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Lung Cancer: Clinical Presentation, Epidemiology, 1 Tumor Staging, Classification, Histologic Grading, and Spread Through Air Spaces

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Lung Cancer: Clinical Presentation, Epidemiology, 1 Tumor Staging, Classification, Histologic Grading, and Spread Through Air Spaces LUNG CANCER: CLINICAL PRESENTATION, EPIDEMIOLOGY, 1 TUMOR STAGING, CLASSIFICATION, HISTOLOGIC GRADING, AND SPREAD THROUGH AIR SPACES CLINICAL PRESENTATION vena cava, or metastasis to distant sites such as Lung cancer presents in different ways, the bone or brain (Table 1-1). largely depending on the location and size of Although the presentation of primary lung the tumor and whether it remains localized to cancer varies with the location and size of the the lung or is metastatic (Table 1-1). One third tumor mass, its extent of spread, and its cell of lung cancer patients present with early stage type, there are many features of lung cancers disease and the rest with advanced disease. Pa- that overlap. Five to 20 percent of patients are tients with early stage tumors may have mini- asymptomatic at the time of diagnosis. These mal or no symptoms; lung cancer screening has patients usually have a chest radiographic im- led to the increased detection of such cancers, aging procedure that reveals a small lung mass resulting in a greater than 20 percent reduction which gets sampled for pathology. However, in mortality (1). Patients with advanced disease over 80 percent of new lung cancer patients can present with symptoms related to invasion have one or more symptoms referable to their or compression of major structures, such as the disease at the time of initial diagnosis, many of Table 1-1 LUNG CANCER PRESENTING SYMPTOMSa Category Symptom Pathogenesis Primary tumor Cough Airway obstruction, atelectasis, infection, airway infammation Hemoptysis Airway infammation or necrosis, tumor necrosis and cavitation Dyspnea Airway compression, lymphangitic spread, pleural effusion, thromboembolism, pericardial effusion Pain from invasion of chest wall or brachial plexus, Direct extension hoarseness from impingement of the recurrent laryngeal nerve, superior vena cava (SVC) syndrome, Horner syndrome (ptosis, miosis, anhidrosis) from invasion of the sympathetic chain and stellate gan- glion, pericardial tamponade Metastases Headache, bony pain, weight loss, anorexia, fatigue Sites: brain, bone, liver, adrenal gland, and lung Paraneoplastic Hyponatremia Syndrome of inappropriate antidiuretic syndromes Hypercalcemia Parathyroid hormone-related peptide Cushing syndrome (SCLC, carcinoid) Ectopic corticotropin Hypertrophic pulmonary osteoarthropathy Lambert-Easton myasthenic syndrome (SCLC) Encephalomyelitis-subacute sensory neuropathy (SCLC) aData from references 3 and 4. 1 Tumors of the Lower Respiratory Tract which are directly related to the presence of the of the arm, especially along the lateral aspect, primary tumor. The most common symptom is which may also manifest muscular atrophy and cough, which is usually related to irritation of associated weakness. Occasionally, a Pancoast bronchial structures by the neoplasm. A new tumor directly extends to compress the spinal cough or one that does not abate in a current or cord, producing paraplegia. a former smoker should be evaluated promptly Another potential syndrome, which may be (2–4). Hemoptysis is also a frequent and char- present at initial diagnosis or develop subse- acteristic presentation, especially for individuals quently, is oculosympathetic palsy, or Horner with squamous cell carcinoma. Dyspnea is often syndrome (3). This results from direct invasion present to some degree, especially with small cell of the paravertebral sympathetic ganglia. Clas- carcinoma. It is usually related to the presence of sic components of this complex are persistent the tumor as it obstructs airways or, less likely, miosis (and anisocoria), enophthalmosis, ptosis, spreads throughout much of the parenchyma; this and anhidrosis. Other manifestations of lo- may also result in wheezing. Chest pain, which cal tumor spread include dysphagia related to is typically described as a dull ache that does compression of the esophagus. not go away, may be related to invasion of soft Metastases occur in any organ or body struc- tissue of the chest wall, ribs, or pleura. Recurrent ture and evoke clinical manifestations, and or persistent infections, especially pneumonias, frequently, fndings at the initial diagnosis are may be related to bronchial obstruction. due to metastases (3). Major extranodal targets Spread of tumor within the thorax also causes of lung cancer spread include the central nervous clinical manifestations (Table 1-1) (2–4). One system (focal neurologic abnormalities, seizures, of the most dramatic is the superior vena cava back pain, and headaches that classically are syndrome. More often associated with small cell worse upon