Accurate histological identification and staging of the tumor, along with preoperative physiologic assessment of lung function, is an important initial step in the optimal management of patients with lung cancer.

A 58-year-old Caucasian man comes to the office with complaints of cough for the past two months and blood-tinged sputum for the past three days.  He has lost approximately 25 pounds over the past six months.  He denies any history of low-grade fevers or night sweats.  He has a long history of heavysmoking and chronic obstructive pulmonary disease.  His temperature is 37.0C (99F), blood pressureis 120/62 mmHg, and heart rate is 82/min.  He is a thin, cachectic man who is in no acute distress. Lung auscultation reveals the presence of rales in the right upper lung fields.  His white cell count is8,000/cubic mm with normal differential count.  His serum calcium level is 12.8 mg/dL.  His chest x-rays shows a 3.2 cm mass in the right upper lung zone, which is suspicious for a lung malignancy. Sputum cytology reveals poorly differentiated squamous cell carcinoma.  Pulmonary function testing shows that his FEV1 is 1200 cc, while quantitative ventilation-perfusion scan shows that 65% of his pulmonary function comes from his right lung.  What is the next best step in the management of thispatient? Lung cancer is the most common cause of cancer death in the United States and throughout the world. The appropriate selection of therapy, as well as the patient's prognosis, depends on the histologic type and accurate staging of the tumor. The important components of the current TNM staging system include the extent of local tumor spread, the presence or absence of nodal involvement, and distant metastases. The presence of local or distant nodal spread or distant metastases to other body parts greatly influences the treatment approaches in patients with lung cancer. It is therefore important to accurately stage the patient before initiating any specific treatment. This is done through a detailed clinical assessment, radiographic imaging via CT scan or PET scan, and radionuclide bone scans. An initial CT scan should be obtained in all patients with lung cancer (small cell or non-small cell lung cancer) to aid in the initial staging work-up. It is extremely useful in detecting any mediastinal lymph node metastases and chest wall invasion. It also allows for accurate measurement of the tumor size, detection of small pleural effusions, and evaluation of liver and adrenal glands for metastatic disease. In easily accessible lesions, it can be useful in obtaining a CT-guided biopsy for tissue diagnosis of lung cancer. For these reasons, this patient should have a CT scan before planning or initiating any further treatment. Surgical resection is the treatment of choice for patients with stage I and some stage II non-small cell lung cancers; however, it is not as effective in patients with stage III disease, and most patients require adjuvant radiation and chemotherapy as well. The exact stage of disease in this patient is unknown, and he should not be referred for lobectomy or pneumonectomy at this point. Moreover, the patient in the vignette has a very low preoperative FEV1 (FEV1 is 1200 cc) and the quantitative ventilation-perfusion scanning shows that a significant portion of his pulmonary 65% reserve comes from his right lung. He would therefore be unable to tolerate a right pneumonectomy. Adjuvant radiation and chemotherapy has been shown to improve the outcomes in patients who undergo local tumor resection; however, radiation or chemotherapy should not be planned, unless a definite and accurate staging of the tumor has been done. Baseline CT scan is required to document the tumor response to chemo/radiation. Mediastinoscopy with mediastinal lymph node sampling is indicated to document the presence or absence of malignancy in patients with suspected nodal involvement on chest CT scanning.