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Das kleinzellige Lungenkarzinom (SCLC) ist ein aggressiver, undifferenzierter und rasch wachsender, fruhzeitig hamatogen metastasierender und nikotinassoziierter Tumor. Das SCLC ist sehr chemotherapie- und strahlensensibel, Resistenzen treten aber rasch auf und Rezidive sind haufig. Initiale molekulare Veranderungen betreffen unter anderem Inaktivierungen des TP53- und RB1-Gens, zusatzlich sind aber multiple weitere Gene und Signaltransduktionswege gestort. Das SCLC gehort zu den Entitaten mit hoher Tumormutationslast (TMB) und ist daher „Kandidat“ fur die Immuntherapie. Das SCLC wird nach dem TNM-System stadiiert, letztlich ist aber vor allem die Unterscheidung zwischen (noch) lokalisierter Erkrankung („limited disease“, LD) und metastasierter Erkrankung („extensive disease“, ED) therapie- und prognoseentscheidend. Standard ist die Chemotherapiekombination Platin/Etoposid. Bei LD-SCLC sollte zusatzlich simultan die Bestrahlung von Tumor und Mediastinum eingesetzt werden. Hirnmetastasen sind haufig; die prophylaktische Hirnbestrahlung (PCI) kann deren Haufigkeit verringern. Fur die zweite Linie ist bisher Topotecan alleiniger Standard. Immuntherapeutische Ansatze sind beim SCLC vielversprechend und werden zurzeit in vielen Studien gepruft. Neuer Standard wird ab Herbst 2019 in erster Linie beim ED-SCLC die Kombination Platin/Etoposid plus Immuntherapie (Atezolizumab). Bei fortgeschrittener Erkrankung ist die Prognose ungunstig. Das mittlere Uberleben im Stadium IV betragt bisher weniger als ein Jahr. Beim LD-SCLC kann mit simultaner Strahlenchemotherapie bei ca. 10–25 % der Patienten eine Heilung erwartet werden.

Epidemiologisch zeigt sich in Deutschland, in Europa und in den USA eine zunehmende Lungenkrebshaufigkeit bei Frauen! Besonders der Vergleich der altersspezifischen Erkrankungsraten nach Geschlecht zeigt bei jungeren Frauen eine hohere Lungenkrebserkrankungsrate als bei Mannern. Histologisch sind bei Frauen mehr Adenokarzinome als bei Mannern zu beobachten. Ursachlich sind einerseits sicherlich die geanderten Rauchgewohnheiten der Frauen, zusatzlich spielen aber noch andere Faktoren bei der Lungenkrebs-Karzinogenese der Frauen eine Rolle. Wesentlich haufiger manifestiert sich der Nichtraucher-Lungenkrebs bei Frauen als bei Mannern. Ursachlich konnten unterschiedliche Lungenkrebs-Empfanglichkeiten oder auch unterschiedliche Karzinogen-Expositionen, z. B. gegenuber Radon, durch Passivrauchen oder Herddampfe der Geschlechter sein. Auf molekularer Ebene finden sich bei Frauen haufiger genetische „Treiber-Mutationen“ als bei Mannern und demzufolge konnen neue „zielgerichtete Therapien“, z. B. gegen EGFR oder Alk, haufiger bei Frauen zum Einsatz kommen. Die Prognose beim klein- und nichtkleinzelligen Lungenkarzinom ist bei Frauen insgesamt etwas besser als bei Mannern.

Epidemiologisch zeigt sich in Deutschland, in Europa und in den USA eine zunehmende Lungenkrebshaufigkeit bei Frauen! Besonders der Vergleich der altersspezifischen Erkrankungsraten nach Geschlecht zeigt bei jungeren Frauen eine hohere Lungenkrebserkrankungsrate als bei Mannern. Histologisch sind bei Frauen mehr Adenokarzinome als bei Mannern zu beobachten. Ursachlich sind einerseits sicherlich die geanderten Rauchgewohnheiten der Frauen, zusatzlich spielen aber noch andere Faktoren bei der Lungenkrebs-Karzinogenese der Frauen eine Rolle. Wesentlich haufiger manifestiert sich der Nichtraucher-Lungenkrebs bei Frauen als bei Mannern. Ursachlich konnten unterschiedliche Lungenkrebs-Empfanglichkeiten oder auch unterschiedliche Karzinogen-Expositionen, z. B. gegenuber Radon, durch Passivrauchen oder Herddampfe der Geschlechter sein. Auf molekularer Ebene finden sich bei Frauen haufiger genetische „Treiber-Mutationen“ als bei Mannern und demzufolge konnen neue „zielgerichtete Therapien“, z. B. gegen EGFR oder Alk, haufiger bei Frauen zum Einsatz kommen. Die Prognose beim klein- und nichtkleinzelligen Lungenkarzinom ist bei Frauen insgesamt etwas besser als bei Mannern.

