Download Initial Evaluation of the Patient With Lung Cancer

CLINICAL
PRESENTATION OF
LUNG CANCER
Joint ERS-AIPO Postgraduate Course,
Florence, 4th December 2007
Professor SG Spiro
Department of Thoracic Medicine
UCLH NHS Trust, London
Cancer Statistics 2003
New
cases
(no.)
Deaths
(no.)
Lung
171,900
157,200
12
15
Colorectal
147,500
57,100
50
62
Breast
212,600
40,200
75
86
Pancreas
30,700
30,000
3
4
Prostate
220,900
28,900
67
97
Primary site
5 Year Survival
1974-76
1992-98
Tumour size
1mm
1cm 3cm 10cm
1014
1012
1010
108
106
Zone of
routine clinical
detection
104
102
10
20
Number of doublings
30
40
Initial Evaluation of the Patient With
Lung Cancer: Symptoms, Signs,
Laboratory Tests, and Paraneoplastic
Syndromes
ACCP Evidenced-Based Clinical Practice
Guidelines (2nd Edition)
Stephen G Spiro MD; Michael K Gould MD FCCP; and
Gene L Colice MD FCCP
[CHEST 2007;132:149S-160S]
PRESENTATION
LATE
 80% inoperable at diagnosis
 7 month delay from first symptom to
presentation
 10-15% proceed to attempted resection
 Overall 5 year mortality 90-93%
Range of Frequencies of Initial Symptoms and Signs of Lung Cancer
Symptoms and Signs
Cough
Weight loss
Dyspnoa
Chest pain
Hemoptysis
Bone pain
Clubbing
Fever
Weakness
Superior vena cava obstruction
Dysphagia
Wheezing and stridor
Range of Frequency (%)
8-75
0-68
3-60
20-49
6-35
6-25
0-20
0-20
0-10
0-4
0-2
0-2
[CHEST 2007;132:149S-160S]
SYMPTOMS OFTEN MULTIPLE
In series of 678 consecutive lung cancer
patients;



183 (27%) symptoms were primary tumour
232 (34%) non-specific suggestive of
metastases (anorexia, weight loss, fatigue)
219 (32%) site specific metastatic symptoms
CHEST X-RAY





Very few have incidental abnormal chest x-ray
6% (44) of 678
7% (24) of 364
13% (154) of 1277
The five year survival is better for
asymptomatic patients – 18% versus 12% for
symptoms
CHANGE OF SYMPTOMS



Patients with lung cancer may note a new
symptom or a change in a usual symptom
and delay reporting this
Delay may be 4 – 24 months
Specific symptom of haemoptysis – least
delay
PRIMARY CARE DELAY



To chest x-ray - 56 days (a GP sees one case
every 8 months!)
Cough – lung cancer not listed in 20
commonest diagnoses in Dutch GP study
Commonest symptoms at presentation were
poor predictors of survival, eg. weight loss
DOES DELAY MATTER?




84 patients resected, no effect on 5 year
survival for delays more or less than 90 days
1082 patients – resected in Spain – delays in
time from diagnosis to surgery – no effect
Swedish study of 466 patients – those with
more advanced disease had shorter time
from first symptom to treatment (3.4m),
compared to stage I-II (5.5m)
Those with shortest delays did the worst
PRESENTATION
1) Chest X-ray
 Variable presentation
 Right side commoner
 40% central + consolidation
 Adenocarcinoma commonest peripheral
tumour
 SCLC proximal, involving hilum and
mediastinum
PRESENTATION
2) Symptoms and Signs of Intrathoracic Spread
 Recurrent laryngeal nerve
(2-18%)
 Phrenic nerve
(2-6%)
 Brachial plexus
(1-2%)
 Sympathetic chain
(1-2%)
 Chest wall, pleura
(up to 50%)
 Vascular - SVCO
(10%)
- pericardium
- heart
 Oesophagus
(5%)
PRESENTATION
3) Extrathoracic Metastases
30% present with these
 Bones
(up to 25%)
 Liver
(up to 30%)
 Adrenals
(10%)
 Brain/cord
(10%)
 Nodes
(15-20%)
 Skin
(1-5%)
PARANEOPLASTIC SYNDROMES ASSOCIATED WITH LUNG CANCER
SIADH production
Nonmetastatic hypercalcemia
Cushing syndrome
Gynecomastia
Hypercalcitonemia
Elevated levels of LSH and FSH
Hypoglycemia
Hyperthyroidism
Carcinoid syndrome
Neurologic syndromes
Subacute sensory neuropathy
Mononeuritis multiplex
Intestinal pseudo-obstruction
LEMS
Encephalomyelitis
Necrotizing myelopathy
Cancer associated retinopathy
Skeletal syndromes
Hypertrophic osteoarthropathy
Clubbing
Renal syndromes
Glomerulonephritis
Nephrotic syndrome
Metabolic syndromes
Lactic acidosis
Hypouricemia
Systemic syndromes
Anorexia and cachexia
Fever
Collagen-vascular syndromes
Dermatomyositis
Polymyositis
Vasculitis
Systemic lupus erythematosus
Cutaneous
Acquired hypertrichosis languinosa
Erythema gyratum repens
Erythema multiforme
Tylosis
Erythrpoderma
Exfoliative dermatitis
Acanthosis nigricans
Sweet syndrome
Pruritus and urticaria
Hematologic
Anemia
Leucocytosis and eosinophilia
Leukemoid reactions
Thrombocytosis
Thrombocytopenic purpura
Coagulopathies
Thrombophlebitis
Disseminated intravascular coagulation
PRESENTATION
4) Paraneoplastic Syndromes
Hypercalcaemia 2-6%
 Squamous cell primary – parathyroid hormone
 Bone mets
SIADH production
 Usually small cell - 10%
- 50% abnormal water secretion
 Low Na
 Low urea
 Low plasma osmolality
 High (>2.5x) urine osmolality
PRESENTATION
4) Paraneoplastic Syndromes
ACTH production
 SCLC
 ACTH levels increased in 50%
 Very few have florid Cushings
Clubbing and Hypertrophic Osteoarthropathy
 Squamous and adenocarcinoma
 Clubbing - occurs in up to 30%
- commoner in women
 HPOA in <5% of NSCLC
PRESENTATION
4) Paraneoplastic Syndromes
 Lambert-Eaton Syndrome
 Limbic encephalopathy
 Polyneuropathy
 Cerebellar degeneration
 Retinopathy
 Autonomic neuropathy
 All SCLC – up to 5% of cases
ACCP RECOMMENDATIONS
1.
It is recommended that patients with known or suspected
lung cancer receive timely and efficient care. Grade of
recommendation, 1B
2.
It is recommended that all patients with known or
suspected lung cancer give a thorough history, and
undergo a thorough physical examination and standard
laboratory tests as a screen for metastatic disease. Grade
of recommendation, 1C
3.
It is recommended that patients with lung cancer and a
paraneoplastic syndrome not be precluded from
potentially curative therapy on the basis of these
symptoms, alone. Grade of recommendation, 2C