History and exam

Your Organisational Guidance

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Kleincellige en niet-kleincellige longkanker: diagnose, behandeling en opvolgingPublished by: KCELast published: 2013Cancer du poumon à petites cellules et non à petites cellules : diagnostic, traitement et suiviPublished by: KCELast published: 2013

Key diagnostic factors

common

Include cigarette smoking and exposure to second-hand tobacco smoke, radon gas, and asbestos.

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 post-obstructive pneumonia, endobronchial tumour, or pleural effusion.[4]​​

Present at diagnosis in the majority of patients.​[4]

Possible causes include airway obstruction, underlying COPD, pneumonia, phrenic nerve paralysis, or a pleural effusion.

Occurs in approximately 25% of patients.[4]​​

Although massive haemoptysis is rare, patients with lung cancer often cough up blood-tinged sputum. Haemoptysis in a smoker is suspicious for lung cancer.

Chest pain or discomfort is present in approximately 33% of patients.[4]​​

The lung is devoid of pain fibres. Therefore, most patients with chest pain have tumours that are invading the pleura or chest wall. However, patients with early disease can present with chest discomfort.

Cancer-associated cachexia (more common in patients with advanced disease) is an independent negative prognostic factor and should be specifically evaluated and addressed according to established practice guidelines.[36][37]​​

Other diagnostic factors

common

The median age at diagnosis of lung cancer is 65-74 years.[7] Less than 10% of cases are diagnosed before 55 years of age.[7]​​

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).[7]

Non-specific symptom of lung cancer; often multifactorial.

Auscultation of the lungs may demonstrate wheeze, rales, decreased breath sounds, and dullness to percussion.

uncommon

2% to 18% can present with hoarseness, secondary to recurrent laryngeal nerve paralysis.[4]​​

A common symptom of brain metastases. Up to 40% to 50% of patients with lung cancer develop brain metastases.[30]​​

May occur in the setting of brain metastases.

May indicate brain metastases.

May indicate brain metastases.

May occur if tumour has narrowed or obstructed the oesophagus.

Pain or pathological fractures can result from bone metastases. The axial skeleton and proximal long bones are most frequently involved.[4]​​

A potential symptom of brain metastases.

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.

May indicate compression of the superior vena cava, either from mediastinal adenopathy or from a right upper lobe tumour extending centrally into the mediastinum.

Distended neck veins or venous collaterals on the chest or abdominal wall may indicate compression of the superior vena cava.

More common in non-small cell lung cancer than SCLC (35% vs. 4%).[4]​​

Painful arthropathy of the wrists, ankles, and knees with periosteal new bone formation. SCLC is a rare cause.​[4]

Risk factors

strong

Numerous epidemiological studies link lung cancer and cigarette smoking.[13][14][15]

Tobacco smoke contains multiple carcinogens, including polynuclear aromatic hydrocarbons, aromatic amines, N-nitrosamines, and other organic and inorganic compounds.[16] Some data suggest that the presence of COPD may be an independent risk factor for lung cancer development, regardless of smoking status.[19]

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.[20] 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.[21]

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.[22][23]

weak

Asbestos fibres are carcinogens that lodge in the lung and are a risk factor for lung cancer, especially in smokers and heavily exposed people.[24] Epidemiological data have linked asbestos with lung cancer (all histological variants), whether or not the patient has developed asbestosis - a diffuse interstitial lung fibrosis secondary to asbestos exposure.[25]

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