Clinical Presentations of Lung Cancer: Slideshow

A 78-year-old woman with a 60-pack-year history of smoking presents to her primary care physician with chronic cough of 6 months’ duration, which worsened over the preceding 2 weeks and is accompanied by fever. Computed tomography (CT) reveals a mass in the right upper lobe.

Which of the following conditions is the most likely explanation for this mass?

1. Infection
2. Tuberculosis
3. Chronic granulomatous disease
4. Lung cancer

Image courtesy of Winston W Tan, MD, FACP.

Answer: D. Lung cancer.

Several points should lead to the suspicion of lung cancer as the most likely diagnosis, including the irregular borders of the mass (arrow), the subacute presentation (especially with a mass that is not responding to antibiotics), and the absence of major symptoms. Other historical data that would suggest lung cancer include a history of smoking or exposure to second-hand smoke, especially if it is of long duration. The presence of other systemic symptoms or a history of exposure to someone with tuberculosis would make one of the other choices more likely.

Image courtesy of Winston W Tan, MD, FACP.

For this patient, which of the following diagnostic procedures is the best next step?

1. Positron emission tomography (PET)
2. Fine-needle aspiration (FNA)
3. Bronchoscopic biopsy
4. Thoracoscopic biopsy

Images courtesy of Wikimedia Commons (left, center top, center bottom, right).

Answer: C. Bronchoscopic biopsy.

The modality that is safest and carries the lowest morbidity should be preferred. In this scenario, where the patient has a central mass in the right upper lobe (arrow), bronchoscopic biopsy would be ideal. PET would not establish the pathology of the disease.

Image courtesy of Winston W Tan, MD, FACP.

After the bronchoscopic biopsy, what is the most appropriate next step for staging the disease?

1. Thoracoscopy
2. Mediastinoscopy
3. PET-CT
4. No additional test

Image courtesy of Winston W Tan, MD, FACP.

Answer: C. PET-CT.

PET-CT will be the least invasive procedure for assessing the extent of the disease. It can determine whether the mediastinal nodes are positive and whether there is involvement of the other lung, the liver, bone, or even the adrenal. To refrain from any additional testing would not be appropriate, because this is a mass that is large enough to undergo biopsy. Mediastinoscopy, though sometimes helpful if the PET scan is equivocal, is not often done, because of the associated morbidity.

Image courtesy of Wikimedia Commons.

A 74-year-old patient who was exposed to secondhand smoke for 30 years underwent chest radiography, which revealed a mass in the right upper lobe. PET-CT was subsequently done, and FNA showed adenocarcinoma of the lung.

Which of the following is the most appropriate next step?

1. Chemotherapy
2. Chemoradiation therapy
3. Surgical resection of the mass
4. Observation

Image courtesy of Winston W Tan, MD, FACP.

Answer: C. Surgical resection of the mass.

The PET scan showed no other sites of metastasis. Therefore, referral to thoracic surgery would be in order. For resectable disease, surgery in the form of lobectomy or pneumonectomy would be curative. The PET-CT scan indicated that the right-upper-lobe mass was resectable. Accordingly, the mass was resected by means of a lobectomy. The patient is currently in complete remission, as confirmed by CT (shown).

Once it is confirmed that a patient has localized disease, it is important to refer the patient to a thoracic surgeon.

Image courtesy of Winston W Tan, MD, FACP.

During the staging scan of a patient who has been diagnosed with lung cancer, CT reveals a mass in the liver.

Which of the following is the most appropriate next step?

1. Liver biopsy
2. Magnetic resonance imaging (MRI) of the liver
3. Observation

Image courtesy of Winston W Tan, MD, FACP.

Answer: B. Magnetic resonance imaging (MRI) of the liver.

A cystic mass in the liver found on CT should not be biopsied if there is concern that it could be a hemangioma. In this case, MRI was done, and the lesion (arrow) turned out to be a hemangioma. It would have been disastrous to biopsy a hemangioma. A metastasis is often a solid mass, but in rare cases, it can be a complex cystic mass.

Image courtesy of Winston W Tan, MD, FACP.

A 63-year-old female smoker with 30 pack-years of exposure presents with chronic cough of 4 months’ duration. Diagnostic imaging identifies a central mass in the lung.

Which of the following pathologies is most likely?

1. Squamous cancer of the lung
2. Adenocarcinoma of the lung
3. Small cell carcinoma of the lung
4. Carcinoid

Image courtesy of Winston W Tan, MD, FACP.

Answer: A and C.

Central lesions are commonly of squamous and small cell morphology. In this case, the central mass (arrow) turned out to be a small cell carcinoma of the lung.

Image courtesy of Winston W Tan, MD, FACP.

In patients diagnosed with lung cancer, which subgroups should undergo MRI of the brain?

1. Patients with neurologic symptoms
2. All lung cancer patients
3. Patients with small cell carcinoma of the lung
4. Patients with squamous cancer of the lung

Image courtesy of Winston W Tan, MD, FACP.

Answer: A and C.

Patients with neurologic symptoms are more likely to have a lesion in the brain, and brain MRI is therefore warranted. MRI is not done routinely in patients with no neurologic symptoms; the only exception is in patients with small cell carcinoma of the lung. There is an increased risk of brain metastasis in patients with small cell lung cancer, and brain MRI is part of the staging process. Shown here are hyperintense basal ganglia lesions on T2-weighted MRI.

Image courtesy of Wikimedia Commons.

Diagnostic imaging identifies a middle-lung nodule.

What is the most appropriate next step for diagnosis of this lesion?

1. Observation
2. Bronchoscopic biopsy
3. Open lung biopsy

Image courtesy of Winston W Tan, MD, FACP.

Answer: B. Bronchoscopic biopsy.

With this central lesion (arrow), the least invasive and safest way of making a diagnosis is to perform a bronchoscopic biopsy with bronchial washing. In this case, the biopsy was done and revealed an adenocarcinoma of the lung. This is the lung cancer most commonly diagnosed today, frequently found in females, nonsmokers, patients with scar tissue, and Asians.

Image courtesy of Winston W Tan, MD, FACP.

The chest x-ray can be an initial test that can find a lung mass. In some patients, this is the initial test that leads to further testing and diagnosis. Although randomized trials have shown low-resolution CT to be the screening tool of choice for smokers, chest radiography can sometimes help answer the question of what is causing a chronic cough in a given instance.

Image courtesy of Winston W Tan, MD, FACP.

Which of the following conditions is the most likely diagnosis for the mass shown on this CT scan?

1. Infection
2. Lung cancer
3. Chronic granulomatous disease

Image courtesy of Winston W Tan, MD, FACP.

Answer: B. Lung cancer.

This lesion (arrow) is a right-middle-lung mass that turned out to be an adenocarcinoma of the lung.

Image courtesy of Winston W Tan, MD, FACP.