CLINICAL

Wide range of symptoms and signs is related to:

1. Histologic features which often help determine the anatomic site of origin in the lung 2. The specific tumor location in the lung and its relationship to surrounding structures 3. Biologic features and the production of a variety of paraneoplastic syndromes 4. The presence or absence of metastatic disease

Clinical Presentation of Lung Cancer

Pulmonary symptoms
Cough Bronchus irritation or compression Dyspnea Airway obstruction or compression Wheezing >50% airway obstruction

Nonpulmonary thoracic symptoms

Hemoptysis Pneumonia Pleuritic pain Local chest wall pain Tumor erosion or irritation Airway obstruction Parietal pleural irritation or invasion Rib and/or muscle involvement

Radicular chest pain Intercostal nerve involvement Pancoast's syndrome Stellate ganglion, chest wall, brachial plexus involvement Hoarseness involvement Recurrent laryngeal nerve

Swelling of head and arms : 1.Bulky involved mediastinal lymph nodes 2.Medially based right upper lobe

TUMOR HISTOLOGY
Squamous cell and small cell carcinomas:
segmental airways} Arise in main lobar, or first bronchi{central

Adenocarcinomas: located peripherally, Asymptomatic peripheral lesion on chest radiograph BAC : solitary nodule, as multifocal nodules, or as a diffuse infiltrate mimicking(PNEUMONIC FORM) air bronchograms may be seen radiographically within the tumor

SITE OF TUMORS

Squamous cell = 66% occur centrally in lung hilus(sq=central) Adenocarcinoma = Peripheral, Central, highly malignant, Usually peripheral, very

Small (oat) cell = usually not operable Large cell malignant =

TUMOR LOCATION
Pulmonary Symptoms
direct effect of the tumor on the bronchus or lung tissue Symptoms : cough,dyspnea, wheezing , hemoptysis pneumonia and lung abscess

Nonpulmonary Thoracic Symptoms

OCCURS DUE TO invasion of the primary tumor directly into a contiguous structure or from mechanical compression of a structure by enlarged tumor-bearing lymph nodes Peripherally located tumors ( adenocarcinomas) extending through the visceral pleura lead to irritation or growth into the parietal pleura and to continued growth into the chest wall structures SYMPTOMS depending on the extent of chest wall involvement 1.pleuritic pain 2.localized chest wall pain 3.radicular pain

Superior sulcus tumors (usually adenocarcinomas) may produce the Pancoast syndromeTumor at the apex of the lung or superior sulcus that may involve the brachial plexus, sympathetic ganglia, and vertebral bodies, leading to pain, upper extremity weakness, and Horners syndrome Injury to the cervical sympathetic chain(MAP)
1. Miosis (small pupil) 2. Anhydrosis of ipsilateral face 3. Ptosis

Depending on the exact tumor location, symptoms can include

Invasion of the primary tumor into the mediastinum

may lead to involvement of the phrenic or recurrent laryngeal nerves. Direct invasion of the phrenic nerve occurs with tumors of the medial surface of the lung, or with anterior hilar tumors.

Symptoms may include

1.shoulder pain (referred), 2.hiccups, and dyspnea with exertion Because of diaphragm paralysis

Diagnosis;chest radiograph,fluoroscopic examination of the

diaphragm and with breathing and sniffing (the sniff test)

Recurrent laryngeal nerve (RLN)

most commonly occurs on the left side. Paralysis may occur 1. invasion of the vagus nerve above the aortic arch by a medially based left upper lobe (LUL) tumor, 2.invasion of the RLN directly by a hilar tumor, 3.invasion by hilar or aortopulmonary lymph nodes involved with metastatic tumor.

Symptoms:
Voice change,often referred to as hoarseness, Loss of tone associated with a breathy quality, Coughing( when drinking liquids)

Tumor Biology
Lung cancers both nonsmall-cell and small-cell carcinoma Capable of producing a variety of paraneoplastic syndrome Most often from tumor production and release of biologically active materials systemically. Majority of such syndromes are caused by small-cell carcinomas, including many endocrinopathies.

Paraneoplastic syndromes Early diagnosis. Presence does not influence resectability or the potential to successfully treat the tumor. Symptoms of the syndrome often will abate with successful treatment, and recurrence may be heralded by recurrent paraneoplastic symptoms. 5 general types of paraneoplastic syndromes.
1. Metabolic: Cushings, SIADH, hypercalcemia 2. Neuromuscular: Eaton-Lambert,cerebellar ataxia 3. Skeletal: hypertrophic osteoarthropathy 4. Dermatologic: acanthosis nigricans 5. Vascular: thrombophlebitis

SCLC :: hypertrophic pulmonary osteoarthropathy (HPO)

Most common paraneoplastic syndromes Syndrome is characterized by tenderness and swelling of the ankles, feet, forearms, and hands. Because of periostitis of the fibula, tibia, radius, metacarpals, and metatarsals.

Hypercalcemia
10% of patients with lung cancer and is most often because of metastatic disease 15 % of cases are because of secretion of ectopic parathyroid hormonerelated peptide, most often with squamous cell carcinoma Diagnosis of ectopic parathyroid hormone secretion can be made by measuring elevated serum levels of parathyroid hormone; the clinician must also rule out concurrent metastatic bone disease by a bone scan.

Metastatic Symptoms
METASTASES occur most commonly Central nervous system (CNS), Vertebral bodies, Bones,Liver, Adrenal glands, Lungs,Skin and Soft tissues. 10 % of patients with lung cancer have CNS metastases 1015 %will develop CNS metastases SYMPTOMS: headache, nausea and vomiting, seizures, hemiplegia, and speech difficulty.

Nonspecific Symptoms

Lung cancer often produces a variety of nonspecific symptoms such as Anorexia Weight loss Fatigue Malaise The cause of these symptoms is often unclear, should raise concern about possible metastatic disease

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