AMERICAN COLLEGE
OF
RADIOLOGY
Appropriateness Criteria Review
ACR Appropriateness Criterias Noninvasive Clinical Staging of Bronchogenic Carcinoma James G. Ravenel, MD,* Tan-Lucien H. Mohammed, MD,w Benjamin Movsas, MD,z Mark E. Ginsburg, MD,yJ Jacobo Kirsch, MD,z Feng-Ming Kong, MD, PhD, MPH,# J. Anthony Parker, MD, PhD, ** w w Gautham P. Reddy, MD, MPH,zz Kenneth E. Rosenzweig, MD,yy and Anthony G. Saleh, MDJJzz; Expert Panels on Thoracic Imaging and Radiation Oncology–Lung
Abstract: In order to appropriately manage patients with lung cancer, it is necessary to properly stage the tumor. The ACR Appropriateness Criterias is designed to provide an overview of the value of different imaging techniques in the non-invasive staging of lung cancer and allow for the rational selection of imaging studies to arrive at the appropriate clinical stage.
(J Thorac Imaging 2010;25:W107–W111)
SUMMARY OF LITERATURE REVIEW Non-small Cell Lung Carcinoma Staging The TNM staging system is widely used to classify lung tumors. In 2007, it was revised after epidemiologic evidence demonstrated differences in the survival of several tumor features that warranted reclassification.1 In the TNM classification, “T” indicates the features of the primary tumor; “N” indicates metastasis to regional lymph nodes; and “M” refers to the presence or absence of distant metastases (Tables 1 and 2). The appropriateness of various imaging techniques is summarized in Table 3. This article is a summary of the complete version of this topic, which is available on the ACR website at www.acr.org/ac. Practitioners are encouraged to refer to the complete version. From the *Department of Radiology, Medical University of South Carolina, Charleston, SC; wImaging Institute, Cleveland Clinic Foundation, Cleveland, OH; zDepartment of Radiation Oncology, Henry Ford Health System, Detroit, MI; #Department of Radiation Oncology, VA Health Center, Ann Arbor, MI; yDepartment of Surgery, Columbia University; yyDepartment of Radiation Oncology, Mount Sinai School of Medicine, New York, NY; JJInstitute for Asthma and Lung Disease, New York Methodist Hospital, Brooklyn, NY; JSociety of Thoracic Surgeons, Chicago; zzAmerican College of Chest Physicians, Northbrook, IL; zDivision of Radiology, Cleveland Clinic, Weston, FL; **Department of Nuclear Medicine, Beth Israel Deaconess Medical Center, Boston, MA; wwSociety of Nuclear Medicine, Reston, VA; and zzDepartment of Radiology, University of Washington School of Medicine, Seattle, Washington. The American College of Radiology (ACR) seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criterias through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply society endorsement of the final document. Reprints: James G. Ravenel, MD, Department of Quality & Safety, American College of Radiology, 1891 Preston White Dr., Reston, VA 20191 (e-mail:
[email protected]). Copyright r American College of Radiology. Reprinted with permission.
