-2 :: Case - 13971 ::
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Tx and Followup:
The patient will need a PET or CT to complete her metastatic workup. Palliative external beam radiotherapy can be utilized for local tumor control, and to reduce her symptoms. Subsequent systemic chemotherapy will be required.

Additional Discussion:
Based on the findings of the CXR there was a broad differential to consider. It appeared as if there were a single nodule, which could be caused by a number of benign processes as well as malignancy. However, when a CT scan was obtained it showed that the diagnosis was most likely not benign. Not only did it show additional tissue involvement, it revealed an invasive process with lymphadenopathy. While the AST elevation may not have been impressive, the presence of multiple nodules that appeared similar in density to the pulmonary process must bring to mind malignant metastases.

Given this patient's age and exposure to smoke, lung cancer should be at the top of the differential. Her new cough and SOB signaled the increasing amount of pulmonary invasion. The hoarseness she was experiencing could be explained by involvement of the recurrent laryngeal nerve as it hooks around the aortic arch. In addition leukocytosis and thrombocytosis can be seen with lung cancer. While the exposure to smoke and predominately central pulmonary involvement might make you favor small cell or squamous cell carcinoma, this patient actually had atypical adenocarcinoma. Adenocarcinoma of the lung is the most common histologic type of lung cancer.

Discussion Author: Lou Rose Malamug

Lung cancer has surpassed breast cancer in becoming the leading cause of cancer death in women. Adenocarcinoma accounts for 30-40% of lung cancers and is the most common histologic type. It is also the most common type of lung cancer in non-smokers (an estimated 10-15% of patients diagnosed with lung cancer are non-smokers). The most common sites of distant metastases are the brain, bones (most commonly vertebrae), liver, adrenals, and skin. The American Thoracic Society recommends measurement of a CBC, serum electrolytes, calcium, alkaline phosphatase, albumin, AST, ALT, total bilirubin, and creatinine in all patients with lung cancer. Abnormal LFTs should be followed up with a contrast-enhanced CT of the liver, and an elevated alkaline phosphatase or calcium level should be followed up with a bone or PET scan to detect metastases (there is conflicting evidence as to which imaging modality has greater sensitivity). With regard to monitoring response to therapy, one study reported that changes in FDG uptake on PET scan rather than changes in lesion size on CT more accurately correlates with response to therapy. Stage IV disease is primarily managed with chemotherapy or with palliative measures for symptomatic relief, and the five year survival rate is less than 5%.

Systematic screening for lung cancer is not currently recommended by any major medical organizations. The USPSTF concluded that there is currently insufficient evidence to argue for or against screening asymptomatic individuals for lung cancer with either chest x-ray, low dose computerized tomography, sputum cytology, or a combination of these tests. Studies evaluating the benefits of screening have shown increased detection of early stage lung cancer in asymptomatic individuals but have not shown a reduction in mortality. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial is an ongoing trial evaluating the use of a single posterior-anterior CXR, and the Early Lung Cancer Action Project is currently evaluating the use of low-dose spiral CT for screening.

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