Diagnostic imaging in the preoperative management of lung cancer

Abstract

Surgical resection is the accepted standard of care for patients with non-small cell lung cancer (NSCLC). Several imaging modalities play central roles in the detection and staging of the disease. The aim of this review is to evaluate the utility of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and PET/CT for NSCLC staging. Radiographic staging refers to the use of CT as a non-invasive diagnostic technique. However, while the vast majority of patients undergo only CT, CT is a notoriously inaccurate means of tumor and nodal staging in many situations. PET/CT clearly improves the staging, particularly nodal staging, compared to CT or PET alone. In addition, as a result of the increased soft-tissue contrast, MRI is superior to CT for distinguishing between tissue characteristics. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), which is a minimally invasive technique, also has pathological diagnostic potential. Extensive research and the resultant improvements in the understanding of genetics, histology, molecular biology and oncology are transforming our understanding of lung cancer, and it is clear that imaging modalities such as CT, MRI, PET and PET/CT will have an important role in its preoperative management. However, thoracic surgeons should also be aware of the limitations of these techniques.

Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience

“…We should no longer use UCS during vessel dissection, but limit its use to hilar, nodal, or pleural adhesion dissection. However, energy devices are one of the powerful tools [17], so we can also use the bipolar type (BT) vessel sealing device such as LigaSure ® (Covidien, Mansfield, MA, USA) and Enseal ® (Ethicon Endo-Surgery, LLC, Guaynabo, PR, USA). It should be recognized that both UCS and BT have their own advantages and disadvantages.…”

“…According to the guideline committee of the Japanese Association for Chest Surgery [15], despite a lack of established evidence, VATS lobectomy by an experienced surgeon is associated with minimal invasiveness and an outcome equivalent to that of open lobectomy for stage I NSCLC (Recommendation grade: Level C1). Moreover, the indications for VATS are expanding to advanced stage disease and a wider range of procedures including segmentectomy [16] and bronchoplasty, with the development of endoscopic instruments, diagnostic imaging [17] and surgeons' skills. However, these procedures are still complicated and not recommended to be performed by all thoracic surgeons.…”

The Diagnostic Value of MR Imaging in Determining the Lymph Node Status of Patients with Non–Small Cell Lung Cancer: A Meta-Analysis

“…A high diagnostic accuracy is essential for reliable cN staging, determining resectability and associated treatment decision making (ie, surgical resection vs chemotherapy and/or radiation therapy) on a per-patient basis (4,59,60). These decisions are currently based on results of endobronchial and/or endoesophageal US-guided TBNA and/ or mediastinoscopy and additional FDG PET/CT.…”

Positron Emission Tomography (PET) in Oncology

“…Actually, pleural effusion is relatively frequent in patients with NSCLC, and may be malignant or benign, in particular in patients with post-obstructive pneumonia. The sensitivity and specificity of FDG-PET/CT in determining pleural invasion range from 70% to 95% and 64% to 94% respectively [ 15 ]. The limitations of FDG-PET/CT for T staging are due to the anatomical localization and size measurement difficulties, microscopic disease underestimation, or absence of FDG uptake in case of low-metabolism tumors (bronchoalveolar cell carcinoma, carcinoid tumors).…”

“…However, the sensitivity of N staging by FDG-PET/CT remains disappointingly low (45%) and false negative cases have been reported [ 19 ], particularly for lymph nodes size <10 mm (Se = 32.4%) compared with lymph nodes >10 mm (Se = 85.3%). Other limitations are the false-positive rates due to unspecific FDG uptake like inflammation or granulomatous disease (e.g., sarcoidosis), leading to a reduction in specificity [ 15 ]. Despite the above improvement in accuracy of N staging with FDG-PET/CT, surgical staging remains the standard, especially to detect occult mediastinal nodal invasion [ 20 , 21 ].…”