J Thorac Imaging
Volume 25, Number 4, November 2010
Evaluation of Primary Tumor (the T Factor) Computed Tomography The distinction between T1 and T2 lesions is generally based on size and rarely impacts the choice of therapy. Imaging cannot reliably determine the presence of visceral pleural invasion for peripheral tumors. Confirming T3 or T4 status based on imaging alone, however, can be quite difficult. Features such as discrete bone destruction, rib erosion, or tumor adjacent to a mediastinal structure without an associated fat plane are diagnostic of chest wall or mediastinal invasion. Computed tomography (CT) features of chest wall invasion include >3 cm of contact with the pleural surface, pleural thickening, absence of fat planes, and an obtuse angle of tumor with the chest wall.2
Magnetic Resonance Imaging Magnetic resonance imaging (MRI) can aid in problem solving and is superior to CT imaging for detecting the involvement of the neural foramina, spinal canal, and brachial plexus in superior sulcus tumors. Surgery is contraindicated by local extension if the brachial plexus is involved above the level of T1, if more than 50% of a vertebral body is invaded, or if there is invasion of the trachea or esophagus. Invasion of the subclavian, common carotid, and vertebral arteries, less than 50% vertebral body invasion, and extension into the neural foramina should be considered relative contraindications to surgery.3
Evaluation of Nodal Metastasis (the N Factor) Computed Tomography As size is the main criterion for malignancy, CT imaging is a rather inaccurate modality for staging the mediastinum. A lymph node >1 cm in short-axis diameter is generally considered “positive.”4 Although there is no lower threshold that guarantees freedom from disease, the overall chance that a node harbors malignancy is influenced by size.5 Among 43 studies conducted from 1991 to 2005, the sensitivities of CT imaging for nodal disease ranged from 26% to 86% and the specificity ranged from 31% to 97%. Pooled sensitivity and specificity from a total of 5111 patients in whom the prevalence of nodal disease was 28% were 51% and 86%, respectively.6
Positron Emission Tomography/CT Integrated fluorodeoxyglucose positron emission tomography (FDG-PET)/CT imaging outperforms CT www.thoracicimaging.com |
W107
J Thorac Imaging
Ravenel et al
Volume 25, Number 4, November 2010
TABLE 1. TNM Descriptors
Stage
Definition
Primary Tumor (T) TX Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus* (ie, not in the main bronchus) T1a Tumor 2 cm or less in greatest dimension T1b Tumor more than 2 cm but 3 cm or less in greatest dimension T2 Tumor more than 3 cm but 7 cm or less or tumor with any of the following features (T2 tumors with these features are classified as T2a if 5 cm or less): involves main bronchus, 2 cm distal to the carina; invades visceral pleura (PL1 or PL2); associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung T2a Tumor more than 3 cm but not more than 5 cm in greatest dimension T2b Tumor more than 5 cm but not more than 7 cm in greatest dimension T3 Tumor more than 7 cm or one that directly invades any of the following: parietal pleura (PL3), chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus (less than 2 cm distal to the carina* but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung or separate tumor nodule(s) in the same lobe) T4 Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, or separate tumor nodule(s) in a different ipsilateral lobe Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s) N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s) Distant Metastasis (M) M0 No distant metastasis M1 Distant metastasis present M1a Separate tumor nodule(s) in a contralateral lobe tumor, pleural nodules, or malignant pleural (or pericardial) effusionw M1b Distant metastasis *The uncommon superficial spreading tumor of any size with its invasive component limited to the bronchial wall, which may extend proximally to the main bronchus, is also classified as T1a. wMost pleural (and pericardial) effusions associated with lung cancer are due to tumor. In a few patients, however, multiple cytopathologic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is nonbloody and is not an exudate. Where these elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patient should be classified as M0.
imaging alone, FDG-PET imaging alone, conventional visual correlation, or superimposition of CT and FDG-PET imaging acquired individually.7–10 Pooling all FDG-PET studies (many without the CT component) resulted in a sensitivity of 74% and a specificity of 85% in 2865 patients, with a prevalence of mediastinal disease of 29%.6 Even when the results of CT and FDG-PET imaging are negative, the false-negative rate in the mediastinum ranges from 8% to 16%.11,12 Sensitivity is often enhanced when qualitative evaluation is used, whereas it tends to suffer when quantitative measures are used. Although FDG-PET imaging is not an endpoint in the staging workup, FDG-PET scans can decrease the number of futile thoracotomies by 20%.13–15 A retrospective study of FDG-PET false-negative results found that occult metastases were more likely to occur with increasing T-stage, central tumors, adenocarcinoma histology, and higher primary tumor standard uptake volume (>6), although the actual number of false-negative lymph nodes in this study was small (n=16).16 Other groups have found that, in addition to these features, upper lobe tumors and those with N1-positive disease also have a relatively high
W108 | www.thoracicimaging.com
r
rate of occult disease in the mediastinum with histologic staging.17,18
Evaluation of Distant Metastasis (the M Factor) Adrenal Glands Adrenal nodules are a common incidental finding in the general population and in patients with lung cancer, but a density measurement of 3 cm in size or mediastinal adenopathy May be useful as a baseline comparison to help detect complications of therapy and other nontumor-related disease in follow-up
CT of the abdomen with contrast CT of the head with contrast Tc-99m bone scan of the whole body MRI of the chest with contrast
5 5 5 3
If MRI is contraindicated and neurological symptoms are present Not necessary if PET has been done Useful for evaluating chest wall invasion, cardiac invasion, and for local staging of superior sulcus tumors
Rating scale: 1, 2, and 3, usually not appropriate; 4, 5, and 6, may be appropriate; 7, 8, and 9, usually appropriate.
