Synopsis
Integrate pathology, TNM stage, invasive nodal assessment, molecular drivers, PD-L1, cardiopulmonary reserve and patient priorities to select curative local, multimodality or advanced systemic treatment.
- NSCLC includes adenocarcinoma, squamous carcinoma and less common subtypes; subtype determines tissue handling, predictive testing and systemic options.
- Diagnosis requires adequate tissue with morphology and immunohistochemistry while preserving material for genomic and PD-L1 testing.
- First-line anatomical staging uses contrast CT chest and upper abdomen, followed by PET-CT when curative treatment is possible; suspicious nodes often need EBUS or EUS tissue confirmation.
Key red flags
Large-volume haemoptysis, stridor, monophonic wheeze, severe hypoxaemia or inability to clear secretions suggests central airway or bleeding threat.
Seizure, bone pain, fracture, jaundice, hypercalcaemia, adrenal lesion or weight loss may reveal distant disease.
Investigation priorities
Confirm malignancy and distinguish adenocarcinoma, squamous and other NSCLC while preserving predictive material.
Define primary anatomy, nodes, pleura, liver and adrenal disease and identify biopsy targets.
Management branches
Imaging suggests a primary lung cancer.
- Review CT with respiratory and radiology teams and choose bronchoscopy, EBUS, CT-guided core or metastatic-site biopsy that offers adequate tissue with lowest harm.
- Confirm NSCLC subtype and preserve material for the national genomic panel and PD-L1 rather than exhausting it on broad non-decision-changing stains.
Key medicines
Osimertinib for qualifying EGFR-mutated NSCLCGive osimertinib 80 mg orally once daily under the current licensed and NICE-funded early, locally advanced or metastatic indication, continuing until the protocol stop point or unacceptable toxicity.
PembrolizumabGive pembrolizumab 200 mg intravenously every 3 weeks or 400 mg every 6 weeks within the licensed NSCLC regimen and current NICE biomarker and combination criteria.