Respiratory : Lung Cancer (Complete)

• Lung cancer: Lung Cancer: What It Is | Symptoms and Urgent Referral | Diagnosis and Staging | Treating Non-small Cell Lung Cancer | Small Cell Lung Cancer | Paraneoplastic Syndromes | Local Spread and Complications | Immunotherapy Side Effects | Supportive and Palliative Care
• Nodules and screening: Pulmonary Nodules | Lung Cancer Screening | Other Lung Tumours
• Pleural disease: Pleural Effusion: Approach | Malignant Pleural Effusion | Mesothelioma | Asbestos and the Pleura | Pneumothorax: Follow-up and Recurrence | Chylothorax and Haemothorax
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🎗️ Lung cancer is the UK's biggest cancer killer - about 35,000 deaths a year - mainly because most cases are found late. Earlier diagnosis (screening, prompt chest X-rays), precise staging and new targeted drugs and immunotherapy are changing outcomes. This chapter also covers lung nodules and pleural disease, including effusions and mesothelioma.
Your four questions for every patient: Could this be cancer, and has it been referred fast enough? What type and stage is it? Is the patient fit for curative treatment? What symptoms and complications need treating now?

Lung Cancer: What It Is

Risk factors:

• Smoking - about 70–85% of cases; risk rises with pack-years and falls after stopping.
• Passive smoking.
• Radon gas.
• Asbestos and other occupational carcinogens.
• Air pollution.
• Previous chest radiotherapy.
• Family history; COPD and pulmonary fibrosis.
• HIV.

About 1 in 7 cases occur in never-smokers, often women and people of East Asian descent, usually with adenocarcinoma.

Main types:

• Non-small cell lung cancer (NSCLC) - about 85%:
  • Adenocarcinoma - the commonest. Usually peripheral; the commonest type in never-smokers. Often has targetable mutations (EGFR, ALK, ROS1, KRAS).
  • Squamous cell carcinoma - usually central, smokers. May cavitate; linked to hypercalcaemia (PTHrP).
  • Large cell carcinoma - less common, poorly differentiated.
• Small cell lung cancer (SCLC) - about 15%:
  • Central, almost always in smokers.
  • Neuroendocrine; grows and spreads very fast.
  • Linked with paraneoplastic syndromes (SIADH, ectopic ACTH, Lambert–Eaton).
• Carcinoid tumours - low-grade neuroendocrine tumours, often in younger people.

Outlook: 5-year survival is over 60% for stage I but under 10% for stage IV - so early diagnosis is everything.

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Symptoms and Urgent Referral

Symptoms:

• Local: Persistent cough, change in a chronic cough, haemoptysis, breathlessness, chest pain, recurrent chest infection, hoarseness.
• General: Weight loss, loss of appetite, fatigue.
• Spread: Bone pain, confusion and headache (brain), jaundice, lymph nodes in the neck.
• Signs: Clubbing, supraclavicular nodes, signs of effusion or collapse, thrombocytosis.

NICE NG12 (suspected cancer):

• Refer urgently on the suspected cancer pathway if:
  • The chest X-ray suggests lung cancer, or
  • The patient is aged 40 or over with unexplained haemoptysis.
• Offer an urgent chest X-ray (within 2 weeks) to people aged 40 or over with two or more unexplained symptoms - or one if they have ever smoked:
  • Cough.
  • Fatigue.
  • Breathlessness.
  • Chest pain.
  • Weight loss.
  • Appetite loss.
• Consider an urgent chest X-ray for those aged 40 or over with persistent or recurrent chest infection, clubbing, supraclavicular or persistent cervical nodes, chest signs consistent with cancer, or thrombocytosis.
• A normal chest X-ray does not exclude cancer - refer or arrange CT if symptoms persist.

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Diagnosis and Staging

The aim: Get the diagnosis and stage in the fewest, safest steps - ideally one biopsy that confirms both. The National Optimal Lung Cancer Pathway aims for treatment within 49 days of referral.

