Lung Cancer.pdf

Clinical Examination of Patients with Suspected Lung Cancer 33
KEY PRACTICE POINTS
• In patients with suspected lung cancer, the clinical examination should include
a history and physical examination, routine blood work, chest radiography,
CT of the chest, other radiographic imaging as dictated by the findings
on these preliminary studies and the patient’s symptoms, appropriate
diagnostic biopsy, and preoperative testing of patients whose disease is
deemed potentially operable.
• Eliciting nonspecific constitutional symptoms (e.g., fatigue and weight loss)
in the history is important because their existence may direct the remainder
of the workup, offer useful prognostic information, and help the physician
determine which palliative care measures would be most appropriate.
• CT of the chest is more precise than chest radiography in the detection of
enlarged hilar and mediastinal lymph nodes, pleural and pericardial effusion,
invasion into the chest wall and mediastinal structures, lymphangitic carcinomatosis,
and smaller lung parenchymal metastases.
• When chest CT is used to determine whether mediastinal lymph node
metastases are present, the rate of false-positive findings is 30%, and the
rate of false-negative findings is 10%.
• CT of the abdomen with a contrast agent is warranted if the index of suspicion
of liver metastasis is high and the finding of liver metastases would
affect the patient’s treatment.
• Owing to the 2% to 10% incidence of benign adrenal adenoma in the general
population, patients in whom the sole indication of possible metastases
is adrenal enlargement of uncertain etiology noted on a CT scan of the chest
or abdomen should have further evaluation to exclude a benign tumor.
• MR imaging of the chest is generally superior to chest CT in determining the
presence of chest wall or vertebral body invasion.
• The diagnosis of malignancy in patients with suspected lung cancer should
be obtained with the least invasive procedure needed to obtain tissue.
Flexible Fiber-Optic Bronchoscopy
Flexible fiber-optic bronchoscopy is a useful tool for diagnosing suspected
lung cancer, although this method is somewhat dependent on the size, location,
and accessibility of the primary tumor. Endobronchial lesions that
can be directly visualized are sampled with the use of biopsy forceps,
washings, and brushings; the yield of bronchoscopy for such lesions is
greater than 80%. More peripheral lesions may be sampled with transbronchial
biopsy, washings, and brushings, with the diagnostic yield
highly dependent on the size of the lesion. For example, the yield is about
25% for lesions smaller than 2 cm but may be as high as 80% for lesions
larger than 4 cm. Submucosal tumors (e.g., small cell carcinoma) may be
sampled with transbronchial biopsy as well.