Diagnosis & Treatment
Lung Cancer

Lung cancer treatment and diagnosis in Spain: therapy and surgery

Lung cancer treatment and diagnosis in Spain: therapy and surgery

Medical tourists choose the lung cancer treatment and diagnosis in Spain due to surprisingly affordable costs, the high level of professionalism and comfort of private clinics.

Every year, about 28 000 cases of lung cancer are diagnosed in Spain.

This is the most common type of oncology in the world, which is still difficult to treat.

Local government and private companies are investing huge sums to ensure that cancer care in the country meets the best standards. These efforts are beginning to yield results.

Cancer treatment in Spain is traditionally popular among medical tourists from Europe, America, Middle East, Northern Africa, and the former USSR.

The reasons are obvious:

• The latest western technologies
• First-class multilingual private clinics
• Relatively low cost of procedures and tests
• Well-developed tourism infrastructure
• High service, especially in private sector

Lung cancer treatment in Spanish clinics is carried out in strict accordance with world and European standards. There is a lot of health facilities accredited by JCI / TJC.

How does lung cancer develop?

Our tissues consist of cells that continuously divide to replace old or dead cells. This allows maintaining the integrity and proper functioning of various systems of the human body.

Everything goes fine until the cell division is failed under the pressure of external factors.

With random mutations, the regulatory mechanisms of the cell fail, and uncontrolled division can begin, which eventually leads to disease. This is how lung cancer develops.

Among the possible causes of disease smoking is #1. Radioactive gas radon, industrial and environmental toxins, dust and asbestos also play a role in cancer development. As a result of DNA mutations, malignant cells acquire the ability to invade healthy tissues (infiltration) and multiply in distant parts of the body forming the secondary tumors (metastasis).

Within months, the tumor grows, disrupting lung function, poisoning the body with toxic products and interfering with organ functions. The earlier treatment is started, the more chances for success.

University Clinic of Navarra (Clínica Universidad de Navarra)

This well-known academic hospital in Pamplona consists of more than three dozen specialized departments and 10 centers. Numerous international awards and certificates confirm the achievements of the clinic in medical science and patient care.

Since 2004, the Clínica Universidad de Navarra has been accredited by JCI / TJC.

The Joint International Commission is the world leader in quality assessment and accreditation of medical institutions. The JCI certificate is a symbol of patient confidence and trust.

Other awards of the University Clinic of Navarra:

• Recognition by the European Society of Medical Oncology (ESMO)
• Award “The best oncology department for patient care”
• Award “The best clinic in Spain for patient care”
• Award “The best clinic for Research and Innovation”

Thanks to the high quality of services and the latest technical advances, this teaching hospital is named one of the best clinical institutions in Western Europe.

Prognosis and survival rate for lung cancer

The prognosis of lung cancer depends on the type, stage and aggressiveness of the specific malignancy. It has a very low survival rate compared to other cancers. Survival directly depends on the stage of the disease at the time of diagnosis. Nonspecific symptoms often lead to late diagnosis. It can develop rapidly, sometimes within months.

Typical causes of death in lung cancer include:

• Respiratory failure
• Infections (pneumonia, sepsis)
• Pulmonary haemorrhage
• Thromboembolism, etc.

Very often, lung cancer occurs in the elderly with other chronic diseases of the respiratory system. These cases are extremely difficult to timely diagnose and treat.

Survival strongly depends on the stage. At stages I-II, the tumor is limited to the organ and is well treatable. At the stage III, advanced cancer leaves fewer opportunities. When metastases are found in distant organs (stage IV lung cancer), the disease is considered incurable.

The prognosis also depends on the type of cells and aggressiveness. To determine the histological features of malignant tissues, a biopsy (collecting a tissue sample) is performed.

In Spain, 1 out of 3 patients live more than 1 year from the date of diagnosis, and a 5-year survival rate of 12%. Recent advances in genetics, as well as promising clinical trials are aimed at improving these indicators, so we can see an increase in survival rate over the next few years.

Symptoms and early detection of lung cancer in Spain

In the early stages, lung cancer does not cause any symptoms or the sings are nonspecific. According to Spanish oncologists, there are no diagnostic tests that have shown an advantage in overall survival, so there is no benefit in conducting preventive tests. Nevertheless, there are specific laboratory tests that find malignant cells in saliva and blood, especially in patients with bad habits (smoking) and risk factors.

