Clinical Evaluation of ES-NSCLC in Japan

Masahiro Tsuboi, MD: Our strategy is similar to the NCCN guidelines. As for the patient risk factors, it’s age, smoking status—especially the current one—previous cancer history, patient exposures, and other primary disease such as COPD [chronic obstructive pulmonary disease], pulmonary fibrosis, and ILD [interstitial lung disease]. As you know, in Japan, there are a lot of patients with interstitial lung disease, so we are very careful at watching this point. Also, we care about infectious disease. Other factors are the size, shape, location, and density of the primary nodules. Those are associated with primary abnormalities, such as parenchymal fibrosis or scarring, and inflammatory changes.

We have a PET [positron emission tomography]/CT scan, so we are considering if it is malignant disease or not. As for the diagnostic variation, patients with strong clinical suspicion for stage I or II lung cancer, we don’t require a biopsy before surgery. Preoperative biopsy may be appropriate if it’s a known lung cancer, especially if an infectious disease is strongly suspected; that can be diagnosed in the core biopsy or bronchoscopy.

The bronchoscopy is required before surgical resection. It depends on the case. I think in this population in the United States with early stage lung cancer, mediastinal staging is essential because there is quite a difference between stage I, II, and IIIA disease. Stage I and II, usually the surgery is prior, but in stage III disease, some combination treatment should be considered. In patients, mediastinal staging, especially by using the EBUS [endobronchial ultrasound], is commonly used. Unfortunately, Japanese surgeons are not familiar with the mediastinoscopy. Usually, EBUS is the prior procedure.

The preferred diagnosis strategy for the individual patient depends on the size and location of the tumors, the presence of the mediastinal and distant disease, the patient characterization such as primary pathology and other clinical comorbidities, and the local experience and expertise. The decision about the optimal diagnosis with a suspected stage I, II, IIIA lung cancer should be made by the multidisciplinary team discussions. It’s a very essential point. Once a week, every week, my institution discusses new patients and those complicated cases in the multidisciplinary team.

Transcript Edited for Clarity