Lung Cancer.pdf

Clinical Examination of Patients with Suspected Lung Cancer 27
face, neck, and chest wall. Cough may result from endobronchial tumor,
pneumonia, or pleural effusion. Hemoptysis is commonly seen in patients
with endobronchial lesions and may also result from associated complications
of lung cancer, such as pulmonary embolus or pneumonia. Dyspnea
may be due to a variety of factors, including endobronchial disease, atelectasis,
postobstructive pneumonia, pleural effusion, pulmonary embolus,
and lymphangitic spread. Dyspnea may also be due to arrhythmia or
tamponade resulting from pericardial effusion.
Fever may result from pneumonia, or it may occur in the absence of
frank infection in patients with postobstructive atelectasis. Chest pain commonly
occurs in patients whose disease involves the pleura or chest wall.
Hoarseness may result from vocal cord paralysis in patients with mediastinal
disease affecting the recurrent laryngeal nerve; occasionally, patients
with massive mediastinal disease may develop bilateral vocal cord paralysis,
resulting in stridor due to upper airway obstruction. Patients with large
right-sided central tumors may develop obstruction of the superior vena
cava, resulting in a typical syndrome of swelling and venous distension of
the face, neck, and chest wall, sometimes associated with shortness of
breath, headache, and, in extreme cases, altered mental status.
Symptoms and Signs Due to Distant Metastases
Distant metastatic disease may also cause symptoms and findings on
physical examination that are pertinent to treatment planning and prognosis.
The most common sites of metastasis of lung cancer are the adrenal
glands, liver, central nervous system (CNS), and bone.
Adrenal metastases are quite common in patients with non–small cell
lung cancer (NSCLC) but rather uncommon in patients with small cell
lung cancer (SCLC). Adrenal metastases are rarely symptomatic, are not
typically associated with any findings on physical examination, and are
usually only discovered on routine radiographic studies (chest radiography
and CT of the chest). Occasionally, however, massive adrenal metastases
can cause flank pain. In addition, patients with advanced bilateral
adrenal metastases may develop symptoms of adrenal insufficiency.
Liver metastases occur frequently in patients with lung cancer, more
commonly with SCLC than with NSCLC. The symptoms of hepatic metastases
may include jaundice and right upper quadrant pain associated with
the findings of hepatomegaly and liver tenderness on examination. However,
these findings usually occur only in patients with very advanced
liver disease. More commonly, hepatic metastases present with less specific
symptoms, such as anorexia, malaise, and weight loss.
Metastases to the CNS are commonly seen in both SCLC and NSCLC
(particularly adenocarcinoma). While CNS metastases are often asymptomatic
and discovered only incidentally during radiographic evaluation,
there are certainly many symptoms and physical findings related to CNS
involvement that the clinician should be attuned to when doing the baseline