Some sensitive imaging studies are conducted to detect this pathology early, such as spiral CT, without convincing results. This technology is used in Cleveland Clinic (USA).

Generally, there is no benefit in conducting preventive tests for lung cancer. In most cases, lung cancer is diagnosed when a growing tumor causes coughing, shortness of breath, hemoptysis, and voice changes. This is observed in the late stages of the disease. At the first unusual symptoms it is important to talk with oncologist or pulmonologist.

Oncology consultation in Spain costs 100 euros or more, depending on clinic.

Local doctors are usually well trained and disciplined. They pay great attention to the questioning and examination, complementing the picture by lab tests (urine, blood, sputum) and imaging.

Spanish laboratories are not inferior to the American in terms of quality and lab tests completion time. CBC costs 200 euros and the tumor marker test 100-1000 euros.

Suspicious symptoms that could turn out to be signs of lung cancer:

Cough: it is a result of irritation of the bronchi. Cough is often produces sputum. This symptom is more common in tumors that are located in the central lung region.
Hemoptysis: unlike other non-obvious signals, this is a shocking symptom that usually force the patient to visit the hospital immediately. Hemoptysis occurs as a result of damage to the pulmonary vessels. Bleeding may require surgery.
Shortness of breath: the patient may notice that shortness of breath interferes with a daily life. This symptom is also common in centrally located tumors.
Chest pain: pain usually occurs when the tumor affects the chest wall or pleura. This most often occurs when the neoplasm is located in the peripheral lung region.
Dysphonia: voice change can be observed when the tumor is spreading right to the mediastinum affecting the nerve that controls our vocal cords.
Dysphagia: sometimes there is a feeling that solid food stops in the middle of the chest. This occurs when a tumor or affected lymph nodes compress the esophagus.
Horner syndrome: after nerve damage in the upper part of the chest so called palpebral ptosis (drooping of the eyelids), narrowing of the pupils and the absent sweating in the middle of the face can be observed.

The disease is often manifested by general symptoms such as weakness, fatigue, bone pain, confusion, dizziness and unexplained weight loss.

Any other symptom can be a result of metastases in distant organs.

For example, a headache is a possible sign of a secondary tumor in the brain. Back pain sometimes indicates metastasis in the spine.

But all these symptoms can mean other, completely harmless conditions. It is important to seek professional help as soon as possible.

Baselga Oncology Institute in Barcelona (Instituto Oncológico IOB)

The world-famous Institute has been working in Barcelona since 1995. This is a project of talented physician Jose Baselga, who raised cancer treatment in the Catalan capital to a new level. Today Instituto Oncológico IOB deals with a wide range of solid tumors and hematological diseases.

Since 2007, the Institute has been working at the Hospital Quirónsalud Barcelona. This place is visited by almost twenty thousand patients from around the world each year. Undoubtedly, this is one of the best clinics for lung cancer diagnosis and treatment in Spain.

Experienced specialists from Baselga Oncology Institute can provide you with a qualified second opinion and offer an alternative to previously prescribed treatment.

Lung cancer diagnosis in Spain: tests and procedures

Current diagnostic tests that are used for lung tumors have two purposes: determining the stage of disease and choosing the most appropriate treatment. Below are the methods used by Spanish cancer clinics. Keep in mind that in most cases there is no need to do all of these tests. Consult your doctor for the diagnosis in your particular case.

Complex diagnostics of lung cancer in Spain costs 6000-8000 euros.

This price includes consultations of specialists, radiography, CT, MRI, and laboratory tests.

Chest X-ray

This is a diagnostic test, which is widely used for suspected cancer. Chest X-ray is very fast, simple and cheap diagnostic instrument, although this is not the most accurate imaging method.

Chest X-ray in Spanish clinics costs only about 80-120 euros.

Computed Tomography (CT)

Spiral CT is a radiation study using X-rays, which form a detailed image of organs and tissues from numerous sections (slices). CT provides a higher level of detail identifying involved areas inside the bone that can go unnoticed by conventional plain X-ray.

A special contrast agent is injected before the procedure to improve image quality. Some of the contrast agents can cause kidney damage and even serious allergic reactions, so it's important to consult your doctor.

