Lung Cancer

Primary Authors Wallander, Michelle, PhD. Heichman, Karen A., PhD.

Key Points

Molecular Markers in Lung Cancer

The presence of molecular markers in non-small cell lung cancer (NSCLC) is associated with responsiveness to certain targeted therapies. The current markers discussed below are usually detected almost exclusively in adenocarcinoma subtypes. Simultaneous ordering of EGFR, ALK, ROS1 and possibly KRAS is recommended.

  • EGFR

    EGFR (epidermal growth factor receptor)

    Pathophysiology

    Receptor tyrosine kinase involved in cell proliferation

    • Inhibition of tyrosine kinase activity diminishes tumor growth

    Two methods for blocking kinase activity (basis of current therapies in lung cancer)

    • Prevent ligand binding to the extracellular domain with a monoclonal antibody OR
    • Inhibit activity with small molecules (tyrosine kinase inhibitors) that block the magnesium-ATP binding pocket of the intracellular TK domain
    Mutation

    Certain EGFR mutations are associated with increased sensitivity to tyrosine kinase inhibitors (TKIs) (eg, gefitinib and erlotinib)

    Lack of EGFR mutations (wild type) is associated with decreased sensitivity to TKIs

    Mutation status of EGFR does not appear to predict response to treatment with EGFR monoclonal antibody (cetuximab)

    T790M mutation associated with decreased sensitivity to TKIs – mutation that usually develops when treatment resistance occurs

    Mutation characteristics

    • 10-15% of NSCLC
    • Highest rate in Asians, females, and nonsmokers or light smokers (<10 packs per year)

    Recommended Testing Strategy

    ARUP Tests 

    • Lung Cancer Panel 2008894 – includes EGFR, ALK, and ROS1
    • Lung Cancer Panel with KRAS 2008895 – includes KRAS, EGFR, ALK, and ROS1
    • EGFR Mutation Detection by Pyrosequencing 2002440

    Mutational analysis is preferred over gene amplification (Lindeman, 2013)

    • IHC and FISH are not recommended

    Simultaneous EGFR, ALK, ROS1, and possibly KRAS testing recommended

    • Presence of EGFR is usually mutually exclusive for ALK translocation
  • ALK

    ALK (anaplastic lymphoma receptor tyrosine kinase)

    Pathophysiology

    Fusion of ALK gene with echinoderm microtubule-associated protein-like-4 (EML-4) or other fusion partners mediates ligand-independent oligomerization of ALK resulting in ALK kinase activation

    • Functions as potent oncogenic driver
    Translocation

    Certain ALK rearrangements are associated with increased sensitivity to specific TKIs (ALK/MET/ROS1 TKIs [eg, crizotinib]) and decreased sensitivity to EGFR TKIs

    Mutation characteristics

    • Relatively rare mutation in NSCLC (~7%)
    • ~30% are young patients, male, nonsmokers or light smokers (<10 packs per year), signet rings, and mucinous subtype

    Recommended Testing Strategy

    ARUP Tests

    • Lung Cancer Panel 2008894 – includes EGFR, ALK, and ROS1
    • Lung Cancer Panel with KRAS 2008895 – includes KRAS, EGFR, ALK, and ROS1
    • ALK (D5F3) with Interpretation by Immunohistochemistry 2007324

    Simultaneous EGFR, ALK, ROS1, and possibly KRAS testing recommended

    Immunohistochemistry detects protein expression and is a surrogate marker for ALK gene fusion; more cost effective and efficient compared to FISH and RT-PCR

    RT-PCR may be used to detect the most common ALK rearrangements but may not detect all ALK fusion partners, and is therefore not recommended (Lindeman, 2013)

    FISH interpretation is challenging due to small inversions involving chromosome 2p (2p21 and 2p23)

    Presence of ALK rearrangements are generally mutually exclusive of EGFR and KRAS mutations

    KRAS

    KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog I)

