8. clinical presentation

7/29/2019 8. Clinical Presentation

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CLINICALCLINICAL


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Wide range of symptoms and signs isWide range of symptoms and signs is

related to:related to:

1. Histologic features which often help determinethe anatomic site of origin in the lung

2. The specific tumor location in the lung and itsrelationship to surrounding structures

3. Biologic features and the production of avariety of paraneoplastic syndromes

4. The presence or absence of metastatic disease


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Clinical Presentation of Lung CancerClinical Presentation of Lung Cancer

Pulmonary symptoms

Cough Bronchus irritation orcompression

Dyspnea Airway obstruction orcompression

Wheezing >50% airway obstruction


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Nonpulmonary thoracic symptomsHemoptysis Tumor erosion or irritation

Pneumonia Airway obstruction

Pleuritic pain Parietal pleural irritation or invasion

Local chest Rib and/or muscle involvement

wall pain


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Radicular chest pain Intercostal nerve involvement

Pancoast's syndrome Stellate ganglion, chest wall,brachial

plexus involvement

Hoarseness Recurrent laryngeal nerveinvolvement

Swelling of head and arms :1.Bulky involved mediastinal

lymph nodes

2.Medially based right upper lobe


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TUMOR HISTOLOGYTUMOR HISTOLOGY

Squamous cell and small cell carcinomas:Arise in main lobar, or first

segmental bronchi{centralairways}

Adenocarcinomas: located peripherally,Asymptomatic peripheral lesion on chest

radiograph

BAC : solitary nodule, as multifocal nodules, or as a

diffuse infiltrate mimicking(PNEUMONIC FORM)air bronchograms may be seen radiographically

within the tumor


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SITE OF TUMORS

Squamous cell = 66% occur centrally in lunghilus(sq=central)

Adenocarcinoma = Peripheral,

Small (oat) cell = Central, highly malignant,usually not operable

Large cell = Usually peripheral, verymalignant


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Nonpulmonary Thoracic Symptoms

OCCURS DUE TO invasion of the primary tumor directlyinto a contiguous structure or from mechanicalcompression of a structure by enlarged tumor-bearinglymph nodes

Peripherally located tumors ( adenocarcinomas)extending through the visceral pleura lead to irritationor growth into the parietal pleura and to continuedgrowth into the chest wall structures

SYMPTOMS depending on the extent of chest wall

involvement1.pleuritic pain

2.localized chest wall pain

3.radicular pain


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Superior sulcus tumors (usuallyadenocarcinomas)

may produce the Pancoast syndromeTumoratthe apex of the lung or superior sulcus that mayinvolve the brachial plexus, sympathetic ganglia,

and vertebral bodies, leading to pain, upperextremity weakness, and

Horners syndrome

Injury to the cervical sympathetic chain(MAP)

1. Miosis (small pupil)

2. Anhydrosis of ipsilateral face

3. Ptosis

Depending on the exact tumor location, symptoms

can include


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Invasion of the primary tumor into the mediastinummay lead to involvement of the phrenic or recurrent laryngealnerves. Direct invasion of the phrenic nerve occurs withtumors of the medial surface of the lung, or with anterior hilartumors.

Symptoms may include

1.shoulder pain (referred),

2.hiccups, and dyspnea with exertion

Because of diaphragm paralysis

Diagnosis;chest radiograph,fluoroscopic examination of thediaphragm and with breathing and sniffing (the sniff test)


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Recurrent laryngeal nerve (RLN)

most commonly occurs on the left side.

Paralysis may occur

1. invasion of the vagus nerve above the aortic arch by amedially based left upper lobe (LUL) tumor,

2.invasion of the RLN directly by a hilar tumor,

3.invasion by hilar or aortopulmonary lymph nodes

involved with metastatic tumor.


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Symptoms:

Voice change,often referred to as hoarseness,

Loss of tone associated with a breathy quality,

Coughing( when drinking liquids)


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Tumor BiologyTumor Biology

Lung cancers both nonsmall-cell andsmall-cellcarcinoma

Capable of producing a variety of paraneoplasticsyndrome

Most often from tumor production and release ofbiologically active materials systemically.

Majority ofsuch syndromes are caused by small-cellcarcinomas, including many endocrinopathies.


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Paraneoplastic syndromes

Early diagnosis. Presence does not influence resectabilityor the potential to successfully treat the tumor.

Symptoms of the syndrome often will abate with

successful treatment, and recurrence may be heraldedby recurrent paraneoplastic symptoms.

5 general types of paraneoplastic syndromes.

1. Metabolic: Cushings, SIADH, hypercalcemia

2. Neuromuscular: Eaton-Lambert,cerebellar ataxia3. Skeletal: hypertrophic osteoarthropathy

4. Dermatologic: acanthosis nigricans

5. Vascular: thrombophlebitis


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SCLC :: hypertrophic pulmonaryosteoarthropathy (HPO)

Most common paraneoplasticsyndromes

Syndrome is characterized by tenderness andswelling of the ankles, feet, forearms, and hands.

Because of periostitis of the fibula, tibia, radius,metacarpals, and metatarsals.


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HypercalcemiaHypercalcemia

10% of patients with lung cancer and is most oftenbecause of metastatic disease

15 % of cases are because of secretion of ectopicparathyroid hormonerelated peptide, most often

with squamous cell carcinoma

Diagnosis of ectopic parathyroid hormone secretioncan be made by measuring elevated serum levels

of parathyroid hormone; the clinician must also ruleout concurrent metastatic bone disease by a bonescan.


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Metastatic SymptomsMetastatic Symptoms

METASTASES occur most commonly

Central nervous system (CNS),

Vertebral bodies,

Bones,Liver,

Adrenal glands,

Lungs,Skin and Soft tissues.

10 % of patients with lung cancer have CNSmetastases

1015 %will develop CNS metastases

SYMPTOMS: headache, nausea and vomiting,

seizures, hemiplegia, and speech difficulty.


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Nonspecific SymptomsNonspecific Symptoms

Lung cancer often produces a variety ofnonspecific symptoms such as

Anorexia

Weight loss

Fatigue

Malaise

The cause of these symptoms is oftenunclear, should raiseconcern about possible metastatic disease


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8. clinical presentation

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