• CT chest, liver and adrenals with contrast - before any biopsy.
• PET-CT - for patients being considered for curative treatment, to look for nodal and distant spread.
• Tissue sampling - choose the site that gives the highest stage:
  • EBUS-TBNA of mediastinal nodes (diagnosis and staging together).
  • Bronchoscopy for central tumours.
  • CT-guided biopsy for peripheral lesions.
  • Pleural fluid cytology or thoracoscopy for effusions.
  • Ultrasound-guided neck node or liver biopsy.
• Brain MRI - for stage II–III disease being considered for curative treatment, or with neurological symptoms.
• Molecular testing on non-squamous NSCLC (and some squamous):
  • EGFR, ALK, ROS1, BRAF, KRAS G12C, MET, RET, NTRK, HER2.
  • Plus PD-L1 expression.
  • Increasingly done as a panel (next-generation sequencing), including blood-based "liquid biopsy".

TNM staging (simplified):

• T - tumour size and invasion.
• N - lymph nodes:
  • N1 - same-side hilar.
  • N2 - same-side mediastinal.
  • N3 - opposite side or supraclavicular.
• M - metastases (pleural effusion, opposite lung, distant organs).
• Stage I–II: Localised - usually treated with curative surgery or radiotherapy.
• Stage III: Locally advanced (mediastinal nodes) - combined treatment.
• Stage IV: Metastatic - systemic treatment.

Performance status (ECOG / WHO 0–4) matters as much as stage when choosing treatment:

• 0 - fully active.
• 1 - restricted in strenuous activity.
• 2 - up and about more than half the day.
• 3 - in bed or chair more than half the day.
• 4 - bedbound.

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Treating Non-small Cell Lung Cancer

Treatment is planned by the lung cancer MDT and depends on stage, molecular profile, fitness and patient choice.

Early stage (I–II):

• Surgery - usually lobectomy (often keyhole, VATS or robotic) with lymph node sampling. Segmentectomy for small peripheral tumours.
• Fitness assessment: Lung function (predicted post-operative FEV1 and TLCO), exercise testing (shuttle walk or CPET), cardiac risk.
• Stereotactic ablative radiotherapy (SABR) - highly focused radiation for people unfit for or declining surgery, with excellent local control.
• Added systemic treatment to reduce recurrence, for larger or node-positive tumours:
  • Neoadjuvant chemo-immunotherapy (e.g. nivolumab with chemotherapy before surgery).
  • Adjuvant chemotherapy.
  • Osimertinib after surgery for EGFR-mutant disease.
  • Immunotherapy.

Locally advanced (stage III):

• Usually concurrent chemoradiotherapy, followed by durvalumab (immunotherapy) for a year if PD-L1-positive.
• Selected patients have surgery as part of combined treatment.

Advanced (stage IV):

• Targetable mutation: Oral targeted therapy:
  • EGFR: Osimertinib.
  • ALK: Alectinib or lorlatinib.
  • Others for ROS1, BRAF, KRAS G12C, MET, RET.
  Responses are often dramatic and long-lasting.
• No targetable mutation: Immunotherapy (checkpoint inhibitors such as pembrolizumab), alone if PD-L1 is high (50% or more), or with platinum chemotherapy.
• Chemotherapy for those unsuitable for immunotherapy.
• Palliative radiotherapy for symptoms (bone pain, haemoptysis, airway obstruction, brain metastases).
• Best supportive care for those too frail for anticancer treatment.

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Small Cell Lung Cancer

• Behaviour: Grows and spreads very quickly - most patients have spread at diagnosis. It is very sensitive to chemotherapy and radiotherapy at first, but usually relapses.
• Limited stage (confined to one hemithorax and treatable in one radiotherapy field):
  • Concurrent chemoradiotherapy (platinum plus etoposide).
  • Prophylactic cranial irradiation or brain MRI surveillance.
  • Rarely surgery for very small tumours.
• Extensive stage:
  • Platinum-etoposide chemotherapy plus immunotherapy (atezolizumab or durvalumab), then maintenance immunotherapy.
  • Thoracic radiotherapy in selected patients.
• Urgency: SCLC can deteriorate within days - fast-track to oncology. Treat SVCO, SIADH and other complications promptly.
• Prognosis: Median survival is about 12–18 months for extensive disease, longer for limited disease.

