Diagnosis and staging of locally advanced non-small cell lung cancer

T4 non-small cell lung cancer (NSCLC) might include a wide range of clinical scenarios. In very selected cases a surgical treatment might be indicated, after careful staging and thorough functional evaluation. Performance status, cardiac and pulmonary function should be evaluated in detail, in a tailored fashion according to the planned surgical operation. Besides the anatomical lung unit (lobectomy or pneumonectomy), resection may involve several vital structures, including great vessels and some portion of the atria. Given the particular nature of T4, surgery is often a part of a multimodal approach. In case of induction therapies, pulmonary function should be re-assessed, to rule out any deterioration that could eventually jeopardize survival. Computed tomography (CT) scan and positron emission tomography (PET)-CT should be always performed to stage the disease, but in case of chest wall, airways or other mediastinal organs involvement, more detailed exams, such us Magnetic Resonance, echocardiography or CT angiography (CTA) and magnetic resonance angiography (MRA) should be carried out. Additionally, a careful investigation for possible mediastinal nodal involvement should be routinely performed, given the detrimental effect of nodal diffusion on survival in this subset of patients. Nowadays endobronchial ultrasound (EBUS), endoscopic (esophageal) ultrasound are reliable and semi-invasive tools that can be used as first step prior to more invasive surgical diagnostic procedures such as video assisted mediastinoscopy or even video-assisted mediastinoscopic lymph-adenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA). Bronchoscopy and EBUS can be safely used for yield diagnostic tissue in case of central tumors, while in case of peripheral masses, transthoracic biopsy is more sensitive.