Lung Cancer Initial Assessment

Clinical Presentation

Primary tumor-related symptoms include cough, dyspnea, hemoptysis, and wheezing. Symptoms due to intrathoracic spread may involve the nerves (hoarseness, dyspnea, muscle wasting of upper limb, Horner’s syndrome), chest wall and pleura (chest pain, dyspnea), vascular structures (facial swelling, dilated neck veins, cardiac tamponade, superior vena cava syndrome) and the viscera (dysphagia).  Other symptoms include malaise, fever, loss of appetite, and weight loss.  

Lung Cancer_Initial Assesment

History

Patients should be asked for the presence or absence of dizziness or headache to rule out brain metastasis, bone or joint pain to rule out bone metastasis, and other head or neck symptoms to rule out other tumors. 

Physical Examination

During a physical examination, the 2 important factors that predict the survival of patients following treatment are weight loss and performance status. Patients who lost <10% of their pre-treatment weight and are mobile have better chances of survival. It is therefore vital to assess these parameters during a physical examination for risk factor assessment. 

Diagnosis or Diagnostic Criteria

The diagnosis of a patient will depend on the size of the tumor, location of the tumor, presence of mediastinal or distant disease, presence of pulmonary pathology and/or other comorbidities, and the experience and expertise of the healthcare personnel. 

Screening

Several recommendations have emerged for the screening of lung cancer, including those by the American Association for Thoracic Surgery, the National Comprehensive Cancer Network (NCCN), the United States Preventive Services Task Force (USPSTF), the European Society of Radiology (ESR), and the European Respiratory Society (ERS). NCCN, ESR and ERS recommend that lung cancer screening be conducted within clinical trials or routine clinical practice with multidisciplinary medical centers, to include individuals 55-80 years old, with smoking history of ≥30 pack-years, current smoker, or those who have quit smoking within the last 15 years. However, it must be noted that the number of lung cancers among non-smoking individuals is increasing; other relevant risk factors should be examined to augment lung cancer screening recommendations in the future. 

Screening is not recommended in individuals with comorbidities precluding curative therapy and without consent to undergo curative therapy.  

Screening Trials  

The National Lung Screening Trial (NLST) is the first US-based randomized controlled lung screening trial for current smokers or who used to consume >30 pack-years with ages of 55-74 years old. The European NEderlands-Leuvens Screening ONderzoek (NELSON) trial is the second largest screening trial and the largest European randomized controlled trial in Europe used to assess patient risk based on age and smoking history.  

Recommendations for Patients with Lung Nodules on Initial Screening Using Low-Dose CT Scan (LDCT)  

Solid Nodule  

For solid nodules <6 mm, annual low-dose CT is recommended until the patient has been excluded from definitive treatment. For single solid nodules ≥6 to <8 mm, a low-dose CT scan should be fulfilled at 6 months. For ≥8 to <15 mm solid nodules, a low-dose CT scan should be considered at 3 months and PET/CT may also be considered.  

For patients with ≥15 mm solid tumors, a chest CT with contrast and/or PET/CT is recommended. A low-dose CT after 3 months should be considered in patients with low risk for lung cancer. Biopsy or surgical excision is recommended for patients at high risk for lung cancer.  

For patients with solid endobronchial nodules, a low-dose CT in ≤1 month is recommended, followed by bronchoscopy if without resolution.  

Part-solid Nodule  

For part-solid nodules <6 mm, annual low-dose CT is recommended until the patient has been excluded from definitive treatment. A low-dose CT scan after 6 months is recommended for patients with ≥6 mm part-solid nodules with solid component of <6 mm. If with ≥6 to <8 mm solid component, low-dose CT is recommended 3 months after initial screening or may also consider PET/CT.  

For patients with part-solid nodules with solid component of ≥8 mm, chest CT with contrast and/or PET/CT is recommended. If highly suspicious for lung cancer, biopsy or surgical resection should be considered. low-dose CT after 3 months is recommended for patients at low risk for lung cancer.  

Non-solid Nodule  

Annual low-dose CT is recommended for non-solid nodules <20 mm until the patient has been excluded from definitive treatment. Low-dose CT 6 months after initial screening is recommended for patients with ≥20 mm non-solid nodule.  

