5.Smooth versus irregular appearance of the border

6.Location

Additional clinical features are suggestive of a benign versus a malignant lesion but are somewhat less reliable. In individuals younger than 35 years, primary lung cancer is an unlikely but certainly not impossible diagnosis. A history of heavy smoking and/or exposure to asbestos indicates a high risk for a malignant lesion; however, the absence of a smoking history does not rule out the diagnosis of lung cancer, particularly a peripheral adenocarcinoma. Finally, the presence of a previously diagnosed distant carcinoma obviously raises the possibility that a lung nodule is a metastatic focus of tumor.

The practical question of how to evaluate and manage these cases often is difficult, and the decisionmaking process must be individualized for each patient. A number of online calculators are available that estimate the likelihood of malignancy based on patient and nodule characteristics. This estimate may be helpful to both the physician and the patient when discussing and deciding how aggressively to pursue the diagnostic evaluation. Based on the estimated likelihood of malignancy, the options for management include no further work-up, follow-up (serial) CT scans to look for growth of the lesion, immediate sampling via a biopsy procedure, or even surgical removal of the nodule.

A simple noninvasive test such as sputum cytologic examination is helpful if results are positive; however, the yield is low, even with peripheral nodules that eventually are proven to be carcinoma. Unless the lesion has been stable on chest radiograph for more than 2 years, chest CT scanning is performed routinely to look at border characteristics, assess the presence and pattern of calcification, and identify other abnormalities, especially lymph nodes within the mediastinum. If a nodule is larger than 1 cm, FDG-PET scanning (see Chapter 3), if available, is helpful when the diagnosis is uncertain after evaluation of the clinical information and other imaging studies. Uptake of labeled FDG suggests that the lesion has high metabolic activity and could be malignant, whereas lack of uptake suggests a metabolically inactive, benign lesion.

More invasive procedures, such as percutaneous needle aspiration or biopsy and transbronchial biopsy (through a flexible bronchoscope), may be used to make a histologic diagnosis. However, in many cases biopsy findings that are negative for malignancy do not obviate the need for surgery because malignant cells may be missed by the limited sampling of a needle or biopsy forceps. Hence, a commonly used approach with a lesion suspicious for carcinoma is to proceed directly to resection with video-assisted thoracic surgery (VATS) using a thoracoscope, assuming no contraindications to surgery and no clinical evidence that the lesion has spread elsewhere or has metastasized from a distant primary malignancy. A more definitive resection, such as a lobectomy performed by thoracotomy, then is performed if the nodule is found to be malignant.

When lung cancer presents as a solitary peripheral nodule, the prognosis is much better than for the general group of patients with lung cancer. As a result of frequently curative surgical resection, more than 50% of patients with an initial solitary peripheral lung cancer survive 5 years, compared with less than 10% of lung cancer patients if the disease has metastasized outside the chest.

Suggested readings

Lung cancer: General reviews and clinical aspects

Anwar A, Jafri F, Ashraf S, Jafri M.A.S. & Fanucchi M. Paraneoplastic syndromes in lung cancer and their management Annals of Translational Medicine 2019;7: 359.

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

PET Clinics 2017;12: 53-62.

Lung cancer: Treatment

Barnes H, See K, Barnett S. & Manser R. Surgery for limited-stage small-cell lung cancer

Cochrane Database of Systematic Reviews 2017;4: CD011917.

Brunelli A. Preoperative functional workup for patients with advanced lung cancer Journal of Thoracic Disease Suppl. 11, 2016;8: S840-S848.

Chaft J.E, Rimner A, Weder W, Azzoli C.G, Kris M.G. & Cascone T. Evolution of systemic therapy for stages I-III non-metastatic non-small-cell lung cancer Nature Reviews Clinical Oncology 2021;18: 547-557.

Chee J, Robinson B.W.S, Holt R.A. & Creaney J. Immunotherapy for lung malignancies. From gene sequencing to novel therapies Chest 2017;151: 891-897.

Ernst A, Feller-Kopman D, Becker H.D. & Mehta A.C. Central airway obstruction American Journal of Respiratory and Critical Care Medicine 2004;169: 1278-1297.

Hiddinga B.I, Raskin J, Janssens A, Pauwels P. & Van Meerbeeck J.P. Recent developments in the treatment of small cell lung cancer European Respiratory Review 2021;30: 210079.

Hiley C.T, Le Quesne J, Santis G, Sharpe R, de Castro D.G, Middleton G., et al. Challenges in molecular testing in non-small-cell lung cancer patients with advanced disease Lancet 2016;388: 1002-1011.

Hirsch F.R, Suda K, Wiens J. & Bunn P.A,Jr. New and emerging targeted treatments in advanced non-small-cell lung cancer Lancet 2016;388: 1012-1024.

Howlader N, Forjaz G, Mooradian M.J, Meza R, Kong C.Y, Cronin K.A., et al. The effect of advances in lung-cancer treatment on population mortality New England Journal of Medicine 2020;383: 640-649.

Lievense L.A, Sterman D.H, Cornelissen R. & Aerts J.G. Checkpoint blockade in lung cancer and mesothelioma American Journal of Respiratory and Critical Care Medicine 2017;196: 274-282.

Luo H, Yu X, Liang N, Xie J, Deng G, Liu Q., et al. The effect of induction chemotherapy in patients with locally advanced nonsmall cell lung cancer who received chemoradiotherapy: A systematic review and meta-analysis Medicine (Baltimore) 2017;96: e6165.

McDonald F, De Waele M, Hendriks L.E.L, Faivre-Finn C, Dingemans A.C. & Van Schil P.E.

Management of stage I and II nonsmall cell lung cancer European Respiratory Journal 2017;49: 1600764.

Moon E.K, Langer C.J. & Albelda S.M. The era of checkpoint blockade in lung cancer: Taking the brakes off the immune system Annals of the American Thoracic Society 2017;14: 1248-1260.

Ramalingam S.S, Vansteenkiste J, Planchard D, Cho B.C, Gray J.E, Ohe Y., et al. Overall survival with osimertinib in untreated, EGFR-mutated advanced NSCLC New England Journal of Medicine 2020;382: 41-50.

Reck M. & Rabe K.F. Precision diagnosis and treatment for advanced non-small-cell lung cancer New England Journal of Medicine 2017;377: 849-861.

Steuer C.E, Khuri F.R. & Ramalingam S.S. The next generation of epidermal growth factor receptor tyrosine kinase inhibitors in the treatment of lung cancer Cancer 2015;121: E1E6.

Suresh K, Naidoo J, Lin C.T. & Danoff S. Immune checkpoint immunotherapy for non-small

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/