red-flag presentations of solid tumours

Framework for recognising, triaging, and initiating workup of common solid tumours from an internal medicine perspective. Pathology — not imaging — confirms diagnosis. Start supportive care at first encounter; do not delay pending tissue.

core principle

History & physical → imaging → tissue diagnosis → staging → treatment.

Never initiate cancer-directed therapy (chemotherapy, immunotherapy, targeted therapy) without tissue confirmation, except in rare life-threatening oncologic emergencies under direct oncology guidance.

urgency triage

Tier	Presentations	Action
emergent (same-day)	airway compromise, SVC syndrome with respiratory/neurological signs, malignant spinal cord compression, symptomatic hypercalcaemia (>3.0 mmol/L), massive GI bleeding/perforation, massive haematuria with clot retention or obstructive uropathy + AKI	immediate admission — high-dose dexamethasone (cord compression/raised ICP), aggressive IV saline + bisphosphonates (hypercalcaemia), urgent specialty consults
urgent (within days)	progressive solid→liquid dysphagia, recurrent haemoptysis, iron deficiency anaemia + constitutional symptoms or age >50, large/hard/fixed breast mass, progressive biliary or urinary obstruction, rapidly proliferating tumours (SCLC, high-grade neuroendocrine, high-grade sarcoma)	fast-track diagnostics — urgent endoscopy, CT chest/bronchoscopy, triple assessment
expedited outpatient	incidental stable pulmonary nodule, painless breast lump without high-risk features, low-risk microscopic haematuria, mild IDA without haemodynamic instability, small incidental renal mass	expedited outpatient imaging/endoscopy — structured follow-up essential (do not lose to follow-up)

baseline investigations

minimum initial panel

haematology — CBC with differential (anaemia, thrombocytosis)
renal — electrolytes (Na⁺, K⁺, Cl⁻, HCO₃⁻), creatinine, eGFR (contrast eligibility, organ function)
calcium — total calcium, albumin, corrected calcium (± phosphate)
hepatic — ALT, AST, ALP, GGT, total bilirubin, albumin
coagulation — INR, aPTT (pre-biopsy)
symptom-directed — ferritin, iron panel, TSH, CRP/ESR, LDH, urinalysis, pregnancy test if relevant

tumour markers — use appropriately

do not order broad tumour marker panels

Indiscriminate panels → false positives, patient anxiety, delayed diagnosis. Order only with a specific clinical question.

Marker	Appropriate context
PSA	prostate — screening/diagnostic context
AFP / β-hCG	HCC surveillance; suspected germ cell tumours; always check β-hCG in reproductive-age females with pelvic mass
CA-125	selected suspicious ovarian masses (never general screening)
CEA	monitoring known CRC (not for initial diagnosis)

tissue diagnosis & biopsy strategy

preferred — image-guided core needle biopsy of the safest, most accessible peripheral lesion (e.g. enlarged supraclavicular node over deep mediastinal mass) → preserves architecture for histology, IHC, and molecular profiling
FNA — restricted to thyroid nodules, cervical lymph nodes, or confirming recurrent/metastatic disease; avoid for primary solid tumour diagnosis (insufficient architecture, limited molecular material)

biopsy contraindications — do not violate

suspected ovarian cancer — never percutaneous or transvaginal biopsy in the community → risk of tumour seeding, alters surgical staging → refer directly to gynae-oncology
suspected sarcoma — never excisional or uncoordinated biopsy → biopsy must be planned with the surgical oncologist performing definitive resection to preserve limb-sparing options

organ-specific red flags

lung

red flags — persistent cough >8 weeks, haemoptysis, non-resolving/recurrent same-lobe pneumonia, persistent chest pain, hoarseness, supraclavicular lymphadenopathy, digital clubbing, weight loss
emergencies — malignant airway obstruction (stridor), SVC syndrome, massive haemoptysis (>200–600 mL/24h), brain metastases with raised ICP, symptomatic hypercalcaemia
workup — chest X-ray alone is insufficient → contrast CT chest required as first-line imaging; biopsy supraclavicular nodes, peripheral lesions (CT-guided), or central lesions via EBUS/bronchoscopy

colorectal

red flags — unexplained iron deficiency anaemia, haematochezia, change in bowel habits >6 weeks, palpable right iliac fossa mass, bowel obstruction
by location:
- right-sided — occult bleeding, anaemia, fatigue, late large abdominal mass (clinically silent longer)
- left-sided / rectal — haematochezia, altered bowel habits, tenesmus, obstructive symptoms

never attribute IDA to haemorrhoids or diet without complete GI evaluation

workup — colonoscopy with biopsy (gold standard) → staging CT chest/abdomen/pelvis after tissue diagnosis

gastroesophageal

red flags — progressive dysphagia (solids → liquids), odynophagia, early satiety disproportionate to meal size, refractory GERD, persistent vomiting, epigastric pain, weight loss
advanced physical signs — Virchow node (left supraclavicular), Sister Mary Joseph nodule (periumbilical metastasis), Blumer shelf (rectal shelf)

progressive dysphagia → urgent upper endoscopy

Never treat empirically with prolonged PPI alone.

