Any pulmonary symptoms persisting beyond 3 weeks are an indication for a more extensive evaluation, and smokers and patients older than 40 years should receive a more aggressive workup. Diagnostic evaluation can begin with chest x-ray film, but a negative film does not rule out lung cancer or provide tissue diagnosis or staging. HRCT scanning is a more sensitive test for identifying lung cancers even at asymptomatic stages. HRCT can also provide some anatomic detail for staging and determining operability of the cancer. Tissue diagnosis is essential not only for confirming the presence of malignancy but also for determining the histopathology. Fiberoptic bronchoscopy with biopsy brushings and washings is highly accurate for diagnosing centrally located bronchogenic carcinoma in the proximal bronchial tree. Transbronchial biopsy can reach deeper tissues for diagnosis of metastatic pulmonary nodules or even lymph node biopsy. Peripheral pulmonary lesions or pleural lesions can be reached by CT-guided needle biopsy or by surgical open-lung biopsy.

The combination of tissue biopsy and imaging studies yields both the histopathologic type and the stage of cancer. The non-small cell lung cancers may be further classified into various histopathologic cell types, such as adenocarci-noma and squamous cell carcinoma. Staging of non-small cell cancers is summarized in Table 18-6 (American Cancer Society, 2005).

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