CT usually lasts about 10-15 minutes. Modern machines installed in leading clinics of Madrid, Barcelona and Navarre, speed up the procedure and make it much more comfortable for patients.

Computed tomography in Spain costs 200 euros or more.

Positron Emission Tomography (PET / CT)

This is a scan in which radioactive glucose is injected through a vein and absorbed by body tissues. Malignant tumors absorb the largest amount of the labeled substance, so they are highlighted in the images. PET / CT is useful for searching lung cancer metastases.

In addition, PET can distinguish between benign non-cancerous lesions (infections and inflammatory diseases) and malignant tumors. This is a long test, which requires adequate control of blood glucose levels.

Patients with diabetes need to be very careful.

PET / CT in Spain usually costs 1000 euros or more.

Magnetic Resonance (MRI)

This study is mainly used by Spanish oncologists to search for metastases in the brain and spinal cord. Magnetic resonance imaging is rarely performed at the beginning of the diagnostic process, except for suspected metastases.

MRI of the lung can be performed when planning surgical treatment to study the connection of the tumor with large vessels. This method does not use x-rays, and therefore the MRI is completely safe method. Certain risks can only be represented by a contrast agent.

The cost of an MRI in Spain starts from 300 euros for one area.

Bone Scintigraphy

Scintigraphy determines whether the tumor has spread to the bone. Before the procedure, patient is given a radioactive isotope, which is absorbed by the affected parts of the bone tissue.

Lung cancer diagnosis in Spain: tests and procedures

Scintigraphy is recommended for symptoms that may indicate bone metastases.

For example, bone pain or pathological fractures. Spanish doctors rarely use this diagnostic test, because positron emission tomography provides more opportunities.

Teknon Oncology Institute (Instituto Oncológico Teknon)

Barcelona is a home of one of the best clinics for lung cancer treatment in Spain IOT. The latest technologies and medications are available here, and the institute itself is built according to the model of Sloan-Kettering Memorial Cancer Center in New York.

Quiron Teknon is one of the best, but not the cheapest clinics in the country. Some diagnostic tests and procedures are much more expensive here than in regular Catalonian hospitals:

• MRI costs 700+ euros for one area
• Oncologist consultation - 400 euros or more
• Radiation therapy costs approximately 8500 euros
• Chemotherapy is 2000-3500 euros per course

Quiron Teknon has long been considered a synonym for quality and reliability. The best part of the IOT is the ultramodern radiation therapy center, where you can see all the achievements of Western nuclear medicine under one roof. The department offers:

• virtual CT simulation system
• double linear accelerator for radiotherapy
• amorphous silicone detector for monitoring radiotherapy
•proton accelerator for stereotactic radiosurgery (SRS)

If you are looking for an uncompromising quality but do not want to spend all your savings in the US or Canadian clinics – the Teknon Oncology Institute is the best place.


The procedure is performed using a flexible tube a few millimeters in diameter (bronchoscope).

The tube is inserted through the patient’s mouth or nose, passes through the trachea and reaches the lungs. During bronchoscopy, the doctor makes a series of pictures and video, collecting samples of suspicious tissue. The procedure may require local anesthesia and sedation.

Endobronchial ultrasound (EBUS)

In recent years, Spanish doctors widely use endobronchial ultrasound. This technique provides access to the area between the heart and the lungs (mediastinum) without the need for surgical intervention. The ultrasonic probe provides high-quality images in real time, allowing simultaneous collection of samples for further lab tests.

EBUS is used in lung cancer diagnosis and planning for surgical treatment.


Mediastinoscopy is considered to be the best existing method of examination of mediastinal lymph nodes. Visually examining the lymph nodes, an experienced surgeon can evaluate the spread of the tumor, especially if MRI and CT provide incomplete information.

Transthoracic needle biopsy

This CT guided procedure is designed to obtain samples of peripheral tumors that are inaccessible to the bronchoscope. Transthoracic needle biopsy requires local anesthesia, as the needle is inserted directly into the thorax between the patient's ribs.


The term thoracoscopy literally means "examination of the chest". This surgical procedure is performed by a thoracic surgeon under general anesthesia through a small incision on the chest.

It is used to collect samples and assess the condition of the pleura.

Thoracenthesis (pleural tap)

Thoracenthesis is an aspiration of pleural fluid, which is performed under local anesthesia using a special needle. The doctor inserts the needle between the ribs under ultrasound control, removing the pus or liquid that has accumulated in the pleural cavity.

