|Year : 2008 | Volume
| Issue : 6 | Page : 74-78
|Evaluation of the patient with lung cancer
Hamdan Al Jahdali
King Abdulaziz Medical City for National Guard, Riyadh, Saudi Arabia
Hamdan Al Jahdali
Head Pulmonary Division (Mail code 1445), King Abdulaziz Medical City for National Guard, P.O. Box 22490, Riyadh 11426
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The initial comprehensive evaluation of lung cancer is a critical step in the management of patients afflicted with this disease. The confirmation of diagnosis and the assessment of the disease as well as the patient is the basis of further treatment decision. This manuscript describes the evaluation of patients with suspected lung cancer as well as the subsequent evaluation after diagnosis, especially in the preparation of potentially curative surgical interventions.
Keywords: Lung cancer, evaluation, diagnosis
|How to cite this article:|
Al Jahdali H. Evaluation of the patient with lung cancer. Ann Thorac Med 2008;3, Suppl S2:74-8
| Initial Evaluation of Patients with Lung Cancer|| |
Initial evaluation of the patient with known or suspected lung cancer should include an assessment of symptoms, signs and laboratory tests
Unfortunately, the symptoms of lung cancer can be nonspecific, thereby delaying the diagnoses for patients who present with this disease and leading to an advanced stage at the time of diagnosis. In general, 80% of the patients with lung cancer are inoperable at presentation. Consequently, at the initial presentation, most patients with lung cancer have advanced disease. ,
Patients with lung cancer usually present with multiple symptoms, including both respiratory and nonrespiratory. Symptoms related to the primary tumor present in 27% of the patients, 34% had nonspecific systemic symptoms suggestive of metastases, including anorexia, weight loss and fatigue, and 32% had symptoms specific to a metastatic site.
Cough is reported to be the most common presenting symptom of lung cancer (45-75%). Other respiratory symptoms include dyspnea (37-58%), chest pain (27-47%) and hemoptysis (27-57%). Most of these symptoms are nonspecific; however, understanding of how patients with lung cancer initially present will possibly allow an earlier identification of this increasingly common disease. Some clues can be gained from the history thus raising the clinician's suspicion that lung cancer is present. ,,,,,, For example, many smokers have productive cough; however, when they develop lung cancer, patients may notice a change in the character of their cough. , The cough may increase in frequency or strength or may not be relieved with usual measures. Chest pain can be present in 25-50% of the patients at the time of presentation for evaluation for lung cancer. ,, Chest pain is usually related to involvement of the pleura but can be related to extension into the mediastinum or chest wall. The pain is generally dull in nature, tends to be persistent and may increase with cough or deep breathing.
Dyspnea is a frequent complaint of patients who present with bronchogenic carcinoma, occurring in approximately half of all new patients at presentation. There are many etiologies of dyspnea that may be related directly or indirectly to bronchogenic carcinoma. It may be caused by pulmonary embolism, superior vena cava syndrome, endobronchial obstruction with tumor, malignant pleural effusion or extrinsic compression of the airway by tumor. Hemoptysis can present as blood streaking of the sputum. It may be attributed to smoking-related bronchitis, which may further delay the diagnosis. Therefore, hemoptysis in a smoker should always raise the suspicion of lung cancer. The clinician should not exclude bronchogenic carcinoma based on normal chest radiograph because up to 5% of those with a smoking history and a normal radiograph can harbor lung cancer. ,,,,,
A review of the system is very important. Direct questions about evidence of metastasis are crucial, such as the constitutional symptoms of weight loss greater than 10 lb. The patient should be asked about any neurological symptoms such as headaches, syncope, seizures, extremity weakness or recent change in mental status. Patient should also be asked about any changes in the voice: ' hoarseness,' focal skeletal pain or any lymphadenopathy or new soft tissue masses.
Review of the systems should also assess respiratory and cardiovascular status and over all performance status. Patients should be asked specific questions about dyspnea at rest or exertion or any symptoms of angina, or recent cardiac problems, in particular myocardial infarction.
Physical examination should be thorough. The physician should pay attention to any evidence of lymphadenopathy more than 1cm, in particular supraclavicular lymphadenopathy, clubbing, which may be associated with any cell type of lung cancer, although it is associated most frequently with squamous cell carcinoma and adenocarcinoma and least frequently with small cell lung carcinoma.  Other significant findings include hoarseness, superior vena cava syndrome, bone tenderness, jaundice or hepatomegaly more than a 13-cm liver span, focal neurologic signs and or papilledema and or soft tissue mass. A superior pulmonary sulcus tumor (Pancoast's tumor) may present with Horner's syndrome and is characterized by a brachial plexopathy and pain along the involved nerve roots.
Approximately 10% of patients with lung cancer develop systemic symptoms related to paraneoplastic syndromes. Symptoms may precede the diagnosis, appear late in the disease course or suggest recurrence. Common endocrine syndromes include hypercalcemia, syndrome of inappropriate antidiuretic hormone and Cushing's syndrome. Digital clubbing and hypertrophic pulmonary osteoarthropathy are common skeletal manifestations. ,, Less well-defined neurologic syndromes include Lambert-Eaton myasthenic syndrome, peripheral neuropathy and cortical cerebellar degeneration.