Bone and joint tuberculosis, as all other types of tuberculosis is generally treated with antituberculotic combination chemotherapy. This has to be continued for a minimum of six months, or nine months in case of extensive spreading. A two- to three-month initial phase with four or five different drugs (H, R, Z, and additionally E and/or S) is followed by a four- to six-month therapy with H and R alone, provided the pathogen is fully susceptible to a standard regimen. The main side effects are hepatotoxic or allergic reactions. A frequent contra-indication is existing, often toxicity-induced, liver damage. The main local complications requiring surgery are spinal instability or neurologic deficiencies.

The clinical records of 17 patients with HIV-associated lymphoblastic mostly Burkitt-type lymphomas, are reviewed (54% of a total of 31 patients with HIV-associated malignant lymphomas, treated between 1/85-1/90). The lymphomas were diagnosed histologically with additional immuno-histochemical analyses, or cytologically, with subsequent immunocyto-chemistry. All patients were homosexual and HIV antibody positive, and the average age was 39 y. At initial staging evaluation an Ann Arbor stage III or IV was present in 15 patients (88%); a CDC-stage II of HIV-infection was present in 10 patients, CDC-stage III in 5 patients, and CDC-stage IV in 2 patients. An extranodal or mixed nodal/extranodal pattern of organ involvement was seen in 14 cases, with predominance of the gastrointestinal tract (30%) and the bone marrow (30%). The response rate to chemotherapy (CR + PR) was 81%, a CR was achieved in 53% of the patients, and relapses within a few months after CR were common. Survival following relapses in the CR- and PR group was similar, namely 5.2 and 4.9 months respectively. 2 patients in the CR-group and 1 patient in the PR group have been alive for 13, 19 and 30 months. An optimal therapeutic regimen for this disorder does not seem to have been found yet.

Nach Erstlinientherapie des fortgeschrittenen nichtkleinzelligen Lungenkarzinoms („non-small-cell lung carcinoma“, NSCLC) kann die Behandlung als sog. Erhaltungstherapie fortgesetzt werden. Moglich ist dabei die Gabe eines der primaren Chemotherapiekombinationspartner oder der Wechsel auf eine „fruhe“ Zweitlinientherapie wie z. B. Docetaxel, Pemetrexed oder Erlotinib, den Inhibitor der Tyrosinkinasedomane des „epidermal growth factor receptor“ (EGFR-TKI). Eindeutiger Vorteil einer Erhaltungstherapie ist das verlangerte progressionsfreie Uberleben, wichtig z. B. bei drohendem symptomatischen Progress. Das Gesamtuberleben kann durch die Erhaltungstherapie nur gering positiv beeinflusst werden. Entscheidend ist immer die Abwagung zwischen moglichen Toxizitaten und dem Uberlebensvorteil fur den einzelnen Patienten.

A 62-year-old female presented with a 1-month history of irritating cough and increasing dyspnea. A chronic idiopathic myelofibrosis had been diagnosed 5 years ago. CT of the chest and abdomen showed bilateral pleural effusions with a thickened pleura, nodular infiltrations in both lungs, enlarged intraabdominal lymph nodes and splenomegaly. Pleuroscopy (medical thoracoscopy) on the left side revealed dense tumorous nodules mainly on the posterior chest wall pleura, but also on the diaphragm and the lung. Biopsies taken from the chest wall pleura revealed extramedullary hematopoiesis (EMH) with abnormal megakaryocytes as well as myeloid and erythroid precursors. After unsuccessful tetracycline pleurodesis, talcum slurry was instilled via the chest tube without recurrence of the pleural effusion. Furthermore, treatment with hydroxyurea was started, and the disease regressed and then remained stable over the next 24 months. In conclusion, the pleuropulmonary findings were caused by EMH due to chronic idiopathic myelofibrosis. The definite diagnosis was established by pleuroscopy followed by successful pleurodesis with talc slurry, after tetracycline pleurodesis had failed.

