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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