Chest
Volume 123, Issue 1, Supplement, January 2003, Pages 97S-104S
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Initial Evaluation of the Patient With Lung Cancer*: Symptoms, Signs, Laboratory Tests, and Paraneoplastic Syndromes

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This chapter describes the components of the initial evaluation for a patient either suspected or known to have lung cancer. The components of the initial evaluation are based on the recognized manifestations of localized lung cancer, ie, symptoms referable to the primary tumor, intrathoracic spread of lung cancer, and patterns of metastatic dissemination. Features of the history and physical signs may be useful indicators of the extent of disease. A standardized evaluation, relying on symptoms, signs, and routinely available laboratory tests, can serve as a useful screen for metastatic disease. Also described are the common features of the various paraneoplastic syndromes associated with lung cancer.

Section snippets

Chest Radiography

The chest radiograph plays a pivotal role in the recognition of lung cancer. Certainly, in the asymptomatic patient, an abnormality on the chest radiograph would be the first clue to the presence of lung cancer. In patients with symptoms related to the primary tumor, the chest radiograph may often strongly support a suspicion of carcinoma of the lung. For patients presenting with either nonspecific systemic complaints or symptoms suggestive of metastatic disease, the chest radiograph will be

Symptoms, Signs, and Laboratory Tests in Lung Cancer

Symptoms, signs and abnormalities in laboratory tests relating to the lung cancer can be classified as follows: (1) those related to the primary lesion, (2) those related to intrathoracic spread, (3) those related to distant metastasis, and (4) those related to paraneoplastic syndromes.

Symptoms and Signs Related to the Primary Tumor

The frequencies of local and systemic symptoms in patients with lung cancer are summarized in Table 1. 8910111213

Signs and Symptoms of Intrathoracic Spread

Intrathoracic spread of lung cancer, either by direct extension or lymphatic spread, produces a variety of symptoms and signs. These may be caused by involvement of the following structures: (1) nerves, eg, recurrent laryngeal nerve, phrenic nerve, brachial plexus, and sympathetic nerve trunks; (2) chest wall and pleura; (3) vascular involvement, eg, superior vena cava (SVC), pericardium, and heart; and (4) viscera, including esophagus.

Symptoms, Signs, and Laboratory Tests Indicating Extrathoracic Metastases

Approximately one third of patients present with symptoms as a result of distant metastases. The most common sites of distant metastasis from lung cancer are the bones; liver, adrenal glands, and intraabdominal lymph nodes; brain and spinal cord; and lymph nodes and skin.

Paraneoplastic Syndromes

Paraneoplastic syndromes are a group of clinical disorders associated with malignant diseases that are not directly related to the physical effects of primary or metastatic tumor. The exact mechanism by which paraneoplastic syndromes occur is not fully understood. Paraneoplastic syndromes occur in at least 10% of patients with bronchogenic carcinoma.89

The extent of paraneoplastic symptoms is unrelated to the size of the primary tumor, and in some cases can precede the diagnosis of malignant

Summary

More than 90% of patients with lung cancer will be symptomatic at presentation. A minority present with symptoms related to the primary tumor, and most patients present with either nonspecific systemic symptoms, including anorexia, weight loss and fatigue, or specific symptoms indicating metastatic disease. Prognosis is related to the type of presenting symptoms. Asymptomatic patients and patients with symptoms related to the primary tumor have better 5-year survivals than those with systemic

Summary of Recommendations

  • 1.

    All patients with known or suspected lung cancer should undergo a thorough history, physical examination, and standard laboratory tests as a screen for metastatic disease. Level of evidence, fair; benefit, substantial; grade of recommendation, B

  • 2.

    Patients with lung cancer and a paraneoplastic syndrome should not be precluded from potentially curative therapy on the basis of these symptoms alone. Level of evidence, fair; benefit, substantial; grade of recommendation, C

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