NCCN Guidelines for Patients® | Lung Cancer - Non-Small Cell Lung Cancer

34 NCCN Guidelines for Patients ® : Lung Cancer – Non-Small Cell, 2018 stage IA. A mediastinal biopsy is advised for clinical stage IB, II, and IIIA. For stages IIIB and IIIC, the type of biopsy depends on which nodes may have cancer. For some people, a mediastinal biopsy may be best. For others, a biopsy of supraclavicular or scalene nodes might be better to confirm N3 disease. The timing of a mediastinal biopsy can differ across stages. For stages I and II, a mediastinal biopsy may not be needed until the day of surgery. It should be done right before surgery as one procedure. Doing so saves money and time, and reduces health risks. For some stage III (N2 or N3) cancers, a mediastinal biopsy may be done before the day of surgery. It may also be done beforehand if lab tests for cancer can’t be done during the operation. If tests suggest stage IV, a biopsy is needed before treatment. Your doctor will use imaging results to select the biopsy sites. This site is often the adrenal gland, liver, and bone. A mediastinal biopsy is very rarely done for stage IV cancers. Some lung cancers spread into the fluid around the lungs or heart. If this has likely happened, some fluid may need to be removed. There are many ways to biopsy lymph nodes and other sites. Navigational bronchoscopy, described in the prior section, is one way to access mediastinal nodes. Other common types of biopsies are described next. TTNA TTNA ( t rans t horacic n eedle a spiration) can be used to biopsy certain lung nodules and also some lymph nodes. This test is also called a percutaneous needle biopsy. A very thin needle will be inserted through your chest wall to get a tissue sample. Before inserting the needle, your skin will be cleaned and numbed with local anesthesia. Next, a small cut will be made into your skin. The needle will be inserted through the cut and into the nodule by your doctor. An imaging test should be used to help guide the needle to the right spot. This test may be a CT or ultrasound. During the biopsy, you may be asked to stay still and hold your breath at times. After the biopsy, the cut will be bandaged and you will be given a chest x-ray to check the results. After TTNA, you may feel sore and have some redness at the needle site. Mediastinoscopy This biopsy accesses lymph nodes in the middle of the chest with a mediastinoscope. A mediastinoscope is very much like a bronchoscope. A cut right above your breastbone will be made to insert the mediastinoscope into your body. When a cut alongside the breastbone is made, the biopsy is called a Chamberlain mediastinoscopy. This method allows access to lymph nodes on the left side of your chest. General anesthesia will be used for these biopsies. You may have some pain and swelling and a small scar afterward. EBUS-TBNA EBUS-TBNA ( e ndo b ronchial u ltra s ound-guided t rans b ronchial n eedle a spiration) can access mediastinal lymph nodes. A flexible bronchoscope fitted with an ultrasound device will be guided down your trachea. For this biopsy, the device doesn’t need to be removed in order to insert the sampling tool. Once the bronchoscope is in place, a needle will be inserted through the bronchus and into a lymph node to obtain a sample. EBUS-TBNA requires local anesthesia. EUS-FNA Food passes from the throat into the stomach through the esophagus. The esophagus extends lower into the body than the bronchi. Thus, lymph nodes below the bronchi can be accessed through the esophagus. For EUS-FNA ( e ndoscopic 4 Treatment planning Biopsy