Brain Imaging in Lung Cancer Staging

Recommendation Regarding Brain Imaging in Lung Cancer Staging.


Brain imaging is an important component of the accurate staging of newly diagnosed patients with non-small cell and small cell lung cancer. However, there is a paucity of robust evidence in the literature to give guidance as to the best imaging modality and those that should have brain imaging performed. Most recommendations come from large professional bodies such as NCCN, ESMO, NICE and the ACCP. Brain MRI is generally felt to be the most accurate modality. CT is an acceptable alternative if access to MRI is not possible or if there would be considerable delay in patient workup if waiting for an MRI to be completed.


Based on a review of the most recent guidelines from the organizations noted above:

  • Brain imaging is absolutely recommended for:
    • Patients with Clinical Stage III and IV NSCLC
    • Patients with symptoms (H/A, slurred speech etc…)
    • Patients with Small Cell Lung Cancer
  • Brain imaging for clinical Stage II NSCLC continues to be a matter of debate, however some national bodies have recommended it particularly NCCN.
  • MRI is the modality of choice over CT but depends on availability, wait time and cost.

Suggested Reading List

  • National Comprehensive Cancer Network (NCCN) – Clinical Practice Guidelines in Oncology, Non-Small Cell Lung Cancer v6.2018.
  • National Institute for Health and Care Excellence (NICE) – Lung cancer: diagnosis and management (2011) NICE guideline CG121. lung-cancer
  • Silvestri G. et. al., Methods for Staging Non-small Cell Lung Cancer.
  • Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2013; 143(5) (Suppl):e211S–e250S.
  • ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Early and locally advanced non-small-cell lung cancer (NSCLC). Ann Oncol (2017) 28 (suppl 4): iv1–iv21
  • Vernon J, Andruszkiewicz N, Schneider L, Schieman C, Finley CJ, Shargall Y, Fahim C, Farrokhyar F, Hanna WC. Comprehensive clinical staging for resectable lung cancer: Clinico-pathological correlations and the role of brain imaging. J Thorac Oncol. 2016 Nov;11(11):1970-1975

Surgical Wait-Times for Resectable Lung Cancer.


Timely care is a fundamental component of quality. Although what constitutes timely care in lung cancer remains a subject of debate, many international/national/regional bodies have set consensus targets for wait times. Given the lack of level I evidence, the committee reviewed various recommendations and adopted one best supported by the available evidence for a Canadian context.

CATS recognizes all too well that thoracic surgeons are only able to achieve timely care if adequate resources (e.g. OR time, CT guided biopsies, imaging resources including PET scans to mention a few) are made available in a timely fashion. CATS also recognizes that local/provincial factors and limitations vary. CATS hopes that adopting such recommendations based on best available evidence helps empower surgeons and care providers to demand the resources they need to deliver quality care.


  • For patients with lung cancer whose primary treatment modality is surgical resection, time from referral* for initial consultation to resection should not exceed 6 weeks**.

* We purposefully avoided specifying time from referral to consultation as centres may have different preferences about performing certain investigations prior to consultation or starting with a consultation

** We believe that in the majority of cases, surgeons do have an understanding early on as to which patients will likely be operable and so diagnostic, staging and physiologic investigations can be arranged in parallel making 6 weeks a realistic goal.

Summary of Literature

Several guidelines highlighting recommended wait times based on different time intervals in the treatment pathway have been published. The table below highlights some of these guidelines.  Two main areas of debate in the wait-times literature persist: 1) the effect of timely care on survival and 2) the ability of healthcare providers to meet established (recommended) wait time guidelines.

No strong association between earlier initiation of anticancer treatment and improved survival has been reported. In addition, recent publication out of McGill University, demonstrated that roughly 60% of patients met the target of first contact, and only 62% of cases were operated on within the recommended time frame (28 days) after being initially seen by a surgeon. Interventions that are associated with improved timeliness include: nurse-led care coordination, access to multidisplinary meetings and a standardized diagnostic process.


Olson JK, Shultz EM, Gould MK. Timeless of care in patient with lung caner: a systematic review. Thorax 2009. Sep; 64(9): 749-56.

Kasymjanova G, Small D. Cohen V.  et al. Lung Cancer care trajectory at a Canadian center: an evaluation of how wait times affect clinical outcomes. Curr Oncol. 2017 October 24(5): 302-309

Time Interval Recommended wait time (days)
  British Thoracic Society UK National Health Service RAND Corporation American College of Chest Physician Cancer Care Ontario
Referral → Lung cancer specialist 7 14
Lung cancer speciality → Diagnosis 30 35
Referral → 1st Treatment 62 62 60
Lung specialist → Surgery 56 104 68
Diagnosis → Surgery Consult 60
Surgery Consult → Surgery 28 14-84
Surgery → Adjuvant Chemotherapy 120 120
Diagnosis → 1st Treatment 30 31 42 35 52
Diagnosis → Chemotherapy 28 30 42 39
Diagnosis → Radiotherapy 42
Decision to treat → Non-surgical treatment 7-28
Ready to treat → Radiation 28

Adapted from: Curr Oncol. 2017 October 24(5): 302-309


Follow-up and Surveillance Recommendations for Patients Treated Curatively for Lung Cancer.


