Diagnosis

• RED FLAGS: haemoptysis OR
  • SOB
  • Cough
  • Chest / shoulder pain
  • Wt loss
  • Chest signs
  • Finger clubbing
  • Hoarseness (recurrent laryngeal)
  • Cervical / Supraclavicular lymphadenopathy
  • Features of metastasis (Bone, brain, liver etc)
  • Stridor, vena cava obstruction (elevated JVP)

Investigation

• Urgent X ray per above criteria (+ suspicion: pleural effusion or slowly resolving consolidation)
• Contrast enhanced CT to include liver and adrenals to stage disease BEFORE bronchoscopy / biopsy
• PET-CT for curative patients (ie low probability of mediastinal malignancy)
• If peripheral tumour: trans-thoracic USS / CT guided biopsy
• If central primary tumour: fibreoptic bronchoscopy (where nodal staging not influencing treatment)
• Neck USS if high probability of mediastinal malignancy
• Stage M1b if curative treatment, confirm presence of distant metastasis biopsy or image (MRI/PET)
• Bone metastasis: X ray, if inconclusive then bone scan or MRI
• Spirometry in all patients with curative intent, TLCO if breathlessness is disproportionate

Management

• Urgent referral to lung Ca MDT
• Rapid access clinics for necessary investigation
• Cancer nurse specialists
• Smoking cessation, though do not postpone surgery awaiting cessation

Non-small cell lung Ca

• Offer lobectomy, if FEV1 within normal limits & good exercise tolerance
• In small tumours of borderline fitness: i.e. T1aM0N0 consider lung parenchymal sparing operations
• Perform hilar and mediastinal lymph node sampling if undergoing surgery for curative intent
• Radical radiotherapy for NSCLC I, II, III with good performance (WHO 0,1), with or without surgery suitability
• CHART regimen if I, II but medically inoperable or do not want chemotherapy
• Chemo-radiotherapy for patients with stage II or III NSCLC who are not suitable for surgery
• Offer post-operative chemotherapy to patients with good performance status (WHO 0 or 1) and T1–3 N1–2 M0 NSCLC
• Cisplatin-based combination chemotherapy regimen for adjuvant chemotherapy
• Chemotherapy should be offered to patients with stage III or IV NSCLC and good performance status (WHO 0, 1) to improve survival, disease control and QoL

Small Cell Ca

• Consider surgery in patients with early-stage SCLC (T1–2a, N0, M0)
• Offer platinum-based combination chemotherapy to patients with extensive-stage disease SCLC
• Palliative care including symptom limited radiotherapy
• Bone metastasis hypercalcaemia: single fraction radiotherapy

NICE Source: CG121 Lung cancer: diagnosis and management. Summary compiled by Dr D P Sheppard MBBS.