r
2010 American College of Radiology. Reprinted with Permission.
www.thoracicimaging.com |
W109
J Thorac Imaging
Ravenel et al
Volume 25, Number 4, November 2010
TABLE 4. Small-cell Lung Carcinoma
Radiologic Procedure
Rating
CT scanning of the chest with or without contrast (including upper abdomen) MRI of the head with contrast FDG-PET
9 9 8
CT of the abdomen with contrast
7
X-ray of the chest
5
CT of the head with contrast Tc-99m bone scan of the whole body MRI chest with contrast
5 5 2
Comments CT with contrast is preferred if there are no strong contraindications With CT for attenuation correction (skull base to thighs). Diagnostic chest CT should be performed if not done previously Due to high incidence of liver metastases at initial diagnosis, the entire liver should be scanned May be useful as a baseline comparison to help detect complications of therapy and other nontumor-related disease in follow-up If MRI contraindicated and neurological symptoms are present Not necessary if PET has been done
Rating scale: 1, 2, and 3, usually not appropriate; 4, 5, and 6, may be appropriate; 7, 8, and 9, usually appropriate.
Cerebral metastases have been said to be present in up to 10% of individuals at the time of diagnosis.41,42 Bone is considered to be the most common site of metastatic disease overall (35% of cases), and therefore bone scintigraphy has generally been part of the initial staging evaluation.43 As data accumulate in other malignancies as well as SCLC, it is likely that bone scintigraphy will be replaced in the imaging algorithm by whole-body FDG-PET/CT imaging.
4. 5.
6.
DISCLAIMER The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for the diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for the evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other coexistent diseases or other medical consequences of this condition are not considered in this article. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the Food and Drug Administration have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.
8.
9.
10.
11.
12.
13.
REFERENCES 1. Groome PA, Bolejack V, Crowley JJ, et al. The IASLC Lung Cancer Staging Project: validation of the proposals for revision of the T, N, and M descriptors and consequent stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumours. J Thorac Oncol. 2007;2:694–705. 2. Glazer HS, Duncan-Meyer J, Aronberg DJ, et al. Pleural and chest wall invasion in bronchogenic carcinoma: CT evaluation. Radiology. 1985;157:191–194. 3. Bruzzi JF, Komaki R, Walsh GL, et al. Imaging of non-small cell lung cancer of the superior sulcus: part 2: initial staging
W110 | www.thoracicimaging.com
7.
r
14.
