Primary Lung Cancer (Most Likely Squamous Cell or Small Cell Carcinoma)
This patient's presentation of hemoptysis, nonproductive cough, dyspnea, constitutional symptoms (weight loss, fatigue, decreased appetite), hoarseness, digital clubbing, hypoxemia, and 25-year occupational exposure to pesticides is highly consistent with primary lung cancer, most likely a centrally-located tumor such as squamous cell carcinoma or small cell lung cancer.
Clinical Reasoning
Classic Lung Cancer 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 1
- Dyspnea often accompanies cough caused by cancer in the airway, especially with centrally-located tumors that obstruct airflow 1
- Constitutional symptoms including unintentional weight loss, decreased appetite, and fatigue are common presenting features of lung cancer 1
Specific Features Pointing to Central Airway Tumor
- Hoarseness indicates recurrent laryngeal nerve involvement, which is typically seen with tumors that compress or invade the nerve, particularly left-sided tumors 1
- 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
Digital Clubbing as a Key Finding
- Clubbing of the fingernails is a paraneoplastic manifestation strongly associated with lung cancer, particularly non-small cell lung cancer
- The presence of clubbing with respiratory symptoms significantly increases the likelihood of malignancy
Occupational Exposure
- 25-year history of working at a pesticide manufacturing plant represents significant occupational carcinogen exposure 1
- 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 1
- Occupational lung cancer should be included in the differential diagnosis when there is a history of workplace exposure to carcinogens 1
Hypoxemia
- Oxygen saturation of 91% indicates significant hypoxemia, consistent with impaired gas exchange from tumor burden, airway obstruction, or postobstructive pneumonia 1
Diagnostic Approach
Immediate Imaging
- Chest radiograph should be obtained when a patient with cough has risk factors for lung cancer 1
- 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 1, 2
- Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, or risk factors for lung cancer 3
Tissue Diagnosis
- Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with frank hemoptysis and can provide tissue diagnosis 3
- The diagnostic evaluation should target the most advanced site of disease first to efficiently obtain both diagnosis and staging information 1
Common Pitfalls to Avoid
- Do not dismiss small amounts of blood streaking in sputum as related to bronchitis, especially in patients with occupational exposures 1
- 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 1
- Do not attribute all symptoms to chronic bronchitis or COPD without ruling out malignancy in patients with significant risk factors 1