ESMO E-Learning: Diagnostic Work Up in NSCLC and the Importance of Optimal Tissue Management in the Era of Precision Medicine

Learning Objectives

  1. To provide an update on the diagnostic work-up of lung cancer in terms of sample types, morphology and histology, as well as material for biomarker studies
  2. To provide an overview of key actionable genetic alterations in non-small cell lung cancer and summarise available techniques for their detection
  3. To provide an overview of the latest guidelines’ recommendations in terms of molecular testing in patients with non-small cell lung cancer
Title Duration Content CME Points CME Test
Diagnostic Work Up in NSCLC and the Importance of Optimal Tissue Management in the Era of Precision Medicine 38 min. 53 slides 1 Take Test
Noemi Reguart
Noemi Reguart
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Cristina Teixidó
Cristina Teixidó
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In the last years, lung cancer classification has moved from histologic to a molecular classification, with non-small cell lung cancer (NSCLC) becoming a paradigm for rapid development of new molecularly targeted agents. More than 50% of all lung adenocarcinomas harbour driver oncogenes. Furthermore, the incidence of genomic drivers is variable among ethnic populations. This E-learning module describes the current standard of care in terms of diagnostic work-up in NSCLC and optimal tissue management.

In lung cancer, optimal management of biopsy specimens is needed to avoid repeating biopsies. Diagnostic material is generally scarce, and it is essential to balance the requirements for an accurate histologic diagnosis with the need for molecular analyses. The authors underline that, nowadays, pathologists and molecular biologists have a key role in treatment decisions. In this module, the authors provide an overview of key genetic alterations in NSCLC and those features for which the determination in tumour specimens is currently standard of care in advanced disease setting.

In terms of samples for molecular testing, the authors emphasise that, before starting, it is important to review relevant clinical information such as sample site, clinical suspicion on primary lung tumour or metastasis, as well as a reason for biopsy, in particular establishing diagnosis, molecular evaluation, or resistance. It is also important to evaluate the smoking history. Diagnostic work-up considers the steps for establishing malignancy, defining the type of malignancy, performing molecular testing as appropriate and prioritising testing according to individual patients.

In terms of types of samples, the authors underline that it is essential that histo-pathologists and cytologists share information when biopsy and cytology material from an individual patient are analysed by both. Today 40% of NSCLC is diagnosed by cytology. In this module the authors also cover liquid biopsy as a mean of analysing some molecular alterations in NSCLC.

The authors also tackle issues in the tissue quality control for molecular testing. The first step for molecular testing is the adequacy of biopsy material for molecular profiling in NSCLC. Then the molecular specialist should evaluate whether the percentage of tumour in a given specimen reaches the detection threshold of the specific molecular test or tests. The next step is a valuation of tumour percentage and viability. 

In terms of molecular techniques available for diagnosis, the authors report that the biomarker analyses needed at present for selecting treatment in patients with NSCLC are based on routine single marker molecular tests for particular gene status analysisand multiple marker molecular tests are emerging.

The authors conclude that in NSCLC, the determination of histologic subtype and molecular predictive markers is standard of care. Close interaction between pulmonologists, pathologists, molecular biologists, and oncologists is required. In the era of precision cancer medicine, it is important that medical professionals involved in lung cancer diagnosis and management keep abreast in terms of multidisciplinary tissue management strategy to obtain tumour specimens and process them sufficiently. 

Last update: 23 August 2019

The authors have reported no conflict of interest.