Summary
Definition
History and exam
Key diagnostic factors
- cough
- dyspnea
- hemoptysis
- chest and/or shoulder pain
- weight loss
Other diagnostic factors
- 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
- 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)
- CBC
- 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
Contributors
Authors
Consultant Respiratory Physician
Nottingham University Hospitals
Honorary Professor of Medicine
University of Nottingham
Respiratory Medicine Unit
David Evans Research Centre
City Hospital Campus
Nottingham
UK
Disclosures
DRB declares that he has no competing interests.
Consultant Medical Oncologist
Department of Medicine
Royal Marsden Hospital
London
UK
Disclosures
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.
Disclosures
MP has received lecture fees: 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
Professor
Assistant Dean
Undergraduate Program
McMaster University
Hamilton
Ontario
Canada
Disclosures
AN declares that he has no competing interests.
Assistant Attending Surgeon
Thoracic Service
Memorial Sloan Kettering Cancer Center
New York
NY
Disclosures
JH declares that he has no competing interests.
Consultant Medical Oncologist
University College Hospital
London
UK
Disclosures
SML declares that he has no competing interests.
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