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INTRODUCTION

Lung cancer is the deadliest malignancy, accounting for more annual deaths than breast, prostate, and colorectal cancer combined. In 2018, 1.7 million people died worldwide from this disease, which accounts for 18.4% of all cancer deaths.1 In 2020, it will claim the lives of 135,0000 Americans.2 Lung cancer was a rare disease until the early part of the 20th century. In 1879, lung cancer represented only 1% of cancers identified at autopsy compared with 14% in 1927.3

The link between tobacco use and lung cancer is indisputable. Some of the carcinogenic chemicals found in cigarette smoke include NNK (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone) and benzo(a)pyrene diol epoxide,4–6 affecting first- and second-hand smokers.7 Other toxins that increase the lung cancer risk include arsenic, asbestos, nickel, cadmium, beryllium, silica, and diesel fume exposure.

Lung cancer treatment is multimodal. Physicians diagnosing and treating this disease must collaborate to determine the best treatment for an individual patient.

DIAGNOSIS

Lung cancer is often diagnosed during work-up of an abnormal chest x-ray or CT scan. These studies are often performed in response to a symptom a patient may be experiencing or as a screening examination. Common imaging findings include a lung nodule (solid pulmonary tumor ≤3 cm), mass (tumor >3 cm), or ground glass opacity.

The estimated risk that the nodule represents a cancer guides the evaluation and work-up.8 Externally validated models can provide patients and physicians with an initial cancer risk assessment.9,10 Lung nodule management is guideline driven, principally via the widely adopted Fleischner Society guidelines.8 Generally, low-risk (<5% risk of malignancy) solid nodules between 6 and 8 mm should undergo imaging surveillance. Management options for solid nodules larger than 8 mm in low-risk patients include radiographic surveillance, 18F-FDG PET-CT, or biopsy, depending on nodule size and morphology, assessment of cancer risk, and patient comorbidities. For high-risk patients (≥5%), radiographic surveillance is discretionary for solid nodules smaller than 6 mm, and endorsed for nodules 6 to 8 mm. Solid nodules larger than 8 mm with high malignancy risk should be managed with radiographic surveillance, 18F-FDG PET-CT, and/or biopsy, depending on individual nodule and patient characteristics. Subsolid nodules (ground glass or part solid) at least 6 mm should be followed with serial CT imaging for 5 years independent of patient risk assessment, and biopsied or resected if growth is demonstrated.

Nonsurgical biopsy can be performed through the airway or chest wall. Central nodules or those fed by a nearby airway are amenable to bronchoscopic biopsy often with use of computer-assisted navigation or endobronchial ultrasound. Peripheral nodules may be addressed via transthoracic needle biopsy. The diagnostic yield of electromagnetic navigational bronchoscopy approximates 75% to 85%,11 while the accuracy of CT-guided biopsy can be as high as 93.5%.7 Risks of both procedures include bleeding and pneumothorax.8 The decision ...

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