1. Thoracic cancer -- Case presentation, differential diagnosis
三軍總醫院胸腔暨重症醫學科
沈志浩醫師

2. Outline Clinical presentation of thoracic cancer
Case presentation and differential diagnosis

3. Most patients with early stage lung cancer is
free from symptoms !

4. Lung cancer with advanced disease
The majority of diagnosed lung cancer patients have advanced disease (stage IIIb or stage IV)
Absence of symptoms until locally advanced or metastatic disease is present
Aggressive biology of lung cancer
From Midthun DE, Jett JR: Clinical presentation of lung cancer. In Pass HI, Mitchell JB, Johnson DH, et al (eds): Lung Cancer: Principles and Practice. Philadelphia: Lippincott-Raven, 1996, p 422.
Principles and Practice. Philadelphia: Lippincott-Raven, 1996, p 422

5. Symptoms of thoracic cancers
Symptoms were varied
Origin (lung, major airway, pleura, chest wall, mediastinum)
Cancer cell types and para-neoplastic syndrome
Involved region (bone, liver, brain, adrenal gland metastasis, etc.)

6. Intrathoracic effects of the cancer

7. Cough
Occurs most frequently in squamous cell carcinoma and small cell carcinoma
Tendency to involve central airways
Bronchorrhea (productive of large volumes of thin, mucoid secretions)
May be a feature of mucinous adenocarcinoma
Post-obstructive pneumonia
Bronchiectasis (after chronic bronchial obstruction)
Slow-growing neoplasms such as carcinoid tumor or hamartoma
Malignant pleural effusion

8. Hemoptysis Bronchitis is the most common cause of hemoptysis !
Involve central airways
Large volumes of hemoptysis may cause asphyxia
Diagnosis – bronchoscopy
Bronchitis is the most common cause of hemoptysis !
bronchitis is the most common cause of hemoptysis !

9. Chest pain More common in younger patients
On the same side of the chest as the primary tumor
Dull and persistent pain
Occur from mediastinal, pleural, or chest wall extension
Sharp pain; more severe when the lungs move during breathing, coughing, sneezing, etc. -- pleuritic pain
Direct pleural involvement, obstructive pneumonitis, pulmonary embolus (hypercoagulable state)

10. Dyspnea

11. Dyspnea Extrinsic or intraluminal airway obstruction
Partial obstruction of a bronchus -- localized wheeze
Obstruction of larger airways -- stridor
Obstructive pneumonitis or atelectasis
Lymphangitic tumor spread
Tumor emboli
Pleural effusion; pericardial effusion with tamponade
Unilateral paralysis of the diaphragm -- damage of the phrenic nerve
Pneumothorax

12. Hoarseness
Malignancy involving the recurrent laryngeal nerve along its course under the arch of the aorta and back to the larynx

13. Superior vena cava syndrome
Obstruction of blood flow through the superior vena cava (SVC)
A sensation of fullness in the head and dyspnea
Dilated neck veins, a prominent venous pattern on the chest, facial edema, and a plethoric appearance
More common in patients with small cell carcinoma

14. Pancoast syndrome Lung cancers arising in the superior sulcus
Pain (usually in the shoulder), Horner's syndrome, bony destruction, and atrophy of hand muscles
Most commonly caused by NSCLC (typically squamous cell)
*** Horner's syndrome: miosis (constriction of the pupils), anhidrosis (lack of sweating), ptosis (drooping of the eyelid) and enophthalmos (sunken eyeball)

15. Para-neoplastic syndrome

16. Hypercalcemia Bony metastasis or tumor secretion
Parathyroid hormone-related protein (PTHrP)
Calcitriol
Cytokines activetes osteoclast
Advanced disease (stage III or IV)
Symptoms of hypercalcemia
Anorexia, nausea, vomiting, constipation, lethargy, polyuria, polydipsia and dehydration
Renal failure and nephrocalcinosis

17. SIADH (syndrome of inappropriate antidiuretic hormone secretion)
Frequently caused by small cell carcinoma
Hyponatremia
Severity of symptoms is related to the degree of hyponatremia
Anorexia, nausea, and vomiting
Cerebral edema
Acute or chronic ?

18. Neurologic manifestations
Associated with small cell carcinoma
Diverse neurologic manifestations
Lambert-Eaton myasthenic syndrome (LEMS), cerebellar ataxia, sensory neuropathy, limbic encephalitis, encephalomyelitis, autonomic neuropathy, retinopathy, and opsomyoclonus

19. Hematologic manifestations
Anemia
Leukocytosis
Thrombocytosis
Eosinophilia
Hypercoagulable disorders
Trousseau's syndrome (migratory superficial thrombophlebitis)
Deep venous thrombosis and thromboembolism
Disseminated intravascular coagulopathy
Thrombotic microangiopathy
Nonthrombotic microangiopathy

20. Others Hypertrophic osteoarthropathy Dermatomyositis and polymyositis
Clubbing; periosteal proliferation of the tubular bones
Dermatomyositis and polymyositis
Inflammatory myopathy
Cushing's syndrome (Small cell carcinoma and carcinoid tumors)
Ectopic production of adrenal corticotropin (ACTH)

22. Case presentation and differential diagnosis

23. Case 1
七十五家庭主婦。從不抽菸也無氣喘病史，自半年前就開始乾咳，咳嗽症狀並沒有日夜差異、沒有氣促、濃痰或發燒、也沒鼻腔症狀，飲食習慣正常也沒有消化性潰瘍病史，本也不以為意，但在這兩周開始除了咳嗽外還伴隨左後背疼痛。於是至門診就診。

24. Chest CNY-CT

25. How to describe pulmonary lesions?
Shape
spherical, oval, or lobulated
corona radiata
Size
Nodule < 3cm
Mass ≧ 3cm
Location
Contrast enhancement
Rate of growth
Volume doubling times are very rarely less than 1 month or more than 18 months
Calcification and cavitation
Ground-glass density
Obstruction signs
Golden S sign

26. Case 2
58歲男性，老煙槍，每日二包菸38年。慢性咳嗽兩年。半年前斷斷續續咳痰帶血絲。最近四週因胸悶、喘和臉、頸和雙臂腫脹就診。

27. Chest CNY-CT

29. Location Intrapulmonary Central Peripheral Extrapulmonary
Arising at or close to the hilum/segmental bronchi
Golden S sign
Pneumonia or expansion confined to one lobe
Pneumonia that is unchanged for more than 2 weeks or one that recurs in the same lobe after a short interval
Peripheral
Arising beyond the hilum/segmental bronchi
Rarely visible on chest radiographs when below 1 cm in diameter
Extrapulmonary
Pleural tumor
Mesothelioma
Metastatic
Mediastunum
Lymphoma
Esophageal tumors
Germ cell tumor
Thymoma
Thyroid cancer
Neurogenic tumors
Chest wall
Bone tumor
Sarcema

30. Case 3
38女性，早餐店老闆娘。氣喘長期用藥控制。右側胸痛三個月。

32. Missed lung cancers
The miss rate was particularly high in the CXR
About 65% of cancers in a yearly screening program had been overlooked on the previous film
Most cancers missed at CT are endobronchial in location or are situated in the perihilar region and confused with blood vessels

35. Discussion