Examine this patient's chest.
· Symptoms related to:
-Primary tumour (cough, dyspnoea, haemoptysis, post-obstructive pneumonia).
-Mediastinal spread (hoarseness with left-sided lesions due to recurrent laryngeal nerve palsy; obstruction of the superior vena cava
with right-sided tumours or associated lymphadenopathy; elevation of the hemidiaphragm as result of phrenic nerve paralysis;
dysphagia from oesophageal obstruction and pericardial tamponade).
- Metastases (sites include liver, brain, pleural cavity, bone, adrenal glands, contra-lateral lung and skin). (Initial presentation
with symptoms from a metastatic focus is particularly common with adenocarcinoma.)
-Paraneoplastic syndrome (pain in arms or legs due to hypertrophic osteo-arthropathy, symptoms of hypercalcaemia due to
squamous cell carcinoma, neurological syndromes).
-Systemic effects (anorexia, weight loss, weakness and profound fatigue).
· History of smoking.
· Patient 1 has clubbing and tar staining of the fingers.
-Dull percussion note at the apex with absent breath sounds.
-Look for Homer's syndrome and wasting of the small muscles of the hand.
· Patient 2 has signs of pleural effusion on one side.
· Patient 3 shows signs of unilateral collapse or consolidation of the upper lobe on one side.
Note. If you suspect bronchogenic carcinoma, always look for clubbing, tar staining, cervical lymph nodes and radiation marks, and
comment on cachexia.
This patient with marked clubbing and large pleural effusion (lesion) probably has bronchogenic carcinoma (aetiology) and is very
short of breath due to the large
Read BMJ 1992; 304: 1298; BMJ 1990; 301: 1287.
How may patients with bronchogenic carcinoma present?
· Cough (in 80% of cases), haemoptysis (70%) and dyspnoea (60%); loss of weight, anorexia.
· Skeletal manifestations: clubbing (in 30% of cases).
· Local pressure effects: recurrent laryngeal nerve palsy, superior vena caval obstruction, Homer's syndrome.
· Endocrine manifestations: 12% of tumours - in particular small cell tumours -present with syndrome of inappropriate antidiuretic
hormone (SIADH), hyper-calcaemia, adrenocorticotrophic hormone (ACTH) secretion, gynaecomastia. SIADH does not usually
cause symptoms. When Cushing's syndrome occurs the manifestations are primarily metabolic (hypokalaemic alkalosis).
· Neurological manifestations: Eaton-Lambert syndrome, cerebellar degeneration, polyneuropathy, dementia, proximal
myopathy, encephalomyelitis, subacute sensory neuropathy, limbic encephalitis, opsoclonus and myoclonus.
· Cardiovascular: thrombophlebitis migrans, atrial fibrillation, pericarditis, non-bacterial thrombotic endocarditis.
· Cutaneous manifestations: dermatomyositis, acanthosis nigricans, herpes zoster.
· Anaemia, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura. Hypercoagulopathy in the form of
venous thromboembolism is seen, especially with adenocarcinoma.
· Membranous glomerulonephritis.
How would you investigate this patient?
· Sputum cytology: high yield for endobronchial tumours such as squamous cell and small cell carcinoma but poor yield for
· Pleural fluid cytology.
· Bronchoscopy gives a high yield in excess of 90%, particularly when the tumour is viewed endobronchially. For tumours that
are not visualized , the yield for washing and brushing is about 75% in central lesions and 55% in peripheral lesions. The yield
in small-cell and squamous cell carcinomas is higher than in adenocarcinomas.
· CT scan of the chest and upper abdomen (to image the liver and adrenals).
· Bone scan for metastases (helpful in staging).
· PET scanning is highly sensitive and specific for mediastinal staging.
· Pulmonary function tests (most surgeons aim for a FEV1 of about I litre after planned resection); a DLCO below 60% predicted
is associated with a mortality rate as high as 25% due to respiratory complications.
What is the aim of staging?
The main aim of staging is to identity candidates for surgical resection, since this approach offers the highest potential cure for lung
cancer. The staging assessment covers three major issues: distant metastases, the state of the chest and media-stinum, and the
condition of the patient.
What is the role of surgery in lung carcinoma?
Surgery is beneficial in peripheral non-small cell carcinoma. Its role is limited in small cell carcinoma, as over 90% have
metastasized by the time of diagnosis.
Which tumours respond well to chemotherapy?
Small cell carcinoma: cyclophosphamide, doxorubicin, cisplatin, etoposide and vincristine are some of the drugs used. The
combination of etoposide and cisplatin appears to have the best therapeutic index of any regimen. A meta-analysis of the role of
chemotherapy in non-small cell lung cancers suggested that the benefits are small.
What are the drugs used in non-small cell lung cancer?
· Old agents: cisplatin, carboplatin, etoposide, vinblastine, vindesine.
· Newer agents: docetaxel, paclitaxel, irinotecan, vinorelbine, gemcitabine.
What are the indications for radiotherapy?
· Pain - either local or metastatic.
· Breathlessness due to bronchial obstruction.
· Superior venal caval obstruction.
· Pancoast's tumour.
· Before and after operation in selected patients.
What are the contraindications for surgery?
· Metastatic carcinoma.
· FEVt less than 1.5 litres.
· Transfer factor less than 50%.
· Severe pulmonary hypertension.
· Uncontrolled major cardiac arrhythmias.
· Carbon dioxide retention.
· Myocardial infarction in the past 3 months.
Is the progression of cancer associated with genetic change?
Yes: it is accompanied by a mutation in the p53 gene and loss of a portion of' the short arm of chromosome 3 in small cell cancer;
the functional significance of this is not clear.
Robert Souhami, Professor of Clinical Oncology, University College and Middlesex School of Medicine, London.