What are the clinical examination findings of lung cancer?

Clinical Examination Findings of Lung Cancer

The majority of patients with lung cancer present with symptoms related to the primary tumor or intrathoracic spread, while approximately one-fourth are asymptomatic at diagnosis and typically have less advanced disease. 1

Primary Pulmonary Symptoms and Signs

Most Common Presentations

• Cough is the most frequent presenting symptom, resulting from endobronchial irritation, parenchymal infiltration, or postobstructive pneumonia 1
• Dyspnea accompanies endobronchial obstruction, parenchymal involvement, or pleural effusion 1
• Hemoptysis, even in scant amounts with blood-streaked sputum, warrants concern especially in patients with smoking history and COPD—this may occur even with normal chest radiographs 1
• Localized or unilateral wheezing reflects endobronchial obstruction and should prompt evaluation for neoplasm 1
• Recurrent pneumonia in the same anatomic distribution or relapsing COPD exacerbations should raise suspicion for underlying malignancy 1

Chest Pain Patterns

• Nonspecific chest discomfort is common and often dismissed by patients 1
• Pleuritic chest pain indicates invasion of the pleura or chest wall 1

Signs of Intrathoracic Spread

Superior Vena Cava Syndrome

Physical examination reveals facial edema and plethora, dilated neck veins, and prominent venous pattern on the chest wall—lung cancer is the most common cause of SVC syndrome 1

• Patients experience facial and neck swelling, and less commonly dysphagia, cough, headache, dizziness, and blurred vision 1
• Chest radiographs typically show widened mediastinum or right hilar mass but may appear normal 1

Pancoast Syndrome (Superior Sulcus Tumors)

• Shoulder and arm pain from brachial plexus invasion and involvement of adjacent soft tissues, ribs, and vertebrae 1
• Horner syndrome (unilateral ptosis, miosis, and lack of facial sweating) from sympathetic chain and stellate ganglion infiltration 1
• Weakness, pain, and paresthesias in the arm and hand following the distribution of C8, T1, and T2 nerve roots 1

Vocal Cord Dysfunction

• Hoarseness from left recurrent laryngeal nerve palsy due to its circuitous route under the aortic arch, which renders it susceptible to compression by tumor or malignant nodes 1
• May predispose to coughing and aspiration 1

Phrenic Nerve Involvement

• Elevated hemidiaphragm on chest radiograph from phrenic nerve dysfunction caused by tumor extension into the mediastinum 1

Cardiac and Pericardial Involvement

• Pericardial effusion is the most common cardiac manifestation, occurring through direct extension or lymphatic spread 1
• May present as pericardial tamponade with hypotension, elevated jugular venous pressure, and muffled heart sounds 1
• Arrhythmias may result from pericardial involvement 1

Signs of Distant Metastases

Systemic Symptoms

• Anorexia, weight loss, and fatigue are nonspecific but common in patients with distant metastases and associated with worse prognosis even within the same cancer stage 2

Bone Metastases (6-25% at presentation)

• Bone pain and bony tenderness, most commonly involving vertebral bodies 2
• Elevated serum calcium or alkaline phosphatase may be present 2

Brain Metastases

• Headache, nausea, vomiting from increased intracranial pressure 2
• Seizures or mental status changes from mass effect or irritation 2
• May be asymptomatic and detected only on imaging 2

Liver Metastases

• Weakness and weight loss are typical presenting symptoms 2
• Liver function tests typically remain normal until very advanced stages of involvement 2

Lymph Node Metastases

• Palpable supraclavicular or cervical lymphadenopathy may be the presenting sign 2
• Hilar and mediastinal adenopathy is typically asymptomatic unless very bulky 2

Pleural Involvement

• Pleural effusion should always raise concern for malignancy in the context of known or suspected lung cancer 2
• May present with progressive dyspnea and decreased breath sounds on examination 1

Asymptomatic Presentation

• Approximately 25% of patients are asymptomatic at diagnosis, typically discovered incidentally on chest imaging performed for unrelated reasons 1
• These patients are more likely to have stage I or II disease with better prognosis 1
• Asymptomatic patients often have solitary pulmonary nodules or masses on chest radiographs or CT scans 1

Clinical Examination Pitfalls

A critical pitfall is dismissing symptoms as related to common conditions like bronchitis or COPD exacerbations—persistent or recurrent symptoms in high-risk patients (smokers, age >50) warrant thorough evaluation 1

• Pain distribution outside the chest (shoulder, arm) in Pancoast syndrome may delay recognition of lung cancer as the primary etiology 1
• Small amounts of hemoptysis are often dismissed by patients as bronchitis-related but require investigation 1
• Normal chest radiographs do not exclude lung cancer, particularly with hemoptysis or persistent symptoms 1