Direct invasion of adjacent structures or metastases within the thorax may produce all of the foregoing symptoms and signs to a greater or lesser degree. In addition, however, there are other clinical features which may arise as the disease progresses. Usually those denote late, advanced, inoperable disease, but occasionally:

1. They may be present in early, localized, curable disease when the lesion chances to be strategically located. This is quite rare, however.

2. And/or singly or in combination they may be the first manifestations of the disease.

The commonest ones are superior vena caval syndrome, superior sulcus syndrome or Pancoast's tumor, vocal cord paralysis, esophageal obstruction, phrenic nerve paralysis, Horner's syndrome, and cardiac involvement.

Superior vena caval syndrome

1. Due to obstruction of this vessel as a result of compression, invasion, or secondary thrombosis

2. Characterized by:

(a) Signs limited to the head, neck, upper thorax, and usually the upper extremities

(1) Edema

(2) Cyanosis

(3) Venous pattern

(b) Symptoms

(1) Dyspnea

(2) Orthopnea

(3) Cough

Superior sulcus syndrome or Pancoast's tumor

1. Due to an apically situated tumor with involvement of the vertebrae, ribs, cervical sympathetics, and brachial plexus

2. Characterized by:

(a) Pain in the upper chest, shoulder, and upper extremity (often severe)

(b) May be associated weakness of the part and paresthesias

(c) Horner's syndrome

Vocal cord paralysis

1. Due to involvement of the left recurrent laryngeal nerve in the mediastinum (occasionally the right recurrent laryngeal nerve in the base of the neck)

2. Characterized by hoarseness

Esophageal obstruction

1. Due to compression or invasion of the esophagus by tumor in the posterior mediastinum

2. Cliaracterized by dysphagia

Phrenic nerve paralysis

1. Due to involvement of the phrenic nerve in the thorax

2. Characterized by:

(a) Progressive elevation of the diaphragm

(b) Paradoxical motion of the diaphragm

(c) Hiccoughs

Horner's syndrome

1. Due to involvement of the sympathetic nervous system, usually last cervical and first thoracic segments

2. Characterized by:

(a) Enophthalmus

(b) Miosis

(c) Ptosis

(d) Narrowed palpebral fissure

(e) Unilateral sweating and temperature changes

Cardiac involvement

1. Due to direct extension or metastasis to the pericardium or myocardium

2. Characterized by:

(a) Pericardial effusion

(b) Tachycardia

(c) Arrhythmias

(d) Congestive failure

Advanced Disease Due To Distant Spread

Symptoms and signs reflecting distant spread of the disease denote inoperability. They will be mentioned here primarily because manifestations arising from a metastatic focus not uncommonly are the first indication of lung cancer. Lung cancer may metastasize to virtually any part of the body, but most frequently this is demonstrable only at autopsy. The most common sites of metastases giving rise to clinical signs are as follows:

1. The central nervous system. Spread of tumor to the brain may give rise to a clinical picture indistinguishable from a cerebrovascular accident or a primary brain neoplasm.

2. The bones. Metastases to the bones, especially the ribs, vertebrae, and pelvis, may give rise to severe local pain and not infrequently pathologic fracture.

3. The liver. Hepatic enlargement, sometimes with palpable nodularity, usually denotes liver metastases. These may be present without jaundice and in the absence of major systemic deterioration.

The other most common, but often silent, sites of metastases from lung cancer are as follows:

1. Extrathoracic lymphatics, e.g., cervical, axillary, abdominal, and pelvic.

2. Adrenal glands. These are very commonly involved but only rarely is a picture of adrenal insufficiency produced.

3. Miscellaneous. Kidneys, spleen, gastrointestinal tract, skin, and muscle.

Steps In The Diagnosis And Initial Management Of The Lung Cancer Suspect

Once a suspicion of lung cancer has been raised by the presence of any of the symptoms or signs previously mentioned or by any abnormality noted on chest films taken routinely or for detection purposes, certain diagnostic studies are indicated for definitive investigations. The following is the most commonly recommended order of procedure.

1. Additional chest films and comparison with any available previous films.

2. Cytologic examination of several sputum specimens.

3. Bronchosocopy with biopsy and/or cytologic examination of bronchial washings.

4. Exploratory thoracotomy if the initial steps fail to yield a histologic diagnosis.

The foregoing is intended only as a general outline. The many additions, variations, and modifications possible in the individual case will be discussed below.

X-Ray Studies

The standard 14 x 17 posteroanterior and lateral films of the chest represent fundamental x-ray coverage for any patient suspected of having lung cancer. Assuming good film and competent interpretation, virtually all lung cancer lesions can be visualized in this fashion and a presumptive diagnosis may be possible in about 85? of cases.

It is strongly recommended that comparison with previous films be undertaken even if prior x-ray films have been read as negative. Not uncommonly, with the increased diagnostic acumen of hindsight, it is possible to find overlooked lesions.

1. If previous films are truly negative (and particularly if they are rather recent), then one is justified in concluding that he is dealing with a new lesion-and the chances of lung cancer are increased.

2. If previous films are truly abnormal and there has been no change in the lesion, then it would seem likely that the process is an old and inactive one. In this setting the chances of lung cancer decrease, particularly if the interval between films is a long one.

3. If previous films are truly abnormal and there has been a change in the lesion, the chances of lung cancer are increased. This may be true even if the time interval is a matter of years.

4. If no previous films whatever are available, then one is deprived of a valuable starting point, and all decisions must be based on current evidence at hand. This fact should emphasize the importance and value of a periodic chest film.

If the suspicion of lung cancer is confirmed or strengthened by the standard posteroanterior and lateral chest films, in selected cases further x-ray studies may be of real assistance in clarifying the diagnosis. The indications for these additional radiographic studies are rather specific and require correlation with the particular case at hand. With the possible exception of fluoroscopy, most of these fall outside the scope of the average practitioner's equipment and experience in radiographic interpretation. It seems likely, therefore, that the best interests of the patient are served by consultation of the physician with a radiologist with regard to what additional x-ray studies are advisable at this point.

It must be remembered that if the practitioner makes a routine of obtaining sputum for cytology on the first day a suspicious lung lesion is found, the need for further x-ray studies may be obviated by a positive cytologic report.

It cannot be too strongly emphasized that much precious time can be dissipated by insistence on complicated and repetitious x-ray studies, which at best can serve only to bolster an already existing clinical impression-not make a definite or final diagnosis. Even worse is the attitude of so-called "watchful waiting" in which a lesion may progress from an operable to an inoperable stage while interval or follow-up films are taken over a period of weeks or months.