Biopsy request 1. Educate referring clinicians that NSCLC workup requires comprehensive molecular testing through designated training modules or workshops 2. Add a “checkbox” to the biopsy request in the electronic medical record to indicate the request for molecular testing. Have the requesting provider check this box in all suspected and confirmed cases of advanced NSCLC 3. Pre-screen lung needle biopsy requests and call the referring provider for clarification if the need for molecular testing is unclear |
Biopsy procedure 4. Review available imaging prior to the procedure and stratify targets by imaging characteristics, if possible. For example, assess FDG and intravenous contrast to avoid areas of necrosis 5. Use real-time CT guidance during the procedure 6. Obtain multiple tissue cores using coaxial technique while angling the biopsy device in all four quadrants 7. Sample the periphery of large tumors to avoid areas of central necrosis 8. During ROSE, have the cytotechnologist verify that the specimen contains viable tumor cells 9. Collect at least four tissue cores once ROSE confirms viable tumor cells 10. Consider a higher tolerance for potential risk and obtain additional cores if molecular testing is likely to affect survival, especially in suspected advanced NSCLC |
Specimen analysis 11. Clarify how to allocate the specimens depending on institutional requirements 12. Use NGS panels instead of sequential single-gene tests to conserve tissue and obtain more comprehensive results 13. If feasible, bank tissue for future molecular testing 14. Institute “reflex-molecular testing” following histologic diagnosis of NSCLC to reduce turnaround time |
Communication 15. Track frequency of insufficient tissue, reasons for insufficiency, molecular testing results (especially true negatives versus insufficient sample), complications from the biopsy procedure, and patient treatment outcomes 16. Integrate radiologists who perform lung needle biopsies more closely into the oncology care team and foster a culture of continuous feedback and follow-up 17. Institute a multidisciplinary tumor board with data-driven discussions to increase the quality of lung needle biopsies 18. Report tissue adequacy and cellularity in uniquely identified fields (not free-form comments) in the molecular testing report 19. Institute patient navigators to facilitate multidisciplinary follow-up on molecular testing outcomes |