Samples can be sent for cytological evaluation.

Lab tests for lung cancer in Spain: methods and costs

Modern lab is able to identify the disease using different biological samples – from the removed tumor tissues to blood and urine. Tumor marker blood tests can cost 100 euros or more. But the lung cancer diagnosis by blood (tumor marker tests) is still an experimental and inaccurate method. Therefore, the main role in the diagnostic process belongs to a biopsy.

Tissue samples obtained during bronchoscopy, needle biopsy or thoracocentesis are sent to laboratories. Here specially trained pathologists identify the presence of malignant cells and their specific type, suggesting the most appropriate treatment.

The pathologist will check the size and location of the tumor, the number of affected lymph nodes and any other aspects that will help to make the correct diagnosis.

If the sample is too small, more tissue will need to be extracted for histological typing.

Genetic mutations in lung tumors

Thanks to the latest advances in genetics, scientists have discovered some specific changes (mutations) that affect the development of non-small cell lung cancer (NSCLC). More importantly, these findings allow us to predict the response to targeted therapy.

Each mutation is associated with a number of clinical characteristics listed below:

Genetic changes: EGFR mutation
High risk groups: Women, Non-smokers, Asians
NSCLC types: More common with adenocarcinoma; rarely with squamous cell carcinoma
Recommendation: Patients with advanced adenocarcinoma

Genetic changes: KRAS mutation
High risk groups: Current smokers or ex-smokers, Africans
NSCLC types: More common with adenocarcinoma; rarely with squamous cell carcinoma
Recommendation: Test is recommended in most cases

Genetic changes: EML4-ALK Translocation
High risk groups: Young adults, Non-smokers
NSCLC types: Adenocarcinoma
Recommendation: Only patients negative for EGFR mutation

These three types of mutations are exclusive. Any cancer cell can contain only one of them. Identification of specific mutations is an important part of the diagnosis of non-small cell lung cancer, especially with aggressive and rapidly progressive disease.

The presence of ALK, KRAS or EGFR changes predicts response to targeted drugs.

Biopsy and tumor genetic analysis in Spain costs approximately 3000 euros.

MD Anderson Cancer Center in Madrid

In 2000, the first foreign branch of the legendary MD Anderson Cancer Center was opened in the Spanish capital. Today it is one of the best oncological clinics in the country, where medical assistance of the American model is available.

Patients of MD Anderson Cancer Center in Madrid can get:

• a full range of diagnostic procedures and laboratory tests
• second opinion of the leading experts of Europe and the USA
• innovative surgical treatment for all types of cancer

Their regularly undergo training in Houston, Texas. On the basis of MD Anderson Cancer Center in Madrid, there are numerous studies and clinical trials are underway.

The cost of diagnosis and treatment in MD Anderson is slightly higher compared to the national average, but the quality of services is worth every cent.

Lung cancer treatment in Spain: costs and procedures

When planning therapy, three factors are taken into account: the stage, the type of tumor (small cell tumors, NSCLC, squamous cell carcinoma) and the patient's health. The main option in the early stages of the disease is surgical resection of the tumor along with part of the lung. The problem is that a weakened smoking patient with COPD may not survive such a surgery. Then doctors have to look for compromise options.

Spanish clinics practice a multidisciplinary approach, when the planning involves specialists from different areas of medicine. The team includes medical oncologists, pulmonologists, thoracic surgeons, pathologists, radiation oncologists, nuclear medicine specialists, and even clinical psychologists.

Lung cancer treatment in Spain: costs and procedures

There are four different therapeutic approaches: surgery, radiation therapy, chemotherapy and targeted therapy (aimed against molecular targets on malignant cells).

Surgery and radiotherapy are considered local treatment, whereas chemotherapy and targeted therapy are considered systemic (drugs are distributed throughout the body). As a rule, several methods are used in combination to achieve optimal long-term results. For example, chemotherapy and radiation after surgical resection.

Surgical treatment (segmentectomy, lobectomy)

Surgery is usually recommended for patients with localized tumors (stage I-III). At stage IV, cancer cells penetrate into distant organs by lymphogenous and hematogenous routes, so removal of the primary tumor does not provide complete cure.

Instead of this, metastatic cancer requires aggressive systemic therapy.

