Shanghai; 8Shanghai Pulmonary Hospital, Tongji University, Shanghai; 9General Hospital of Chinese People's Liberation Army, Beijing; 10Beijing Sino-Japan Hospital, Beijing; 11Hangzhou Cancer Hospital, Hangzhou; 12Cancer Institute and Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing; 13Tianjin Cancer Hospital, Tianjin Medical University, Tianjin; 14Beijing Cancer Hospital, Peking University, Beijing; 15Tianjin Key Laboratory of Lung Cancer Metastasis and Tumor Microenvironment, Tianjin Lung Cancer Institute, Tianjin Medical University General Hospital J Thorac Dis 2012;4:88-101. DOI: 10.3978/j.issn.2072-1439.2010.08.01 Introduction . smoking with a smoking index of greater than 400 cigarettes/ year; a history of high-risk occupational exposure (eg. exposure Primary lung cancer (PLC) is one of the most common to asbestos) and family history of PLC; or at the age of 45 years malignant tumors in China. According to the Health Statistics or above. Yearbook 2010, PLC was the first leading cause of cancer death nationwide in 2005. Clinical manifestations These guidelines are developed to standardize the diagnosis and treatment protocols for this condition and enhance the At the early stage, patients with PLC may have few, if any, related practice at medical institutions, so as to improve obvious symptoms. With the progression of disease, the the prognosis of PLC patients and the quality and safety of following symptoms may occur: healthcare services. 1. Irritating cough; 2. Blood in the sputum or bloody sputum; Diagnostic techniques . 3. Chest pain; 4. Fever; and Risk factors 5. Shortness of breath. Respiratory symptoms that persist longer than two weeks Populations at risk of PLC include those have a history of unresponsive to treatment, particularly blood in the sputum, irritating cough, or exacerbation of existing respiratory symptoms, can be a sign of PLC. No potential conflict of interest. If invasion of the surrounding tissues or metastasis occurs, the *Co-chairmen. following symptoms may be present: Corresponding to: Xiu-yi Zhi, MD. Beijing Lung Cancer Center, Capital Medical 1. Hoarse voice if the recurrent laryngeal never is affected; University. No. 45, Changchun Rd, Beijing 100053, China. Tel/Fax: +86-10- 2. Superior vena cava obstruction syndrome such as facial 83198277. Email: [email protected]. and neck edmea, when the superior vena cava is involved; Submitted July 3, 2011. Accepted for publication Aug 3, 2011. 3. Pleural effusion, often bloody, due to pleural invasion, and Available at www.jthoracdis.com shortness of breath if a large amount of fluid is present; 4. Severe, persistent chest pain if the pleura and chest wall is ISSN: 2072-1439 affected; © Pioneer Bioscience Publishing Company. All rights reserved. 5. Cervical sympathetic syndrome such as severe chest pain, Journal of Thoracic Disease, Vol 4, No 1, February 2012 89 upper extremity venous engorgement, edema, arm pain guidance for biopsy. Ultrasound is also commonly used as a and upper limb movement disorder, ipsilateral ptosis, positioning guidance for pleural aspiration; miosis, enophthalmos, and facial anhidrosis, as a result of MRI: it is useful for staging of PLC, and particularly invasion and compression of organs at the thoracic inlet identification of metastases to the spine, ribs, and brain; (eg. first rib, subclavian vein, brachial plexus, cervical Bone scan: it is a routine examination for bone metastases. sympathetic) by cancer located at the tip of the upper When a suspected bone metastasis is suggested by bone scan, lobe; MRI of that area could be conducted for confirmation; and 6. Newly-occurring neurological symptoms and signs such PET-CT: this is not recommended for routine use. It is more as headache, nausea, dizziness and blurred vision, which sensitive and specific in diagnosing mediastinal lymph node may indicate brain metastases; metastases than CT scan. 7. Persistent bone pain at a fixed site with elevated serum alkaline phosphatase or calcium, which may indicate bone Endoscopy metastasis; 8. Right upper quadrant pain, hepatomegaly, and elevated Bronchoscopy: this is the most common tool for diagnosis alkaline phosphatase, aspartate aminotransferase, lactate of PLC -- it enables brush biopsy under direct vision with a dehydrogenase or bilirubin, which can be suggestive of bronchoscope, biopsy