Lung cancer: investigation and staging

In the modern lung cancer service, the first visit to hospital is where the initial investigation pathway is formulated to ensure that as much diagnostic and staging information is obtained with least risk and discomfort for the patient. It is of over-riding importance to ensure that this is in line with the patient’s wishes and appropriate to the fitness of the individual as well as the potential treatment. To do this a contrast-enhanced computed tomogram (CT) of the lower neck, chest and upper abdomen should be available at the time of the first clinical assessment. At this time, performance status is recorded, and blood tests and spirometry obtained. The most effective next test (usually a biopsy) can then be selected. Clear information should be given to the patient, who must have access to support from a lung cancer nurse specialist. Clinical assessment and spirometry will identify the need for further tests to assess fitness. The exact sequence of investigations will vary according to the clinical and CT findings, but to ensure the most accurate stage and therefore most effective treatment, pathological confirmation of findings on imaging is usually sought, with samples provided that are adequate for sub-classification of tumours.