Maligne Pleuraergusse treten bei allen Tumoren auf, am haufigsten beim Lungenkrebs, beim Mammakarzinom und bei den malignen Lymphomen. Je nach Tumortyp kommt eine systemische Behandlung (Zytostatika, Hormone) mit oder ohne Ergussentfernung in Betracht. Bei der Mehrzahl der Falle erfolgt eine symptomatisch/palliative Lokalbehandlung mit Ergussentfernung, in der Regel mit Drainage, die mit der Pleurodese verbunden wird. Unter den Substanzen, die fur eine Pleurodese benutzt werden, ist Talkum am effektivsten, entweder in Form einer Puderung wahrend der Thorakoskopie oder mittels Einbringen von „Talc slurry“. Beim malignen Pleuramesotheliom (MPM) wurden in den letzten Jahren wesentliche Fortschritte in der Therapie erzielt. Zwei grose randomisierte Studien bewirkten, dass die Antifolat-Platin-Zweifachkombination jetzt zur Standardtherapie des MPM werden konnte. Eine Metaanalyse bestatigte die Aktivitat platinhaltiger Kombinationstherapien. Zweitlinientherapien und neue Substanzen werden zurzeit getestet. Zusammen mit einer effektiven Chemotherapie werden zukunftig auch multimodale Therapiekonzepte mit Chemotherapie, Operation und Bestrahlung optimiert werden konnen.

The course of disease in 119 HIV-infected patients (117 men, 2 women; median age 38.5 years) with malignant tumours other than Kaposi's sarcoma was analyzed in a multi-centre retrospective study. This was conducted to obtain initial information concerning the incidence, clinical features and results of therapy in HIV-associated neoplasms, especially malignant lymphomas. The most frequent tumour was malignant non-Hodgkin's lymphoma (98 patients, 82.5%), seven patients had Hodgkin's disease, five had solid tumours, four a polyclonal lymphoproliferative syndrome, three an acute lymphocytic leukaemia, and two had other lymphoproliferative diseases. 58% of the non-Hodgkin's lymphomas occurred in patients with marked immunodeficiency, 85% were high grade malignancies and 47% had primary extranodal disease. 56% of primary nodal lymphomas also had visceral spread (Stage IV). Lymphoblastic non-Hodgkin's lymphoma was more common in patients with favourable immunological status, presented less frequently with primary extranodal disease, was diagnosed earlier than other non-Hodgkin's lymphomas, and appeared to carry a better prognosis. 78 out of the 98 patients with non-Hodgkin's lymphoma had been treated, 66 with cytotoxics. The median survival time was 6 months. Longer remission periods, of at least 12 months, were seen in ten of the 78 patients (13%). Despite the overall poor prognosis and the pre-existing immune defect, palliative (chemo-)therapeutic measures are both justified and promising, and may also result in life-prolonging remissions.

Bronchoscopy is the most important diagnostic procedure for the work-up of central bronchial processes and parenchymal lung diseases, such as lung cancer, pneumonias or diffuse lung diseases. Recent progress - ultrasound, navigation systems or ultrathin bronchoscopes - was made to achieve a better yield in the diagnosis of peripheral and peribronchial lesions. Bronchial recanalisation by thermal ablation or stenting is mainly performed with rigid instruments; these procedures as well as brachytherapy in local anaesthesia should be restricted to specialized centers. If pleuracentesis does not provide the etiology of pleural effusion, thoracoscopy in local anaesthesia is the method of choice. The procedure does not only provide a definite diagnosis for almost all of the patients, it also allows the immediate option for talcum poudrage in case of pleural malignancy.

Lung cancer is divided into two types: non-small cell and small cell lung cancer. Small-cell lung cancer is a very aggressive rapid growing tumour type treated primarily with chemotherapy and, in the minority of patients with limited disease, with radiotherapy. Non-small cell lung cancer is treated in a multidisciplinary way with surgery, radiotherapy and chemotherapy depending on stage. Surgery is the mainstay of treatment for early stage non-small cell lung cancer patients. Adjuvant therapy has become state of the art in stage II and IIIA patients and must be considered in stage IB. Stage III patients should be treated in a multimodal way with radiotherapy and chemotherapy, and, if possible, with surgery. Treatment for every stage III patient should be discussed in a multidisciplinary team. Stage IV patients in good performance status will benefit from a combination chemotherapy, preferably platinum-based. Second line therapy has become standard and targeted therapies are under evaluation and are common in second line chemotherapy.