Despite advances in the care of patients with NSCLC, the overall 5-year survival for patients treated with curative intent remains poor. The rationale for surveillance following the treatment of lung cancer is the detection of recurrent disease or a new primary lung cancer, no randomized data exist to support specific recommendations for surveillance modality and interval. Most recommendations are based on expert consensus and cohort studies, and the effect of surveillance on survival continues to be debated. Data extrapolated from screening trials does demonstrate a survival benefit to the detection of early stage cancers and most guideline-setting groups recommend a surveillance strategy involving regular clinical examinations and imaging. 1-8, 10-16


  • Surveillance for early recurrence or new primaries in patients treated with curative intent for NSCLC:
    • Low dose CT chest +/- contrast q6mo in years 1 and 2 1-5,9,17,18
    • Low dose CT chest +/- contrast q12mo years thereafter1-5,9,17,18
  • CT dose (i.e. Low dose vs Minimal dose) and the use of contrast is controversial. There are no data to suggest one dose over another. Extrapolation of data from the National Lung Cancer Screening Trial would suggest Low dose CT provides good sensitivity for the detection of early stage cancers.4,5,6
  • Surveillance for early recurrence or new primaries in patients treated with curative intent for SCLC:
  • Surveillance recommendations for surveillance post curative intent treatment of SCLC are based on expert consensus and parallel those for NSCLC.
  • Contrast enhanced CT chest may provide superior assessment of mediastinal nodal involvement18


  1. Calman L, Beaver K, Hind D, Lorigan P, Roberts C, Lloyd-Jones M. Survival benefits from follow-up of patients with lung cancer: a systematic review and meta-analysis. J Thorac Oncol. 2011;6(12):1993-2004.
  2. Sugimura H, Yang P. Long-term survivorship in lung cancer: a review. Chest.2006;129(4):1088-97
  3. Srikantharajah D, Ghuman A, Nagendran M, Maruthappu M. Is computed tomography follow-up of patients after lobectomy for non-small cell lung cancer of benefit in terms of survival? Interact Cardiovasc Thorac Surg. 2012;15(5):893-8.
  4. Hanna WC, Paul NS, Darling GE, Moshonov H, Allison F, Waddell TK, et al. Minimal-dose computed tomography is superior to chest x-ray for the follow-up and treatment of patients with resected lung cancer. J Thorac Cardiovasc Surg. 2014;147(1):30-5.
  5. National Lung Screening Trial Research Team, Church TR, Black WC, Aberle DR, Berg CD, Clingan KL, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368(21):1980-91.
  6. Crabtree TD, Puri V, Chen SB, et al. Does the method of radiologic surveillance affect survival after resection of stage I non-small cell lung cancer? J Thorac Cardiovasc Surg 2015;149:45-52, 53 e41-43.
  7. Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR, et al. Results of the two incidence screenings in the National Lung Screening Trial. N Engl J Med. 2013;369(10):920-31.
  8. Erb CT, Su KW, Soulos PR, et al. Surveillance practice patterns after curative intent therapy for stage I non-small-cell lung cancer in the medicare population. Lung Cancer 2016;99:200-207. Available at:
  9. Colt HG, Murgu SD, Korst RJ, et al. Follow-up and surveillance of the patient with lung cancer after curative-intent therapy: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e437S-454S. Available at:
  10. Lou F, Huang J, Sima CS, et al. Patterns of recurrence and second primary lung cancer in early-stage lung cancer survivors followed with routine computed tomography surveillance. J Thorac Cardiovasc Surg 2013;145:75-81; discussion 81-72. Available at:
  11. Srikantharajah D, Ghuman A, Nagendran M, Maruthappu M. Is computed tomography follow-up of patients after lobectomy for non-small cell lung cancer of benefit in terms of survival? Interact Cardiovasc Thorac Surg 2012;15:893-898. Available at:
  12. Dane B, Grechushkin V, Plank A, et al. PET/CT vs. non-contrast CT alone for surveillance 1-year post lobectomy for stage I non-small-cell lung cancer. Am J Nucl Med Mol Imaging
  13. Nakamura R, Kurishima K, Kobayashi N, et al. Postoperative follow-up for patients with non-small cell lung cancer. Onkologie. 2010;33(1-2):14-18
  14. Johnson BE. Second lung cancers in patients after treatment for an initial lung cancer. J Natl Cancer Inst 1998; 90: 1335–1345.
  15. Demicheli R, Fornili M, Ambrogi F et al. Recurrence dynamics for non-small-cell lung cancer: effect of surgery on the development of metastases. J Thorac Oncol 2012; 7: 723–730.
  16. Toba H, Sakiyama S, Otsuka H et al. 18F-fluorodeoxyglucose positron emission tomography/computed tomography is useful in postoperative follow-up of asymptomatic non-small cell lung cancer patients. Interact Cardiovasc Thorac Surg 2012; 15: 859–864
  17. Vansteenkiste, et al. 2nd ESMO Consensus Conference on Lung Cancer: early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up. Annals of Oncology 25: 1462–1474, 2014
  18. Ung YC, Souter LH, Darling G, Dobranowski J, Donohue L, Leighl N, et al. Follow-up and surveillance of curatively treated lung cancer patients. Toronto (ON): Cancer Care Ontario; 2014 Aug 29. Program in Evidence-Based Care Evidence-Based Series No.: 26-3.