Lung cancer 

Symptoms of lung cancer

1.History of smoking, occupational exposure to irradiation, history of T.B.

2.Asymptomatic presentation one fourth of patients who have cancer present with no symptoms at the time of diagnosis.

3.General non specific symptoms e.g. weight loss, loss of appetite, anorexia, fever, and easy fatigability. Symptoms of lung cancer

4.Primary tumor symptoms expectoration, dyspnea, chest haemoptysis.

e.g. pain,

cough, and

5.Symptoms due to intra thoracic spread e.g. hoarseness of voice, dysphagia, chest wall swelling, superior vena caval obstruction with swelling of face or arms.

6.Symptoms due to extra thoracic metastases e.g. bony aches or swelling, pain in right hypochondrium, and neurological symptoms. Signs of lung cancer Signs of lung cancer

No signs can be detected may be detected accidentally on routine chest X-ray.

General Examination may show:

• Inequality in pulse, edema of face and upper limb, palpable cervical lymph node, congested non pulsating neck vein (signs of superior vena cava obstruction and superior sulcus syndrome) Signs due to distant organ metastasis

Liver metastasis ® jaundice, palpable tender liver mass.

• Bone metastasis ® bone pain or pathological fracture.

• C.N.S metastasis ® paralysis or paresis, polyneuropathy, myopathy, any area of sensory loss, and any muscular atrophy.

• C.V.S arrhythmia or manifestation of pericardial effusion. Systemic non metastatic manifestations (paramalignant syndromes)

• Cachexia.

• Clubbing of fingers (+ HOPA).

• Endocrine abnormalities e.g cushing syndrome, hypercalcaemia, inappropriate antidiuretic hormone.

• Neurological abnormalities e.g polyneuropathy, autonomic neuropathy and myasthenic.

• Hematologic abnormalities e.g thromboembolic manifestation, anemia, and leukomoid reaction.

• Cutaneaues manifestations e.g acanthosis negricans, dermatomyositis. Local chest signs

Local signs due to direct effect of the tumor:

•Consolidation, collapse, effusion.

abscess,

and

•Manifestation of underlying diseases e.g. COPD and old pulmonary TB Local signs due to extrapulmonary intrathoracic infiltration

• Chest wall swelling.

• Plural effusion

• Pancoast's tumor or superior sulcus syndrome.

• Superior vena cava obstruction Pancoast's tumor

• It is a tumor occupying the apex of one lung and invading the following:

• The chest wall thus leading to rib erosion of the first rib.

• Infiltrating the brachial plexus leading to pain, hypothesia, weakness and atrophy of small muscles of the hand, at the hypothenar eminence, which are supplied by the ulnar nerve.

• Obstruction of vessels of the thoracic inlet leading to arterial ischemia and inequality of the pulse and venous engorgement. Horner's syndrome

Ptosis, myosis, enophthalmos and unilateral anhydrosis due to compression or involvement of the sympathetic chain. Superior vena cava obstruction (Superior vena cava syndrome mediastinal syndrom)

• It is a sign of inoperability.

• It is caused compression or direct invasion by tumor to:

• Superior vena cava, Subclavian artery, Trachea, Esophagous, left recurrent laryngial nerve and phernic nerve.

• So, patients with mediastinal syndrome may presents with odema of face and upper limb, congested non pulsating neck veins, inequality of radial pulse, stridor, hoarseness of voice and dilated veins on chest wall. Investigation of lung cancer • Investigation of lung cancer can be classified into:-

• Investigation for primary tumor for cell type and staging

• Investigation for detection of metastases Sputum cytology:

For detection of any malignant cells Chest X-ray: may show

• Area of collapse.

• Area of consolidation.

• Lung abscess: usually shaggy, thick walled with hilar enlargement.

• Mediastinal mass.

• Elevated diaphragm.

• Pleural effusion.

• Computed tomography CT of the chest:

• For accurate localization and evaluation hilar and mediastinal lymph nodes for staging.

 Positron emission tomography (PET) scan: Fluorodeoxyglucose or FDG is injected IV, It help for detection of early stage lung cancer or evaluation of metastases or LN if surgery may be a solution.

 • Fibreoptic bronchoscopy for: Endobronchial morphology of the tumor. Any widening of carina and distance of tumor from it for staging.

• Tissue diagnosis can be detected by biopsy brushing and bronchial washing.

• Evaluation of the vocal cords. Carcinoma at entrance to right upper lobe

• Transthoracic needle aspiration:

• For biopsy from peripheral lung lesion. • Mediastinoscopy:

• For evaluation of mediastinal lymph

nodes for staging • Pleural fluid cytology and pleural biopsy:

• For diagnosis of any associated pleural effusion. • Laboratory investigations:

• Hemoglobin percentage, ESR, liver function, serum Ca, serum alkaline phosphatase. • Assessment of metastases by:

• Abdominal ultrasound.

• Bone survey.

• Bone scan.

• Brain CT.