    Pathophysiology

    RAS genes regulate signal conduction pathways that control cell growth

    Three distinct genes – HRAS, NRAS, and KRAS

    Mutation

    Almost all RAS mutations in NSCLC are in KRAS gene

    Mutations in KRAS gene are associated with decreased sensitivity to EGFR TKIs and overall poor prognosis

    • Double mutations in EGFR and KRAS are associated with decreased sensitivity to TKIs despite the presence of EGFR mutation

    Mutation characteristics

    • 25-30% of adenocarcinomas
    • Highest rate in mucinous subtype and current smokers

    Recommended Testing Strategy

    ARUP Tests

    • Lung Cancer Panel with KRAS 2008895 – includes KRAS, EGFR, ALK (D5F3), and ROS1
    • KRAS Mutation Detection 0040248

    Simultaneous EGFR, ALK, ROS1, and possibly KRAS testing recommended

    ROS1

    ROS1 (c-ros oncogene 1, receptor tyrosine kinase)

    Pathophysiology

    Receptor tyrosine kinase involved in cell proliferation

    ROS1 gene rearrangement and fusion with multiple known partners (eg, CD74, SLC34A2, TPM3) mediates constitutive ROS1 kinase activation

    Inhibition of tyrosine kinase activity diminishes tumor growth

    Translocation

    ROS1 rearrangements

    • Increased sensitivity to ALK/MET/ROS1 TKIs (eg, crizotinib)
    • Decreased sensitivity to EGFR TKIs

    Mutation characteristics

    • Rare mutation in NSCLC – 1-2%
    • Highest rate in Asians, young patients, nonsmokers or light smokers (≤10 packs per year history)

    Recommended Testing Strategy

    ARUP Tests 

    • Lung Cancer Panel 2008894 – includes EGFR, ALK, and ROS1
    • Lung Cancer Panel with KRAS 2008895 – includes KRAS, EGFR, ALK, and ROS1
    • ROS1 with Interpretation by Immunohistochemistry with Reflex to FISH if Equivocal 2008414

    Simultaneous EGFR, ALK, ROS1, and possibly KRAS testing recommended

    Immunohistochemistry detects protein expression and is a surrogate marker for ROS1 gene fusion

    • More cost effective and efficient when compared to FISH, but FISH is indicated for equivocal results by IHC
    • FISH detects gene rearrangement but more costly than IHC

    Presence of ROS1 rearrangements are generally mutually exclusive of EGFR and KRAS mutations

Diagnosis

Indications for Testing

  • New pulmonary mass

Laboratory Testing

  • Serum testing is not helpful in diagnosing lung cancer; however, baseline testing (eg, CBC with differential, liver function) may be performed as a general screen for metastases
  • Other testing
    • Neuron specific enolase (NSE), serum – may have diagnostic value for small cell lung cancer (SCLC)  

Imaging Studies

  • Chest x-ray, CT scan, MRI provide basis for initial testing

Histology

  • Invasive testing to obtain tissue necessary for diagnosis
    • Bronchoscopic biopsy
    • Mediastinal node sampling
    • Fine needle aspiration using CT guidance
    • Open lung biopsy
    • Fine needle aspiration using endobronchial ultrasound (EBUS)
  • Immunohistochemistry
    • Should be used adjunctly and interpreted in clinical context
    • Squamous cell carcinoma (SCC)
      • Usually negative for CK 7, CK 20, TTF-1
      • Does not typically require immunohistochemical staining for diagnosis
    • Primary adenocarcinoma and bronchioalveolar carcinoma
      • Positive for CK 7, napsin A, and thyroid transcription factor-1 (TTF-1); negative for CK 20
      • Primary mucinous adenocarcinoma – positive for CK 7 and CK 20, negative for TTF-1
      • ALK immunohistochemistry – more cost effective and efficient than ALK by RT-PCR, FISH
        • Uses ALK clone D5F3
          • D5F3 clone – more sensitive than ALK1 clone
    • SCLC and neuroendocrine carcinomas
      • Typically negative for CK 7, CK 20
      • Typically positive for keratin epithelial membrane antigen and TTF-1
      • Positive for neuroendocrine markers such as chromogranin A, CD56 (NCAM), synaptophysin, NSE
    • Dysregulation in tumor progression, therapeutic target – c-MET
    • Markers used to differentiate cancers