15.
and assessment of resectability and therapeutic response. Radiographics. 2008;28:561–572. Glazer GM, Gross BH, Quint LE, et al. Normal mediastinal lymph nodes: number and size according to American Thoracic Society mapping. AJR. 1985;144:261–265. de Langen AJ, Raijmakers P, Riphagen I, et al. The size of mediastinal lymph nodes and its relation with metastatic involvement: a meta-analysis. Eur J Cardiothorac Surg. 2006; 29:26–29. Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007;132: 178S–201S. Antoch G, Stattaus J, Nemat AT, et al. Non-small cell lung cancer: dual-modality PET/CT in preoperative staging. Radiology. 2003;229:526–533. Aquino SL, Asmuth JC, Alpert NM, et al. Improved radiologic staging of lung cancer with 2-[18F]-fluoro-2-deoxyD-glucose-positron emission tomography and computed tomography registration. J Comput Assist Tomogr. 2003;27: 479–484. Cerfolio RJ, Ojha B, Bryant AS, et al. The accuracy of integrated PET-CT compared with dedicated PET alone for the staging of patients with nonsmall cell lung cancer. Ann Thorac Surg. 2004;78:1017–1023; discussion 1017–1023. Lardinois D, Weder W, Hany TF, et al. Staging of non-smallcell lung cancer with integrated positron-emission tomography and computed tomography. N Engl J Med. 2003;348: 2500–2507. Al-Sarraf N, Aziz R, Gately K, et al. Pattern and predictors of occult mediastinal lymph node involvement in non-small cell lung cancer patients with negative mediastinal uptake on positron emission tomography. Eur J Cardiothorac Surg. 2008;33: 104–109. Herth FJ, Eberhardt R, Krasnik M, et al. Endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes in the radiologically and positron emission tomographynormal mediastinum in patients with lung cancer. Chest. 2008;133:887–891. Fischer B, Lassen U, Mortensen J, et al. Preoperative staging of lung cancer with combined PET-CT. N Engl J Med. 2009; 361:32–39. Reed CE, Harpole DH, Posther KE, et al. Results of the American College of Surgeons Oncology Group Z0050 trial: the utility of positron emission tomography in staging potentially operable non-small cell lung cancer. J Thorac Cardiovasc Surg. 2003;126:1943–1951. van Tinteren H, Hoekstra OS, Smit EF, et al. Effectiveness of positron emission tomography in the preoperative assessment of patients with suspected non-small-cell lung cancer: the PLUS multicentre randomised trial. Lancet. 2002;359:1388–1393.
2010 American College of Radiology. Reprinted with Permission.
J Thorac Imaging
16. Lee PC, Port JL, Korst RJ, et al. Risk factors for occult mediastinal metastases in clinical stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84:177–181. 17. Cerfolio RJ, Bryant AS, Eloubeidi MA. Routine mediastinoscopy and esophageal ultrasound fine-needle aspiration in patients with non-small cell lung cancer who are clinically N2 negative: a prospective study. Chest. 2006;130:1791–1795. 18. Hishida T, Yoshida J, Nishimura M, et al. Problems in the current diagnostic standards of clinical N1 non-small cell lung cancer. Thorax. 2008;63:526–531. 19. Boland GW, Lee MJ, Gazelle GS, et al. Characterization of adrenal masses using unenhanced CT: an analysis of the CT literature. AJR. 1998;171:201–204. 20. Choyke PL. ACR Appropriateness Criteria on incidentally discovered adrenal mass. J Am Coll Radiol. 2006;3:498–504. 21. Vikram R, Yeung HD, Macapinlac HA, et al. Utility of PET/ CT in differentiating benign from malignant adrenal nodules in patients with cancer. AJR. 2008;191:1545–1551. 22. Kagohashi K, Satoh H, Ishikawa H, et al. Liver metastasis at the time of initial diagnosis of lung cancer. Med Oncol. 2003;20:25–28. 23. Delbeke D, Martin WH, Sandler MP, et al. Evaluation of benign vs malignant hepatic lesions with positron emission tomography. Arch Surg. 1998;133:510–515; discussion 515–516. 24. Little AG, Stitik FP. Clinical staging of patients with nonsmall cell lung cancer. Chest. 1990;97:1431–1438. 25. Cheran SK, Herndon JE II, Patz EF Jr. Comparison of wholebody FDG-PET to bone scan for detection of bone metastases in patients with a new diagnosis of lung cancer. Lung Cancer. 2004;44:317–325. 26. Gayed I, Vu T, Johnson M, et al. Comparison of bone and 2deoxy-2-[18F]fluoro-D-glucose positron emission tomography in the evaluation of bony metastases in lung cancer. Mol Imaging Biol. 2003;5:26–31. 27. Hsia TC, Shen YY, Yen RF, et al. Comparing whole body 18F-2-deoxyglucose positron emission tomography and technetium-99m methylene diophosphate bone scan to detect bone metastases in patients with non-small cell lung cancer. Neoplasma. 2002;49:267–271. 28. Cole FH Jr, Thomas JE, Wilcox AB, et al. Cerebral imaging in the asymptomatic preoperative bronchogenic carcinoma patient: is it worthwhile? Ann Thorac Surg. 1994;57:838–840. 29. Colice GL, Birkmeyer JD, Black WC, et al. Cost-effectiveness of head CT in patients with lung cancer without clinical evidence of metastases. Chest. 1995;108:1264–1271.
