Chest
DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)Special Treatment Issues in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition)
Section snippets
Materials and Methods
A formal metaanalysis was not available for any of the particular forms of NSCLC that are the subject of this chapter, and resources did not permit the American College of Chest Physicians (ACCP) to conduct such an analysis independently. Clinical guidelines from other organizations were available only with regard to Pancoast tumors. These involve primarily consensus opinion statements and are discussed in the “Pancoast Tumors” section.1, 2, 3, 4, 5, 6 However, a systematic review of the most
Definitions
Lung cancers that occur in the apex of the chest and invade apical chest wall structures are called superior sulcus tumors, or Pancoast tumors. The classic description of such patients involves a syndrome of pain radiating down the arm as a manifestation of brachial plexus involvement. With improvements in radiographic techniques, earlier diagnosis, and a more detailed understanding of the anatomy, a tumor can be classified as a Pancoast tumor when it invades any of the structures at the apex
Recommendations
1. In patients with a Pancoast tumor, it is recommended that a tissue diagnosis be obtained before initiation of therapy. Grade of recommendation, 1C
2. In patients who have a Pancoast tumor and are being considered for curative intent surgical resection, an MRI of the thoracic inlet and brachial plexus is recommended to rule out tumor invasion of unresectable vascular structures or the extradural space. Grade of recommendation, 1C
3. In patients with a Pancoast tumor involving the subclavian
Recommendations
11. In patients who have a clinical T4N0,1M0 NSCLC and are being considered for curative resection, it is recommend that invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) be undertaken. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
12. In patients with a T4N0,1M0 NSCLC, it is recommended that resection be undertaken only at a
Recommendations
13. In patients with suspected or proven lung cancer and a satellite nodule within the same lobe, it is recommend that no further diagnostic workup of a satellite nodule be undertaken. Grade of recommendation, 1B
14. In patients with a satellite lesion within the same lobe as a suspected or proven primary lung cancer, evaluation of extrathoracic metastases and confirmation of the mediastinal node status should be performed as dictated by the primary lung cancer alone and not modified because of
Recommendations
16. In patients who have two synchronous primary NSCLCs and are being considered for curative surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
17. In patients suspected of having two synchronous primary NSCLCs, a thorough search for an extrathoracic
Recommendation
19. In patients who have a metachronous NSCLC and are being considered for curative surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
Recommendations
20. In patients who have an isolated brain metastasis from NSCLC and are being considered for curative resection of a stage I or II lung primary tumor, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
21. In patients with no other sites of metastases and a synchronous
Recommendations
25. In patients who have an isolated adrenal metastasis from NSCLC and are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection. Grade of recommendation, 1C
26. In patients with a synchronous resectable N0,1 primary NSCLC and no other sites of
Recommendations
28. In patients who have an NSCLC invading the chest wall and are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head CT/MRI plus either whole-body PET or abdominal CT plus bone scan) are recommended. Involvement of mediastinal nodes and/or metastatic disease represents a contraindication to resection, and definitive chemoradiotherapy is recommended for these patients. Grade of recommendation, 2C
29. At the time of resection of a
Conclusions
The available data for patients with Pancoast tumors suggest that the best survival is achieved by preoperative chemoradiotherapy followed by surgical resection in carefully selected patients. Preoperative radiotherapy followed by surgical resection is a reasonable alternative. Involvement of subclavian vessels, vertebral column, or mediastinal lymph nodes is associated with poor survival after resection. At the time of resection, it is important to perform a complete resection that should
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