Patients with metastatic NSCLC to the brain have a poor prognosis. At diagnosis, brain metastases are rare and account for only 7%-10% of cases; however, as many as 20%-40% of patients develop brain metastasis during their disease course. Traditionally, because of poor prognosis and limited survival, palliative treatment with corticosteroids and whole-brain radiation has been the standard treatment. In some selected patients with solitary brain metastasis from NSCLC, more aggressive management with surgical resection or radiosurgery has been pursued.
The most important risk factor in the development of lung cancer is exposure to tobacco smoke, either from active cigarette smoking or passive smoking. The relative risk for lung cancer in lifetime smokers is estimated to be 10-30 times higher than in nonsmokers. A study to assess the impact of smoking at diagnosis and quitting on 1-year survival of NSCLC reported that 77% of never-smokers were alive at 1 year, compared with 60% of ex-smokers and 57% of current smokers.
Other risk factors for development of lung cancer include radiation therapy, occupational and environmental carcinogens, and dietary and genetic factors. Radiation therapy, used to treat such cancers as Hodgkin lymphoma, carries a risk for lung cancer that should be addressed with patients. A review of the literature on long-term complications of the treatment of Hodgkin lymphoma showed that the risk for lung cancer was increased twofold to sevenfold in patients who received radiation therapy.
Patients with risk factors for lung cancer or patients with symptoms of cough, shortness of breath, hemoptysis, or unexplained weight loss and fatigue should undergo investigation for lung cancer. These symptoms are usually related to tumor location and may be due to the primary tumor, local or regional spread, or metastatic disease. Physical examination, complete blood cell count, and chest radiography are the first steps in lung cancer screening. Concerning findings on chest radiography include pulmonary masses, nodules, effusions, or infiltrates. Widening of the mediastinum as well as hilar enlargement and atelectasis are other findings of concern.
Most patients with lung cancer present with advanced-stage disease. Symptoms of metastasis include bone pain, neurologic changes, or spinal cord impingement; therefore, PET plays an important role. In addition, a wide variety of paraneoplastic syndromes are observed in association with lung cancer. Symptoms may include Trousseau syndrome of hypercoagulability, syndrome of inappropriate antidiuretic hormone secretion (SIADH), clubbing, and hypertrophic osteoarthropathy.
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