Diagnosis and staging

1.2 Effectiveness of diagnostic and staging investigations

Terminology used for cancer staging classification changes over time. The guideline recommendations were developed using the 7th edition of the American Joint Committee on Cancer (AJCC) staging system.

1.2.1

Only use sputum cytology for investigation in people with suspected lung cancer who have centrally placed nodules or masses and who decline or cannot tolerate bronchoscopy or other invasive tests. [2005]

1.2.2

Offer people with known or suspected lung cancer a contrast-enhanced chest CT scan to further the diagnosis and stage the disease. Include the liver, adrenals and lower neck in the scan. Use contrast medium with caution in people with known renal impairment. [2005, amended 2019]

1.2.3

When assessing mediastinal and chest wall invasion:

be aware that CT alone may not be reliable
consider other techniques such as ultrasound if there is doubt
be aware that surgical assessment may be necessary if there are no contraindications to resection. [2005]

1.2.4

Ensure that all people with lung cancer who could potentially have treatment with curative intent are offered positron emission tomography CT (PET‑CT) before treatment. [2011]

1.2.5

Every cancer alliance should have a system of rapid access to PET‑CT scanning for people who are eligible for this. [2005, amended 2019]

1.2.6

Do not routinely use MRI to assess the stage of the primary tumour (T‑stage) in non-small-cell lung cancer (NSCLC). [2005]

1.2.7

Use MRI when necessary to assess the extent of disease, for people with superior sulcus tumours. [2005]

1.2.8

Offer endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for biopsy of paratracheal and peri-bronchial intra-parenchymal lung lesions. [2011]

1.2.9

Every cancer alliance should have at least 1 centre with EBUS or endoscopic ultrasound (EUS), or both, to ensure timely access. [2011]

1.2.10

Audit the local test performance of EBUS-TBNA and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). [2011, amended 2019]

1.2.11

When taking samples, ensure they are adequate (without unacceptable risk to the person) to permit pathological diagnosis, including tumour subtyping and assessment of molecular markers. [2011, amended 2019]

1.2.12

See the National Genomics Test Directory for guidance on next-generation sequencing (NGS) panels to guide treatment. [2019,amended 2026]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on effectiveness of diagnostic and staging investigations.

Full details of the evidence and the committee's discussion are in evidence review A: investigations for staging the mediastinum.

Sequence of investigations

1.2.13

Choose investigations that give the most information about diagnosis and staging with the least risk to the person. Think carefully before performing a test that gives only diagnostic pathology when information on staging is also needed to guide treatment. [2011]

1.2.14

Perform contrast-enhanced CT of the chest, liver adrenals and lower neck before any biopsy procedure. [2005, amended 2019]

Peripheral primary tumour

1.2.15

When choosing diagnostic and staging investigations, take into account that some people with lung cancer will not be well enough for treatment with curative intent. [2011, amended 2019]

1.2.16

Offer image-guided biopsy to people with peripheral lung lesions when treatment can be planned based on this test. [2011, amended 2019]

1.2.17

Biopsy any enlarged intrathoracic nodes (10 mm or larger maximum short axis on CT) or other lesions in preference to the primary lesion if determination of nodal stage affects treatment. [2011, amended 2019]

Central primary tumour

1.2.18

Offer flexible bronchoscopy to people with central lesions on CT if nodal staging does not influence treatment. [2011, amended 2019]

Intrathoracic lymph node assessment

1.2.19

For people with lung cancer who could potentially have treatment with curative intent and have a low probability of nodal malignancy (lymph nodes below 10 mm maximum short axis on CT), offer PET-CT as the preferred first test after CT. [2011, amended 2019]

1.2.20

For people with suspected lung cancer who have enlarged intrathoracic lymph nodes (lymph nodes greater than or equal to 10 mm short axis on CT) and who could potentially have treatment with curative intent, offer PET-CT (if not already done), followed by EBUS‑TBNA or EUS‑FNA, or both. [2019]

1.2.21

If nodal status would affect the treatment plan, evaluate PET-CT-positive or enlarged intrathoracic nodes using a systematic approach (sampling any suspicious node on CT, PET or USS) with:

either EBUS‑TBNA or EUS‑FNA or
both EBUS‑TBNA and EUS‑FNA. [2019]

1.2.22

Consider surgical mediastinal staging for people with a negative EBUS‑TBNA or EUS‑FNA if clinical suspicion of nodal malignancy is high and nodal status would affect their treatment plan. [2019]

We have produced an algorithm on intrathoracic nodal staging of NSCLC in patients being considered for radical treatment.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on EBUS-TBNA and EUS-FNA.

Full details of the evidence and the committee's discussion are in evidence review A: investigations for staging the mediastinum.

Further staging

1.2.23

Confirm the presence of isolated distant metastases or synchronous tumours by biopsy or further imaging (for example, MRI or PET-CT) in people for whom treatment with curative intent is an option. [2011]

1.2.24

Do not offer dedicated brain imaging to people with clinical stage 1 NSCLC who have no neurological symptoms and are having treatment with curative intent. [2019]

1.2.25

Offer contrast-enhanced brain CT to people with clinical stage 2 NSCLC who are having treatment with curative intent. If CT shows suspected brain metastases, offer contrast-enhanced brain MRI. [2019]

1.2.26

Offer contrast-enhanced brain MRI for people with stage 3 NSCLC who are having treatment with curative intent. [2019]

1.2.27

Offer people with clinical features suggestive of intracranial pathology CT of the head followed by MRI if normal, or MRI as an initial test. [2011]

1.2.28

Perform an X-ray as the first test for people with localised signs or symptoms of bone metastasis. If the results are negative or inconclusive, offer bone scintigraphy or an MRI scan. [2005]

1.2.29

Avoid bone scintigraphy when PET-CT has not shown bone metastases. [2011]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on brain imaging for people having treatment with curative intent.

Full details of the evidence and the committee's discussion are in evidence review B: brain imaging for people with NSCLC selected for treatment with curative intent.

Service delivery

1.2.30

Provide treatment without undue delay for people who have lung cancer that is suitable for radical treatment or chemotherapy, or who need radiotherapy or ablative treatment for relief of symptoms. [2005, amended 2019]

Multidisciplinary teams

1.2.31

Refer all people with a suspected diagnosis of lung cancer to a member of a lung cancer multidisciplinary team (usually a chest physician). [2005]

1.2.32

Discuss the care of all people with a working diagnosis of lung cancer at a lung cancer multidisciplinary team meeting. [2005]

Fast track lung clinics

1.2.33

Provide fast track lung cancer clinics for investigating suspected lung cancer. [2005]

Cancer clinical nurse specialists

1.2.34

All cancer units or centres should have 1 or more trained lung cancer clinical nurse specialists to:

see people before, at the time of and after diagnosis
provide continuing support
facilitate communication between the secondary care team (including the multidisciplinary team), the person's GP, the community team and the person with lung cancer
help people access advice and support whenever they need it. [2005, amended 2019]