Lung Cancer — Written Clinical Reasoning

Model answer — Part A: the 15 mm spiculated nodule

Frame the problem first. A 15 mm spiculated solid nodule in an older heavy smoker is malignant until proven otherwise — this is a probability problem, not a surveillance problem. My assessment has three aims: estimate malignancy probability, obtain tissue safely, and stage as I diagnose [1] [2].

Assessment. History: smoking exposure and quit date, weight loss, haemoptysis, prior malignancy, occupational exposures, family history, and cardiorespiratory fitness that will shape any curative option. Examination: clubbing, supraclavicular nodes, chest signs. I hunt for prior imaging of any kind — a nodule stable for 2 years changes the whole pathway [1].

Risk estimation. I would quantify risk rather than gesture at it: the Brock (PanCan) model combines age, sex, family history, emphysema with nodule size, spiculation, upper-lobe location, type and count. A 15 mm spiculated upper-lobe nodule in this man sits in a high-probability band — which means I move toward tissue, not toward interval scanning [2].

Investigation sequence. Dedicated thin-slice CT chest if the abdominal CT is technically limited; PET/CT to characterise metabolic activity, detect nodal and distant disease and direct the biopsy target; then tissue by the route that answers diagnosis and staging together — EBUS-TBNA if nodes are involved, CT-guided biopsy for the peripheral nodule itself. For a nodule above 8 mm at high risk, Fleischner supports PET/CT or tissue sampling, not surveillance [1] [3].

Close the loop. Referral to the lung-cancer multidisciplinary meeting with pulmonary function tests if resection is plausible, an honest conversation with the patient about what we suspect and why each step exists, and smoking-cessation support started now — it improves every downstream outcome [1].

Model answer — Part B: SVC obstruction at presentation

Immediate management. This is an oncological emergency. Assess airway and haemodynamics, sit the patient upright, give oxygen if hypoxaemic, and obtain senior and anaesthetic awareness early — supine procedures can be hazardous with a critical mediastinal mass [4].

The sequence that earns the marks: stabilise, image, tissue, then treat. The histology determines everything — SCLC is treated with chemo-immunotherapy, lymphoma entirely differently, NSCLC by stage and biomarker — so empirical treatment before biopsy sacrifices the diagnosis that directs the plan. Contrast CT defines anatomy; tissue comes from the safest high-yield route (EBUS-TBNA of mediastinal nodes is frequently ideal) [4].

Relief of obstruction. For severe or rapidly progressive obstruction, endovascular SVC stenting provides the fastest symptomatic relief and can precede disease-directed therapy; it is a bridge, not a substitute for treating the cancer. Corticosteroids are used selectively (e.g., steroid-responsive histologies, cerebral oedema), not as a reflex [4].

Definitive treatment and honesty. If SCLC is confirmed, extensive-stage disease is treated with carboplatin–etoposide plus atezolizumab on the IMpower133 evidence, with radiotherapy as local consolidation in selected cases [5]. Whatever the histology, a new metastatic cancer presenting as an emergency is also the moment to introduce palliative care in parallel — early integration improves quality of life and, in the Temel trial, survival [6].