9th January 2024

Presentation

Lung cancers can present with symptoms related directly to the airways (for example, a cough or haemoptysis) or with systemic features of cancer, including an unexplained loss of weight, fevers and night sweats. The features of lung cancer can also be secondary to paraneoplastic syndromes such as Lambert-Eaton Myasthenic Syndrome (see below). Metastatic spread can also produce specific clinical features related to the organ involved.

Respiratory

Common symptoms include:

• Cough, which may be productive of sputum
• Haemoptysis
• Chest pain, which may be pleuritic
• Dyspnoea
• Hoarseness of voice

Dyspnoea may be related to obstruction of the airways, reduced capacity of the lung parenchyma, or from phrenic nerve involvement. An exudative pleural effusion can occur, which is usually unilateral.

The recurrent laryngeal nerve can be compressed by a tumour if in the apex, causing a hoarse voice as part of Horner’s syndrome. A tumour which grows from the apex of the lung is called a Pancoast tumour. Other features of Horner’s include miosis, partial ptosis, anhidrosis and a thoracic outlet syndrome, with pain and weakness in the ipsilateral upper limb.

Superior vena cava (SVC) syndrome may result from compression of the SVC by a tumour. This results in facial oedema, venous distension observed in the chest and upper limbs, along with dyspnoea and a headache. Pemberton’s sign can be seen in SVC syndrome, where elevation of both arms for around one minute causes/worsens facial oedema.

Extra-Respiratory

The extra-respiratory clinical features of lung cancer are largely related to metastasis to the relevant organ system.

• Bone
  • Features of hypercalcaemia include polydipsia, confusion, renal stones, bony pain, constipation and weakness.
  • Severe hypercalcaemia can be associated with cardiac arrhythmias, including ventricular fibrillation.
• Adrenal
  • Abdominal pain
  • Adrenal insufficiency, causing lethargy, weight loss, fatigue, nausea, and vomiting. This can lead to an adrenal crisis, with features including profound hypotension, hyperkalaemia and hyponatraemia, hypoglycemia and syncope. This is a medical emergency.
  • Intra-abdominal haemorrhage
• Brain
  • Headache
  • Vomiting
  • Visual field loss
  • Hemiparesis
  • Cranial nerve deficit
  • Seizures
• Liver
  • Abdominal pain due to stretching of the liver capsule
  • Peripheral oedema
  • Jaundice
  • Ascites
  • Itching

Paraneoplastic

Some types of lung cancers are associated with particular paraneoplastic syndromes.

• Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH)
  • Associated with SCLC. The increased production of ADH causes hyponatraemia, which can result in numerous symptoms, from nausea and vomiting to seizures and coma.
• Lambert-Eaton Myasthenic Syndrome (LEMS)
  • Regarded as an autoimmune disorder associated with SCLC, LEMS is a condition in which antibodies target voltage-gated calcium channels, causing widespread weakness. Largely affecting the lower limbs, it can also lead to weakness of ocular muscles and muscles of respiration, leading to ophthalmoplegia and respiratory failure, respectively.
• Dermatomyositis
  • Heliotropic rash, Gottron’s papules and proximal myopathy
• Hypertrophic Pulmonary Osteoarthropathy (HPO)
  • Associated with nail clubbing, periostitis and arthropathy of the long bones of the limbs
• Cushing syndrome
  • Associated with SCLC, this condition has many features, including weight gain associated with typical facies and dorsocervical fat pad, hirsutism, hypertension, diabetes mellitus, hypernatraemia and hypokalaemia, oligo/amenorrhoea, impotence and osteoporosis.
• Hypercalcaemia secondary to PTH-related protein (PTHrP)

References

• Siddiqui F, Vaqar S, Siddiqui AH. Lung Cancer. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 (https://www.ncbi.nlm.nih.gov/books/NBK482357, accessed October 2022)
• UpToDate [Internet]. Uptodate.com. 2022 [cited 10 October 2022]. Available from: https://www.uptodate.com/contents/clinical-manifestations-of-lung-cancer