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A 67-year-old man with past medical history of chronic obstructive pulmonary disease (COPD) presents with complains of cough, shortness of breath, and weight loss for 2 months. He has smoked 1 pack of cigarettes a day for the past 40 years. His primary care doctor obtains a chest radiograph, which shows a mass in the patient’s left upper lobe. How will you work up this patient?

Learning Objectives

  1. What are the different symptoms and signs associated with lung cancer?

  2. What are the different paraneoplastic syndromes associated with lung cancer?

  3. What investigational methods are needed to diagnose lung cancer?

Lung cancer is the leading cause of cancer-related death worldwide.1 The majority of lung cancer (~80%-85%) includes non–small cell lung cancer (NSCLC) histology, and the remainder is small cell lung cancer (SCLC). It is important to differentiate between NSCLC and SCLC as diagnostic evaluation and management differ.

Most patients with lung cancer are symptomatic at presentation. Some present with a suspicious finding detected on chest imaging done for lung cancer screening, and some can present with an incidental finding on imaging done for other reasons. Lung cancer screening is recommended for early diagnosis in individuals at high risk2 but has had slow uptake.3 Of note, the cumulative risk tends to increase with age and with lifetime exposure to cigarette smoke (Figure 11-1).

Figure 11-1.

Smoking cessation and lung cancer.

The goal of initial evaluation in a patient suspected of having lung cancer is timely diagnosis and staging so appropriate treatment can be administered. In this chapter, we review initial evaluation (history and physical examination) and diagnosis (imaging and pathology) for a patient with suspected lung cancer.

The general approach in the diagnosis of lung cancer includes history and physical examination, imaging, biopsy, pathology, staging, and molecular testing.



The majority of patients with lung cancer have advanced disease at clinical presentation. Symptoms may result from local effects of the tumor, from regional or distant spread, or from distant effects not related to metastases (paraneoplastic syndromes). Many symptoms are associated with lung cancer and are mostly non-specific.

  • Cough: It is the most common symptom and is usually present in 50%-75% of lung cancer patients.4,5 It is more common in squamous cell and SCLC due to its tendency to involve central airways.

  • Dyspnea: The incidence of dyspnea is 25%-50%.4,5 It can be caused by multiple factors, such as intrinsic or extrinsic compression, pulmonary embolism, pleural effusion, pneumonia, or lymphangitic spread.

  • Chest pain: The incidence of chest pain is 30%-50%,4 usually on the same side of the chest as the primary tumor.

  • Hemoptysis: The incidence of hemoptysis ...

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