Modern lung cancer diagnosis and treatment

Author: Chief Editor: Zha Renjun / et al
Publisher:
Publish Date: 1999-12-01
Features: Summary of Content This edition, in addition to slightly editing and deleting some chapters on the diagnosis and early diagnosis of lung cancer, various treatments, prevention and treatment of complications, lung cancer emergencies, evaluation of efficacy, and survival statistics, has supplemented many new experiences and information. The surgical and radiotherapy treatments for lung cancer have been completely rewritten, and new topics have been added, including anesthesia for lung cancer patients, the application of video thoracoscopy in the diagnosis and treatment of lung cancer, stereotactic radiotherapy, integrated traditional Chinese and Western chemotherapy for lung cancer, gene therapy for lung cancer, the use of radionuclides in the diagnosis and treatment of lung cancer, thermal physical therapy for malignant pleural effusion and malignant pericardial effusion in the thoracic (pericardial) cavity, surgical treatment and perioperative management of elderly lung cancer, pulmonary metastatic tumors, as well as new anticancer drugs. The content is novel, comprehensive, easy to understand, and practical. This book is a valuable reference for oncologists, internal medicine physicians, surgeons, radiotherapists, and anesthesiologists. It can also be used as a reference for tumor researchers and medical school students and faculty.
Excerpt:
(1) Asymptomatic or Atypical Symptoms: Approximately 13.3% of cases are asymptomatic, and 5.9% show no symptoms at all. However, upon detailed examination, about half of these cases have already metastasized, with lesion diameters ranging from 2 to 7 cm. In some cases, lung cancer has even metastasized externally when the primary lesion was only 1 cm or smaller in diameter. Some lesions measuring 1 cm and 2.5 cm have also been observed, with no significant changes over 2 years or 7–8 years.
(2) Recurrent Pneumonia: About 10% of patients had a history of pneumonia before admission, and most improved with various antibiotics and treatments, with lung shadows absorbing or even completely disappearing in some cases. However, about one-third of patients experienced repeated episodes of pneumonia in the same location within a relatively short period. This is likely related to bronchial drainage obstruction after lung cancer, making secondary infections more common.
(3) Scar Cancer Complicated with Tuberculosis: Between 1970 and 1976, 37 out of 135 lung cancer patients had a history of tuberculosis and/or pleurisy. Among them, 25 cases were confirmed as scar cancer through surgery or autopsies, including adenocarcinoma (5 cases), bronchioloalveolar carcinoma (4 cases), and small cell carcinoma (1 case). Half of these cases had metastasized, and their clinical manifestations were related to the pathological cell type. These patients likely had lower cellular immune function, making them more susceptible to tuberculosis. After recovery or long-term stability of tuberculosis, their cellular immune function further declined as they aged. Additionally, long-term stimulation from tuberculosis scars or crystalline cholesterol in tuberculous lesions may have led to the development of scar cancer. Therefore, for tuberculosis patients, especially those whose lesions worsen after age 40 and undergo antitubercular treatment, X-ray chest films should be taken every 2–4 weeks. For cases that do not respond to antitubercular treatment, scar cancer should be highly suspected.
(4) Symptoms of Metastatic Lesions as the First Presentation: About 8% of patients first presented with symptoms caused by metastatic lesions, such as headaches, leg or waist pain, hoarseness, dysphagia, and facial or neck edema (superior vena cava obstruction syndrome), which can lead to misdiagnosis and delayed treatment. For example, Horner syndrome caused by metastatic cervical lymph node lesions compressing the sympathetic nerve on the same side, characterized by miosis, mild ptosis of the upper eyelid, and anhydrosis of the face. Additionally, Pancoast syndrome caused by apical lung cancer (lung cancer in the superior sulcus) invading the scapula and vertebrae, leading to severe shoulder and arm pain, sensory abnormalities, mild hemiplegia or weakness on one side, muscle atrophy, and even enophthalmos, ptosis, and miosis, can also be the first symptoms of lung cancer.
