For reasons which have been stated previously and which will be re-emphasized in the diagrammatic representation to follow, it is often very difficult to separate the localized from the advanced disease on the basis of clinical manifestations. The location and size of the lesion are of prime importance in determining the time, sequence, and nature of the symptoms and signs.

Localized Lesion Symptoms

1. May be none.

2. Cough. The cough may present as a new problem to the patient. More commonly there is noted a change in the character of a chronic cough due to endobronchial irritation. What before had been a dry, or only occasionally productive, "smoker's cough," noted especially in the morning on arising or after the first cigarette of the day, takes on new features. It is now more obvious and annoying. It tends to occur throughout the day, especially in fairly severe paroxysms. It tends to assume a harsh or brassy character, and production of mucoid sputum is more apparent. Not infrequently these changes escape the notice of the patient and are apparent only to his family.

3. Hemoptysis. Rarely, blood streaking of the sputum or frank hemoptysis due to bronchial ulceration, more commonly the former, may occur early in the disease. Usually it is a later symptom if it occurs at all.

4. Dyspnea. Slight shortness of breath, precipitated or accentuated by physical effort, may be a relatively early symptom in lung cancer. At this stage it is due to the partial bronchial occlusion by the tumor, giving rise to a ball valve effect, noticeable primarily in forced expiration when the bronchial tree is narrowed and contracted. There is little or no interference with inspiration, and air readily reaches the distal bronchioles and alveoli. Exit of the air from these areas is impeded, however.

When the tumor increases to such size that complete bronchial obstruction is produced, the dyspnea may be on the basis of adjacent compensatory emphysema, atelectasis with or without superimposed infection, and inflammatory pleural effusion (i.e., not necessarily due to pleural involvement by tumor).

5. Pain. Chest discomfort or "awareness" of vague and nonspecific character may be a feature of early lung cancer and antecedes the real pain usually associated with late and inoperable disease. Occasionally the patient may be able to localize the discomfort to the region of the actual tumor.

6. Pneumonitis. One or more recurrent episodes of pneumonitis with the usual local and systemic symptoms and signs may be the first clue to the existence of lung cancer. The episodes themselves have no distinguishing features which set them apart from the usual variety-it is their tendency to recur or resolve incompletely which should alert the physician to the possibility of underlying pathology. The incomplete or complete bronchial obstruction by tumor impedes normal drainage, and the ensuing stasis, necrosis, and superimposed infection in the distal segment may produce the clinical and x-ray picture of atelectasis, pneumonitis, etc. (occasionally an apparent lobar distribution or bronchiectatic component may be noted).

Signs

1. Wheeze. On physical examination the only abnormality may be an expiratory wheeze, usually unilateral and often heard only in certain positions or after exercise. This wheeze may be apparent to the patient, and he often is able to localize it with surprising accuracy. The wheeze is produced by incomplete bronchial obstruction due to tumor plus superimposed infection.

2. Atelectasis. Once bronchial obstruction has become complete, the air in the distal segment is reabsorbed and parenchymal collapse or atelectasis ensues. Only in the case of quite substantial atelectasis will be classical physical signs be present. This is usually an x-ray diagnosis (see Fig. 43, A).

3. Pneumonitis. When stasis and obstruction of a segment of the tracheobronchial tree persists for any length of time, infection usually follows. The auscultatory signs of nonspecific pneumonitis may be present. Occasionally the infection may take the form of lobar consolidation, bronchiectasis, or abscess.

Table 5. Pathogenesis Of Clinical Features Of Bronchogenic Carcinoma

Morphology

Origin

Incomplete obstruction

Complete obstruction

4. Effusion. Signs of pleural effusion may be present in the otherwise apparently favorable case. Most commonly, of course, effusions in this setting are due to involvement of the pleura by tumor. Occasionally it may be an inflammatory or reactive type, secondary to the infectious component of the bronchia] process, and not related to cancer per se. Therefore, effusion does not necessarily denote inoperability. The pathogenesis of the foregoing features of localized bronchogenic carcinoma are summarized and depicted in Table 5.

The patient with relatively early lung cancer may exhibit a variety of constitutional or systemic signs and symptoms. These should not necessarily or by themselves be interpreted as signifying inoperability. Thus weakness, lassitude, weight loss, polyarthralgia, and anorexia, as well as clubbing of the fingers, pallor, and fever, may all be present in individuals with early, localized disease as well as in those with regional or distant metastases.