Summary
Definition
History and exam
Key diagnostic factors
- cough
- dyspnea
- hemoptysis
- chest and/or shoulder pain
- weight loss
Other diagnostic factors
- older age
- male sex
- fatigue
- pulmonary exam abnormalities
- hoarseness
- confusion
- personality changes
- nausea and vomiting
- headache
- dysphagia
- bone pain and/or fractures
- weakness, paresthesias, and/or pain in C8/T1 distribution
- seizures
- cervical or supraclavicular adenopathy
- Horner 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 (COPD)
- family history
- radon gas exposure
- older age
- asbestos exposure
- male sex
Diagnostic tests
1st tests to order
- chest x-ray
- contrast-enhanced CT scan of lower neck, thorax, and upper abdomen
Tests to consider
- sputum cytology
- bronchoscopy
- biopsy
- diagnostic thoracentesis and/or pleural biopsy
- CT with contrast and/or fluorodeoxyglucose (FDG)-PET
- sampling of the mediastinal lymph nodes: mediastinoscopy and endobronchial ultrasound (EBUS)
- video-assisted thoracoscopic surgery (VATS)
- thoracoscopy
- MRI head
- MRI of thoracic inlet
- bone scan
- pulmonary function tests (PFT)
- CBC
- LFTs
- serum calcium
- electrolytes and renal function
- epidermal growth factor receptor (EGFR) mutation testing
- anaplastic lymphoma kinase (ALK) testing
- ROS proto-oncogene 1 (ROS1) testing
- programmed death-ligand 1 (PD-L1) testing
- B-Raf proto-oncogene (BRAF) testing
- neurotrophin tyrosine receptor kinase (NTRK) fusion testing
- mesenchymal-epithelial transition factor (MET) exon 14 (METex14) skipping mutations
- rearranged during transfection (RET) gene mutations testing
- KRAS proto-oncogene (KRAS) point mutations testing
- ERBB2 (HER2) mutations testing
- neuregulin 1 (NRG1) fusion testing
- c-MET overexpression (≥50% immunohistochemistry [IHC] 3+) and EGFR wild-type (no EGFR mutation) testing
Treatment algorithm
stage I and II
stage IIIA
stage IIIB and IIIC
stage III with tumors too extensive for combination chemoradiation therapy or stage IV and suitable for immunotherapy or targeted therapy
stage III with tumors too extensive for combination chemoradiation therapy or stage IV and unsuitable for immunotherapy or targeted therapy (ECOG performance 0-2)
stage III with tumors too extensive for combination chemoradiation therapy or stage IV and unsuitable for immunotherapy or targeted therapy (ECOG performance 3-4)
Contributors
Authors
Alex A. Adjei, MD, PhD, FACP
Chairman, Taussig Cancer Institute
M. Frank Rudy and Margaret Domiter Rudy Distinguished Chair in Translational Cancer Research
Cleveland Clinic
Cleveland
OH
Disclosures
AAA declares that he has no competing interests.
Fen Wang, MD
Peking University Shenzhen Hospital
Shenzhen
Guangdong
China
Disclosures
FW declares that she has no competing interests.
Acknowledgements
Professor Alex A. Adjei and Dr Fen Wang would like to gratefully acknowledge Professor David R. Baldwin, Dr Sanjay Popat, Dr Mick Peake, Dr Chris Kelsey, and Dr Lawrence Marks, previous contributors to this topic.
Disclosures
DRB declares that he has no competing interests. 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. 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
Professor
Assistant Dean
Undergraduate Program
McMaster University
Hamilton
Ontario
Canada
Disclosures
AN declares that he has no competing interests.
James Huang, MD
Assistant Attending Surgeon
Thoracic Service
Memorial Sloan Kettering Cancer Center
New York
NY
Disclosures
JH declares that he has no competing interests.
Siow Ming Lee, PhD, FRCP
Consultant Medical Oncologist
University College Hospital
London
UK
Disclosures
SML declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: non-small cell lung cancer [internet publication].Full text
National Institute for Health and Care Excellence. Lung cancer: diagnosis and management. March 2024 [internet publication].全文
European Society for Medical Oncology. Oncogene-mediated metastatic non-small cell lung cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Jan 2023 [internet publication].全文
Hendriks L E, Kerr K, Menis J, et al. on behalf of the ESMO Guidelines Committee. Non-oncogene-addicted metastatic non-small-cell lung cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Jan 2023;34(4):358-76.全文
Bazhenova L, Ismaila N, Abu Rous F, et al. Therapy for stage IV non-small cell lung cancer with driver alterations: ASCO living guideline, version 2024.2. J Clin Oncol. 2024 Dec 20;42(36):e72-86.全文 摘要
Jaiyesimi IA, Leighl NB, Ismaila N, et al. Therapy for stage IV non-small cell lung cancer without driver alterations: ASCO living guideline, version 2023.3. J Clin Oncol. 2024 Apr 10;42(11):e23-43.全文 摘要
参考文献
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
鉴别诊断
- Small cell lung cancer
- Metastatic cancer
- Pneumonia/bronchitis
更多 鉴别诊断指南
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- Therapy for stage IV non-small-cell lung cancer without driver alterations: ASCO living guideline
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