Despite medical advances lung cancer remains the leading cause of cancer deaths. Lung cancer is usually recognized late in its natural history and at presentation in 80 % unresectable. Smoking history is the most important risk factor. At present time, screening for lung cancer is not recommended. The only chance for cure is tumour resection in early stages, performed in about 20 % of all lung cancer cases. Histological subtypes are non-small cell lung cancer (NSCLC) (80 % of lung cancers) and 20 % small cell lung cancer (SCLC). TNM-staging has important influence on prognosis and therapy. After identification the tumour should be staged using the TNM system. Currently diagnosis and staging rely predominantly on chest radiography and computed tomography (CT) scanning. Positron emission tomography (PET) identifies the tumour by its metabolic activity and helps to find malignant nodal or systemic lesions. Flexible bronchoscopy is the key investigation in the diagnosis and staging of patients with suspected lung cancer. Endobronchial ultrasound guided transbronchial fine needle aspiration (TBNA) may be utilized to improve the bronchoscopic results in mediastinal staging. Internistic thoracoscopy or video assisted thoracoscopic surgery (VATS) may be used in malignant pleural effusions. Mediastinoscopy staging is the gold-standard for mediastinal staging.

An increased understanding of the biology of lung cancer has identified biological targets for rationally designed novel therapies. Most of these targets are components of signalling pathways or metabolic processes. EGFR-tyrosinkinase inhibitors have become standard in second- and thirdline therapy of NSCLC, the anti-VEGF-antibody Avastin combined with first-line chemotherapy showed a significant survival benefit over chemotherapy alone. There are ongoing studies with targeted therapies in all stages of lung cancer. Major advances of these new drugs are their low toxicity and, in part, the oral application.

In the last decade there have been important innovations in the treatment of lung tumors. New combined modality therapies are becoming standard and require a network of cooperating partners. New therapeutic agents are under investigation that will hopefully improve the outcome of small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Principles of chemotherapy in non-small cell und small cell lung cancer depending on stage and combination in multimodal regimens are shown. In the second part single drugs are described with their typical effects and side effects from the viewpoint of a clinician. A following part II will discuss new "targeted" biologicals.

Malignant pleural mesothelioma may be treated with surgery, radiotherapy and chemotherapy. In most patients, the treatment remains palliative with symptom relief and a moderate survival gain. Only a minority of patients with early stage mesothelioma may be cured by a multimodal approach including radical surgery, chemotherapy, and radiotherapy. We discuss the role of surgery with either radical extrapleural pleuropneumonectomy or less invasive palliative pleurectomy and decortication, and the role of radiotherapy, in which the main problem is how to deliver sufficient doses to the pleural surface, sparing radiosensitive structures such as the lung, heart, liver, and kidneys. Chemotherapeutic options are discussed with 'older' mono- and combination regimens and the new promising combination cisplatinum/pemetrexed, now the 'standard regimen' for malignant pleural mesothelioma. Experimental approaches such as hyperthermia, interferons or interleukins, and 'small molecules' or antibodies inhibiting the EGFR oder VEGF receptor are under clinical evaluation. For the majority of our patients we recommend talcum pleurodesis either by medical thoracoscopy or VATS, followed by chemotherapy with platinum/pemetrexed. Radiotherapy may be applied in case of local tumour growth. The individual therapeutic decision will depend on tumour stage, concomitant diseases, performance status, and on the patient's preference.

Previous studies suggested that the characteristics of young female lung cancer patients may differ from those of other patients. Using the cancer registry at the Lungenklinik Heckeshorn hospital, all female patients under the age of 46 yrs with primary lung cancer 1986-1995 were identified. The clinical records were reviewed for risk factors, stage, histology, therapy, and survival. The data were compared with those of other patients. Of the 4,939 patients 96 (1.9%) were females aged

Lung cancer in young adults has been differently described in publications from various regions of the world, in respect of relative incidence, distribution of morphology and stages, and prognosis of the disease. We analysed retrospectively the data from the cancer registry of the Lungenklinik Heckeshorn in Berlin between 1986 and 1995 with regard to this topic. 106/4939 patients were 40 years old or younger (2.1%). The proportion of female patients was higher in the younger group (42 vs. 29%). Adenocarcinoma was the leading subtype in young patients (33 vs. 24%). The younger group showed a higher proportion of inoperable stages IIIB and IV for non-small cell lung cancer (71 vs. 46%). Younger patients with operable stages I to IIIA non-small cell lung cancer underwent surgery much more often than patients older than 40 years (90 vs. 49%), but for all patients with this morphology there was no difference in survival between younger and older patients (302 vs. 314 patients). We conclude that lung cancer presents a clearly different clinical picture in younger patients but not a better prognosis.