      Markers

      Use

      Comments

      p63 and CK 5,6 – positive

      TTF-1 – negative

      Differentiating poorly differentiated SSC form SCLC

      Supports SCC

      CEA-P, b72.3, Ber-EP4, MOC-31, and TTF-1

      Differentiating NSCLC adenocarcinoma for mesothelioma

      Positive in NSCLC

      Negative in mesothelioma

      Micro RNA (mRNA) expression

      Differentiating NSCLC from SCLC

      May be used to distinguish NSCLC from SCLS

      CK 7+/CK 20-, TTF-1+ – pulmonary

      CK 7-/CK20+, TTF-1- – colorectal

      Differentiating metastatic adenocarcinomas

      CDX2

      Differentiating primary lung tumors from metastatic gastrointestinal tumors

      Specific for gastrointestinal tumors

  • Molecular markers
    • Most useful for therapy planning in adenocarcinoma – see Key Points

Solitary Pulmonary Nodule

  • Usually found incidentally on chest x-ray (0.09-0.2% of all x-rays)
    • 35% are malignant
  • Histologic diagnosis required in the following situations
    • Patient is ≥35 years
    • Nodule is >10 mm diameter
    • Growth of lesion
    • Lack of calcification
    • Adenopathy
    • Positive PET scan
    • No previous imaging to review in order to determine if nodule has changed in size

Prognosis

  • Markers
    • EGFR, KRAS, ALK (D5F3), ROS1 – refer to Key Points section
      • Establish eligibility for therapies such as tyrosine kinase inhibitors and ALK inhibitors
  • Promising markers
    • Cytokeratin-19 fragment (CYFRA 21-1)
      • Most sensitive tumor marker for NSCLC (particularly squamous)
      • Uses
        • Prognostication
          • Elevated pretreatment level – associated with unfavorable prognosis
        • Monitoring
          • Decreasing levels predict objective response to treatment
    • BRAF, RET, MET, HER2 (ERBB2)
    • NSE
      • High specificity for SCLC
      • May be useful in assessing prognosis in NSCLC and SCLC
      • Currently in clinical use, but prognostic value has not been validated in high-level study
    • p53 – tumor suppressor gene
      • Presence prognostic of short survival and potential benefit from adjuvant chemotherapy in patients with NSCLC
    • Pro GRP – SCLC
    • CA 125 (available as an immunohistochemical stain) – NSCLC
    • STK11 – adenocarcinoma
    • HER-2 – NSCLC
    • Tumor M2-PK (TU M2-PK) – all types
    • BCL-2 (available as an immunohistochemical stain) – SCLC
    • ERCC1 expression – high level
    • RRM1 expression – high level

Differential Diagnosis

Screening

  • Screening recommendations for lung cancer

    Screening Recommendations for Lung Cancer

     RecommendationAgeSmoking historyMethodologyAdditional information
    American College of Chest Physicians (ACCP) (2012)Annual screening for high-risk individuals based on results of the NLST*55-74 years≥30 pack per year smoking history and currently smoke or smoking cessation within the past 15 yearsLDCT**Screening offered only in clinical settings similar to those in the trial
    American Society of Clinical Oncology (ASCO) (2012)Annual screening for high-risk individuals based on results of the NLST*55-74 years≥30 pack per year smoking history and currently smoke or smoking cessation within the past 15 yearsLDCT**Screening offered only in clinical settings similar to those in the trial
    American Thoracic Society (ATS)(2012)Annual screening for high-risk individuals based on results of the NLST*55-74 years≥30 pack per year smoking history and currently smoke or smoking cessation within the past 15 yearsLDCT**Screening offered only in clinical settings similar to those in the trial
    National Comprehensive Cancer Network  (NCCN) (2012)

