Primary Lung Cancer Diagnosis

Clinical Presentation

Cough is present in >65% of patients at the time lung cancer is diagnosed, and this patient has had a nonproductive cough for three months 1
Hemoptysis, even in small amounts with blood-streaked phlegm, should raise concern for endobronchial tumor, particularly in patients with risk factors 2, 3
Dyspnea often accompanies cough caused by cancer in the airway, especially with centrally-located tumors that obstruct airflow 1, 4
Constitutional symptoms including unintentional weight loss, decreased appetite, and fatigue are common presenting features of lung cancer 2
Hoarseness indicates recurrent laryngeal nerve involvement, which is typically seen with tumors that compress or invade the nerve, particularly left-sided tumors 3
Cancer cell types that are centrally located in the airways (squamous cell carcinoma and small cell undifferentiated lung cancer) are more likely to cause cough at presentation 1
Centrally-located tumors stimulate cough receptors and obstruct airflow to produce dyspnea 1, 4
Clubbing of the fingernails is a paraneoplastic manifestation strongly associated with lung cancer, particularly non-small cell lung cancer 3
The presence of clubbing with respiratory symptoms significantly increases the likelihood of malignancy 5

25-year history of working at a pesticide manufacturing plant represents significant occupational carcinogen exposure 6, 5
The workplace has been estimated to account for approximately 15% of the burden of chronic obstructive lung disease, and occupational exposures should be specifically considered for all patients with respiratory symptoms whose symptoms start during their working life 7, 8
Occupational lung cancer should be included in the differential diagnosis when there is a history of workplace exposure to carcinogens 7

Chest radiograph should be obtained when a patient with cough has risk factors for lung cancer 4
CT chest with IV contrast is the primary modality to determine the etiology and should be performed in all patients with frank hemoptysis and risk factors for lung cancer 9
The diagnostic evaluation should target the most advanced site of disease first to efficiently obtain both diagnosis and staging information 2, 3

Do not dismiss small amounts of blood streaking in sputum as related to bronchitis, especially in patients with occupational exposures 2, 3
Normal chest radiograph findings markedly reduce but do not eliminate the likelihood that cough is due to neoplasm 1
Persistent hemoptysis, even in scant amounts, in patients with occupational exposures should raise concern about endobronchial tumor 2
Do not attribute all symptoms to chronic bronchitis or COPD without ruling out malignancy in patients with significant risk factors 1, 4