Signs & Symptoms

Primary Tumor-Related
  • Cough, dyspnea, hemoptysis, chest discomfort
Due to Intrathoracic Spread
  • May involve the nerves (hoarseness, dyspnea, muscle wasting of upper limb, Horner’s syndrome), chest wall & pleura (chest pain, dyspnea), vascular structures (facial swelling, dilated neck veins, cardiac tamponade) & viscera (dysphagia)
Due to Metastatic Spread
  • Bone pain w/ or w/o pleuritic pain, neurologic symptoms, limb weakness, unsteady gait, cervical lymphadenopathy, skin nodules
Paraneoplastic Syndromes
  • Hypercalcemia (N/V, abdominal pain, constipation, polyuria, thirst, dehydration, confusion, irritability)
  • Syndrome of inappropriate antidiuretic hormone (SIADH) production (confusion, seizures, decreased level of consciousness, coma)
  • Cushing’s syndrome (weakness, muscle wasting, decreased level of consciousness, confusion, psychosis, dependent edema, hypokalemic alkalosis, hyperglycemia)
  • Others (digital clubbing, hypertrophic osteoarthropathy, Lambert-Eaton myasthenic syndrome, peripheral neuropathy, cortical cerebellar degeneration)
Other Symptoms
  • Malaise, loss of appetite & weight loss



Risk Factor Assessment
  • Smoking cigarettes increases the risk of developing lung cancer
    • Number of packs of cigarettes smoked per day & the yrs spent smoking is directly related to the development of lung cancer
  • Passive smokers have 24% increased risk of developing lung cancer
  • Occupational & environmental exposures
    • Asbestos
    • Arsenic
    • Beryllium
    • Chloromethyl ether
    • Chromium
    • Nickel
    • Polycyclic aromatic hydrocarbons
    • Vinyl chloride
    • Radon
    • Cadmium
  • Previous lung disease (eg COPD w/ FEV1 ≤70% predicted)
  • History of any cancer or thoracic radiation
    • Risk of cancer due to radiation is proportional to the dose received & usually starts approximately 20 yrs after exposure
  • Family history of lung cancer
Noninvasive Imaging Procedures Chest X-ray
  • Should be performed in all patients in whom lung cancer is suspected but should not be used alone as a screening tool
  • Not enough sensitivity to determine lymph node involvement
  • Usual findings in lung cancer include:
    • Solitary pulmonary nodule
    • Pulmonary or hilar mass
    • Poorly resolving pneumonia
    • Pleural effusion
Chest Computed Tomography (CT) Scan
  • Defines size, location & characteristics of pulmonary mass
  • Determines presence of lymphadenopathy
  • Allows evaluation of surrounding structures
  • May be used to evaluate presence of pleural effusion
  • Low-dose CT is the recommended screening tool to detect lung cancer
    • May lower lung cancer-specific mortality by 20%
Positron Emission Tomography (PET) Scan
  • Determines normal from neoplastic tissues even as small as 1 cm
  • May be performed in patients w/ solitary lung lesions
  • Can increase accuracy of staging patients w/ SCLC
  • Better than CT scan for mediastinal staging in NSCLC; however, it is not reliable in identifying brain, bone & urinary tract metastases
  • May be done to assess distant metastases (eg bone metastasis) & guide mediastinal evaluation in patients w/ SCLC limited-stage disease & benign lung lesions presenting as a solitary nodule
    • Superior to PET scan alone & to other standard imaging but inferior in detecting metastases to the brain
  • Improves target accuracy of radiation therapy in patients w/ significant atelectasis & in patients w/ contraindication to IV CT contrast
Confirmatory Tests Sputum Cytology
  • Due to poorly controlled sample collection, diagnostic yield tends to be low
  • Should be reserved for patients in whom bronchoscopy or FNAB is contraindicate
  • Used for diagnosing & staging central & peripheral lung lesions
    • May be used as a confirmatory test for suspected central lesions
  • Electromagnetic guidance for bronchoscopy increases bronchoscopy sensitivity (60%), specificity (91%), & accuracy (67%) for peripheral lesions
Fine Needle Aspiration Biopsy (FNAB)
  • Recommended confirmatory test for solitary extrathoracic site suspected to be a metastatic lesion
  • May be done blindly but preferably guided by CT, MRI, fluoroscopy or ultrasound
    • CT-guided FNA/percutaneous core biopsy - 86-94% sensitive, 41-100% specific, 83-93% accurate for peripheral pulmonary lesions
Endobronchial or Esophageal Ultrasound-guided Biopsy [transesophageal endoscopic ultrasound-guided FNA (EUS-FNA) or endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)]
  • Minimally invasive technique used for mediastinal staging, as compared to mediastinoscopy
    • Studies have shown that EBUS-TBNA achieved similar results for the mediastinal staging of lung cancer hence may possibly replace mediastinoscopy in patients w/ potentially resectable NSCLC
      • Diagnostic yield of 80% for peripheral lesions; 82-94% sensitive for central lesions
      • Has low rates of nondiagnostic & false-negative biopsy findings, may be done in small subcentimeter nodes, & can confirm radiographically positive mediastinum
      • Allows access to the hilar & interlobar LN which can not be reached by mediastinoscopy
    • Video-assisted thoracoscopy is another minimally invasive technique used in mediastinal staging
  • EBUS or EUS are done as part of pretreatment evaluation in patients w/ stage I-IIIA (T4 extension, N0-1; T3, N1)
    • May be preferred over mediastinoscopy in sampling mediastinal lymph nodes, reserving mediastinoscopy & mediastinal lymph node dissection until the planned surgical resection
  • Pleural fluid obtained from FNA should be examined rather than discarded to help in the confirmation of diagnosis
  • Gold standard procedure for evaluating mediastinal nodes
    • Recommended in patients w/ peripheral T2a, central T1ab, or T2 lesions w/ negative PET/CT scan
Histologic Diagnosis Non-small Cell Lung Cancer (NSCLC)
  • More common (80%) than small cell lung cancer
  • Includes adenocarcinoma, squamous cell carcinoma, large cell anaplastic carcinoma
Small Cell Lung Cancer (SCLC)
  • Includes small cell carcinoma & combined small cell carcinoma (ie SCLC w/ neoplastic squamous &/or glandular components)