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Lung cancer and the pulmonary nodule
Low-dose CT screening suits ages 50–80 with 20 pack-years or more; an incidental nodule is managed by size and risk (Fleischner); and in lung cancer the type determines the associated syndromes and treatment — SCLC with SIADH and ectopic ACTH, squamous with hypercalcaemia, and adenocarcinoma with molecular testing.
Why it matters in the exam
Questions present a smoker with cough, haemoptysis and weight loss, or an incidental nodule on CT. Screening: annual low-dose CT at ages 50–80 with 20 pack-years or more, for current smokers or those who quit within the last 15 years. An incidental solid nodule at low risk: below 6 mm — no routine follow-up; 6–8 mm — CT after 6–12 months; above 8 mm — CT after 3 months, PET-CT or biopsy. Paraneoplastic syndromes point to the type: SCLC (central) — SIADH, Cushing from ectopic ACTH and Lambert-Eaton; squamous (central, sometimes cavitating) — hypercalcaemia from PTHrP; adenocarcinoma — peripheral, the commonest, also in non-smokers.
Local complications are tested: a Pancoast tumour at the lung apex with shoulder pain and Horner syndrome, and superior vena cava syndrome — swelling of the face and arms. Work-up: PET-CT for staging, brain MRI, and mediastinal node sampling by EBUS. Early non-SCLC disease — surgery (lobectomy); advanced non-squamous disease — molecular tests (EGFR, ALK, ROS1) and PD-L1, with targeted treatment (for example osimertinib for EGFR) or immunotherapy. SCLC is treated with chemotherapy plus immunotherapy, and in limited disease also radiotherapy.
Key points
- Screening: 50–80, 20 pack-years, yearly low-dose CT.
- Nodule: below 6 mm — no follow-up; 6–8 mm — 6–12 months; above 8 mm — work-up.
- SCLC: SIADH, ACTH, Lambert-Eaton.
- Squamous: hypercalcaemia; adenocarcinoma: peripheral, common.
- Staging: PET-CT, brain MRI, EBUS; molecular tests in advanced non-squamous disease.
Summary table
| Topic | Criterion / clue | Action | Exam note |
|---|---|---|---|
| Screening | Age 50–80, 20 pack-years or more, smoker or quit within 15 years | Low-dose CT once a year | Not a chest X-ray |
| Nodule below 6 mm | Low risk | No routine follow-up | Fleischner |
| Nodule 6–8 mm | Low risk | CT after 6–12 months | — |
| Nodule above 8 mm | — | CT after 3 months, PET-CT or biopsy | — |
| SCLC | Central, smoker | SIADH, ectopic ACTH, Lambert-Eaton | Chemotherapy + immunotherapy |
| Squamous / adenocarcinoma | Squamous: central, PTHrP; adeno: peripheral, also in non-smokers | EGFR, ALK, ROS1, PD-L1 in advanced non-squamous | Surgery for early disease |
A free exam question
בן 65 אובחן כסובל מ Non Small Cell Lung Cancer Adenocarcinoma ב קוטר 6 ס"מ באונה ימנית עליונה ב pet CT .בלוטה אחת קולטת בשער הריאה הימני, ללא ממצאים נוספים, מה ה גישה ? (the question as examined, in Hebrew)
- א. לובקטומיה של הגידול וכימותרפיה אדג'ובנטית על בסיס cisplatin
- ב. כימותרפיה וקרינה לסך של 45 גריי, ולאחר מכן durvalumab לשנה
- ג. ביצוע אנליזה מולקולרית מקיפה על הגידול וטיפול לפי סטטוס EGFR ו- ALK
- ד. בדיקה פולשנית לדגימת הבלוטות שלא קולטות FDG במיצר
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Sources
- USPSTF Recommendation: Screening for Lung Cancer, 2021 — Low-dose CT eligibility
- Fleischner Society Guidelines for Management of Incidental Pulmonary Nodules, 2017 — Follow-up by size and risk
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Neoplasms of the Lung
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.