Diagnostic surgical pathology in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

Our plain-English summary of Diagnostic surgical pathology in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines, by A.M. Schwartz, M.K. Rezaei (Chest, 2013).

The study

• Authors: A.M. Schwartz, M.K. Rezaei
• Journal: Chest
• Published: 2013;143(5 Suppl):e251S-e262S
• Type of article: Guideline
• Cited by: 27 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: This article provides evidence-based background and recommendations for the development of American College of Chest Physicians guidelines for the diagnosis and management of lung cancer. Specific population, intervention, comparison, and outcome questions were addressed to arrive at consensus recommendations.

Methods: A systematic search of the medical and scientific literature using MEDLINE and PubMed was performed for the years 1990 to 2011 and limited to literature on humans and articles written in English. Our approach to examining the evidence and formulating recommendations is described in the "Methodology for Lung Cancer Evidence Review and Guideline Development: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (2nd Edition)" and updated in "Methodology for Development of Guidelines for Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines."

Results: Pathologic examination results of lung cancers should be recorded in a synoptic form to include important prognostic features of histologic type, tumor size and location, involvement of visceral pleura, extension to regional and distant lymph nodes, and metastatic spread to visceral organs and bone to increase completeness of recording. It is important for the surgical pathologist to make distinctions between malignant mesothelioma and pleural adenocarcinomas, small cell and non-small cell carcinomas, adenocarcinomas and squamous cell carcinomas, and primary and metastatic carcinomas of the lung. In challenging cases of pathologic differential diagnosis, additional studies may enable the separation of distinct tumor types.

Conclusions: Pathologic assessment of lung cancers is a crucial component for the diagnosis, management, and prognosis of lung cancer, making the pathologist a critical member of the clinical and management team. Selective diagnostic techniques, including limited designed immunohistochemical panels, and decision analysis will increase diagnostic accuracy.

In plain English

This article was an American College of Chest Physicians clinical practice guideline on how pathologists diagnose lung cancer, not a new study of patients. The authors updated an earlier edition using a systematic search of Embase, MEDLINE and the Cochrane Library for English-language human research from 1990 to 2011. Asbestos was mentioned only as background, in a section on telling malignant mesothelioma apart from adenocarcinoma. No exposure was studied. For tumors based in the pleura, the authors recommended a designated limited panel of histochemical and immunohistochemical tests, or ultrastructural (electron microscope) analysis, to distinguish pleural adenocarcinoma from malignant mesothelioma (Grade 1B). They stated that tissue evidence of true invasion is required to diagnose malignant mesothelioma. They cautioned that most sarcomatoid and desmoplastic mesotheliomas stain negative with mesothelial markers. Other recommendations covered standardized (synoptic) pathology reports and separating several lung cancer types from one another and from cancers spread from elsewhere. The authors concluded that much can be learned from routine microscopic examination, with further information from a limited panel of immunohistochemical tests.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Evidence-based clinical practice guideline (an update of the second-edition guideline) based on a systematic literature search; not an original study of patients
• Who was studied: No patients were studied. The authors reviewed published literature on humans, in English, from 1990 to 2011.
• Exposure: No exposure was studied. Asbestos appears only as background in the mesothelioma section, where the article states that mesothelioma incidence is strongly correlated with occupational or environmental asbestos exposure, citing other work.
• Main results:
  • Recommendation 3.1.1 (Grade 1B): for pleural-based tumors, a designated limited panel of histochemical and immunohistochemical assays or ultrastructural analysis to distinguish pleural adenocarcinoma from malignant mesothelioma
  • The article states that tissue evidence of true stromal or parenchymal invasion is required to establish a diagnosis of malignant mesothelioma
  • Recommendation 2.1.1 (Grade 1B): synoptic reporting of histologic type, tumor size and location, tumor grade (if appropriate), lymphovascular invasion, pleural involvement, surgical margins, and status and location of lymph nodes
  • Recommendation 4.1.1 (Grade 1B): distinguish small cell from non-small cell carcinoma; for challenging cases, use an immunohistochemical panel or ultrastructural analysis
  • Recommendation 5.1.1 (Grade 1C): distinguish adenocarcinoma in situ and minimally invasive adenocarcinoma from invasive adenocarcinoma. These cannot be reliably diagnosed from a needle biopsy alone.
  • Recommendation 6.1.1 (Grade 1B): in non-small cell lung cancer, further distinguish adenocarcinoma from squamous cell carcinoma, even on cytologic material or small tissue samples
  • Recommendation 7.1.1 (Grade 1C): when the question is primary lung carcinoma versus metastatic carcinoma, use a directed panel of immunohistochemical assays
• The authors' conclusion: The authors concluded that much diagnostic information comes from routine histopathologic analysis, with additional information from a limited panel of immunohistochemical tests. They also concluded that the pathologist, working with the clinical team, should address difficult distinctions such as pleural-based adenocarcinoma versus malignant mesothelioma.
• Limitations the authors state:
  • The authors note that some immunomarkers are not as well established for separating mesotheliomas from nonpulmonary adenocarcinomas (peritoneal and ovarian serous carcinomas) and other carcinomas
  • The authors note that diagnosing sarcomatoid and desmoplastic mesotheliomas remains challenging because most of these tumors stain negative with mesothelial markers

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer.

Medical terms in this study, explained in our Lexicon: Pathology, Lung Cancer, Visceral Pleura, Malignant Mesothelioma, Adenocarcinoma, Carcinoma, Squamous Cell Carcinoma, Differential Diagnosis.

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