In this review article we present an overview of recent developments in EGFR TKIs in lung cancer therapy. Besides the approved drugs erlotinib and gefitinib, clinical data on second-generation irreversible TKIs including afatinib, dacomitinib, neratinib, pelitinib, and canertinib are mentioned; these drugs not only inactivate EGFR but show a broader range of activity. We also report on NSCLC data of TKI that are known and approved in other indications, such as lapatinib and vandetanib. We stress the importance of quality of life in the treatment of patients with TKIs, an important aspect of the treatment that should also be considered in the selection of the appropriate NSCLC therapy in advanced stages.

More and more differences in lung cancer are being detected between men and women. Lung cancer, at the beginning of the last century a rare disease in women, has a growing incidence in women, in particular in young females. Lung cancer is a leading cause of cancer death in women in developed countries with different histological types and adenocarcinomas are more frequent in women than in men. Cigarette smoking is the most prevalent cause of lung cancer in women, in addition susceptibility to carcinogens may differ between the sexes. As more non-smoking women than men develop lung cancer, it is likely that they are exposed to excessive environmental carcinogens such as second-hand-smoking, in-house-radon or cooking fumes. Furthermore, genetic and hormonal influences play a role in lung cancer etiology for women. Taken together, women have a better overall survival than men with lung cancer. Differences in molecular susceptibility patterns are observed between men and women, and show that molecular targets such as EGFR or ALK more frequent in women.

Pleural metastases are common in the course of breast cancer, but, to date, the role of oestrogen receptor (OR) and progesterone receptor (PgR) content in metastatic tissue has been poorly evaluated. A series of 50 consecutive patients with a history of breast cancer (median age 64 yrs, range 40–86 yrs), which presented with pleural effusion and therefore underwent medical thoracoscopy, was analysed. Metastatic pleural involvement was histologically confirmed in all patients. The hormone receptor status of the pleural metastases was investigated using the immunohistochemical method in 49 and the biochemical method in 31 cases. The immunohistochemical test was performed using monoclonal antibodies. Biochemical analysis was performed on specimens quick-frozen in liquid nitrogen. OR and PgR were measured with the dextran-coated charcoal assay and Scatchard analysis. Immunohistochemical analysis yielded 29 OR-positive and 25 PgR-positive cases and biochemical analysis yielded 16 OR-positive and four PgR-positive cases, sometimes discrepant to hormone status of the primary breast cancer. Using a semiquantitative immunoreactive score, there was a significant association between receptor positivity and survival, but only for PgR positivity. Immunohistochemical and biochemical detection of hormone receptors (oestrogen and progesterone) in pleural metastases of breast cancer is feasible based on medical thoracoscopy as the method of choice, by which sufficient specimens may be obtained. The receptor status may enable a decision on antihormonal treatment. Whether a positive receptor status in pleural metastatic tissue is associated with a better prognosis remains to be confirmed.

High-frequency electrocautery is a relatively new method in the treatment of malignant or benign airway stenoses. We report on the results of 58 sessions in 41 patients (malignant condition n = 30, benign n = 11) within a three-year period. Various instruments were available for coagulation (blunt probe, knives of 4, 5 and 7 mm length, forceps and wire snare). 53/58 sessions were performed under general anaesthesia, energy was limited to 40 W with unlimited duration of pulses. The knives were the most frequently used devices, preferably with a length of 5 mm, which enabled us to either cut the tumour or scar tissue precisely slice by slice or to resect by direct coagulation. The use of the blunt probes and forceps was frequently rendered more difficult by detritus covering the instrument during coagulation. Polypes were easily resected with the wire snare, but this kind of tumour was found in four patients only. Major (> 100 ml) bleeding occurred in two patients. Obstructing fibrinous membranes were never seen after electrocautery. In conclusion, high-frequency electrocautery is an effective and safe method for endobronchial resection and can be considered a good alternative to the laser as the classical method for endobronchial resection.

