Symptoms

• Cough, dyspnea, hemoptysis, chest discomfort

• 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)

• Bone pain w/ or w/o pleuritic pain, neurologic symptoms, limb weakness, unsteady gait, cervical lymphadenopathy, skin nodules

• 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)

• Malaise, loss of appetite & weight loss

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Diagnosis

• 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

• 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

• 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%

• 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

• 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

• 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

• 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

• More common (80%) than small cell lung cancer
• Includes adenocarcinoma, squamous cell carcinoma, large cell anaplastic carcinoma

• Includes small cell carcinoma & combined small cell carcinoma (ie SCLC w/ neoplastic squamous &/or glandular components)

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