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Paraneoplastic Syndromes

Effects of the cancer caused by hormones or antibodies rather than by direct spread. They may appear before the cancer is found.

• SIADH (mostly SCLC):
  • Euvolaemic hyponatraemia.
  • Treat the cancer; fluid restriction; tolvaptan or urea.
• Ectopic ACTH (SCLC, carcinoid):
  • Rapid Cushing's - often without the classic appearance.
  • Hypokalaemic alkalosis, hypertension, hyperglycaemia, weakness, pigmentation.
• Hypercalcaemia (squamous cell - PTHrP):
  • Thirst, confusion, constipation.
  • Fluids and IV bisphosphonate.
• Lambert–Eaton myasthenic syndrome (SCLC):
  • Antibodies to voltage-gated calcium channels.
  • Proximal leg weakness that improves briefly with repeated effort.
  • Reduced reflexes; dry mouth and other autonomic symptoms.
• Paraneoplastic neurological syndromes (often SCLC, anti-Hu antibodies):
  • Cerebellar degeneration.
  • Limbic encephalitis.
  • Sensory neuronopathy.
• Hypertrophic pulmonary osteoarthropathy (NSCLC): Clubbing plus painful swelling of the wrists and ankles, with periosteal new bone on X-ray.
• Other:
  • Dermatomyositis.
  • Thrombosis (Trousseau's - migratory thrombophlebitis).
  • Gynaecomastia (hCG).
  • Anaemia, thrombocytosis.
  • Cachexia.

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Local Spread and Complications

• Superior vena cava obstruction (SVCO):
  • Cause: A tumour (often SCLC or lymphoma) compresses or invades the SVC.
  • Signs: Facial and arm swelling, headache worse on bending, distended neck and chest wall veins, breathlessness. Stridor or confusion means an emergency.
  • Tests: CT with contrast; tissue diagnosis if possible.
  • Treatment:
    • Sit up; dexamethasone (if lymphoma is not suspected, or after biopsy).
    • Endovascular stenting for quick relief.
    • Then chemotherapy (SCLC, lymphoma) or radiotherapy.
    • Anticoagulate if there is thrombus.
• Pancoast tumour (apical tumour invading the chest wall and nerves):
  • Shoulder and arm pain (C8–T1).
  • Wasting of the small hand muscles.
  • Horner's syndrome (sympathetic chain) - ptosis, small pupil, reduced sweating.
• Nerve involvement:
  • Recurrent laryngeal nerve (left-sided tumours or nodes) - hoarse voice, weak cough.
  • Phrenic nerve - raised hemidiaphragm.
• Airway obstruction: Collapse, post-obstructive pneumonia, stridor - airway stents, debulking or radiotherapy.
• Malignant pleural and pericardial effusions (tamponade).
• Haemoptysis - palliative radiotherapy, tranexamic acid, bronchial artery embolisation.
• Metastases:
  • Brain - headache, seizures, focal signs; dexamethasone, stereotactic radiosurgery.
  • Bone - pain, fracture, hypercalcaemia, spinal cord compression.
  • Liver and adrenal.

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Immunotherapy Side Effects

Mechanism: Checkpoint inhibitors (pembrolizumab, nivolumab, atezolizumab, durvalumab, ipilimumab) release the brakes on the immune system. As well as attacking the cancer, they can cause immune-related adverse events in almost any organ - at any time, even months after stopping.

