Imaging
Non-Small Cell Lung Cancer
- Preliminary Diagnosis: Non-Small Cell Lung Cancer
-
I. What imaging technique is first-line for this diagnosis?
- II. Describe the advantages and disadvantages of this technique for diagnosis of non-small cell lung cancer.
-
III. What are the contraindications for the first-line imaging technique?
-
IV. What alternative imaging techniques are available?
- V. Describe the advantages and disadvantages of the alternative techniques for non-small cell lung cancer.
- VI. What are the contraindications for the alternative imaging techniques?
Preliminary Diagnosis: Non-Small Cell Lung Cancer
I. What imaging technique is first-line for this diagnosis?
CT of the chest with intravenous contrast
II. Describe the advantages and disadvantages of this technique for diagnosis of non-small cell lung cancer.
Advantages
Can adequately assess the T stage of the tumor
Useful for identifying pleural nodules, pleural plaques, pleural/pericardial effusions, or metastasis
CT should include the upper abdomen to assess for adrenal metastasis
Easily accessible at most medical facilities
Better tolerated in obese or claustrophobic patients
Disadvantages
Low sensitivity (40-84%) and specificity (57-94%) for identifying mediastinal and lymph node involvement
Positive predictive value (PPV) of 50% and negative predictive value (NPV) of 85%
Limited in detecting chest wall or parietal pleural invasion
Limited in detecting extra-thoracic metastatic disease
Requires the use of IV contrast
Exposure to ionizing radiation
III. What are the contraindications for the first-line imaging technique?
Contraindicated in pregnant patients, especially during the first and second trimester
Contraindicated in patients with iodine allergies
It should be used with caution in patients with acute renal insufficiency.
IV. What alternative imaging techniques are available?
PET/CT (commonly used as adjunct to chest CT for full staging)
MRI of chest
Chest X-ray
V. Describe the advantages and disadvantages of the alternative techniques for non-small cell lung cancer.
PET/CT
Advantages
Delineates anatomy and also determines metabolic activity of suspicious lesions
Improved sensitivity (98%) versus CT alone at identifying mediastinal invasion and lymph node metastases
Improved sensitivity and specificity for detecting extrathoracic metastatic disease versus CT alone
Can help determine locations for highest-yield biopsy, especially if considering invasive mediastinal lymph node staging
Helpful when planning definitive courses of radiation and determining disease response to treatment
Can drastically alter management by upstaging patients, making them inoperable, thus eliminating unnecessary surgery
Disadvantages
Expensive and not easily accessible at certain medical centers
High false positive rate (20%), which may require pathologic confirmation to rule out.
PET scans alone (without CT hybrid) are not as sensitive in detecting mediastinal or extrathoracic metastases and often more difficult to elucidate anatomy
MRI of chest/abdomen/brain with IV contrast
Advantages
Can help better assess extrathoracic and chest wall invasion
Does not expose patient to ionizing radiation
Can help delineate brain, adrenal, or spinal metastases
Disadvantages
Loss of signal from physiologic lung movement
Not as well tolerated in obese, claustrophobic, or patients with SOB or not able to hold breath
More time consuming than CT
Chest X-ray
Advantages
Cheap, easily accessible, easy to administer
Requires lower dose of radiation exposure
Helpful in comparing with previous films to determine if further workup is necessary
Disadvantages
Unable to determine full staging
Insufficient to assess mediastinal and lymph node metastases
Cannot determine extrathoracic metastases
VI. What are the contraindications for the alternative imaging techniques?
PET/CT
Because CT is a component of this imaging technique, it is contraindicated in pregnant women.
MRI
Contraindicated in patients with pacemakers and other implantable, MRI-incompatible devices
Since contrast is administered, caution should be used in patients with renal insufficiency
CXR
There are no major contraindications for this imaging modality.
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