Background The combination of radio-chemotherapy is accepted standard in limited-disease small cell lung cancer, but the best way of combining the two modalities is still unknown. To test an alternating regime of early radiotherapy with hypofractionated radiotherapy we performed a phase II study in stage III small cell lung cancer. Method 32 SCLC patients (n = 7 IIIa, n = 25 IIIb) were treated with a weekly alternating regime with either chemotherapy or radiotherapy. Chemotherapy included carboplatin (AUC5), etoposide (3 x 120 mg/m2) and vincristine (2 mg), repeated on day 28 for six cycles. Radiotherapy started one week before chemotherapy and was applied weekly 1 x 4 Gy, using a split-course regimen. Results Combined radio-chemotherapy was well tolerated with dose-limiting hemotoxicity and very few cases of oesophagitis. Overall response was 75%, median survival 14.5 months and the 2-year survival was 34.4%. 5 patients are still living now for more than 29 months. Treatment failure was local and systemic in 34% of the patients. Systemic failure included 6 patients with brain metastases. Conclusion Combined radio-therapy in small-cell lung cancer using an alternating hypofractionated regimen is well tolerated. Response rate and 2-year survival are promising. Local and systemic failure is an ongoing problem and requires better local and systemic control of the disease.

Summary Background: Clinical information on paclitaxel extravasation is scarce. A clinical course following paclitaxel extravasation is reported wit

Bronchoscopy is the most important diagnostic procedure for the work-up of central bronchial processes and parenchymal lung diseases, such as lung cancer, pneumonias or diffuse lung diseases. Recent progress - ultrasound, navigation systems or ultrathin bronchoscopes - was made to achieve a better yield in the diagnosis of peripheral and peribronchial lesions. Bronchial recanalisation by thermal ablation or stenting is mainly performed with rigid instruments; these procedures as well as brachytherapy in local anaesthesia should be restricted to specialized centers. If pleuracentesis does not provide the etiology of pleural effusion, thoracoscopy in local anaesthesia is the method of choice. The procedure does not only provide a definite diagnosis for almost all of the patients, it also allows the immediate option for talcum poudrage in case of pleural malignancy.

Lung cancer is divided into two types: non-small cell and small cell lung cancer. Small-cell lung cancer is a very aggressive rapid growing tumour type treated primarily with chemotherapy and, in the minority of patients with limited disease, with radiotherapy. Non-small cell lung cancer is treated in a multidisciplinary way with surgery, radiotherapy and chemotherapy depending on stage. Surgery is the mainstay of treatment for early stage non-small cell lung cancer patients. Adjuvant therapy has become state of the art in stage II and IIIA patients and must be considered in stage IB. Stage III patients should be treated in a multimodal way with radiotherapy and chemotherapy, and, if possible, with surgery. Treatment for every stage III patient should be discussed in a multidisciplinary team. Stage IV patients in good performance status will benefit from a combination chemotherapy, preferably platinum-based. Second line therapy has become standard and targeted therapies are under evaluation and are common in second line chemotherapy.

Despite medical advances lung cancer remains the leading cause of cancer deaths. Lung cancer is usually recognized late in its natural history and at presentation in 80 % unresectable. Smoking history is the most important risk factor. At present time, screening for lung cancer is not recommended. The only chance for cure is tumour resection in early stages, performed in about 20 % of all lung cancer cases. Histological subtypes are non-small cell lung cancer (NSCLC) (80 % of lung cancers) and 20 % small cell lung cancer (SCLC). TNM-staging has important influence on prognosis and therapy. After identification the tumour should be staged using the TNM system. Currently diagnosis and staging rely predominantly on chest radiography and computed tomography (CT) scanning. Positron emission tomography (PET) identifies the tumour by its metabolic activity and helps to find malignant nodal or systemic lesions. Flexible bronchoscopy is the key investigation in the diagnosis and staging of patients with suspected lung cancer. Endobronchial ultrasound guided transbronchial fine needle aspiration (TBNA) may be utilized to improve the bronchoscopic results in mediastinal staging. Internistic thoracoscopy or video assisted thoracoscopic surgery (VATS) may be used in malignant pleural effusions. Mediastinoscopy staging is the gold-standard for mediastinal staging.