Non-small cell lung cancer

Case history

A 65-year-old man presents with a 2-month history of a dry persistent cough and 4.5 kg unintentional weight loss. He denies fevers, dyspnoea, sore throat, rhinorrhoea, chest pain or haemoptysis. Medical history is significant for COPD and hypertension. Family history is non-contributory. He smoked one pack of cigarettes daily for 40 years but quit 5 years ago. No adenopathy is palpable on examination and breath sounds are diminished globally without focal wheezes or crackles.

Other presentations

Lung cancer can present without symptoms. This is possibly due to the large functional reserve of the lungs and lack of pain fibres within the lung parenchyma. Consequently, lung cancer can present as an incidental mass on chest x-ray or computed tomography. Eventually, patients develop symptoms from local tumour growth within the lung, including cough, dyspnoea, chest pain, and/or haemoptysis.[3]Ost DE, Yeung SC, Tanoue LT, et al. Clinical and organizational factors in the initial evaluation of patients with lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e121S-e141S. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694609 http://www.ncbi.nlm.nih.gov/pubmed/23649435?tool=bestpractice.com Cough is the most common symptom, followed by dyspnoea. Haemoptysis typically consists of blood-tinged sputum, blood streaks in sputum, or small clots. It is a relatively uncommon symptom (compared with cough and dyspnoea) but more specific for lung cancer. Massive haemoptysis is rare. Invasion of the pleura or chest wall can cause chest pain. Obstruction of major airways can cause dyspnoea, wheezing, or post-obstructive pneumonia. A pneumonia that does not rapidly clear with antibiotics is cause for concern for lung cancer, especially in patients with a tobacco history.

Lung cancer often spreads to mediastinal lymph nodes. Symptoms from mediastinal adenopathy are relatively rare. However, bulky adenopathy can cause hoarseness (impingement of the recurrent laryngeal nerve), paralysis of the diaphragm (impingement of the phrenic nerve), difficulty swallowing (impingement of the oesophagus), or superior vena cava syndrome, typically characterised by upper extremity and facial oedema, orthopnoea, cough, and venous distension of the neck and chest wall.[4]Wudel LJ, Nesbitt JC. Superior vena cava syndrome. Curr Treat Options Oncol. 2001 Feb;2(1):77-91. http://www.ncbi.nlm.nih.gov/pubmed/12057143?tool=bestpractice.com

Lung cancer can also present as a superior sulcus tumour (sometimes called a Pancoast tumour), most commonly presenting with shoulder pain.[5]Archie VC, Thomas CR Jr. Superior sulcus tumors: a mini-review. Oncologist. 2004 Sep 1;9(5):550-5. https://academic.oup.com/oncolo/article/9/5/550/6387973 http://www.ncbi.nlm.nih.gov/pubmed/15477640?tool=bestpractice.com These tumours may also compress and invade the brachial plexus (causing weakness and/or atrophy of the intrinsic muscles of the hand, paraesthesias, and/or pain in a C8/T1 distribution) or sympathetic chain (causing Horner's syndrome, characterised by ptosis, miosis, and ipsilateral anhidrosis). Other presentations include clubbing, hypertrophic osteoarthropathy, hypercalcaemia of malignancy, and symptoms or signs of metastases to other organs such as bones and the brain.