Cervical lymphadenopathy in lung cancer
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Overall, in the thesis we showed that cervical lymphadenopathy is frequently present in patients with lung cancer and mediastinal lymphadenopathy on CT to a degree that justifies screening for it routinely. We have shown that lower neck CT done routinely in patients with lung cancer reduced the need for the number of invasive procedures needed and was associated with a higher rate of detection of cervical lymphadenopathy. We have also shown that in a single centre where respiratory physicians frequently performed cervical lymph node needle sampling that adequacy was acceptable and comparable to radiologists performing the procedure. We have also prospectively shown that it is feasible to train a respiratory physician to perform NUS and needle sampling to an acceptable standard by a respiratory consultant with experience in the procedure with support from radiology. We replicated the current literature regarding the rate of cervical lymphadenopathy in patients with lung cancer and mediastinal lymphadenopathy when NUS was performed by respiratory physicians compared to radiologists in the previous literature. We finally showed that in patients with lung cancer and mediastinal lymphadenopathy that are candidates for curative treatment based on staging CT, PET was associated with an unacceptably high false positive rate for neck lymph nodes and had only minimum impact on treatment planning when NUS was routinely performed. At this stage further research is required to assess the impact of a pathway that includes routine NUS in patients with lung cancer and mediastinal lymphadenopathy versus routine inclusion of the lower neck on the initial staging CT in all patients with suspected lung cancer. We also recommend another multicentre study to assess whether the feasibility of training respiratory physicians on NUS can be replicated in different settings and therefore generalised. A structured approach to training respiratory physicians in NUS is needed and must be developed by stakeholders to maintain an acceptable level of competency and safety.