    Annual screening for high-risk individuals 

    55-74 years

    ≥30 pack per year smoking history and if former smoker, smoking cessation ≤15 yearsLDCT**

    Does not recommend screening for

    • Moderate risk individuals – ≥50 years with ≥20 pack per year smoking history or second hand smoke exposure but no additional risk factors
    • Low risk individuals – <50 years or <20 pack per year smoking history
    ≥50 years

    ≥20 pack per year smoking history and one additional risk factor (other than second-hand smoke)

    Additional risk factors – radon exposure; occupational exposure; cancer history; family history; COPD or pulmonary fibrosis

    U.S. Preventive Services Task Force (USPSTF) (2013)

    Annual screening for high-risk individuals

    55-80 years

    ≥30 pack per year smoking history and currently smoke or smoking cessation within the last 15 years

    LDCT**

    Screening can be discontinued once an individual has not smoked for 15 years or develops a health problem that limits life expectancy or the ability to have curative surgery

    American Association for Thoracic Surgery (AATS)(2012)

    Annual screening in current and former smokers

    55-79 years

    30 pack per year smoking history

    LDCT** 

    50-79 years

    20 pack per year smoking history with additional comorbid conditions that produce a cumulative risk for cancer of at least 5% over the next 5 years

    55-79 years

    Long-term cancer survivors
    American Cancer Society (ACS)(2012)Annual screening in high-risk individuals with relatively good health and meet NLST* criteria55-74 years

    ≥30 pack per year smoking history and currently smoke or smoking cessation within the last 15 years

    LDCT**Recommends against the use of chest radiography and strongly suggests individuals enter an organized screening program that has experience in LDCT**

    *NLST (National Lung Screening Trial ) – high-risk smokers and former smokers 55-74 years with ≥30 packs per year smoking history and no history of lung cancer (former smokers must have quit within the past 15 years)

    **LDCT – low-dose computed tomography

Monitoring

  • Recommended monitoring (postcurative approach)
    • History and physical, chest x-ray, CBC and chemistries every 3-6 months for first 2 years (National Comprehensive Cancer Network [NCCN] recommends CT every 6 months in non-small cell lung cancer [NSCLC])
  • Small cell lung cancer (SCLC)
    • Serial NSE may be useful to monitor tumor recurrence in SCLC
  • NSCLC
    • CK 19 – potential role for monitoring therapy in advanced NSCLC

Clinical Background

Lung cancer is the leading cause of cancer-related mortality in the U.S. and worldwide.

Epidemiology

  • Incidence – 62.5/100,000
    • ~160,000 deaths from lung cancer estimated in 2014 (NCCN, 2014)
  • Age – peak incidence is 65-74 years; median is 71 years
  • Sex – M>F, minimal
    • Female prevalence has increased; male prevalence has stabilized
  • Ethnicity – highest incidence in African American males

Risk Factors

  • Tobacco use – 85-90% of all lung cancers attributed to tobacco use
    • 13-fold increase in risk for primary user
    • Secondhand exposure – 20-30% increased risk for those who live/lived with smokers
  • Radon exposure – likely main cause of lung cancer in nonsmokers
  • Asbestos exposure – cumulative risk; estimated to cause 3-4% of cases
    • Risk increased if patient also smokes
  • Occupational exposure to carcinogens (eg, bis(chloromethyl)ether, polycyclic aromatic hydrocarbons, chromium, nickel, organic arsenic)
  • Previous chest irradiation
  • Genetic – positive family history combined with tobacco use increases the risk

