Multidisciplinary Evaluation of Patients With Suspected Lung Cancer

Abstract

Lung cancer diagnosis and treatment has evolved to require the input and expertise of multiple diverse medical and surgical specialties. The approach to lung cancer patients requires the adherence to a few principles that include thorough use of staging modalities to assure the proper treatment for each patient, and an understanding of the limitations and advantages of each of these modalities. Evidence is continuing to emerge that supports the notion that diagnostic workup and treatment of lung cancer patients is best done within the context of a multidisciplinary team devoted to this purpose.

Figure 1

Patients undergoing lung cancer surgery bring with them to the OR a certain burden that can be measured in both anatomic (tumor) and physiologic (co-morbid) terms. Only so much of each can be sustained for a patient to successfully withstand lobectomy or greater operations (chest wall resection, pneumonectomy). Considering patients for surgery requires an accurate knowledge of not just the tumor stage (as determined by parameters of tumor “T”, nodal “N”, and metastatic “M” extent), but also of the patients “physiologic stage”. Patients with more extensive disease can undergo surgery if they are otherwise in good physiologic condition. Likewise, patients with more co-morbidity can withstand more limited operations, but (for example) not pneumonectomy or chest wall resection.

Figure 2

CT scan showing the presence of a left hilar nodule (Dashed arrow, top left). Combined CT-PET scan shows uptake in the left hilar mass, as well as a small left paratracheal lymph node (Station 4L. Middle row arrow). Endobronchial ultrasound (EBUS) shows the 4L node adjacent to the pulmonary artery (bottom left). Color doppler allows the bronchoscopist to confirm the presence of vessels. EBUS guided needle aspiration of the 4L node demonstrated malignant involvement of the N2 nodes, providing a stage and a diagnosis in one procedure (Bottom right panel shows the needle in the plane of the ultrasound, entering the node). The top right panel shows the linear array ultrasound at the end of the bronchoscope with the needle protruding from the working channel.