Last reviewed: 29 Dec 2021
Last updated: 27 Oct 2020



History and exam

Key diagnostic factors

  • presence of risk factors
  • cough
  • dyspnoea
  • haemoptysis
  • chest and/or shoulder pain
  • weight loss

Other diagnostic factors

  • male sex
  • fatigue
  • pulmonary examination abnormalities
  • hoarseness
  • confusion
  • personality changes
  • nausea and vomiting
  • headache
  • dysphagia
  • bone pain and/or fractures
  • weakness, paraesthesias and/or pain in C8/T1 distribution
  • seizures
  • cervical or supraclavicular adenopathy
  • Horner's syndrome
  • facial swelling
  • dilated neck or chest/abdominal wall veins
  • finger clubbing
  • hypertrophic pulmonary osteoarthropathy

Risk factors

  • cigarette smoking
  • environmental tobacco exposure
  • chronic obstructive pulmonary disease
  • family history
  • radon gas exposure
  • asbestos exposure
  • older age

Diagnostic investigations

1st investigations to order

  • chest x-ray
  • contrast-enhanced CT scan of lower neck, thorax, and upper abdomen

Investigations to consider

  • sputum cytology
  • bronchoscopy
  • biopsy
  • diagnostic thoracentesis and/or pleural biopsy
  • sampling of the mediastinal lymph nodes: mediastinoscopy and endobronchial ultrasound
  • video-assisted thoracoscopic surgery (VATS)
  • thoracoscopy
  • MRI or CT of brain
  • MRI of thoracic inlet
  • PET-CT
  • bone scan
  • contrast-enhanced CT liver and adrenals
  • pulmonary function tests (PFT)
  • FBC
  • LFTs
  • serum calcium
  • electrolytes and renal function
  • electrocardiogram and echocardiogram
  • epidermal growth factor receptor (EGFR) mutation testing
  • anaplastic lymphoma kinase (ALK) testing
  • ROS1 testing
  • programmed death-ligand 1 (PD-L1) testing
  • BRAF testing
  • NTRK fusion testing

Treatment algorithm



Professor David R. Baldwin, MD, FRCP

Consultant Respiratory Physician

Nottingham University Hospitals

Honorary Professor of Medicine

University of Nottingham

Respiratory Medicine Unit

David Evans Research Centre

City Hospital Campus




DRB declares that he has no competing interests.

Sanjay Popat, FRCP, PhD

Consultant Medical Oncologist

Department of Medicine

Royal Marsden Hospital




SP has been paid and acted as a consultant to BMS, Eli Lilly, Roche, Takeda, AstraZeneca, Chugai, Novartis, Pfizer, MSD, EMD Serono, Guardant Health, AbbVie, Boehringer Ingelheim, and Tesaro. SP has received research grants from Pierre Fabre, Otsuka, and Boehringer Ingelheim. SP has received assistance for travel from Boehringer Ingelheim, MSD, and Pfizer.


Professor David R. Baldwin and Dr Sanjay Popat would like to gratefully acknowledge Dr Mick Peake, Dr Chris Kelsey, and Dr Lawrence Marks, previous contributors to this topic.


MP has received lecture fees from AstraZeneca Pharmaceuticals, Lilly Oncology Ltd, Pierre-Fabre, GSK Ltd, and Roche Pharmaceuticals Ltd. MP has also received educational grants to attend scientific conferences from Roche Pharmaceuticals Ltd and Boehringer Ingelheim Ltd. CK and LM declare that they have no competing interests.

Peer reviewers

Alan Neville, MD


Assistant Dean

Undergraduate Program

McMaster University





AN declares that he has no competing interests.

James Huang, MD

Assistant Attending Surgeon

Thoracic Service

Memorial Sloan Kettering Cancer Center

New York



JH declares that he has no competing interests.

Siow Ming Lee, PhD, FRCP

Consultant Medical Oncologist

University College Hospital




SML declares that he has no competing interests.

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