• Common:
  • Rash, itch.
  • Colitis (diarrhoea).
  • Hepatitis.
  • Thyroiditis - often hyperthyroid then hypothyroid.
• Serious - must not be missed:
  • Pneumonitis (new cough, breathlessness, CT shadowing).
  • Hypophysitis (headache, fatigue, low cortisol - check a 9 am cortisol).
  • Adrenal insufficiency.
  • New type 1 diabetes (DKA).
  • Myocarditis (troponin, arrhythmia - high mortality).
  • Myositis, myasthenia, neuropathy, encephalitis.
  • Nephritis.
• Management:
  • Contact the acute oncology team; grade the severity.
  • Withhold the drug.
  • Steroids (oral prednisolone or IV methylprednisolone) for moderate or severe events; further immunosuppression (e.g. infliximab for colitis) if refractory.
  • Endocrine problems usually need lifelong hormone replacement.

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Supportive and Palliative Care

• Lung cancer clinical nurse specialist for every patient; early specialist palliative care improves quality of life (and in some studies survival).
• Breathlessness:
  • Treat reversible causes - effusion, anaemia, airway obstruction, infection, PE.
  • Breathing techniques, a hand-held fan.
  • Low-dose opioids; benzodiazepines for anxiety.
• Cough: Treat the cause; simple linctus, opioids (codeine or morphine).
• Pain: WHO analgesic approach; radiotherapy for bone pain.
• Smoking cessation - it still improves outcomes after diagnosis.
• VTE risk is high - have a low threshold to investigate.
• Nutrition and cachexia; fatigue; psychological support.
• Advance care planning: Preferred place of care and death; DNACPR discussions.
• Benefits: Help with financial support, including the special rules for terminal illness.

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Pulmonary Nodules

What it is: A round shadow up to 3 cm in the lung (larger is a "mass"). Nodules are very common on CT, and most are benign (old infection, scars, lymph nodes).

Management (BTS pulmonary nodule guideline):

• Very small nodules (below 5 mm, or below 80 mm³): No follow-up.
• 5–8 mm (80–300 mm³): CT surveillance to check growth - usually volumetric CT at 3 months and 1 year.
• 8 mm or more (300 mm³ or more): Estimate the risk of cancer with the Brock model, which uses:
  • Age and sex.
  • Family history; emphysema.
  • Nodule size, type, upper-lobe location, spiculation and number.
• Brock risk 10% or more: PET-CT, then recalculate the risk with the Herder model:
  • Low risk: Surveillance.
  • Intermediate risk: Biopsy, or treatment, or surveillance.
  • High risk: Treat as cancer - surgery or SABR, sometimes without a biopsy.
• Growth - volume doubling time under 400 days suggests cancer. No growth over 2 years means a solid nodule is very likely benign.
• Ground-glass (subsolid) nodules grow slowly - longer follow-up. A part-solid nodule has a higher cancer risk.

Features suggesting cancer:

• Larger size.
• Spiculated edge.
• Upper lobe.
• Growth.
• Part-solid.
• Smoker.
• Emphysema.

Benign features: "Popcorn" or central calcification (hamartoma, old granuloma), fat (hamartoma), stability.

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Lung Cancer Screening

• Evidence: Low-dose CT screening of high-risk people reduces lung cancer deaths by about 20–25% (NLST and NELSON trials).
• NHS Lung Cancer Screening Programme (England; previously the Targeted Lung Health Check):
  • Who: People aged 55–74 who have ever smoked, identified from GP records.
  • Risk assessment: A telephone assessment calculates their risk (e.g. PLCOm2012 or LLP models). Those at high risk are offered a low-dose CT.
  • Follow-up: Repeat CT every 2 years until age 74.
  • Includes smoking cessation support.
  • Being rolled out across England by the end of the decade.
• Results: Most cancers found are early stage (about three-quarters at stage I–II, compared with about a quarter in routine care).
• Downsides:
  • False positives and anxiety.
  • Incidental findings - coronary calcium (treat CVD risk), emphysema, ILD.
  • Radiation (small).
  • Over-diagnosis.

