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.
- Gold-standard pathological stage comes from systematically sampled or dissected nodes and resection tissue when surgery occurs; PET uptake alone is neither cancer proof nor complete nodal exclusion.
- Early resectable disease is considered for anatomical resection with systematic nodal evaluation; stereotactic ablative radiotherapy is a preferred curative alternative for selected medically inoperable early disease.
- Stage III disease requires a thoracic MDT because resectable and unresectable subgroups need different sequences of surgery, systemic treatment and radiotherapy.
- Before non-emergency advanced treatment, obtain the current NHS genomic panel and PD-L1 result; an actionable driver usually changes the preferred first systemic sequence.
- Supportive and palliative care, smoking treatment, nutrition, exercise and symptom control run alongside curative or systemic therapy rather than after anticancer options end.
Key red flags
Large-volume haemoptysis, stridor, monophonic wheeze, severe hypoxaemia or inability to clear secretions suggests central airway or bleeding threat.
Facial and arm swelling with chest-wall collaterals suggests superior vena cava obstruction and needs severity-based urgent imaging and decompression review.
New focal neurological deficit, seizure, spinal pain with weakness or sphincter change indicates possible metastatic neural compression.
A solitary distant lesion that alone removes curative intent should be confirmed with high diagnostic confidence or tissue where feasible.
New breathlessness during immunotherapy or thoracic radiotherapy requires assessment for pneumonitis, infection, embolism, effusion and progression.
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.
- Complete PET-CT and brain or other imaging appropriate to intended treatment and verify any solitary finding that alone removes curative intent.