History and exam
Key diagnostic factors
common
cough
A new or persistent cough, especially in a current or former smoker, is suspicious and requires imaging of the chest.
Cough is present at diagnosis in over 50% of patients with lung cancer and may be secondary to postobstructive pneumonia, endobronchial tumor, or pleural effusion.[4]
dyspnea
Present at diagnosis in the majority of patients.[4]
Possible causes include airway obstruction, underlying COPD, pneumonia, phrenic nerve paralysis, or a pleural effusion.
hemoptysis
Occurs in approximately 25% of patients.[4]
Although massive hemoptysis is rare, patients with lung cancer often cough up blood-tinged sputum. Hemoptysis in a smoker is suspicious for lung cancer.
chest pain
Chest pain or discomfort is present in approximately 33% of patients.[4]
The lung is devoid of pain fibers. Therefore, most patients with chest pain have tumors that are invading the pleura or chest wall. However, patients with early disease can present with chest discomfort.
Other diagnostic factors
common
age 65 to 74 years
male sex
More common in men. Age-adjusted incidence in males is 56.4 new cases per 100,000, compared with 45.3 cases per 100,000 in females (SEER 2016-2020).[6]
fatigue
Nonspecific symptom of lung cancer; often multifactorial.
pulmonary exam abnormalities
Auscultation of the lungs may demonstrate wheeze, rales, decreased breath sounds, and dullness to percussion.
uncommon
hoarseness
2% to 18% can present with hoarseness, secondary to recurrent laryngeal nerve paralysis.[4]
confusion
A common symptom of brain metastases. Up to 40% to 50% of patients with lung cancer develop brain metastases.[29]
personality changes
May occur in the setting of brain metastases.
nausea and vomiting
May indicate brain metastases.
headache
May indicate brain metastases.
dysphagia
May occur if tumor has narrowed or obstructed the esophagus.
bone pain and/or fractures
Pain or pathologic fractures can result from bone metastases. The axial skeleton and proximal long bones are most frequently involved.[4]
seizures
A potential symptom of brain metastases.
cervical or supraclavicular adenopathy
The most common sites of regional spread are the hilum and mediastinum. The next levels of lymph node spread are the supraclavicular fossae and cervical chains.
facial swelling
May indicate compression of the superior vena cava, either from mediastinal adenopathy or from a right upper lobe tumor extending centrally into the mediastinum.
dilated neck or chest/abdominal wall veins
Distended neck veins or venous collaterals on the chest or abdominal wall may indicate compression of the superior vena cava.
finger clubbing
More common in non-small cell lung cancer than SCLC (35% vs. 4%).[4]
hypertrophic osteoarthropathy
Painful arthropathy of the wrists, ankles, and knees with periosteal new bone formation. SCLC is a rare cause.[4]
Risk factors
strong
cigarette smoking
Numerous epidemiologic studies link lung cancer and cigarette smoking.[12][13][14]
Tobacco smoke contains multiple carcinogens, including polynuclear aromatic hydrocarbons, aromatic amines, N-nitrosamines, and other organic and inorganic compounds.[15] Some data suggest that the presence of COPD may be an independent risk factor for lung cancer development, regardless of smoking status.[18]
environmental tobacco exposure
Environmental tobacco smoke (second-hand smoke) is an important cause of lung cancer and represents one of the risk factors for lung cancer development among never-smokers.[19] Available data demonstrate that second-hand smoke exposure both in the workplace and in the home is associated with higher incidence of lung cancer and increased lung-cancer associated mortality.[20]
radon gas exposure
Uranium is normally found in the earth's crust. Uranium decay produces radon gas, which can percolate into homes. Radon gas is inert but decays with a half-life of 3.8 days into polonium 214 and polonium 218. Both substances emit alpha particles, which damage DNA and can lead to malignant transformation.
Numerous case-control studies have associated both occupational (mining) and residential radon exposure with lung cancer. Radon may contribute up to an estimated 10% of all lung cancer cases.[21][22]
weak
asbestos exposure
Asbestos fibers are carcinogens that lodge in the lung and are a risk factor for lung cancer, especially in smokers and heavily exposed people.[23] Epidemiologic data have linked asbestos with lung cancer (all histologic variants), whether or not the patient has developed asbestosis - a diffuse interstitial lung fibrosis secondary to asbestos exposure.[24]
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