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Other Lung Tumours

• Lung metastases - commoner than primary lung cancer on CT:
  • Multiple round "cannonball" nodules.
  • From kidney, colorectal, breast, sarcoma, melanoma, testis, head and neck.
  • Lymphangitis carcinomatosa (breast, stomach, lung) - breathlessness with interstitial thickening.
• Bronchial carcinoid:
  • Low-grade neuroendocrine tumour in younger adults (often non-smokers).
  • Central - wheeze, haemoptysis, recurrent pneumonia (blocked bronchus).
  • Carcinoid syndrome is rare.
  • Surgery is usually curative.
• Hamartoma: The commonest benign lung tumour - "popcorn" calcification and fat on CT.
• Lymphoma: Mediastinal masses (anterior mediastinum), lymph nodes, effusions.
• Anterior mediastinal masses - the "4 Ts":
  • Thymoma (myasthenia).
  • Thyroid (retrosternal goitre).
  • Teratoma (germ cell).
  • "Terrible" lymphoma.

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Pleural Effusion: Approach

Mechanism: Fluid builds up in the pleural space when production outstrips drainage.

• Transudates: Pressure problems - high venous pressure or low protein.
• Exudates: Leaky, inflamed or blocked pleura.

Causes:

• Transudates:
  • Heart failure - the commonest overall, usually bilateral.
  • Cirrhosis (hepatic hydrothorax, usually right-sided).
  • Nephrotic syndrome; hypoalbuminaemia.
  • Peritoneal dialysis.
  • Hypothyroidism.
  • Meigs' syndrome (ovarian fibroma).
• Exudates:
  • Parapneumonic effusion and empyema.
  • Malignancy (lung, breast, lymphoma, mesothelioma, ovary).
  • TB.
  • PE.
  • Rheumatoid arthritis, SLE.
  • Pancreatitis (high amylase); oesophageal rupture.
  • Drugs (methotrexate, amiodarone, dasatinib).
  • Benign asbestos effusion.
  • Post-cardiac injury (Dressler's).

Approach (BTS 2023):

• Typical bilateral effusions with clear heart failure: Treat the heart failure. Aspirate only if atypical (unequal sizes, fever, chest pain) or not responding.
• Unilateral or unexplained: Ultrasound-guided diagnostic aspiration:
  • Appearance.
  • Protein and LDH (with serum, for Light's criteria).
  • pH (blood gas analyser).
  • Glucose.
  • Cytology.
  • Gram stain, culture and AFB.
  • Amylase, triglycerides or haematocrit if relevant.
• Light's criteria - exudate if any of:
  • Protein ratio above 0.5.
  • LDH ratio above 0.6.
  • Pleural LDH above two-thirds of the upper limit of normal serum LDH.
• Clues from the fluid:
  • Low pH and low glucose - infection, rheumatoid, malignancy, TB.
  • Lymphocytes - TB, malignancy, lymphoma, chronic effusions.
  • Milky - chylothorax.
  • Bloody - malignancy, PE, trauma, asbestos.
• Still undiagnosed exudate: Contrast CT chest (pleural thickening, nodules), then thoracoscopy with pleural biopsy. Cytology alone misses many cancers, especially mesothelioma.
• Consider TB - pleural biopsy culture has a much higher yield than fluid.

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Malignant Pleural Effusion

• What it means: It usually means stage IV disease. Common primaries are lung, breast, lymphoma, mesothelioma and ovary. Median survival depends on the cancer type and fitness.
• Goal: Relieve breathlessness with as few procedures and hospital days as possible.
• Options (discussed with the patient - BTS 2023):
  • Therapeutic aspiration - quick relief, but fluid usually returns. Useful when life expectancy is very short.
  • Talc pleurodesis (via a drain or thoracoscopy) - sticks the pleural layers together to stop fluid returning. Needs a hospital stay and an expandable lung.
  • Indwelling pleural catheter (IPC) - a tunnelled drain, drained at home by district nurses or family. It can be used when the lung does not re-expand ("trapped lung"), and reduces hospital time.
• Trapped (non-expandable) lung: The lung cannot re-expand because of thick visceral pleura - pleurodesis will fail; use an IPC.
• Treat the cancer - chemotherapy-sensitive cancers (lymphoma, SCLC, breast) may control the effusion.