Staging can be accomplished by a number of noninvasive and invasive studies.
The choice of the most appropriate study rests with the clinician and is based on how the patient presents.
Some patients may be referred for immediate surgery as both a diagnostic and a therapeutic maneuver, as in a patient with an isolated pulmonary nodule. Others may undergo no testing at all, as in a patient who is suspected of having widely metastatic disease and who has an extremely poor performance status.
| Noninvasive Investigations|| |
1. Chest radiography
The majority of lung cancers are initially detected by a plain chest radiograph. In certain situations, the plain film may be sufficient to detect spread to the contralateral mediastinum or to the bone or the other lung. This may be considered adequate evidence of metastatic disease to preclude further imaging evaluation of the chest. However, the chest radiograph is an insensitive measure of mediastinal lymph node involvement with lung cancer and thus further noninvasive or invasive assessment is usually necessary.
2. Computed tomography (CT) of the chest
The majority of patients who present with lung cancer undergo CT scanning of the chest and liver. Adrenal glands should be routinely included if lung cancer is suspected. CT is helpful in defining the size, location and characteristics of the primary mass, the presence or absence of lymphadenopathy and the presence of abnormalities in the liver and adrenal glands. It is recommended if no contraindication to request a contrast CT. It is useful in helping to distinguish vascular structures from lymph nodes as well as in delineating mediastinal invasion by centrally located tumors. The most widely accepted criterion for an abnormal lymph node is a short-axis lymph node diameter of 1 cm or greater on CT. CT can also be helpful in the evaluation of pleural effusion in patients with lung cancer. The CT scan can indicate the presence or absence of fluid, the contour of the pleural space and whether or not nodules or masses are present on the pleural surface. 
3. Positron emission tomography (PET scan)
The PET scan is based on the biologic activity of neoplastic cells. It is a metabolic imaging technique based on the function of a tissue rather than its anatomy. Lung cancer cells demonstrate increased cellular uptake of glucose and a higher rate of glycolysis when compared with normal cells. The radiolabeled glucose analogue [18F] fluoro-2-deoxy-D-glucose undergoes the same cellular uptake as glucose, but after phosphorylation is not further metabolized, and becomes trapped in cells. Accumulation of the isotope can then be identified using a PET camera. 
It has proved useful in differentiating neoplastic from normal tissues. However, false-positive results were seen with inflammatory disease and false-negative results were seen with very small lesions less than 1cm. 
The pooled sensitivity of PET is 85% (79-89%) and the pooled specificity is 88% (82-92%). The overall positive predictive value was 78% (40-100%) and the negative predictive value was 93% (range from 75 to 100%). ,,,, PET has both a higher sensitivity and a higher specificity for evaluation of mediastinal lymph nodes than CT scanning. ,,,
The use of PET in the preoperative evaluation for lung cancer may lead to different preoperative staging in approximately 20% of the cases. , Therefore, if PET scan is available, it should be obtained during the staging evaluation for lung cancer.
4. Magnetic resonance imaging (MRI)
MRI is useful in evaluating superior sulcus tumors, especially for possible invasion of the brachial plexus, and for evaluating vertebral or vascular invasion.
5. Search for metastatic disease
The initial clinical evaluation may reveal abnormalities such as abnormal symptoms, physical findings and routine blood tests, which then lead to an expanded clinical evaluation. For example, if bone pain or high alkaline phosphates are present, a bone scan should be obtained. If a patient had headache, syncope, seizures, extremity weakness or recent change in mental status, an MRI, if available, or CT with contrast of the brain should be obtained. The presence of thrombocytopenia or abnormal blood smear may indicate the need for bone marrow aspirate/biopsy.
Whole-body PET scans, if available, can be used as an alternative for the above diagnostic test to disclose non central nervous system metastasis.
6. Diagnostic test
In patients suspected of having lung cancer based on radiographic and clinical findings, it is recommended that the diagnosis be confirmed by the easiest and least-invasive method as dictated by the patient's presentation. The diagnostic approaches include sputum cytology, thoracentesis, transthoracic lung biopsy (fine-needle aspirate), bronchoscopy, including transbronchial needle aspiration, and endobronchial ultrasound-needle aspiration (if available).
In patients suspected of having lung cancer who have an accessible pleural effusion, thoracentesis is recommended to diagnose the cause of the pleural effusion. If pleural fluid cytology is negative (after at least two thoracentesis), thoracoscopy is recommended as the next step, especially if the effusion is bloody or if establishing the cause of the pleural effusion is believed to be clinically important.
| Preoperative Assessment of Bronchogenic Carcinoma|| |
Lung resection remains the treatment of choice in the curative approach to non small cell lung cancer. When a tumor is considered resectable, curative resection should be attempted, which is rarely less than an entire lobe and often a pneumonectomy. This means resection of a substantial amount of the pulmonary parenchyma.
Most lung cancer patients are current or former smokers. They are at an increased risk of chronic obstructive pulmonary disease and coronary artery disease, conditions associated with increased surgical morbidity and mortality. Therefore, a careful preoperative assessment of the cardiopulmonary reserves is of great importance to know the functional status of the patient before operating.