Pathophysiology

  • Any tumor arising from respiratory epithelium or pneumocytes
  • Two main types
    • Non-small cell lung cancer (NSCLC) – ~85% of all lung cancers
      • Adenocarcinoma (non-squamous cell) – most common
        • Occurs in glandular tissue of lung lining
      • Squamous (epidermoid) cell carcinoma (SCC)
      • Large cell (large cell anaplastic), other types
    • Small cell lung cancer (SCLC) – ~15% of all lung cancers
      • Epithelial tumor of small cells
        • 95% arise in lung; may also arise from extrapulmonary sites (eg, nasopharynx, gastrointestinal tract, genitourinary tract)
      • Nearly all cases result from smoking
      • Two subtypes
        • Small cell carcinoma (oat cell)
        • Combined small cell carcinoma
  • Other tumors (rare)
  • Undifferentiated bronchial-gland tumors, sarcomas, neuroendocrine tumors

Clinical Presentation

  • 20% of cases incidentally identified while asymptomatic by chest x-ray for other reasons
  • Symptoms based on area of tumor growth
    • Central – cough, wheeze, hemoptysis, stridor, dyspnea, postobstructive pneumonia
    • Peripheral – pleural/chest wall pain, cough, dyspnea
    • Invasion and obstruction of adjacent structures
      • Tracheal obstruction – dyspnea, wheezing
      • Esophageal compression – dysphagia
      • Recurrent laryngeal nerve invasion – hoarseness
      • Phrenic nerve invasion – diaphragmatic paralysis
      • Sympathetic nerve invasion – Horner syndrome
        • Ptosis
        • Miosis
        • Enophthalmos
        • Unilateral loss of sweating
      • Invasion of lung apex – Pancoast tumor, superior vena caval syndrome
    • Distant metastases
      • Superior vena caval syndrome
      • Pericardial tamponade
      • Pleural effusions
      • Pathologic bone fractures
      • Adrenal insufficiency (rare) 
    • Paraneoplastic syndromes – common; may be first presenting symptoms of lung cancer (SCLC in particular)

Indications for Laboratory Testing

  • Tests generally appear in the order most useful for common clinical situations
  • Click on number for test-specific information in the ARUP Laboratory Test Directory
Test Name and Number Recommended Use Limitations Follow Up
Cytology, Pulmonary 8209702
Method: Microscopy

May be used as initial screening test in detection of lung cancer

Negative screening does not mean cancer is not present

Bronchial brushings, washings, tissue biopsy (transbronchial and open lung) from site of lung involved

Cytology, Bronchoalveolar Lavage, Malignancy 8280005
Method: Microscopy

May be used as initial screening test in detection of lung cancer

Negative result does not mean cancer is not present

Bronchial brushings, washings, tissue biopsy (transbronchial and open lung) from site of lung involved

Lung Cancer Panel 2008894
Method: Polymerase Chain Reaction/Pyrosequencing/Immunohistochemistry

Screening panel to determine eligibility for TKI therapy

EGFR, ALK, and ROS1 genes tested simultaneously

Results of these tests must be interpreted in the context of morphological and other relevant data

Tests should not be used alone to diagnose malignancy

 
Lung Cancer Panel with KRAS 2008895
Method: Polymerase Chain Reaction/Pyrosequencing/Immunohistochemistry

Screening panel to determine eligibility for TKI therapy

KRAS, EGFR, ALK, and ROS1 genes tested simultaneously

Results of these tests must be interpreted in the context of morphological and other relevant data

Tests should not be used alone to diagnose malignancy

 
CYFRA 21-1 (Cytokeratin 19 Fragment), Serum 0081344
Method: Quantitative Enzyme-Linked Immunosorbent Assay

Use for prognostication and monitoring in NSCLC

Clinical sensitivity – varies by disease stage

Analytical sensitivity – limit of detection is 0.5 ng/mL

Do not use for screening

Results obtained with different methods or kits cannot be used interchangeably

 
Neuron Specific Enolase 0098198
Method: Quantitative Enzyme-Linked Immunosorbent Assay
Use for prognostication and monitoring in NSCLC

