Daniel K C Lee,
MB, BCh, MRCP, MD
Department of Thoracic Oncology, Papworth Hospital, Papworth Everard, Cambridge, CB3 8RE, England,
Robert C Buttery, Robert C Rintoul
Send rapid response to journal:
Re: 10-minute consultation: Suspected lung cancer
dkclee{at}doctors.org.uk Daniel K C Lee, et al.
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A 60-year-old ex-smoker presents to your surgery with mild breathlessness and cough. These symptoms have persisted for about 4 weeks despite treatment with a penicillin antibiotic prescribed by one of your colleagues.
What you need to do
- Organise an urgent chest x-ray (CXR) in view of the smoking history and persisting cough (see box). CXR is widely and rapidly available, inexpensive and results in minimal radiation exposure.
- Send sputum sample to microbiology for culture and antibiotic sensitivity testing.
- Consider a further course of antibiotic such as a macrolide antibiotic to treat penicillin-resistant organisms and atypical organisms.
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Clinical features requiring an urgent CXR
Any of the following unexplained symptoms or signs persisting more than three weeks
- Breathlessness
- Chest signs
- Cough that is unexplained or persisting
- Features suggestive of metastases from lung cancer (bone, brain, liver or skin)
- Finger clubbing
- Hoarseness of voice
- Pain in the chest or shoulder
- Persistent cervical or supraclavicular lymphadenopathy
- Weight loss
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The CXR shows a solitary mass-like shadow in the lung and is reported by a radiologist as being suspicious of lung cancer.
What issues you should cover
- Revisit the history paying particular attention to certain pertinent aspects that may point towards either lung cancer or other differential diagnoses (see box).
- Discuss the benefits of stopping smoking. There is good evidence that smoking cessation improves outcome for patients with lung cancer. It reduces the perioperative risk and improves outcome following chemotherapy as well as long-term survival and quality of life in both small cell and non-small cell lung cancer.
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Patients with a solitary lung shadow
Relevant history
- Respiratory
- Chest or shoulder pain
- Cough
- Haemoptysis
- Hoarseness of voice
- Shortness of breath
- Sputum production
- Wheezing
- Constitutional
- Lethargy
- Night sweats
- Poor appetite
- Weight loss
- Asbestos exposure
- Previous malignancy
- Smoking history
- Travel history
Differential diagnoses
- Abscess
- Adenoma
- Aspergilloma
- Carcinoma
- Hamartoma
- Metastasis from another organ
- Pulmonary infarction
- Round atelectasis
- Round pneumonia
- Round pulmonary oedema
- Tuberculosis
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What you should do
- Examine the patient carefully, observing for finger clubbing and signs indicating locally extensive or metastatic disease, such as peripheral lymphadenopathy, organomegaly, superior vena cava (SVC) obstruction and stridor. Urgent referral for specialist care should be made whilst awaiting the results of CXR in patients who present with stridor or SVC obstruction.
- Assess the general fitness of the patient taking into account the build of the patient and whether the patient appears well nourished or cachetic while making a note of the height and weight.
- Discuss the results of the CXR with the patient and convey your concerns to the patient regarding your suspicion of lung cancer if appropriate. Further tests will be required to clarify the diagnosis and extent of the problem. These will usually include a computed tomography (CT) of the thorax, and (depending on fitness) either bronchoscopy or percutaneous biopsy.
- Refer the patient to a chest physician without delay in keeping with the Department of Health guidelines on the '2-week wait' scheme for referral of patients with suspected lung cancer to secondary care.
- Address and treat any associated conditions such as concomitant chest infection or airway bronchoconstriction for patient optimisation prior to further investigation and management.
Conflict of Interest:
None declared |
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10-minute consultation: Suspected lung cancer
