1. CLINICAL PRESENTATION OF LUNG CANCER
Joint ERS-AIPO Postgraduate Course, Florence, 4th December 2007
Professor SG Spiro
Department of Thoracic Medicine
UCLH NHS Trust, London

4. Cancer Statistics 2003 New cases Deaths 5 Year Survival
Primary site (no.) (no.)
Lung 171, ,
Colorectal 147, ,
Breast 212, ,
Pancreas 30, ,
Prostate 220, ,

5. Tumour size 1014 1012 1010 Number of tumour cells 108 106 104 102 10
1mm cm 3cm 10cm
1014
1012
1010
Number of tumour cells
108
106
Zone of
routine clinical
detection
104
102 10 20 30 40
Number of doublings

6. Initial Evaluation of the Patient With Lung Cancer: Symptoms, Signs, Laboratory Tests, and Paraneoplastic Syndromes ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition) Stephen G Spiro MD; Michael K Gould MD FCCP; and Gene L Colice MD FCCP
[CHEST 2007;132:149S-160S]

7. PRESENTATION LATE 80% inoperable at diagnosis
7 month delay from first symptom to presentation
10-15% proceed to attempted resection
Overall 5 year mortality 90-93%

12. Range of Frequencies of Initial Symptoms and Signs of Lung Cancer
Symptoms and Signs Range of Frequency (%)
Cough Weight loss Dyspnoa Chest pain Hemoptysis Bone pain Clubbing Fever Weakness Superior vena cava obstruction Dysphagia Wheezing and stridor
[CHEST 2007;132:149S-160S]

13. SYMPTOMS OFTEN MULTIPLE
In series of 678 consecutive lung cancer patients;
183 (27%) symptoms were primary tumour
232 (34%) non-specific suggestive of metastases (anorexia, weight loss, fatigue)
219 (32%) site specific metastatic symptoms

14. CHEST X-RAY Very few have incidental abnormal chest x-ray
6% (44) of 678
7% (24) of 364
13% (154) of 1277
The five year survival is better for asymptomatic patients – 18% versus 12% for symptoms

15. CHANGE OF SYMPTOMS
Patients with lung cancer may note a new symptom or a change in a usual symptom and delay reporting this
Delay may be 4 – 24 months
Specific symptom of haemoptysis – least delay

19. PRIMARY CARE DELAY
To chest x-ray - 56 days (a GP sees one case every 8 months!)
Cough – lung cancer not listed in 20 commonest diagnoses in Dutch GP study
Commonest symptoms at presentation were poor predictors of survival, eg. weight loss

20. DOES DELAY MATTER?
84 patients resected, no effect on 5 year survival for delays more or less than 90 days
1082 patients – resected in Spain – delays in time from diagnosis to surgery – no effect
Swedish study of 466 patients – those with more advanced disease had shorter time from first symptom to treatment (3.4m), compared to stage I-II (5.5m)
Those with shortest delays did the worst

21. PRESENTATION 1) Chest X-ray Variable presentation Right side commoner
40% central + consolidation
Adenocarcinoma commonest peripheral tumour
SCLC proximal, involving hilum and mediastinum

24. PRESENTATION 2) Symptoms and Signs of Intrathoracic Spread
Recurrent laryngeal nerve (2-18%)
Phrenic nerve (2-6%)
Brachial plexus (1-2%)
Sympathetic chain (1-2%)
Chest wall, pleura (up to 50%)
Vascular - SVCO (10%) pericardium heart
Oesophagus (5%)

29. PRESENTATION 3) Extrathoracic Metastases 30% present with these
Bones (up to 25%)
Liver (up to 30%)
Adrenals (10%)
Brain/cord (10%)
Nodes (15-20%)
Skin (1-5%)

32. PARANEOPLASTIC SYNDROMES ASSOCIATED WITH LUNG CANCER
SIADH production Systemic syndromes Nonmetastatic hypercalcemia Anorexia and cachexia Cushing syndrome Fever Gynecomastia Collagen-vascular syndromes Hypercalcitonemia Dermatomyositis Elevated levels of LSH and FSH Polymyositis Hypoglycemia Vasculitis Hyperthyroidism Systemic lupus erythematosus Carcinoid syndrome Cutaneous Neurologic syndromes Acquired hypertrichosis languinosa Subacute sensory neuropathy Erythema gyratum repens Mononeuritis multiplex Erythema multiforme Intestinal pseudo-obstruction Tylosis LEMS Erythrpoderma Encephalomyelitis Exfoliative dermatitis Necrotizing myelopathy Acanthosis nigricans Cancer associated retinopathy Sweet syndrome Skeletal syndromes Pruritus and urticaria Hypertrophic osteoarthropathy Hematologic Clubbing Anemia Renal syndromes Leucocytosis and eosinophilia Glomerulonephritis Leukemoid reactions Nephrotic syndrome Thrombocytosis Metabolic syndromes Thrombocytopenic purpura Lactic acidosis Coagulopathies Hypouricemia Thrombophlebitis Disseminated intravascular coagulation

33. PRESENTATION 4) Paraneoplastic Syndromes Hypercalcaemia 2-6%
Squamous cell primary – parathyroid hormone
Bone mets
SIADH production
Usually small cell % % abnormal water secretion
Low Na
Low urea
Low plasma osmolality
High (>2.5x) urine osmolality

34. PRESENTATION 4) Paraneoplastic Syndromes ACTH production SCLC
ACTH levels increased in 50%
Very few have florid Cushings
Clubbing and Hypertrophic Osteoarthropathy
Squamous and adenocarcinoma
Clubbing - occurs in up to 30% commoner in women
HPOA in <5% of NSCLC

35. PRESENTATION 4) Paraneoplastic Syndromes Lambert-Eaton Syndrome
Limbic encephalopathy
Polyneuropathy
Cerebellar degeneration
Retinopathy
Autonomic neuropathy
All SCLC – up to 5% of cases

36. ACCP RECOMMENDATIONS
It is recommended that patients with known or suspected lung cancer receive timely and efficient care. Grade of recommendation, 1B
It is recommended that all patients with known or suspected lung cancer give a thorough history, and undergo a thorough physical examination and standard laboratory tests as a screen for metastatic disease. Grade of recommendation, 1C
It is recommended that patients with lung cancer and a paraneoplastic syndrome not be precluded from potentially curative therapy on the basis of these symptoms, alone. Grade of recommendation, 2C