r
ACR Appropriateness Criterias
Volume 25, Number 4, November 2010
30. Ferrigno D, Buccheri G. Cranial computed tomography as a part of the initial staging procedures for patients with nonsmall-cell lung cancer. Chest. 1994;106:1025–1029. 31. Mintz BJ, Tuhrim S, Alexander S, et al. Intracranial metastases in the initial staging of bronchogenic carcinoma. Chest. 1984;86:850–853. 32. Vallieres E, Shepherd FA, Crowley J, et al. The IASLC Lung Cancer Staging Project: proposals regarding the relevance of TNM in the pathologic staging of small cell lung cancer in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol. 2009;4:1049–1059. 33. Mirvis SE, Whitley NO, Aisner J, et al. Abdominal CT in the staging of small-cell carcinoma of the lung: incidence of metastases and effect on prognosis. AJR. 1987;148:845–847. 34. Whitley NO, Mirvis SE. Abdominal CT in the staging of small cell carcinoma of the lung. Crit Rev Diagn Imaging. 1989;29:103–116. 35. Simon GR, Turrisi A. Management of small cell lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:324S–339S. 36. Fischer BM, Mortensen J, Langer SW, et al. A prospective study of PET/CT in initial staging of small-cell lung cancer: comparison with CT, bone scintigraphy and bone marrow analysis. Ann Oncol. 2007;18:338–345. 37. Bradley JD, Dehdashti F, Mintun MA, et al. Positron emission tomography in limited-stage small-cell lung cancer: a prospective study. J Clin Oncol. 2004;22:3248–3254. 38. Brink I, Schumacher T, Mix M, et al. Impact of [18F]FDGPET on the primary staging of small-cell lung cancer. Eur J Nucl Med Mol Imaging. 2004;31:1614–1620. 39. Bradley J, Thorstad WL, Mutic S, et al. Impact of FDG-PET on radiation therapy volume delineation in non-small-cell lung cancer. Int J Radiat Oncol Biol Phys. 2004;59:78–86. 40. van Loon J, Offermann C, Bosmans G, et al. 18FDG-PET based radiation planning of mediastinal lymph nodes in limited disease small cell lung cancer changes radiotherapy fields: a planning study. Radiother Oncol. 2008;87:49–54. 41. Giannone L, Johnson DH, Hande KR, et al. Favorable prognosis of brain metastases in small cell lung cancer. Ann Intern Med. 1987;106:386–389. 42. Hirsch FR, Paulson OB, Hansen HH, et al. Intracranial metastases in small cell carcinoma of the lung: prognostic aspects. Cancer. 1983;51:529–533. 43. Adjei AA, Marks RS, Bonner JA. Current guidelines for the management of small cell lung cancer. Mayo Clin Proc. 1999;74:809–816.
2010 American College of Radiology. Reprinted with Permission.
www.thoracicimaging.com |
W111
