How should I assess a patient with suspected lung cancer before considering referral for thoracic surgery?

Before considering referral for thoracic surgery in a patient with suspected lung cancer, a thorough assessment is essential to determine suitability for surgery and to guide treatment planning.

• Confirm diagnosis and staging: Perform contrast-enhanced CT of the chest, liver, adrenals, and lower neck to assess the primary tumour and possible metastases before any biopsy procedure ¹.
• Use PET-CT: Offer positron-emission tomography CT (PET-CT) to all patients who could potentially have treatment with curative intent to improve staging accuracy ¹.
• Biopsy strategy: Obtain tissue diagnosis preferably from enlarged intrathoracic lymph nodes (≥10 mm short axis on CT) or other lesions rather than the primary tumour if nodal staging will affect treatment decisions ¹. Use endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for biopsy of mediastinal and peri-bronchial lesions ¹.
• Assess mediastinal and chest wall invasion: Recognise that CT alone may be insufficient; consider ultrasound or surgical assessment if resection is contemplated and there is doubt about invasion ¹.
• Evaluate cardiopulmonary fitness: Assess cardiovascular function carefully, avoiding surgery within 30 days of myocardial infarction ¹. Use global risk scores such as Thoracoscore to estimate perioperative mortality risk and discuss this with the patient before consent ¹.
• Smoking cessation advice: Inform patients that smoking increases pulmonary complications after surgery and advise stopping smoking as soon as lung cancer is suspected, offering nicotine replacement or other therapies, but do not delay surgery to allow smoking cessation ¹.

Following this comprehensive assessment, patients suitable for surgery should be referred to a thoracic surgical team, ideally discussed within a lung cancer multidisciplinary team meeting to ensure coordinated care ¹.