Thoracic cancer -- Case presentation, differential diagnosis 三軍總醫院胸腔暨重症醫學科 沈志浩醫師 105.8.16

Outline Clinical presentation of thoracic cancer Case presentation and differential diagnosis

Most patients with early stage lung cancer is free from symptoms !

Lung cancer with advanced disease The majority of diagnosed lung cancer patients have advanced disease (stage IIIb or stage IV) Absence of symptoms until locally advanced or metastatic disease is present Aggressive biology of lung cancer From Midthun DE, Jett JR: Clinical presentation of lung cancer. In Pass HI, Mitchell JB, Johnson DH, et al (eds): Lung Cancer: Principles and Practice. Philadelphia: Lippincott-Raven, 1996, p 422. Principles and Practice. Philadelphia: Lippincott-Raven, 1996, p 422

Symptoms of thoracic cancers Symptoms were varied Origin (lung, major airway, pleura, chest wall, mediastinum) Cancer cell types and para-neoplastic syndrome Involved region (bone, liver, brain, adrenal gland metastasis, etc.)

Intrathoracic effects of the cancer

Cough Occurs most frequently in squamous cell carcinoma and small cell carcinoma Tendency to involve central airways Bronchorrhea (productive of large volumes of thin, mucoid secretions) May be a feature of mucinous adenocarcinoma Post-obstructive pneumonia Bronchiectasis (after chronic bronchial obstruction) Slow-growing neoplasms such as carcinoid tumor or hamartoma Malignant pleural effusion

Hemoptysis Bronchitis is the most common cause of hemoptysis ! Involve central airways Large volumes of hemoptysis may cause asphyxia Diagnosis – bronchoscopy Bronchitis is the most common cause of hemoptysis ! bronchitis is the most common cause of hemoptysis !

Chest pain More common in younger patients On the same side of the chest as the primary tumor Dull and persistent pain Occur from mediastinal, pleural, or chest wall extension Sharp pain; more severe when the lungs move during breathing, coughing, sneezing, etc. -- pleuritic pain Direct pleural involvement, obstructive pneumonitis, pulmonary embolus (hypercoagulable state)

Dyspnea

Dyspnea Extrinsic or intraluminal airway obstruction Partial obstruction of a bronchus -- localized wheeze Obstruction of larger airways -- stridor Obstructive pneumonitis or atelectasis Lymphangitic tumor spread Tumor emboli Pleural effusion; pericardial effusion with tamponade Unilateral paralysis of the diaphragm -- damage of the phrenic nerve Pneumothorax

Hoarseness Malignancy involving the recurrent laryngeal nerve along its course under the arch of the aorta and back to the larynx

Superior vena cava syndrome Obstruction of blood flow through the superior vena cava (SVC) A sensation of fullness in the head and dyspnea Dilated neck veins, a prominent venous pattern on the chest, facial edema, and a plethoric appearance More common in patients with small cell carcinoma

Pancoast syndrome Lung cancers arising in the superior sulcus Pain (usually in the shoulder), Horner's syndrome, bony destruction, and atrophy of hand muscles Most commonly caused by NSCLC (typically squamous cell) *** Horner's syndrome: miosis (constriction of the pupils), anhidrosis (lack of sweating), ptosis (drooping of the eyelid) and enophthalmos (sunken eyeball)

Para-neoplastic syndrome

Hypercalcemia Bony metastasis or tumor secretion Parathyroid hormone-related protein (PTHrP) Calcitriol Cytokines activetes osteoclast Advanced disease (stage III or IV) Symptoms of hypercalcemia Anorexia, nausea, vomiting, constipation, lethargy, polyuria, polydipsia and dehydration Renal failure and nephrocalcinosis

SIADH (syndrome of inappropriate antidiuretic hormone secretion) Frequently caused by small cell carcinoma Hyponatremia Severity of symptoms is related to the degree of hyponatremia Anorexia, nausea, and vomiting Cerebral edema Acute or chronic ?

Neurologic manifestations Associated with small cell carcinoma Diverse neurologic manifestations Lambert-Eaton myasthenic syndrome (LEMS), cerebellar ataxia, sensory neuropathy, limbic encephalitis, encephalomyelitis, autonomic neuropathy, retinopathy, and opsomyoclonus

Hematologic manifestations Anemia Leukocytosis Thrombocytosis Eosinophilia Hypercoagulable disorders Trousseau's syndrome (migratory superficial thrombophlebitis) Deep venous thrombosis and thromboembolism Disseminated intravascular coagulopathy Thrombotic microangiopathy Nonthrombotic microangiopathy

Others Hypertrophic osteoarthropathy Dermatomyositis and polymyositis Clubbing; periosteal proliferation of the tubular bones Dermatomyositis and polymyositis Inflammatory myopathy Cushing's syndrome (Small cell carcinoma and carcinoid tumors) Ectopic production of adrenal corticotropin (ACTH)

Case presentation and differential diagnosis

Case 1 七十五家庭主婦。從不抽菸也無氣喘病史，自半年前就開始乾咳，咳嗽症狀並沒有日夜差異、沒有氣促、濃痰或發燒、也沒鼻腔症狀，飲食習慣正常也沒有消化性潰瘍病史，本也不以為意，但在這兩周開始除了咳嗽外還伴隨左後背疼痛。於是至門診就診。

Chest CNY-CT

How to describe pulmonary lesions? Shape spherical, oval, or lobulated corona radiata Size Nodule < 3cm Mass ≧ 3cm Location Contrast enhancement Rate of growth Volume doubling times are very rarely less than 1 month or more than 18 months Calcification and cavitation Ground-glass density Obstruction signs Golden S sign

Case 2 58歲男性，老煙槍，每日二包菸38年。慢性咳嗽兩年。半年前斷斷續續咳痰帶血絲。最近四週因胸悶、喘和臉、頸和雙臂腫脹就診。

Chest CNY-CT

Location Intrapulmonary Central Peripheral Extrapulmonary Arising at or close to the hilum/segmental bronchi Golden S sign Pneumonia or expansion confined to one lobe Pneumonia that is unchanged for more than 2 weeks or one that recurs in the same lobe after a short interval Peripheral Arising beyond the hilum/segmental bronchi Rarely visible on chest radiographs when below 1 cm in diameter Extrapulmonary Pleural tumor Mesothelioma Metastatic Mediastunum Lymphoma Esophageal tumors Germ cell tumor Thymoma Thyroid cancer Neurogenic tumors Chest wall Bone tumor Sarcema

Case 3 38女性，早餐店老闆娘。氣喘長期用藥控制。右側胸痛三個月。

Missed lung cancers The miss rate was particularly high in the CXR About 65% of cancers in a yearly screening program had been overlooked on the previous film Most cancers missed at CT are endobronchial in location or are situated in the perihilar region and confused with blood vessels

Discussion