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Symptoms
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
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Diagnosis
History
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
PET/CT Scan
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
Bronchoscopy
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
Mediastinoscopy
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)
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