and bronchoalveolar lavage for cytological liver metastasis; and histological diagnosis; the combination of these methods 9. Palpable subcutaneous nodules in the case of subcutane- can improve the detection rate; ous metastasis; and Transbronchial needle aspiration (TBNA) and 10. Symptoms as a result of hematogenous metastasis to other endobronchial ultrasound-guided transbronchial needle organs. aspiration (EBUS-TBNA): they are helpful to accurate N2 staging of PLC before treatment, although not recommended Physical examination as routine screening methods. Some well-equipped hospitals are encouraged to use these tools to facilitate diagnosis when Most PLC patients do not have symptoms on examination; applicable. EBUS-TBNA provides more reliable evidence for Some have unexplained, persistent extrapulmonary signs accurate pathological diagnosis of N1 and N2 PLC in a safe such as clubbing (toes), non-migratory pulmonary joint pain, manner; gynecomastia, dark skin or dermatomyositis, ataxia, and Mediastinoscopy: it is useful in confirmation of PLC and phlebitis; evaluation of N staging, and is regarded as the gold standard for Findings of vocal cord paralysis, superior vena cava clinical assessment of mediastinal lymph nodes. Although CT, obstruction, Horner's syndrome and Pancoast syndrome in MRI and the latest PET-CT are good enough to furnish valuable patients with clinical manifestations highly suspicious for PLC evidence on pre-treatment staging of PLC, mediastinoscopy has are indicative of local invasion and metastasis; and still been indispensable for diagnosis; and Findings of nodular hepatomegaly, subcutaneous nodules Thoracoscopy: it enables accurate diagnosis and staging of and swollen supraclavicular lymph nodes in patients with highly PLC, and is particularly useful for diagnosing early-stage lesions suspected PLC are indicative of distant metastasis. (such as small lung nodules), of which pathological specimen can not be obtained through bronchoscopy or transthoracic needle Imaging aspiration biopsy (TTNA), by thoracoscopic excision. Lymph node, pleural and percardial biopsy, and pleural and pericardial Chest X-ray: this is an important tool for early detection of PLC, effusion cytology can be performed under thoracoscopy to and is also used in postoperative follow-up; provide a reliable basis for the development of comprehensive Chest CT scan: an essential technique in the diagnosis of PLC, treatment programs for mid- to late-stage ling cancer. it can further verify the location and extension of any lesion and generally identify benign and malignant tumors. Low-dose spiral Other examination techniques chest CT can effectively detect early PLC, while CT-guided transthoracic biopsy is critical for cytological and histological Sputum cytology: this is a simple, non-invasive diagnostic diagnosis; method for PLC, in which the cytological result is obtained Ultrasound: this is mainly used to identify metastasis to through smear examination of early morning deep-cough abdominal organs and retroperitoneal lymph nodes, as well as specimens on three consecutive days; supraclavicular lymph nodes; it can identify cystic and solid Transthoracic needle aspiration biopsy (TTNA): this lesions on the chest wall or lung tissues nearby and provide is a sensitive and specific detection tool for peripheral PLC 90 Zhi et al. Chinese guidelines on the diagnosis and treatment of primary lung cancer performed under CT or ultrasound guidance; benign tumors are characterized by varying imaging findings, Thoracentesis: this may be warranted in a pleural effusion but excision is always considered if there is concern about the of unclear cause for cytological diagnosis and definite staging of possibility of a malignancy; PLC; Tuberculosis and associated diseases: they are common and Pleural biopsy: this is used to increase the positive detection most easily confused with PLC, leading to misdiagnosis or delay rate if thoracentesis fails to yield positive cytological results; and in clinical treatment. Repeated sputum cytology, bronchoscopy Superficial lymph node biopsy: enlarged superficial lymph and other laboratory examinations are necessary if a definite nodes in patients with any space-occupying lesion of the lung diagnosis is difficult to make before
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