(5) Primary Multiple Cancers: About 5%–10% of cases involve multiple primary cancers, which may occur simultaneously or at different times. In particular, when a solitary pulmonary mass is found in patients with other malignant tumors, it should not be hastily assumed to be a metastasis from another malignancy, as this could delay surgical treatment.
(6) Extrapulmonary Manifestations: These have gained increasing attention in recent two decades and are related to the production of certain hormones, antigens, enzymes, or metabolic products by lung cancer, rather than metastasis or direct infiltration. Therefore, they can completely disappear after radical lung cancer treatment. The extrapulmonary manifestations of lung cancer include the following:
① Systemic Changes: Anorexia leading to cachexia (31%), often a late symptom; fever (10%–34%), which may appear in earlier stages and persist in some patients; immune suppression.
② Endocrine Disorders or Paraneoplastic Endocrine Syndromes: These have corresponding clinical manifestations and account for about 10%, sometimes as the first symptom. Some patients may have one or more plasma ectopic hormones elevated without clinical symptoms, with small cell carcinoma being most common (11%–89%).
- Ectopic ACTH secretion (60% in small cell carcinoma), leading to Cushing syndrome, characterized by progressive muscle weakness, facial/neck or generalized obesity, abdominal and leg striae, peripheral edema, hypertension, diabetes, hypokalemic alkalosis, etc.
- Antidiuretic hormone secretion excess (more common in small cell carcinoma): hyponatremia (<120 mmol/L), hyponatremia (<270 mOsm/L), and hypertonic urine (specific gravity >1.200); clinical symptoms include fatigue, weakness, drowsiness, dizziness, headaches, nausea, vomiting, abdominal distension, anorexia, muscle cramps, and even confusion or syncope.
- Ectopic parathyroid hormone (more common in squamous cell carcinoma): polyuria, polydipsia, constipation, anorexia, weight loss, tachycardia, arrhythmia, hypercalcemia, hypophosphatemia, and psychiatric abnormalities.
Other ectopic hormones, such as human chorionic gonadotropin (more common in large cell carcinoma, leading to gynecomastia), 5-hydroxytryptamine (more common in carcinoid tumors, leading to carcinoid syndrome), melanocyte-stimulating hormone (leading to acanthosis nigricans, more common in squamous cell carcinoma), growth hormone (leading to skeletal abnormalities, seen in adenocarcinoma or squamous cell carcinoma), and calcitonin (leading to hypocalcemia), may also be detected in plasma with increased concentrations, even with corresponding clinical manifestations.
③ Bone Lesions, Clubbing (29%): More common in squamous cell carcinoma and may precede pulmonary symptoms.
- Hyperostotic arthropathy (1%–10%): More common in adenocarcinoma, with swollen and deep-lying pain in affected joints, worsening at night, periosteal hyperplasia at the ends of long bones, and new bone formation.
④ Neuro-Muscular Lesions (1%–14%):
- Myasthenia gravis syndrome (Eaton-Lambert syndrome): More common in small cell carcinoma, with proximal muscle groups affected. Muscle strength may temporarily improve after sustained activity. High-frequency continuous electrical stimulation in electromyography increases action potential amplitude, and the response to anticholinesterase drugs is poor but sensitive to succinylcholine.
- Peripheral neuropathy: Characterized by pain and weakness in the extremities, more severe in the legs. It involves degeneration of dorsal root ganglia and nerves.
- Subacute cerebellar degeneration: Causes vertigo, nystagmus, ataxia, and difficulty walking, sometimes accompanied by dementia and dysarthria.
- Cortical degeneration.
- Limbic encephalitis and encephalomyelitis: Causes memory impairment.
- Subacute necrotizing myelopathy: Primarily characterized by symmetric, ascending, rapidly progressive motor disorders with mild sensory impairment.
- Amyotrophic lateral sclerosis syndrome.
- Polymyositis, etc., which may precede other symptoms.
⑤ Hematological Changes (8%):
- Cancer-related anemia (may be related to significantly reduced erythropoietin levels; erythropoietin therapy may help).
- Granulocytosis (can manifest as leukemoid reaction).
- Polycythemia.
- Leukocytosis and erythrocytosis.