Recommendations for Follow-up or Annual Screening Using Low-Dose CT Scan  

New Nodule  

For suspected infection or inflammation, a low-dose CT scan should be done in 1-3 months. For suspected infection or inflammation that is resolving, a low-dose CT scan should be repeated in 3-6 months until it reaches resolution or stability. For patients with suspected infection or inflammation that has been resolved, an annual low-dose CT scan is recommended. For patients with suspected infection or inflammation that is persistent, or the nodule is enlarging, and those without suspected inflammation or infection. 

Please see recommendations on Solid or Part-solid, or Non-solid Nodules under Follow-up for further information.  

Solid Nodule  

For <8 mm solid nodule that is unchanged on follow-up, an annual low-dose CT scan is recommended. For ≥8 to <15 mm solid nodule that is unchanged on follow-up, a low-dose CT scan should be done in 6 months, if still unchanged after 6 months, then an annual low-dose CT scan is recommended. For ≥15 mm solid nodule unchanged on follow-up, a low-dose CT scan in 6 months or PET/CT scan is recommended.  

For unchanged findings in a year or for <4 mm new solid nodule on follow-up, an annual low-dose CT scan is still recommended. For 4 to <6 mm new solid nodules on follow-up, a low-dose CT scan should be done in 6 months. For 6 to <8 mm new solid nodules on follow-up, an LDCT should be done in 3 months. For ≥8 mm new solid nodule on follow-up, a chest CT scan with contrast and/or PET/CT scan is recommended. For ≤7 mm growing nodule on follow-up, a low-dose CT scan should be done in 3 months. For ≥8 mm growing nodule on follow-up, a chest CT scan with contrast and/or PET/CT scan is recommended.  

Based on the patient’s risk, if the patient has a low risk for lung cancer, a low-dose CT scan after 3 months is recommended. A low-dose CT scan in 3 months for ≥8 mm solid nodule on chest CT with contrast and/or PET/CT for patients at low risk for lung cancer. Biopsy or surgical resection is recommended for patients at high risk for lung cancer.  

Part-solid Nodule  

For <6 mm part-solid nodule that is unchanged on a follow-up low-dose CT scan, and ≥6 mm part-solid nodule, and with <6 mm solid component, an annual low-dose CT scan is also recommended. For ≥6 mm part-solid nodule and with ≥6 to <8 mm solid component, a low-dose CT scan in 6 months or PET/CT scan is recommended. If with low risk for lung cancer, LDCT after 6 months is recommended. Biopsy or surgical resection is recommended for patients at high risk for lung cancer.  

If the part-solid nodule is unchanged, then an annual low-dose CT scan is recommended. For new part-solid nodule that is <6 mm on follow-up, a low-dose CT scan should be done in 6 months. For new or growing part-solid nodule that is ≥6 mm in size with a growing <4 mm solid component on follow-up, a low-dose CT scan should be done in 3 months.  

For new or growing part-solid nodules with ≥4 mm solid component, a chest CT scan with contrast and/or PET/ CT scan is recommended. If with low risk for lung cancer, LDCT after 3 months is recommended. Biopsy or surgical resection is recommended for patients at high risk for lung cancer.  

Non-solid Nodule  

For <20 mm new and stable non-solid nodules, an annual low-dose CT scan is recommended. For ≥20 mm new and stable non-solid nodules, a low-dose CT scan should be done in 6 months, then annually once stable. For <20 mm growing non-stable nodule, a low-dose CT scan should be done in 6 months. For ≥20 mm growing non-solid nodule, a low-dose CT scan should be done in 6 months or may consider biopsy or surgical excision.  

Multiple Non-Solid Nodules  

For pure non-solid nodules, measure the largest nodule and manage based on the size as a non-solid or part-solid nodule. For dominant nodules with part-solid component, measure the largest nodule and manage it as a part-solid or solid nodule based on the size. All part-solid nodules ≥6 mm should be identified, and solid areas should be measured.  

For patients at high risk for lung cancer without lung malignancy on low-dose CT scan, biopsy, or surgical excision, an annual screening with a low-dose CT scan is recommended. It should be done until the patient is no longer a candidate for definitive treatment.  

A follow-up low-dose CT scan in 1-3 months is recommended for patients with multiple nodules or other findings suggestive of possible occult infection or inflammation.