All functional parameters must be measured when patients are at their best. For pulmonary function tests, this often implies an intensive course of antiobstructive therapy consisting of a systemic steroid trial of approximately 40 mg prednisone daily for 7-14 days and inhalational therapy with bronchodilator drugs. 
Chest physiotherapy and, if possible, a short pulmonary rehabilitation program should be initiated during the same period. Smoking cessation should be encouraged. The effect of treatment must be analyzed by repeating pulmonary function tests. 
Parameters for the functional evaluation before lung resection include age, cardiac function, spirometry, diffusing capacity, blood gas measurements, extent of resection, split function studies and exercise testing if available or stair climbing as an alternative.
Age had been considered to be a factor that might increase perioperative risks. However, patients with a good performance status and intact cardiopulmonary reserves have a long-term survival comparable with younger surgical patients. Therefore, age alone should not be a reason to deny patients with lung cancer access to curative-intent surgical resection. ,
Postoperative complications after pulmonary resections are not only the result of pulmonary causes but are clearly influenced by cardiac comorbidity as well. An abnormal electrocardiogram is associated with an increased risk for sustaining an intraoperative or postoperative cardiac event, defined as heart failure, arrhythmia or myocardial infarction. A myocardial infarction within the previous 6 months, especially within the previous 3 months, is associated with a very high operative risk.
Any patient with active or suspected cardiac disease should first undergo a thorough cardiac work-up and, if necessary, even coronary bypass surgery in case of ischemic heart disease. Only patients whose cardiac condition is amenable to treatment can undergo further investigation for pulmonary resection. ,,
There is a clear correlation between the extent of resection and postoperative morbidity and mortality. Segmental or wedge resections have the lowest and pneumonectomies the highest risk. By international standards, an overall 30-day mortality rate of less than 5% can be considered an acceptable result. The mortality after pneumonectomy is usually twice or more that after lobectomy. ,,
Early recommendations of FEV1 values for safe resections were more than 2 L for pneumonectomy and more than 1.5 L for lobectomy. The DLCO measured with the single-breath technique has gained increasing importance, with values less than 50% of predicted being regarded as risky and values less than 60% regarded as insufficient for 'major pulmonary resections'. However, recent interest has shifted to postoperative remaining function. This function, the so-called predicted postoperative (ppo) function, has to be estimated. ,,,,,
The predictive value of arterial blood gas measurements for functional operability is less than certain. There is no consensus regarding a value of the arterial oxygen tension that would indicate a clearly increased risk for pulmonary resections. Carbon dioxide tension of more than 45 mmHg represents an increased risk for pulmonary resections, but an elevated arterial carbon dioxide tension value alone should not exclude patients from surgery. 
Split function studies
An estimation of the amount of lung tissue that can safely be removed is very important in the preoperative evaluation. The development of split function studies (or studies of regional lung function) has allowed surgeons to calculate the function of the tissue to be removed relative to the total function of both lungs, and thereby to predict postoperative function.
The most accurate predictions are obtained with a split perfusion scan using intravenous Tc-99m (V/Q scan) ,,,,,,
The formula used for all methods to calculate FEV1-ppo is:
- FEV1-ppo=preoperative FEV1×(1−functional contribution of the parenchyma to be resected) ,,
The same formula to predict postoperative FEV1 has also been used successfully to predict postoperative DLCO.
| Indication and Implementation of Split-function Studies|| |
The use of absolute values should be discouraged because they do not take patient gender, age and height into consideration. 
- Patients who have a negative cardiac history (including a normal ECG) and whose FEV1 and DLCO are both ≥80% predicted can undergo lung resection up to a pneumonectomy without any further tests. ,,,,
- Patients who have FEV1 and DLCO are both <80% predicted should go for split function study
2.1. If the predicted postoperative FEV1 and DLCO values are more than 40% of predicted, it is safe to perform lung resection.
2.2 If the predicted post operative FEV1 or DLCO is less than 40%, but otherwise patient seems to be a good candidate for surgery, before excluding the patient from curative surgery an exercise test should be performed.
Exercise testing seems to be an ideal overall parameter for the assessment of cardiopulmonary reserves because it looks at the fitness of a patient, which is an equivalent of cardiopulmonary reserves.
A VO 2 max value of more than 20 ml/kg/min (or more than 75% predicted) qualifies for resection up to pneumonectomy, whereas a value less than 10 ml/kg/min (or less than 40% predicted) is generally prohibitive for any resection. ,,,,,
In the absence of sophisticated exercise equipment, there is considerable evidence that tests of minimal achievements can also be used to estimate the postoperative risk. The most frequently used test by far is stair climbing. The ability to climb three or more flights of stairs and five or more flights of stairs has been suggested as a safe indication to undergo resections of a lobectomy and pneumonectomy, respectively. ,,,,,,,,,
The current recommendation when using stair climbing is to adhere to a standard protocol during which the patient is encouraged, climbs at a constant speed, does not use railings and must achieve a predetermined number of flights or height in meters to qualify for a certain extent of resection [Figure 1].
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