Definitions for the strength of evidence and recommendation grades (1A-2C) follow the recommendations.
- For patients with either a known or suspected lung cancer who are eligible for treatment, a Computed tomography (CT) scan of the chest with contrast including the upper abdomen (liver and adrenal glands) should be performed. Grade of recommendation, 1B
- In patients with enlarged discrete mediastinal lymph nodes seen on CT scans (i.e., > 1 cm on the short axis) and no evidence of metastatic disease, further evaluation of the mediastinum should be performed prior to definitive treatment of the primary tumor. Grade of recommendation, 1B
- Positron emission tomography (PET) scanning to evaluate for mediastinal and extrathoracic staging should be considered in patients with clinical 1A lung cancer being treated with curative intent. Grade of recommendation, 2C
- Patients with clinical 1B-IIIB lung cancer being treated with curative intent, should undergo PET scanning (where available) for mediastinal and extrathoracic staging. Grade of recommendation, IB
- In patients with an abnormal result on fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET) scans, further evaluation of the mediastinum with sampling of the abnormal lymph node should be performed prior to surgical resection of the primary tumor. Grade of recommendation, 1B
- For patients with either a known or suspected lung cancer who are eligible for treatment, a magnetic resonance imaging (MRI) of the chest should not be routinely performed for staging the mediastinum. MRI may be useful in patients with non-small cell lung cancer (NSCLC) in whom there is concern for involvement of the superior sulcus or brachial plexus. Grade of recommendation, 1B
- For patients with either a known or suspected lung cancer, a thorough clinical evaluation similar to that listed in the table below should be performed. Grade of recommendation, 1B
Clinical Findings Suggesting Metastatic Disease*
Testing |
Finding |
Symptoms elicited in history |
Constitutional: weight loss > 10 lb; and musculoskeletal: focal skeletal pain |
Neurological: headaches; syncope; seizures; extremity weakness; and recent changes in mental status |
Signs found on physical examination |
Lymphadenopathy (> 1 cm); hoarseness; superior vena cava syndrome; bone tenderness; hepatomegaly (> 13-cm span); focal neurologic signs, papilledema; and soft-tissue mass |
Routine laboratory tests |
Hematocrit: < 40% in men and 35% in women |
Elevated alkaline phosphatase, GGT, SGOT, and calcium levels |
* GGT = gamma-glutamyltransferase; SGOT = serum glutamic-oxaloacetic transaminase.
- Patients with abnormal clinical evaluation findings should undergo imaging for extrathoracic metastases. Site-specific symptoms warrant a directed evaluation of that site with the most appropriate study (e.g., head CT scanning/MRI plus either whole-body PET scanning or bone scanning plus abdominal CT scanning). Grade of recommendation,1B
- Routine imaging for extrathoracic metastases (e.g., head CT scanning/MRI plus either whole-body PET scanning or bone scanning plus abdominal CT scanning) should be performed in patients with clinical stage IIIA and IIIB disease (even if they have a negative clinical evaluation finding). Grade of recommendation, 2C
- Patients with imaging study findings that are consistent with distant metastases should not be excluded from potentially curative treatment without tissue confirmation or overwhelming clinical and radiographic evidence of metastases. Grade of recommendation, 1B
Definitions:
Quality of Evidence Scale
High - Randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies*
Moderate - RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies*
Low or very low - Observational studies or case series
*Although the determination of magnitude of the effect based on observational studies is often a matter of judgment, the guideline developers offer the following suggested rule to assist this decision: a large effect would be a relative risk > 2 (risk ratio < 0.5) [which would justify moving from weak to moderate], and a very large effect is a relative risk > 5 (risk ratio < 0.2) [which would justify moving from weak to strong]. There is some theoretical justification in the statistical literature for these thresholds (the magnitude of effect that is unlikely or very unlikely to be due to residual confounding after adjusted analysis). However, once the decision is made, authors should be explicit in justifying their decisions.
Grade of Recommendations Scale
Grade |
Recommendation |
1A |
Strong |
1B |
Strong |
1C |
Strong |
2A |
Weak |
2B |
Weak |
2C |
Weak |
Relationship of Strength of the Supporting Evidence to the Balance of Benefits to Risks and Burdens
Balance of Benefits to Risks and Burdens |
Quality of Evidence |
Benefits Outweigh Risks/Burdens |
Risks/Burdens Outweigh Benefits |
Evenly Balanced |
Uncertain |
High |
1A |
1A |
2A |
|
Moderate |
1B |
1B |
2B |
|
Low or very low |
1C |
1C |
2C |
2C |