Multidisciplinary lung cancer teams ideally include representatives from pulmonary medicine, thoracic surgery, medical and radiation oncology, palliative care, radiology, and pathology.

When findings on PET-CT scan appear inflammatory, continued clinical and radiologic surveillance may avoid unnecessary procedures in patients with benign lesions, but may delay diagnosis and treatment in case of malignancy.

Tissue is needed to confirm a diagnosis of advanced lung cancer and to individualize treatment based on genetic alterations such as sensitizing EGFR mutations or EML-ALK fusion genes.

Safe and cost-effective strategies to obtain adequate tissue for diagnosis and molecular analysis are dictated by patient-related factors and lesion characteristics.

Electromagnetic navigation bronchoscopy, also known as ENB, combines simultaneous CT virtual bronchoscopy with real-time flexible bronchoscopy. It has an overall diagnostic yield of 70% and pneumothorax rate of approximately 3%. If available, ENB is a reasonable first option to obtain diagnostic tissue from peripheral lesions, even when their diameter is less than 2 cm. The yield is increased to 80% if an airway is seen leading to the lesion.

Radial probe endobronchial ultrasonography, known as REBUS, is used to obtain tissue samples from peripheral lung lesions, even those too small to be visualized using fluoroscopy. Sensitivity is 0.73 for detecting lung cancer, with a mean positive likelihood ratio of 26 and a negative likelihood ratio of 0.28. REBUS-guided TBNA increases yield from 46% to 69% compared with TBNA without REBUS in nodules less than 2 cm in diameter.

Conventional bronchoscopic lung biopsy for peripheral lesions less than or equal to 2 cm has a diagnostic yield as low as 14%. Bronchoscopy with bronchioloalveolar lavage might be performed to identify infectious etiologies.

The diagnostic yield of CT-guided needle aspiration and biopsy varies between 36% and 84%. Pneumothorax requiring chest tube drainage is reported in 5-10% of procedures. Risk factors for pneumothorax include surrounding emphysema, the proximity of the lesion to fissures, and needle insertion through aerated lung parenchyma.

Video Assisted Thoracic Surgery, also known as VATS, has a sensitivity and specificity approaching 100%, but its associated mortality is approximately 1%. VATS may be appropriate in patients who are surgical candidates. This patient, however, would not be a surgical candidate if the bilateral lesions are confirmed to represent stage IV recurrent lung cancer.


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References:

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2. Gould MK, Fletcher J, Iannettoni MD; et al. American College of Chest Physicians, Evaluation of patients with pulmonary nodules: when is it lung cancer? ACCP evidence-based clinical practice guidelines (2nd edition), Chest 2007 132 (3suppl) 108S-130S.
3. Gildea TR, Mazzone PJ, Karnak D, et al. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Am J Respir Crit Care Med 2006; 174: 982-989.
4. Eberhardt R, Anantham D, Herth F et al. Electromagnetic navigation diagnostic bronchoscopy in peripheral lung lesions. Chest 2007; 131: 1800-1805.
5. Steinfort DP, Khor YH, Manser RL, et al. Radial probe endobronchial ultrasound for the diagnosis of peripheral lung cancer: systematic review and meta-analysis. Eur Respir J. 2011; 37: 902-10.
6. Eberhardt R, Ernst A, Herth FJ. Ultrasound-guided transbronchial biopsy of solitary pulmonary nodules less than 20 mm. Eur Respir J. 2009; 34: 1284-7.