awakening from sleep) and bone me- carcinoma, it is due to extrinsic compression of tastases (vertebrae, ribs, and femur). The resultant the superior vena cava by neoplasm. This results usually lytic lesions are typically associated with in edema of the face and upper extremity; the unrelenting pain. Cachexia is associated with dis- fuid accumulation is accentuated when the seminated disease and a large tumor burden. patient has been recumbent for some time. Some patients present initially with a para- Cerebral edema may be a component, with neoplastic syndrome (Table 1-1) (3,4). The most associated headaches and other neurologic common one associated with lung cancer (espe- complications. Edema of the larynx may occur cially small cell carcinoma) is the syndrome of and rarely precipitates a medical emergency due inappropriate antidiuretic hormone (SIADH). to rapidly developing respiratory distress. Injury Tumor cells produce and release antidiuretic hor- to the recurrent laryngeal nerve may lead to mone (vasopressin), causing the body to retain hoarseness. Neural damage to the phrenic nerve water; a major consequence of this is hypona- may produce dyspnea related to hemidiaphrag- tremia which may cause a number of metabolic matic paralysis. Local dissemination with the disorders of varying severity including muscle development of pleural or pericardial effusions cramps and weakness, irritability, confusion, contributes to shortness of breath, systemic seizures, and even coma. Another paraneoplastic manifestations, or reduced cardiac output. syndrome related to neuroendocrine lung tumors Another striking group of symptoms related is Cushing syndrome, a result of the uncon- to local spread is the superior sulcus syndrome, trolled ectopic secretion of adrenocorticotropic or Pancoast tumor (3). This results from an hormone by the malignant cells. Rare neurologic apical neoplasm, usually nonsmall cell lung car- manifestations related to small cell carcinoma cinomas (NSCLCs), that grows directly into the are limbic encephalopathy, subacute cerebellar ipsilateral proximal brachial plexus as it exits degeneration, and subacute sensory neuropathy. the neural foramina, especially the C8 and T1 Only rarely are neuroendocrine tumors of the branches. Initially, this leads to intense pain in lung associated with the carcinoid syndrome. the ipsilateral subscapular area or upper extrem- Several paraneoplastic complications are much ity (especially the shoulder). With progression, more frequent with NSCLCs. A prominent one the pain may radiate through the entire length is humoral hypercalcemia of malignancy which, 2 Lung Cancer: Presentation, Epidemiology, Staging, Classifcation, Grading, and Spread among lung cancers, is specifc for squamous cell Table 1-2 carcinoma. The tumor cells produce and secrete AGENTS, OCCUPATIONS, AND OCCUPATIONAL parathyroid hormone-related proteins into the PROCESSES CLASSIFIED AS HUMAN LUNG circulation, which enhances osteoclastic bone CARCINOGENS (GROUP 1) BY THE INTERNATIONAL resorption. Patients have weakness, coma, con- AGENCY FOR RESEARCH ON CANCERa fusion, polydipsia, polyuria, constipation, and Acheson process (synthesis of graphite and silicon carbide) nausea. Typically associated with lung adenocar- Aluminum production cinoma is hypertrophic osteoarthropathy (2,3). This includes clubbing of the digits, especially Arsenic and inorganic arsenic compounds the fngers; ossifying periostitis involving the Asbestos (all forms) distal parts of tubular bones, especially the tibia, Beryllium and beryllium compounds fbula, ulna, radius, and the bones of the wrist Bis(chloromethyl) ether; chloromethyl methyl ether and ankles; and arthralgias. This is characterized (technical grade) by progressive ossifcation of newly developed Cadmium and cadmium compounds subperiosteal vascularized connective tissue. Chromium (VI) compounds Clubbing is a related widening of the distal Coal, indoor emission from household combustion phalanx and elevation of the nail. Coal gasifcation EPIDEMIOLOGY Coal-tar pitch (occupations that involve electrode Lung cancer is the most common cause of manufacture, roofng and paving) cancer incidence and mortality worldwide as it Coke production has been for the past few decades (5–7). It was Diesel engine exhaust estimated in 2012 that there were 1.8 million Hematite mining (underground) new cases (12.9 percent of all cancers) and it is Iron and steel founding the cause of almost 20 percent (19.4 percent) of MOPP (vincristine-prednisone-nitrogen mustard-procar- all cancer deaths, with 1.59 million deaths in bazine mixture) 2012 (5,7–9). The highest estimated rates are in Nickel compounds North America (33.8 per 100,000) and Northern Europe (23.7 per 100,000). The incidence rates Outdoor air pollution in women are lower, mainly due to smoking Painting habits (8,9). Lung cancer became the most Particulate matter in outdoor air pollution common
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