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Mesothelioma

• What it is: A cancer of the pleura (or peritoneum) caused almost entirely by asbestos exposure. There is a long latency of 30–50 years. The UK has one of the highest rates in the world, reflecting past use in shipbuilding, construction, railway work and plumbing.
• Clinical pattern:
  • Breathlessness from a pleural effusion.
  • Dull chest wall pain.
  • Weight loss, sweats.
  • Later, encasement of the lung and chest wall invasion.
• Diagnosis:
  • CT shows pleural thickening - nodular, circumferential, involving the mediastinal pleura.
  • Biopsy - usually by thoracoscopy or CT-guided - because fluid cytology is often negative.
• Treatment (specialist MDT):
  • Immunotherapy (nivolumab plus ipilimumab, NICE TA818) or chemotherapy (platinum plus pemetrexed).
  • Effusion control - IPC or pleurodesis.
  • Palliative radiotherapy for pain.
  • Early palliative care.
• Prognosis: Median survival about 1–2 years.
• Legal and benefits:
  • Patients are entitled to compensation (civil claims, government schemes, Industrial Injuries Disablement Benefit).
  • Death from mesothelioma must be reported to the coroner (an industrial disease).

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Asbestos and the Pleura

• Pleural plaques:
  • Discrete, often calcified, thickened patches on the parietal pleura and diaphragm.
  • A marker of exposure only - no symptoms, not pre-malignant.
  • Reassure (but the patient remains at risk of other asbestos diseases from the exposure itself).
• Diffuse pleural thickening: Extensive thickening of the visceral pleura, often after a benign asbestos effusion. It can cause restrictive breathlessness, and may qualify for compensation.
• Benign asbestos pleural effusion: A blood-stained exudate, often within 20 years of exposure - mesothelioma must be excluded.
• Rounded atelectasis: A rounded area of folded, collapsed lung next to thickened pleura ("comet tail" on CT) - can mimic a tumour.
• Asbestosis (lung fibrosis), mesothelioma and lung cancer are the more serious consequences.

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Pneumothorax: Follow-up and Recurrence

Acute management is covered in the Respiratory Emergencies chapter. In the longer term:

• Recurrence: About 1 in 3 primary spontaneous pneumothoraces recur, mostly within the first year. Secondary pneumothorax recurs more often and is more dangerous.
• Smoking (tobacco and cannabis) greatly increases recurrence - stopping is the most effective prevention.
• Surgery (VATS bullectomy with pleurodesis) is offered for:
  • A second pneumothorax (same side).
  • A first contralateral pneumothorax.
  • Bilateral pneumothorax.
  • A persistent air leak.
  • High-risk occupations (pilots, divers).
• Look for an underlying cause in atypical or recurrent cases - e.g. LAM (women, catamenial), Birt–Hogg–Dubé, Langerhans cell histiocytosis, Marfan's syndrome, cystic fibrosis, PCP.
• Catamenial pneumothorax: Linked to periods (thoracic endometriosis).
• Flying and diving:
  • Do not fly until resolution is confirmed on imaging (and usually for 1–2 weeks after).
  • Diving is unsafe unless definitive surgery has been done.

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Chylothorax and Haemothorax

• Chylothorax:
  • What it is: Lymphatic fluid (chyle) in the pleural space - milky fluid with triglycerides above 1.24 mmol/L (chylomicrons present).
  • Causes: Thoracic duct damage - lymphoma, other cancers, surgery (especially oesophagectomy), trauma, LAM.
  • Treatment: Treat the cause; drain; low-fat diet with medium-chain triglycerides; octreotide; thoracic duct embolisation or ligation.
• Pseudochylothorax: A milky, cholesterol-rich effusion in long-standing effusions (e.g. rheumatoid, TB). Cholesterol is high and triglycerides are low.
• Haemothorax:
  • Definition: Pleural fluid haematocrit more than half the blood haematocrit.
  • Causes: Trauma, procedures (biopsy, drain), anticoagulation, malignancy, aortic rupture.
  • Treatment: Large-bore chest drain and surgical review if bleeding continues (e.g. more than 1.5 L initially or ongoing loss).

