Empiric evidence suggests patient management is optimized by the use of multidisciplinary lung cancer conferences. Interaction among key specialists avoids a system of serial and autonomous referrals that may delay and fracture care. The active involvement of key specialists, including those most knowledgeable of the optimal use of small specimens for molecular analysis is increasingly relevant. The impact of compliance or discordance with decisions and recommendations made at multidisciplinary conferences warrants further study.

At this conference, pathologists noted that tissue requirements for molecular analysis may exceed those for diagnostic cytologic or histologic examination. The pulmonologist noted that in peripheral parenchymal lesions, a systematic review showed an overall sensitivity of 69% for conventional bronchoscopy with transbronchial biopsy, brushings and lavage, but without electromagnetic navigation or radial ultrasound assistance. Brushing alone had a sensitivity of 52 %, whereas transbronchial biopsy had a sensitivity of only 46%. BAL and washing had a sensitivity of 43%. The size of the lesion impacts yield. The sensitivity of all modalities for peripheral lesions less than 2 cm was 0.33 compared to 0.62 for lesions greater than 2 cm. At least 4-5 biopsies should probably be performed to obtain sufficient material for molecular testing.

The Interventional radiologist said that diagnostic yield for transthoracic CT-guided biopsy and needle aspiration is reportedly greater than 90%. She argued that CT-guided biopsy was the optimal procedure in this patient because adequate quantity and quality of lung tissue can be obtained for molecular testing if multiple passes are performed. Complications include hemorrhage and pneumothorax, which, in high-risk patients might prompt a preference for a bronchoscopic approach. The pulmonologist responded that EBUS-TBNA from the interlobar node could be performed at the time of bronchoscopy with transbronchial biopsy, brushings and lavage from the right upper lobe mass. Using EBUS-TBNA, cytology and tissue cores for histology are obtained that are adequate for molecular testing.


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