Chest
Volume 132, Issue 3, Supplement, September 2007, Pages 149S-160S
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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Initial Evaluation of the Patient With Lung Cancer: Symptoms, Signs, Laboratory Tests, and Paraneoplastic Syndromes: ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition)

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Background

This chapter of the guidelines is intended to provide an evidence-based assessment of the initial evaluation of patients recognized as having lung cancer and the recognition of paraneoplastic syndromes.

Methods

The current medical literature that is applicable to this issue was identified by a computerized search and was evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee of the American College of Chest Physicians.

Results

Patients with lung cancer usually present with multiple symptoms, both respiratory related and constitutional. There is usually a time delay between symptom recognition by the patient and the ultimate diagnosis of lung cancer by the physician. Whether this time delay impacts prognosis is unclear, but delivering timely and efficient care is an important component in its own right. Lung cancer may be accompanied by a variety of paraneoplastic syndromes. These syndromes may not necessarily preclude treatment with a curative intent.

Conclusions

The initial evaluation of the patient with known or suspected lung cancer should include an assessment of symptoms, signs, and laboratory test results in a standardized manner as a screen for identifying those patients with paraneoplastic syndromes and a higher likelihood of metastatic disease.

Section snippets

Materials and Methods

To update previous recommendations on the initial evaluation of the patient with lung cancer, guidelines on lung cancer diagnosis and management published between 2002 and May 2005 were identified by a systematic review of the literature (see “Methodology for Lung Cancer Evidence Review and Guidelines Development” section). Those guidelines including recommendations that are specific to the initial evaluation of the lung cancer patient were identified for possible inclusion in this section.

Presenting Symptoms of Lung Cancer

Initial presenting symptoms in patients with lung cancer may be respiratory related, but are often constitutional and attributable to metastatic disease (Table 1).2, 3, 4, 5, 6, 7 Cough is reported to be the most common presenting symptom of lung cancer; other respiratory symptoms include dyspnea, chest pain, and hemoptysis.8, 9, 10 Patients with lung cancer usually present with multiple symptoms, including both respiratory and constitutional.8, 9 In a series of 678 consecutive lung cancer

Recommendation

  • 1

    It is recommended that patients with known or suspected lung cancer receive timely and efficient care. Grade of recommendation, 1C

Presenting Radiographic Features of Lung Cancer

The chest radiograph plays a pivotal role in the recognition of lung cancer. Certainly, in the asymptomatic patient an abnormality on the chest radiograph would be the first clue to the presence of lung cancer. In patients with symptoms related to the primary tumor, the chest radiograph may often strongly support a suspicion of carcinoma of the lung. For patients presenting with either nonspecific systemic complaints or symptoms suggestive of metastatic disease, the chest radiograph will be

Symptoms Related to the Primary Tumor

Of the presenting symptoms in patients with lung cancer, cough, dyspnea, chest pain, and hemoptysis may be related to the primary tumor (Table 1). Cough is the most common presenting symptom in patients with lung cancer. Many lung cancers occur in the central airways and may lead to postobstructive pneumonia or may cause lymph node enlargement, which may lead to cough. The failure of acute exacerbations of COPD to clear should raise suspicion of the presence of a neoplasm. Dyspnea develops

Symptoms and Signs of Intrathoracic Spread

The intrathoracic spread of lung cancer, either by direct extension or lymphatic spread, produces a variety of symptoms and signs. These may be caused by the involvement of nerves (eg, recurrent laryngeal nerve, phrenic nerve, brachial plexus, and sympathetic nerve trunks), chest wall and pleura, vascular structures (eg, superior vena cava, pericardium, and heart), and visceral structures (eg, the esophagus).

Recurrent laryngeal nerve palsy, which causes hoarseness, has been reported in 2 to 18%

Symptoms, Signs, and Laboratory Tests Indicating Extrathoracic Metastases

About one third of patients present with symptoms as a result of distant metastases. The most common sites of distant metastasis from lung cancer are the bones; liver; adrenal glands and intraabdominal lymph nodes; brain and spinal cord; and lymph nodes and skin. Lung cancer can metastasize to virtually any bone, although the axial skeleton and proximal long bones are most commonly involved. The primary symptom resulting from bone involvement is pain, which may have a pleuritic component when

Standardized Evaluation for Systemic Metastases

Carbone et al11 and Feinstein and colleagues38, 39, 40, 41, 42 have explored the relationship between symptoms at presentation and prognosis in a large cohort of consecutive lung cancer patients. Patients with the best prognosis were either asymptomatic or had symptoms referable only to the primary tumor. In patients either with systemic symptoms of anorexia, weight loss, and fatigue or with symptoms attributable to metastatic disease, prognosis was especially poor. The relationship between

Recommendation

  • 2

    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, 1B

Paraneoplastic Syndromes

Paraneoplastic syndromes are a group of clinical disorders that are associated with malignant diseases that are not directly related to the physical effects of primary or metastatic tumors.48, 49 Paraneoplastic syndromes may occur in 10% of patients with bronchogenic carcinoma.2, 3 The extent of paraneoplastic symptoms is unrelated to the size of the primary tumor, and in some cases can precede the diagnosis of malignant disease. At other times they may occur late in the illness, or herald the

Hypercalcemia

The incidence of hypercalcemia in patients with lung cancer ranges from 2 to 6% at presentation to 8 to 12% throughout the course of the disease. Symptoms include nausea, vomiting, abdominal pain, constipation, polyuria, thirst, dehydration, confusion, and irritability. Squamous cell carcinoma is most frequently associated with hypercalcemia. Although bone metastases may be found in patients with lung cancer and hypercalcemia, most commonly humoral mechanisms account for the hypercalcemia.50, 51

Digital Clubbing and Hypertrophic Osteoarthropathy

Digital clubbing is an enlargement of the terminal segments of the fingers and/or toes due to proliferation of connective tissue beneath the nail matrix. Quantitative indexes of the nail profile angle, hyponychial angle and phalangeal depth ratio can be determined to assist in identifying clubbing.69 Hypertrophic osteoarthropathy (HOA) is a systemic disorder, which involves both a painful symmetrical arthropathy, usually of the ankles, wrists, and knees, and periosteal new bone formation in the

Neurologic Syndromes

A variety of poorly understood neurologic syndromes may occur in patients with lung cancer.46 The diagnosis of a neurologic paraneoplastic syndrome is made once other causes, such as electrolyte imbalance, metastatic disease, cerebral and spinal vascular disease, infections, and treatment toxicity, are excluded. The neurologic syndromes include the Lambert-Eaton myasthenic syndrome (LEMS), limbic encephalopathy, polyneuropathy, cerebellar degeneration, retinopathy, opsoclonus-myoclonus, and

Recommendation

  • 3

    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

Summary

Most patients with lung cancer will be symptomatic at presentation. A minority of patients presents with symptoms related to the primary tumor, but most patients present with either nonspecific systemic symptoms, including anorexia, weight loss, and fatigue, or specific symptoms indicating metastatic disease. Asymptomatic patients and patients with symptoms related to the primary tumor have better 5-year survival rates than those patients with systemic symptoms or symptoms indicating metastatic

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    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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