Thoracic Oncology: Screening, Staging, and Tissue-First Care
Thoracic oncology tests lung cancer screening, diagnosis, staging, molecular characterisation, and the management of small-cell and non-small-cell lung cancer, plus malignant pleural disease.
Core rules
- Lung cancer screening with low-dose CT is offered to high-risk ever-smokers, usually aged 50–80 with a significant pack-year history; it reduces lung cancer mortality.
- Stage before treating: CT, PET-CT, and tissue confirmation; mediastinal staging with EBUS-TBMS or mediastinoscopy when nodes are enlarged or PET-avid.
- NSCLC management depends on stage, histology, performance status, and molecular markers (EGFR, ALK, ROS1, PD-L1). Test before first-line systemic therapy.
- SCLC is staged as limited or extensive; chemotherapy plus immunotherapy is standard for extensive disease.
Worked example
A 65-year-old with a 30 pack-year history has a 2.8 cm right upper-lobe nodule and PET-avid ipsilateral mediastinal nodes. Staging is incomplete. Perform EBUS-TBMS to sample nodes and confirm histology, then stage. Do not start empirical chemotherapy before tissue diagnosis unless the patient is deteriorating.
Traps
Treating a solitary pulmonary nodule as cancer without tissue; omitting molecular testing in advanced non-squamous NSCLC; forgetting malignant pleural effusion staging; and missing paraneoplastic syndromes.