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Key Features

Essentials of Diagnosis

  • New cough or change in chronic cough

  • Dyspnea, hemoptysis, anorexia, weight loss

  • Enlarging nodule or mass, persistent opacity, atelectasis, or pleural effusion on chest radiograph or CT scan

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

General Considerations

  • Leading cause of cancer deaths

  • Cigarettes smoking causes 85–90% of lung cancers

  • Small cell lung cancer (SCLC) (13%)

    • Bronchial origin, begins centrally, and infiltrates submucosally

    • Prone to early hematogenous spread

    • Is rarely amenable to resection

    • Has a very aggressive course

  • Non–small cell lung cancer (NSCLC)

    • Spreads more slowly

    • Early disease may be cured with resection

    • Histologic types

      • Squamous cell carcinoma (23%) arises from bronchial epithelium; it is usually centrally located and intraluminal

      • Adenocarcinoma (47%) arises from mucous glands or from any epithelial cell within or distal to terminal bronchioles; usually presents as peripheral nodules or masses

      • Adenocarcinoma in situ (formerly bronchioloalveolar cell carcinoma) spreads along preexisting alveolar structures (lepidic growth) without evidence of invasion

      • Large cell carcinoma (2%) is a heterogeneous group and presents as a central or peripheral mass

Demographics

  • Median age at diagnosis in the United States is 70 years

  • Environmental risk factors include

    • Tobacco smoke

    • Radon gas

    • Asbestos

    • Metals

    • Diesel exhaust

    • Ionizing radiation

    • Industrial carcinogens

  • A familial predisposition is recognized

  • Chronic obstructive pulmonary disease, pulmonary fibrosis, and sarcoidosis are associated with an increased risk of lung cancer

Clinical Findings

Symptoms and Signs

  • Majority of patients are symptomatic at diagnosis

  • Presentation depends on

    • Type and location of tumor

    • Extent of spread

    • Presence of distant metastases

    • Any paraneoplastic syndrome

  • Anorexia, weight loss, and asthenia in 55–90%

  • New or changed cough in up to 60%

  • Hemoptysis in 5–30%

  • Pain, often from bony metastases, in 25–40%

  • Local spread may result in endobronchial obstruction and postobstructive pneumonia, effusions, or a change in voice due to recurrent laryngeal nerve involvement

  • Superior vena cava (SVC) syndrome

  • Horner syndrome

  • Liver metastases are associated with asthenia and weight loss

  • Possible presentation of brain metastases

    • Headache

    • Nausea and vomiting

    • Seizures

    • Dizziness

    • Altered mental status

  • Paraneoplastic syndromes (eTable 39–1)

    • Syndrome of inappropriate antidiuretic hormone secretion occurs in 10–15% of SCLC patients

    • Hypercalcemia occurs in 10% of SCLC patients

eTable 39–1.Paraneoplastic syndromes associated with cancer.

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