workup — upper endoscopy (gastroscopy) with biopsy is first-line → CT chest/abdomen/pelvis for staging after tissue confirmation

breast

red flags — hard, irregular, immobile/fixed mass; skin dimpling, peau d’orange, nipple inversion, bloody unilateral nipple discharge; fixed/matted axillary or supraclavicular lymphadenopathy
isolated axillary lymphadenopathy without palpable mass — breast cancer remains the leading differential; requires bilateral mammography + targeted ultrasound + breast MRI ± core biopsy of node (see common solid tumours)
inflammatory breast cancer (IBC) — mimics mastitis (diffuse erythema, warmth, rapid engorgement, skin oedema) but fails to improve with antibiotics over 1–2 weeks → urgent imaging, skin punch/core biopsy, immediate referral

imaging by context:

Age / context	First-line imaging
<30 years or pregnant/lactating	targeted breast ultrasound
≥30 years	diagnostic mammography + targeted ultrasound

triple assessment principle

Diagnosis requires concordance across (1) clinical exam, (2) diagnostic imaging, and (3) core needle biopsy. A normal screening mammogram does not rule out cancer in a patient with a persistent palpable mass.

genitourinary

bladder / urothelial — gross painless haematuria (hallmark), microscopic haematuria, persistent irritative voiding without infection
renal cell carcinoma — classic triad (flank pain, haematuria, palpable mass) usually late; often incidental
prostate — new urinary retention/obstruction, axial skeleton bone pain, pathologic fractures, malignant spinal cord compression

anticoagulation does not cause haematuria

It unmasks underlying pathology. Anticoagulated patients with haematuria require full workup.

workup — requires both lower tract evaluation (cystoscopy + TURBT for biopsy) and upper tract evaluation (CT urography)

gynaecological

ovarian — persistent abdominal bloating, early satiety, pelvic pain, increased abdominal girth, ascites, pelvic mass in women >50; insidious and subtle
endometrial — postmenopausal bleeding = endometrial cancer until proven otherwise → transvaginal ultrasound for endometrial thickness ≥4–5 mm → endometrial biopsy
cervical — postcoital bleeding, intermenstrual bleeding, friable cervical lesion

a Pap smear is a screening tool, not a diagnostic test

A visible cervical lesion requires direct biopsy or colposcopy referral regardless of a recent normal Pap.

early supportive care

Start at first encounter — do not delay pending tissue confirmation:

pain — WHO analgesic ladder; schedule long-acting analgesics + PRN breakthrough (PRN-only is inadequate); add gabapentinoids/SNRIs for neuropathic components
hypercalcaemia (>3.0 mmol/L) — aggressive IV isotonic saline + IV bisphosphonate (zoledronic acid or pamidronate)
VTE — LMWH or DOACs based on bleeding risk; do not delay anticoagulation awaiting biopsy (see deep vein thrombosis)
malignant effusions / ascites — therapeutic thoracentesis or paracentesis for symptomatic dyspnoea/pain; send fluid for cytology
obstructive uropathy / biliary obstruction — urgent nephrostomy tube, ureteric stenting, or biliary drainage (ERCP/PTBD) to prevent irreversible organ dysfunction

what NOT to do

major pitfalls

premature reassurance — reassuring a symptomatic patient based on a single negative test (normal screening mammogram, normal Pap, negative stool FOBT)
nonspecific tumour marker panels — ordering CEA, CA-125, PSA, AFP for undifferentiated symptom workups
serial imaging instead of biopsy — repeated CTs over time when a suspicious lesion has been identified → proceed to tissue
empiric treatment without investigation — treating progressive dysphagia with PPIs, or IDA with oral iron, without GI tract evaluation
community biopsy of ovarian or sarcoma lesions — risks peritoneal seeding or loss of limb-sparing surgical options
blaming anticoagulation for haematuria — dismissing haematuria as a side effect of blood thinners