LUNG CANCER   8A

A 73-year-old man presents to his primary care provider with a new cough productive of blood. He reports gradual weight loss of approximately 15 lb over the past 6 months. He has smoked two packs of cigarettes per day for the past 50 years. On physical examination, he has decreased breath sounds and dullness to percussion at the left lung base. His chest radiograph shows a left-sided pleural effusion and consolidation in the left lung.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Older patient; new cough and hemoptysis; weight loss; heavy cigarette smoking history; dull lung base with likely malignant effusion; consolidation on chest radiograph

How to think through: Lung cancer is the leading cause of cancer-related death, has a high mortality rate at the time of detection, and is largely preventable. This patient presents with significant “red flag” features, including a 100 pack-year smoking history, hemoptysis, and weight loss. Other than primary lung cancer, what other disease processes could cause this presentation? (Tuberculosis, pneumonia, lung abscess, lymphoma, metastatic cancer.) What neurologic examination findings suggest complications of lung cancer? (Any mental status, cranial nerve, motor, sensory, or coordination abnormality may indicate brain metastasis; hoarseness or Horner syndrome may indicate compression of the recurrent laryngeal nerve or sympathetic ganglion by an apical [Pancoast] tumor.) What are the next steps in the evaluation of this patient? (Computed tomography [CT] scan to characterize tumor location, plan biopsy, begin staging, and plan possible surgery. Pathologic diagnosis is essential.) What imaging is needed for staging? (CT, positron emission tomography [PET]–CT, and magnetic resonance imaging [MRI] are all used in staging; the brain and abdomen, in addition to the chest, must be assessed.) In the treatment of primary lung cancer, surgery, chemotherapy, and radiation are used, depending on the cancer type and stage. If this patient is not a candidate for surgery or chemotherapy, what palliative therapies should be considered? (Thoracentesis, radiation, oxygen, opioids for pain and dyspnea.)

LUNG CANCER   8B

What are the essentials of diagnosis and general considerations regarding lung cancer?

Essentials of Diagnosis

New cough or change in chronic cough, dyspnea, hemoptysis, anorexia, weight loss

Enlarging nodule, mass, or persistent opacity on chest radiograph or CT scan

Cytologic or histologic findings of lung cancer in sputum, pleural fluid, or biopsy specimen

General Considerations

Lung cancer is the leading cause of cancer deaths. Cigarette smoking causes more than 90% of cases of lung cancer. Lung cancer is often diagnosed in elderly adults.

Small cell lung cancer (SCLC) (10%–15%) is aggressive and prone to early hematogenous spread.

Non–small cell lung cancer (NSCLC) spreads more slowly and has different histologic types.

    Squamous cell carcinoma (20%) arises from bronchial epithelium (often centrally located).

    Adenocarcinoma (35%–40%) arises from mucous glands as a peripheral nodule or mass.

    Large cell carcinoma (3%–5%) is heterogeneous; presents as a central or peripheral mass.

    Bronchioloalveolar cell carcinoma (2%) arises from epithelial cells distal to the terminal bronchiole and spreads along preexisting alveolar structures (lepidic growth).

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