There are three types of surgery to remove lung tumor:

• Segmentectomy (a small piece of tissue is excised)
• Lobectomy (the affected lobe of the lung is removed)
• Pneumonectomy (lung is completely removed)

Surgery is suitable for people who have a tumor limited to the lung, which is not penetrated into large blood vessels and distant organs (can be removed).

The surgery may be performed for both therapeutic and diagnostic purposes.

Many Spanish thoracic surgeons consider pneumonectomy a controversial procedure, since the quality of life after removal of the whole lung is significantly impaired (especially with right-sided pneumonectomy).

The cost of surgery (lobectomy or segmental resection) in Spain is approximately 18000-25000 euros in the leading cancer clinics of Barcelona and Madrid.

Radiation therapy

Radiotherapy uses high-energy X-rays to destroy or reduce the size of tumors. This method can be combined with surgery and / or chemotherapy. Radiation therapy can be radical (which is aimed at destroying the tumor) or palliative (aimed only at maintaining and improving the patient’s quality of life).

Typically, the duration of therapy ranges from 1 to 5 weeks. Sessions are carried out every day or Monday to Friday, depending on the rules of your clinic. The session can last up to 10-15 minutes. The first session is a simulation without giving a radiation load. Simulation is used to identify tumor location and improve the safety of further treatment.

To prevent complications (weakness, skin reactions, hair loss), doctors use the minimum effective dose of radiation, strictly controlling the regime using special computers. 

Tips to deal with side effects of radiation therapy:

• Moisturize the skin with cream after each procedure
• Wear comfortable clothing, avoiding skin irritation
• Try to avoid hot and spicy foods and alcohol
• Avoid sunlight during therapy
• Never smoke!

Depending on the cancer type, radiotherapy has different purposes:

• In non-small cell lung cancer, radiation therapy helps to control inoperable neoplasms, sometimes combined with chemotherapy drugs.
• In small-cell carcinoma, radiotherapy is prescribed in combination with chemotherapy (including prevention of metastasis in the brain).

The possibilities of radiotherapy depend largely on the technologies used in your clinic. For example, stereotactic radiosurgery (SRS, cyber-knife) cuts out the malignancy in just a few minutes with powerful focused radiation beams.

Radiation therapy in Spain costs 8,500+ euros for 1 course of treatment. Depending on the technologies used and the policy of the clinic, this price can reach 25,000 euros.

Chemotherapy for lung cancer

For systemic therapy, scientists develop cytotoxic drugs that slow down the division of malignant cells or destroy them. This is a deadly weapon with serious disadvantages.

On the one hand, cytotoxic drugs find and destroy malignant cells throughout the body, including distant metastases and micrometastases, which are not visible on CT or MRI. On the other hand, standard chemotherapy is non-selective: toxic molecules attack any quickly dividing cells, including mucous membranes, blood cells, hair follicles.

Spanish oncologists usually prescribe chemotherapy to treat NSCLC of any stage other than stage I. A newly developed tumor is usually surgically removed.

In non-small cell lung cancer, chemo is used in different situations:

• Adjuvant therapy: after surgical resection to prevent local recurrence or metastasis.
• Neoadjuvant therapy: before surgical intervention or radical radiotherapy to reduce the tumor size and simplify the procedure technically.
• Combined chemotherapy and radiotherapy (chemoradiotherapy or CRT) can be used in some cases of locally progressive disease.

Chemotherapy for lung cancer in Spain costs from 1,000 euro per course, which is several times cheaper than the United States.

Local clinics widely use platinum-based drugs (carboplatin, cisplatin), taxanes (paclitaxel, docexatel), vinorelbine, gemcitabine, etoposide and pemetrexed. Some of them are administered intravenously, others are taken in the form of tablets.

Among the possible side effects: nausea, vomiting, diarrhea, sores in the mouth, skin rash, weakness, hair loss, frequent infections, anemia, increased risk of bleeding, etc.

Where is better to go for chemotherapy: Quironsalud

Quironsalud Hospital Group is the local leader in chemotherapy. Clinics of this nationwide provider are scattered throughout Spain: from Badajoz to the Balearic cautions.

The level of treatment and service in Quironsalud compared with the public medical institutions. You can be sure: they do everything possible to minimize the side effects of chemotherapy and provide comfort to every patient.