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 63-year-old smoker has 6 weeks of cough, weight loss and one episode of haemoptysis.
Answer: Unexplained haemoptysis over 40 - urgent suspected cancer referral (NICE NG12), with a chest X-ray.

• CT chest, liver and adrenals with contrast.
• PET-CT and EBUS or biopsy as directed by the lung MDT.
• Smoking cessation support.

2. A 52-year-old never-smoker has stage IV lung adenocarcinoma with an EGFR exon 19 deletion.
Answer: First-line osimertinib (oral EGFR inhibitor) rather than chemotherapy or immunotherapy.

• Brain imaging.
• Monitor for rash, diarrhoea and QT; check for pneumonitis if new breathlessness.

3. A man on nivolumab for lung cancer has 2 weeks of watery diarrhoea, 8 times a day.
Answer: Likely immune-related colitis (grade 3).

• Contact acute oncology; withhold immunotherapy.
• Stool tests to exclude infection.
• IV methylprednisolone; infliximab if no response.
• Check TFTs and cortisol.

4. A 70-year-old former plumber has a right pleural effusion. Fluid is a blood-stained exudate with negative cytology. CT shows nodular pleural thickening.
Answer: Suspected mesothelioma.

• Thoracoscopic or CT-guided pleural biopsy (cytology is often negative).
• Effusion control (IPC or talc).
• Specialist MDT; advise about compensation.

5. A 66-year-old has a 12 mm spiculated upper-lobe nodule on CT. Brock risk is 28%.
Answer: Brock risk of 10% or more - PET-CT and Herder assessment.

• If high risk: surgical resection (or SABR if unfit), with or without a prior biopsy.
• Lung MDT discussion.

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Key Points

• Lung cancer is mostly smoking-related, but about 1 in 7 cases occur in never-smokers (often EGFR-mutant adenocarcinoma).
• Refer urgently for unexplained haemoptysis aged 40 or over. A normal chest X-ray does not exclude cancer.
• Stage with CT, then PET-CT and EBUS. Choose the biopsy that gives both diagnosis and the highest stage.
• Early NSCLC: surgery or SABR. Stage III: chemoradiotherapy then durvalumab. Stage IV: targeted therapy for mutations, otherwise immunotherapy with or without chemotherapy.
• SCLC: fast-growing, chemosensitive, frequent paraneoplastic syndromes.
• Paraneoplastic syndromes: SIADH and ectopic ACTH (SCLC), hypercalcaemia (squamous), Lambert–Eaton (SCLC), HPOA (NSCLC).
• Know SVCO, Pancoast tumour and recurrent laryngeal nerve palsy.
• Immunotherapy toxicity can affect any organ - steroids via acute oncology; check cortisol and TFTs.
• Nodules: under 5 mm needs no follow-up; 5–8 mm CT surveillance; 8 mm or more Brock score, then PET-CT if 10% or more.
• Pleural effusion: ultrasound-guided tap, Light's criteria, pH, cytology. Thoracoscopy for undiagnosed exudates.
• Malignant effusion: IPC or talc pleurodesis; IPC for trapped lung.
• Mesothelioma: asbestos, long latency; biopsy needed; compensation; report to the coroner.

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Guidelines and Further Reading

• NICE NG122: Lung cancer - diagnosis and management
• NICE NG12: Suspected cancer - recognition and referral
• National Optimal Lung Cancer Pathway (NHS England)
• BTS Guidelines for the investigation and management of pulmonary nodules (2015)
• NHS England: Lung Cancer Screening Programme
• BTS Guideline for pleural disease (2023)
• NICE TA818: Nivolumab with ipilimumab for untreated unresectable malignant pleural mesothelioma
• ESMO / UKONS: Management of immune checkpoint inhibitor toxicities
• BNF - for current doses

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