The Society of Thoracic Surgeons

View all recommendations from this society

Released February 21, 2013

Patients with suspected or biopsy proven Stage I NSCLC do not require brain imaging prior to definitive care in the absence of neurologic symptoms.

  • The incidence of occult brain metastasis in Stage I lung cancer is low (<3%) and so routine brain imaging results in increased costs, delays in therapy and rarely changes patient management.
  • False-positive studies occur in up to 11% of patients resulting in further invasive testing or incorrect over staging, with potentially tragic effects on treatment decisions and outcomes.

Some clinicians perform routine screening by brain magnetic resonance imaging (MRI) or computed tomography (CT) scans to rule out occult brain metastasis in asymptomatic patients prior to surgical resection of early stage lung cancer. This practice of routine screening for occult brain metastases has not been evaluated by a randomized clinical trial and may not be cost-effective or medically necessary.

Pooled data from retrospective studies that included a comprehensive clinical evaluation demonstrated  that only 3% of patients who have a negative neurologic evaluation present with intracranial metastasis. One study, limited to Stage I patients, reported a prevalence of 1.3%. The joint statement of the American Thoracic Society and the European Respiratory Society did not advocate preoperative imaging of the brain in patients with NSCLC who present without neurologic symptoms, and the current National Comprehensive Cancer Network (NCCN) non-small cell lung cancer guidelines do not recommend preoperative brain imaging for asymptomatic patients with Stage IA non-small cell lung carcinoma.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The Society of Thoracic Surgeons (STS) list development process was led by the First Vice-President, and involved input from multiple workforces, including the Workforce on Adult Cardiac and Vascular Surgery, Workforce on General Thoracic Surgery, and Workforce on Evidence Based Surgery, and was staffed by STS’ Director of Quality. The initial 17 recommendations from these Workforces were narrowed down to eight based upon frequency, clinical guidelines and potential impact. STS leadership approved these eight recommendations for presentation to members in an online survey. The results of the survey, as well as research and systematic literature review by the Workforce on Evidence Based Surgery, were presented to the STS Executive Committee, which approved the five final recommendations.

Sources

Silvestri GA, Gould MK, Margolis ML, Tanoue LT, McCrory D, Toloza E, Detterbeck F. Noninvasive staging of non-small cell lung cancer. ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition). Chest. 2007;132(3suppl):178S-201S.

Tanaka K, Kubota K, Kodama T, Nagai K, Nishiwaki Y. Extrathoracic staging is not necessary for non-small-cell lung cancer with clinical stage T1–2 N0. Ann Thorac Surg. 1999 Sep;68(3):1039-1042.

American Thoracic Society and European Respiratory Society Consensus Report. Pretreatment evaluation of non-small cell lung cancer. Am J Respir Crit Care Med 1997;156:320-332.

Toloza EM. Harpole L, and McCory DC. Noninvasive staging of non-small cell lung cancer: A review of the current evidence. Chest. 2003;123;(1 Sppl):137S-146S.

National Comprehensive Cancer Network. National Comprehensive Cancer Network clinical practice guidelines in oncology (NCCN Guidelines®): Non-small cell lung cancer. Fort Washington (PA): NCCN;2012.

Colice GL, Birkmeyer JD, Black WC, Littenberg B, Silvestri G. Cost-effectiveness of head CT in patients with lung cancer without clinical evidence of metastases. Chest.1995;108(5):1264-1271.