Definitions for the strength of evidence and recommendation grades (1A-2C) follow the recommendations.
- When pathologically diagnosing patients with lung cancer, the reporting of histologic type, tumor size and location, tumor grade (if appropriate), lymphovascular invasion, involvement of pleura, surgical margins, and status and location of lymph nodes by station is recommended (see Table 1 below). Grade of recommendation, 1B
Table 1: Pathologic Staging of Lung Cancer*
T stage
- Histologic type
- Histologic grade
- Tumor size
- Location
- Pleural involvement
- Lymphovascular invasion
- Mediastinal or chest wall extension
- Resection margins
|
N stage
- Lymph nodes, hilar/bronchial
- Lymph nodes, mediastinal station/location
- Lymph nodes, distant
|
M stage
|
*Refer to cancer protocols at www.cap.org.
- In individuals who are at risk for lung cancer but do not have symptoms or history of cancer, use of single or serial sputum cytologic examinations to screen for the presence of lung cancer is of insufficient clinical benefit and is not recommended. Grade of recommendation, 1A
- In individuals with pleural-based tumors, when distinguishing between pleural adenocarcinoma and malignant mesothelioma, a structured approach using a limited panel of histochemical and immunohistochemical assays is recommended to increase the diagnostic accuracy. More challenging cases may need additional studies, including ultrastructural analysis. Grade of recommendation, 1B
- In individuals with parenchymal-based tumors, distinguishing between small cell carcinoma and non-small cell carcinoma of the lung is recommended. For challenging cases, a diagnostic panel of immunohistochemical assays is recommended to increase the diagnostic accuracy. More challenging cases may need additional studies, including ultrastructural analysis. Grade of recommendation, 1B
- For individuals with glandular-producing tumors, distinguishing pure bronchioloalveolar carcinoma (BAC) from adenocarcinoma with or without BAC component is recommended. Grade of recommendation, 1C
- For individuals who have lung tumors and whose differential includes primary lung carcinoma vs. metastatic carcinoma, a directed panel of immunohistochemical as-says is recommended to increase the diagnostic accuracy. Grade of recommendation, 1C
- For individuals who have lung tumors and have had an assessment of pathologic features and staging parameters, the evaluation of pathobiological and molecular markers is appropriate for protocol investigations and is not routinely recommended for clinical management. Grade of recommendation, 1C
- For individuals who have lung tumors and have had an assessment of pathologic features and staging parameters, the determination of occult or micrometastatic disease, using enhanced pathologic or molecular techniques, is not of sufficient clinical utility and is not recommended. Grade of recommendation, 1C
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 |