Table 2LUNG CANCER: investigations

AuthorSettingDescriptionNo.InclusionExclusionResultsGold StdQuality
Colice, 1997Systematic review which Investigated whether fiberoptic bronchoscopy or CT resulted in the lowest number of tests needed to diagnose lung cancer in patients presenting with haemoptysis and a normal chest radiograph.16 articlesStudies that described the outcome of an evaluation for lung cancer in patients presenting with haemoptysis and a chest x-ray.it was estimated that 6% of patients presenting with haemoptysis and a normal chest x-ray would have lung cancer.
Of the 997 patients described in these studies, 54 (5.4%) were found to have cancer, the vast majority of which were lung primaries.
Performing FOB first with serial follow-up CXRs resulted in a smaller number of tests needed to diagnose (NTND) than the CT first strategy (101 for FOB vs 133 for CT).
These investigations were performed routinely in an outpatient setting. The calculations derived indicate the extent of reliability of CXR in detecting suspected lung cancer
Holmberg and Kragsbjerg, 1993SwedenDiagnostic study. The value of routine convalescent chest radiography was assessed retrospectively using medical records from patients with pneumonia admitted to a Swedish hospital during 1981 and 1985. A second patient group was studied to investigate the clinical onset of pulmonary carcinoma1011Patients with pneumoniaCases were excluded if they had an diagnoses, no x- ray performed, severe chronic debilitating disease resulting in multiple episodes of pneumonia and were aged < 15. there were also multiple other reasons13/1011 pneumonia patients had previously undiagnosed pulmonary carcinoma. Many of these carcinomas (8/13) were disclosed by an acute chest x-ray. Pulmonary carcinoma was found by convalescent chest x-ray in 2/88 patients not feeling well and in 2/524 patients feeling well at follow-up.
Of the 232 inpatients with pulmonary carcinoma, 29 (12.5%) presented with an acute respiratory tract infection; most of these latter patients did not recover as expected and their correct diagnosis was made following a chest x-ray due to persistent symptoms.
Stated that three cases were verified by histological examination.Data were drawn from a large patient sample but a gold standard test was not necessarily applied in all cases.
NICE 2004Guidelines on the diagnosis and treatment of lung cancerStill out for consultation
Pederson and Milman, 2003A diagnostic study which prospectively assessed the diagnostic value of an elevated platelet count and other routine laboratory tests for predicting malignancy in patients with radiologically suspected lung cancer.126Thrombocytosis (platelet count >400×109/1 was present in 8% (5/65) of patients with benign disease and in 57% (35/61) of patients with malignant disease (p<0.00001).
Elevated platelet count was more common in advanced disease (stage III and IV). The sensitivity of thrombocytosis for predicting malignancy was 0.57 and the specificity 0.92.
PathologyHospitalized patients with radiologically suspected cancer were investigated and the relevance of these tests would have to be considered in a primary care setting
Schreiber and McCrory, 2003USASystematic review and meta-analsysis to determine the test performance characteristics of various modalities for the histologic and cytologic diagnosis of suspected lung cancer. The test results compared, included sputum cytology, bronchoscopy, transthoracic needle aspirate (TTNA) or biopsy. The search covered MEDLINE, Healthstar and Cochrane Library databases from 1966 to July 2001 among other sourcesStudies of at least 50 patients with suspected lung cancerThe pooled specificity for sputum cytology from 16 studies was 0.99 and the pooled sensitivity was 0.66, but sensitivity was higher for central than for peripheral lesions (0.71 vs. 0.49 respectively). Studies on bronchoscopic procedures provided data only on diagnostic yield (sensitivity). The diagnosis of endobronchial disease by bronchoscopy in 30 studies showed the highest sensitivity for endobronchial biopsy (0.74), followed by cytobrushing (0.59) and washing (0.48). The sensitivity for all modalities combined was 0.88. Thirty studies reported on peripheral lesions. Cytobrushing demonstrated the highest sensitivity (0.52), followed by transbronchial biopsy (0.46) and BAL/washing (0.43). The overall sensitivity for all modalities was 0.69.
A trend toward lower sensitivity was noted for lesions that were < 2cm in diameter.
Histology and cytologyA thorough and comprehensive systematic review that delineated the criteria for how studies were combined in a series of meta-analyses but not strictly relevant to primary care.
Shure et al, 1991USADiagnostic study. Aimed to prospectively investigate the incidence of radiographically undetectable endobronchial obstruction encountered during routine bronchoscopy in referred patients.77 patientsPatients found to have complete endobronchial obstruction during bronchoscopy81 endobronchial lesions, which completely obstructed the involved bronchus were found in 77 patients.
The chest radiograph was consistent with endobronchial obstruction in 45 lesions; no evidence of obstruction occurred in 36 obstructing lesions (44%). In 13 cases (16%) the chest radiograph was not normal.
patients all had one or more of the following symptoms: new or increased cough, blood-streaked sputum or a weight loss in excess of 10lbs (4.54 kg) over the six months prior to admission
Patients found to have complete endobronchial obstruction during bronchoscopy
Simpson et al, 1988UKA prospective Cohort study. The indications and diagnostic yield of GP referrals for static miniature chest radiography was reported to assess the value of this service.1205Of the 1205 films reviewed 878 (73%) were classified as normal. In 132 (11%) cases the patient was recalled. Of those with significant pathology 15 had pneumonia, 14 cardiac lesion, 5 active tuberculosis, 3 malignant effusions, 4 pulmonary metastases and’ had pneumothorax.
Symptoms most likely to be associated with significant pathology were cough, haemoptysis, wheeze, dyspnoea, weight loss. Non-specific malaise, tiredness, general ill health, chest pain, hypertension rarely associated with abnormal radiographs.
Not stated

From: Appendix A, Evidence Tables

Cover of Referral Guidelines for Suspected Cancer in Adults and Children
Referral Guidelines for Suspected Cancer in Adults and Children [Internet].
NICE Clinical Guidelines, No. 27.
Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences, University of Leicester.
Copyright © 2005, National Collaborating Centre for Primary Care.

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