Although similar chemo agents are used around the world, the secret of the efficacy and safety of chemotherapy is not in the drug name, but in the correctly chosen treatment and continuous comprehensive control.

Targeted therapy

In recent years, genetic research has transformed classical ideas about the development of cancer. We learned that each tumor carries unique genetic mutations.

We created targeted therapy, capable of blocking certain cellular receptors. This is like a surgical strike instead of carpet bombing, maximally preserving healthy cells and organs.

Chemotherapy for lung cancer

Targeted agents in monotherapy and in combination with standard chemotherapy have been approved for recurrent and progressive non-small cell lung cancer. This treatment strategy prolongs patient’s life even with metastases, when complete cure is impossible.

To choose right targeted cancer therapy, a laboratory testing on EGFR and KRAS mutations or EML4-ALK translocation is needed.

There are some targeted drugs available in Spain:

Drugs: Bevacizumab
Administration: intravenously
Mechanism of action: Angiogenesis inhibitor; suppresses VEGF receptors, stopping the formation of new blood vessels that feed the tumor

Drugs: Crizotinib
Administration: orally
Mechanism of action: ALK inhibitor

Drugs: Erlotinib
Administration: orally
Mechanism of action: EGFR inhibitor

Drugs: Gefitinib
Administration: orally
Mechanism of action: EGFR inhibitor

Drugs: Afatinib
Administration: orally
Mechanism of action: EGFR inhibitor

Drugs: Nintedanib
Administration: orally
Mechanism of action: Triple angiogenesis inhibitor; suppresses three families of receptors (VEGF, FGFR, PDGFR)

Most of these drugs are given orally, which is very convenient.

Lung cancer immunotherapy

According to leading Spanish oncologists, chemotherapy is a dead end in the lung cancer treatment. It provides only a modest increase in survival rate, having terrible side effects. Immunotherapy is a future of oncology.

This treatment method activates the patient's immune system to search for and destroy malignant lung cells throughout the body. Immunotherapy is effective in the late stages, when the other treatment options do not work.

For example, the atezolizumab once increased the survival rate in metastatic lung carcinoma twice, revolutionizing the treatment of advanced cancer.

Many patients with inoperable lung tumors receive immunotherapy for years, although cytotoxic drugs had to be discontinued after 2-3 months because of complications.

Today, leading clinics in Barcelona and Madrid treat patients who are still alive for 6 and even 8 years after the initiation of immunotherapy. They would have died long ago if they had received standard chemotherapy.

Every day, immunotherapy agents become "smarter": new immunogenetic tumor tests help to choose the most effective treatment for each cancer patient.

Spanish cancer hospitals use the same drugs that have been approved in the United States. This list includes the immune checkpoint inhibitor durvalumab (Imfinzi) and pembolizumab (Keytruda) for metastatic lung cancer.

The cost of immunotherapy can exceed 10,000 euros.

NM Hospitales private clinics

NM Hospitales is one of the best medical providers in Spain. These days it is a network of nine multidisciplinary institutions across the country, among which there is an excellent cancer diagnosis and radiotherapy center in Madrid.

Comprehensive Cancer Center Clara Campal is also known as HM CIOCC. Created on the basis of the university hospital HM Sanchinarro, this center joined the best doctors and the most advanced equipment from around the world.

Comprehensive Cancer Center Clara Campal specializes in early diagnosis and treatment of any solid tumors. To get a high-tech CT scan or unique biochemical tests, numerous patients from the USA, Canada, the Middle East and Russia fly to Madrid.

Here, the latest technologies of radiotherapy are available.

There is also an excellent psycho-oncology program.

Life after lung cancer treatment

Upon return from the clinic, it is necessary to strictly follow the recommendations of your physician. Do not stop taking medication without permission and immediately report unusual health changes. Stick to a healthy diet and avoid smoking. Patients who survived lung cancer should be carefully monitored. Your doctor will schedule a new treatment as soon as possible in case of sudden cancer recurrence.

Fortunately, the risk of recurrence is steadily declining over time. If you survived 5 years after treatment, the risk of recurrence is small. After 10 years it is considered minimal.

However, in the first years after lung cancer treatment, it is recommended to undergo health examinations more often. During the follow-up visits, Spanish clinics will offer standard blood tests, abdominal ultrasound, CT of the lungs, bronchoscopy.

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