Do not use for screening

Results obtained with different methods or kits cannot be used interchangeably

 
Cytokeratin 7 (CK 7) by Immunohistochemistry 2003854
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Cytokeratin 20 (CK 20) by Immunohistochemistry 2003848
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Thyroid Transcription Factor (TTF-1) by Immunohistochemistry 2004166
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Chromogranin A by Immunohistochemistry 2003830
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
CD56 (NCAM) by Immunohistochemistry 2003589
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Synaptophysin by Immunohistochemistry 2004139
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
p63 by Immunohistochemistry 2004073
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Cytokeratin 5,6  (CK 5,6) by Immunohistochemistry 2003851
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Carcinoembryonic Antigen, Polyclonal (CEA P) by Immunohistochemistry 2003827
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Breast Carcinoma b72.3 by Immunohistochemistry 2003445
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Anti-Human Epithelial Antigen, Ber-EP4 by Immunohistochemistry 2003463
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Epithelial-Related Antigen, MOC-31 by Immunohistochemistry 2003875
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Neuron Specific Enolase, Polyclonal (NSE P) by Immunohistochemistry 2004052
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
CDX2 by Immunohistochemistry 2003821
Method: Immunohistochemistry

Aid in differentiating primary lung tumors from metastatic GI tumors

Stained and returned to client pathologist for interpretation; consultation available if needed

   
c-MET by Immunohistochemistry 2008652
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Napsin A by Immunohistochemistry 2008716
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
P40 by Immunohistochemistry 2010142
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
PD-L1 by Immunohistochemistry 2011158
Method: Immunohistochemistry

Aid in histologic diagnosis of lung cancer

Stained and returned to client pathologist for interpretation; consultation available if needed

   
Additional Tests Available
 
Click the plus sign to expand the table of additional tests.
Test Name and NumberComments
KRAS Mutation Detection 0040248
Method: Polymerase Chain Reaction/Pyrosequencing

Single-gene test in conjunction with EGFR, ROS1 and ALK to determine eligibility for TKIs

Detects mutations at codons 12, 13, and 61

EGFR Mutation Detection by Pyrosequencing 2002440
Method: Polymerase Chain Reaction/Pyrosequencing

Single-gene test in conjunction with ROS1, ALK, and possibly KRAS to determine eligibility for TKIs

Detects mutations at codons 719, 768, 790, 858, and 861; detects deletions in exon 19

ALK (D5F3) with Interpretation by Immunohistochemistry 2007324
Method: Immunohistochemistry

Order if no mutations detected in either KRAS or EGFR genes

Cost-effective, efficient screen for all ALK fusion proteins

D5F3 clone more sensitive than ALK1 clone for detection of ALK protein expression in lung cancer

ROS1 with Interpretation by Immunohistochemistry with Reflex to FISH if Equivocal 2008414
Method: Immunohistochemistry

Cost-effective, efficient screen for ROS1 fusion proteins

EGFR Gene Amplification by FISH 2008605
Method: Fluorescence in situ Hybridization

Not recommended for lung cancer mutation screening

ALK Gene Rearrangements in NSCLC for Crizotinib Eligibility by FISH 2006102
Method: Fluorescence in situ Hybridization

Preferred test is ALK (D5F3) by IHC; interpretation is challenging in FISH for rearrangements due to small inversions involving chromosome 2p

Lung Cancer Assessment and Early Detection (EarlyCDT) 2007513
Method: Semi-Quantitative Enzyme-Linked Immunosorbent Assay

May be useful as screening for patients deemed high risk for lung cancer

Solid Tumor Mutation Panel by Next Generation Sequencing 2007991
Method: Massively Parallel Sequencing

Simultaneously evaluates mutations in multiple genes, including EGFR, KRAS, NRAS, and BRAF

Does not detect translocations

BRAF Codon 600 Mutation Detection by Pyrosequencing 2002498
Method: Polymerase Chain Reaction/Pyrosequencing

May aid in lung cancer therapy decisions

Carcinoembryonic Antigen 0080080
Method: Quantitative Electrochemiluminescent Immunoassay

Prognostication and monitoring in lung cancer

Squamous Cell Carcinoma Antigen, Serum 0081054
Method: Quantitative Enzyme-Linked Immunosorbent Assay

Prognostication and monitoring in lung cancer