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Non-small cell lung cancer
Symptoms and signs

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	Lung Cancer
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Some patients present with an asymptomatic lesion discovered incidentally on the chest radiograph. However, the majority of lung cancers are discovered because of the development of a new or worsening clinical symptom or sign.

(1) those due to local tumor growth and intrathoracic spread,

Centrally located tumors produce cough, a localized wheeze, hemoptysis, and symptoms and signs of airway obstruction and postobstructive pneumonitis such as dyspnea, fever, and productive cough.

large tumor masses, usually of squamous or large-cell histology, cavitate and present as malignant lung abscesses

Peripheral tumors are more likely to be asymptomatic when they are small and confined within the lung; occasionally, cough and pleuritic chest pain may be evident.

Mediastinal invasion may be manifested as vague, poorly localized chest pain in association with other findings of nerve entrapment, vascular obstruction, and/or compression or invasion of the esophagus. One of the most common neurologic disorders arising from mediastinal involvement is hoarseness due to recurrent laryngeal nerve entrapment. Because of its longer intrathoracic course, hoarseness is more common from involvement of the left than the right recurrent laryngeal nerve. With recurrent laryngeal nerve paralysis, a patient may develop dysphagia for both solids and liquids, resulting in recurrent aspiration. Compression of the esophagus by the tumor may also lead to dysphagia. The formation of tracheo- or bronchoesophageal fistula, which occurs with a frequency of 0.16%, can be manifested by vigorous cough, especially on swallowing, and recurrent aspiration pneumonia.141 Involvement of the phrenic nerve is associated with hiccups early and later leads to paralysis and elevation of the hemidiaphragm with resulting dyspnea. The principal vascular syndrome associated with the extension of lung cancer into the mediastinum is superior vena cava (SVC) syndrome, most commonly from invasion of the vein and extrinsic compression by the tumor but also from intraluminal thrombosis.142 Lung cancer accounts for 65% to 90% of the cases of SVC syndrome, with approximately 85% of primary lung tumors occurring on the right, primarily in the right upper lobe or right mainstem bronchus.

With apical tumors, the classic Pancoasts syndrome (lower brachial plexopathy, Horner syndrome, and shoulder pain) may become manifest due to local invasion of the lower brachial plexus (C8 and T1 nerve roots), stellate ganglion, and chest wall.144 In addition, the tumor may cause symptoms due to involvement of the first or second rib or vertebrae and other nerve roots. The radiographic signs are those of an asymmetric apical cap or an apical mass.145 Most superior sulcus tumors are squamous cell carcinomas; less commonly, adenocarcinomas are seen.

Pleural involvement occurs in approximately 15% of patients with lung cancer at initial presentation, and 50% of patients with disseminated lung cancer develop pleural effusion during the course of their illness.147 A pleural effusion may be asymptomatic when small, but it is usually associated with dyspnea, cough, or chest pain. Although a number of pathogenic mechanisms have been invoked, the presence or absence of malignant cells in cytology specimens does not significantly influence the survival outcome, although pleural washings that show malignant cells during the time of pulmonary resection for lung cancer have been shown to impact negatively on survival.148,149 Rarely, lung cancer can present as an ipsilateral spontaneous pneumothorax, generally attributed to erosion of the visceral pleura by a peripheral lung cancer, but underlying emphysema may also play a role.

Pericardial involvement arises from direct extension of the tumor or as a result of retrograde spread through mediastinal and epicardial lymphatics. Lung cancer is the most common neoplasm that produces pericardial metastases, accounting for 37% of the reported cases.150 In many cases, the process is not diagnosed antemortem. Clinical findings include cardiac dysrhythmias, enlargement of the cardiac silhouette on the chest radiograph, and, infrequently, signs and symptoms of cardiac tamponade

(2) those due to distant metastases,

Although non-small cell lung cancer can metastasize to virtually any organ site, the most common sites of hematogenous spread that are clinically apparent are:

• Bones (bone pain)

• Liver (right upper quadrant pain or other liver symptoms)

• Adrenal glands (usually asymptomatic, and most adrenal metastases are discovered incidentally during staging evaluation or at autopsy. If symptomatic, it presents with unilateral pain in the flank, abdomen, or costovertebral angle).

(3) nonspecific systemic symptoms, and

• Weight loss occurs in approximately one-half of the patients

• Generalized weakness in one-third of the patients.

• Anorexia 30%

• Fever (usually associated with a documented infection e.g. postobstructive pneumonia or with liver metastases) in 20% of the cases.

• Anemia in less than 20% of the patients.

(4) paraneoplastic syndromes.

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