Clinical presentations of lung cancer. By: Khaled Zamzam MD, FCCP Head of chest dept. Air Force Hospital.
KhaledZamzam MD, FCCP
Head of chest dept.
Air Force Hospital
The history and physical examination is an important initial step in evaluating patients with suspected lung cancer as it usually will uncover important informationregarding a patient’s stage of disease and prognosis and associated medical complications of the underlying cancer.
The clinical presentation of lung cancer usually relates to the development of a new, or worsening of a preexisting clinical symptom or sign and, less frequently, to an abnormal CXR shadow in an asymptomatic patient.
Patients who present with symptoms at the time of diagnosis have a far worse outcome than those who do not.
Resectable lung cancer will seldom be diagnosed based on the medical history.
Further testing will reveal that another 15% are unresectable.
Most patients also present with a chronic productive cough due to chronic bronchitis, and in these patients the initial manifestation of lung cancer development is a change in the character of cough or the appearance of blood tinged sputum.
Infiltration of the left pulmonary artery by a central bronchogenic neoplasm.
According to Pancost’s classic description, a lung cancer at a definitve location at the thoracic inlet produces constant & characteristic phenomena of pain in the 8th & 1st & 2nd thoracic trunk distribution, & Horner’s syndrome.
Pancosttumour is quite consistantly a lung cancer, however other malignancies as well as inflammatory &infectious diseases (are rare etiologic conditions) that develop peripherally at the apex of the upper lobes, at or near the superior pulmonary sulcus.
Constrained by the narrow confines of the thoracic inlet, the developing carcinoma invades the lymphatics of the endothoracic fascia and involves by direct extension one or more of the following structures:
It’s initial clinical picture is pain localized to the shoulder & the vertebral border of the scapula.
Weakness & atrophy of the muscles of the hand supervenes, as well as the loss of the triceps reflex.
The vast majority of superior sulcus tumours are due to NSCLC & can be staged as T3N0M0 ( stage IIB) or higher.
The SVC is a 6–8cm long, thin-walled, low-pressure vessel that drains venous blood from the head, neck, upper extremities, and upper thorax to the heart.
Several space-occupying lesions in the middle mediastinum may compress or invade the vessel, leading to blood flow reduction or complete obstruction.
SVC syndrome is the clinical syndrome that results from the homonymous vessel obstruction or the severe reduction of venous return from the head, neck, & upper ext.remities.
Clinically, it presents with head, facial, neck, upper thorax, and upper extremity edema and venous distension.
Because of the localization of the causative process in the mediastinum, SVC syndrome may coexist with other mediastinal syndromes such as, dysphagia, vocal horseness, & dyspnea due to large airway obstruction.
The severity of the SVC syndrome depends upon the therapidity of occlusion and collateral vessel development.
The azygos venous system: Azygos vein, Hemiazygos vein, & the connecting intercostal veins.
In the absence of tracheal compression and airway compromise, it is rarely an oncologic emergency.
Sequential venous angiograms, before (left), during (middle, PRESTENT), and , after placement of the stent (right, POSTSTENT)
Compression, entrapment, or invasion of the recurrent laryngeal nerve by the primary cancer or its nodal metastases around the aortic arch, leads to horseness.
Recurrent laryngeal nerve palsy predisposes to lung aspiration and is associated with ineffective ability to cough and expectorate.
Lung cancer is the leading cause of malignant pleural effusion. A pleural effusion is observed in 15% of patients at their first evaluation.
The mechanisms by which a lung cancer leads to pleural effusion may be:
Adrenal metastases are quite common in patients with (NSCLC) but rather uncommon in patients with (SCLC).
Occasionally, however, massive adrenal metastases can cause flank pain. In addition, patients with advanced bilateral adrenal metastases may develop symptoms of adrenal insufficiency.
Liver metastases occur frequently in patients with lung cancer, more commonly with SCLC than with NSCLC.
However, these findings usually occur only in patients with very advanced liver disease.
Metastases to the CNS are commonly seen in both SCLC and NSCLC (particularly adenocarcinoma).
Another form of CNS metastasis from lung cancer is involvement of the spinal cord.
Spinal cord compression and intramedullary metastases are rarely asymptomatic and should be identified rapidly as they constitute neurological emergencies necessitating immediate treatment.
About 90% of patients complain of back pain—either localized or radicular—as their first symptom.
Bowel or bladder incontinence is another less common symptom of cord compression.
Leptomeningeal metastases are most commonly seen with adenocarcinoma of the lung.
Skeletal metastases occur in about one third of patients with lung cancer.
Many patients, however, may be asymptomatic, with this finding discovered incidentally on a routine bone scan or because of elevated alkaline phosphatase levels or hypercalcemia.