Guidelines on the radical management of patients with lung cancer Eric Lim, 1 David Baldwin, 2 Michael Beckles, 3 John Duffy, 2 James Entwisle, 4 Corinne Faivre-Finn, 5 Keith Kerr, 6 Alistair Macfie, 7 Jim McGuigan, 8 Simon Padley, 9 Sanjay Popat, 10 Nicholas Screaton, 11 Michael Snee, 12 David Waller, 13 Chris Warburton, 14 Thida Win, 15 British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland ABSTRACT A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland was undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment. SYNOPSIS OF RECOMMENDATIONS The recommendations of the Guideline Develop- ment Committee (GDC) are listed below and can be cross-referenced in the main document. The list includes recommendations for research denoted by the abbreviation RR. The recommendations should be read in conjunction with figure 1 (medi- astinal diagnosis and staging), figure 2 (tripartite risk assessment) and figure 3 (risk assessment for postoperative dyspnoea). SECTION 1: SELECTION OF PATIENTS FOR RADICAL TREATMENT 1.1 Diagnosis and staging 1.1.1 Imaging 1. View all available historical images at the onset of the diagnostic pathway and review them prior to treatment. [C] 2. Ensure contemporaneous imaging is available at the time of radical treatment. [C] 3. Ensure a CT scan that is <4 weeks old is available at the time of radical treatment of borderline lesions. [D] 4. Arrange a CT scan of the chest, lower neck and upper abdomen with intravenous contrast medium administration early in the diagnostic pathway for all patients with suspected lung cancer potentially suitable for radical treatment. [C] 5. Avoid relying on a CT scan of the chest as the sole investigation to stage the mediastinal lymph nodes. [B] 6. Ensure positron emission tomography (PET)-CT scanning is available for all patients being considered for radical treatment. [B] 7. Offer radical treatment without further medias- tinal lymph node sampling if there is no significant uptake in normal sized mediastinal lymph nodes on PET-CT scanning. [C] 8. Evaluate PET positive mediastinal nodes by further mediastinal sampling. [C] 9. Confirm the presence of isolated distant metastases/synchronous tumours by biopsy or further imaging in patients being considered for radical treatment. [C] 10. Consider MRI or CT scanning of the head in patients selected for radical treatment, especially in stage III disease. [C] 11. Evaluate patients with features suggestive of intracranial pathology by an initial CT scan of the head followed by MRI if normal or MRI as an initial test. [C] 12. Biopsy adrenal lesions that show abnormal uptake on PET-CT scanning before radical treat- ment. [D] 13. RR The role of PET-CT scanning in patients with small cell lung cancer considered suitable for radical treatment should be evaluated in clinical trials. 1.1.2 Endoscopic procedures for diagnosis and staging 14. When obtaining diagnostic and staging samples, consider the adequacy of these in the context of selection of patients for targeted therapy. [D] 15. Ensure biopsy samples are taken in adequate numbers and size where there is negligible additional risk to the patient. [D] 16. Use transbronchial needle aspiration (TBNA) and endobronchial ultrasound/endoscopic ultra- sound (EBUS/EUS)-guided TBNA as an initial diagnostic and staging procedure according to findings on CT or PET-CT scans. [C] 17. Consider EBUS/EUS-guided TBNA to stage the mediastinum. [C] 18. Confirm negative results obtained by TBNA and EBUS/EUS-guided TBNA by mediastinoscopy and lymph node biopsy where clinically appro- priate. [C] 19. RR The use of narrow band and autofluor- escence imaging should be investigated in clinical trials. 1.1.3 7th Edition of TNM for lung tumours 20. The 7th edition of the TNM classification of lung cancer should be used for staging patients with lung cancer. [B] 21. The IASLC international nodal map should be used in the assessment and staging of lymph node disease. [C] 1.2 Management of specific disease subsets 1.2.1 T3 disease 22. Offer patients with T3N0e1M0 disease radical treatment. [D] < Appendix 2 is published online only. To view this file, please visit the journal online (http://thorax.bmj.com). 1 Royal Brompton Hospital, London, UK 2 Nottingham University Hospitals, Nottingham, UK 3 Royal Free Hospital, London, UK 4 University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK 5 Christie Hospital, Manchester, UK 6 Grampian University Hospitals NHS Trust, Aberdeen, UK 7 Golden Jubilee National Hospital, Clydebank, UK 8 Royal Victoria Hospital, Belfast, UK 9 Chelsea and Westminster Hospital, London, UK 10 Royal Marsden Hospital, London, UK 11 Papworth Hospital NHS Trust, Papworth Hospital, Papworth Everard, Cambridge, UK 12 Leeds Teaching Hospitals Trust, Leeds, UK 13 Glenfield Hospital, Leicester, Leicester, UK 14 Aintree Chest Centre, University Hospital Aintree, Liverpool, UK 15 Lister Hospital, Stevenage, Hertfordshire, UK Correspondence to Eric Lim, Imperial College and the Academic Division of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK; e.lim@rbht.nhs.uk Received 28 June 2010 Accepted 29 June 2010 Thorax 2010;65(Suppl III):iii1eiii27. doi:10.1136/thx.2010.145938 iii1 Supplement on June 5, 2020 by guest. 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