PRIMARY LUNG CANCER

RULE IN RULE OUT

EPIDEMIOLOGY 18 year old female

RISK FACTORS No vices

Unremarkable past medical history
and unremarkable family history

SIGNS AND SYMTOMS Cough, recurrent with whitish to No shortness of breath

yellowish phlegm No chest pain/oppression, No
Dyspnea hoarseness or loss of voice
Weight loss No hemoptysis
Anorexia
Fever Clear breath sounds
Weakness No rales, no wheezes

Recurrent pneumonia
METASTASIS SPINAL CORD: Numbness of the CNS: No headache, nausea,
groin area and both legs. vomiting, seizures, hemiplegia, and
dysarthria
BONE: multiple osteoblastic and
osteolytic changes involving the
thoracic vertebra and pelvic bones

LIVER: Upper abdominal

enlargement; UTZ of
hepatomegaly with multiple
hypoechoic nodules t/c abscess,
infected hepatic cyst, liver
metastasis

SKIN AND SOFT TISSUE: anterior

chest mass

RULE OUT

The World Health Organization (WHO) defines lung cancer as tumors arising from the
respiratory epithelium such as the bronchi, bronchioles and alveoli. It is the most common
cancer in the world today, about 12.6% of all new cancers and 17.8% of cancer deaths (Travis,
et al). Lung cancer is rare below age below 40, with rates increasing until age 80 (Kasper, et al).
In the epidemiologic aspect, having our patient as an 18-year old female, lung cancer can be
ruled out. First-degree relatives of lung cancer probands ha.ve two- to three fold excess risk of
lung cancer, many which are not smoking related. However, the patient does not have a strong
family history of lung cancer nor any form of cancer.
Because tobacco smoking is such a powerful determinant of risk, trends in lung cancer incidence
and mortality are a reflection of population-level changes in smoking behavior, including dose,
duration, and type of tobacco used (Travis, et al). Cigarette smokers have a 10-fold or greater
increased risk of developing lung cancer (Kasper, et al)

Lung cancer displays one of the most diverse presentation patterns of all human maladies.
Pulmonary symptoms result from the direct effect of the tumor on the bronchus or lung tissue.
Symptoms include cough that is secondary to irritation or compression of a bronchus, dyspnea
that is usually due to central airway obstruction or compression, with or without atelectasis,
wheezing due to narrowing of a central airway of >50%, hemoptysis, typically, blood streaking
of mucus that is rarely massive which indicates a central airway location, pneumonia that is
usually due to airway obstruction by the tumor, and lung abscess due to necrosis and cavitation,
with subsequent infection (Brunicardi, et al). Our patient presents with cough that is present in
8-75 % in patient’s with lung cancer (Kasper, et al). The other symptoms that were not present
were used to rule out lung cancer. Systemic symptoms such as weight loss, loss of appetite,
malaise and fever are common in approximately 5-20% cases are also present in out patient
(Travis, et al).

Lung cancer metastasizes most commonly to the CNS, vertebral bodies, bone, liver, adrenal
glands, lungs, skin, and soft tissues. Lung cancer is the most common cause of spinal cord
compression, either by primary tumor invasion of an intervertebral foramen or direct extension
of vertebral metastases. (Brunicardi, et al). The patient experiences numbness of the groin area
and both legs. Spinal cord compression may be the reason behind these symptoms.

Bony metastases are identified in 25% of all patients with lung cancer. They are pri- marily lytic
and produce pain locally; thus any new and localized skeletal symptoms must be evaluated
radiographically (Brunicardi, et al). The patient presents with lumbar AP/L finding of multiple
osteoblastic and osteolytic changes involving the thoracic vertebra and pelvic bones which may
be attributed to bone metastasis.

Those with liver metastases may present with right upper quadrant pain, fever, anorexia and
weight loss. Physical examination suggesting of liver metastases include hepatomegaly, our
patient experienced upper abdominal enlargement that was not supported by any physical
examination howerver the ultrasound report showed hepatomegaly with multiple hypoechoic
nodules t/c abscess, infected hepatic cyst, liver metastasis (Kasper, et al).

Skin and soft tissue metastases occur in 8% of patients dying of lung cancer and generally
present as painless subcutaneous or intramuscular masses (Kasper, et al). Occasionally, the
tumor erodes through the overlying skin, with necrosis and creation of a chronic wound. Our
patient presents with multiple hard masses, variably-sized, some movable, others fixed to
underlying tissue; some well-circumscribe, others with borderns not well-delineated on the
anterior chest.

CNS metastases are present at diagnosis in 10% of patients.Focal symptoms, including

headache, nausea, vomiting, seizures, hemiplegia, and dysarthria, are common but was not
present in our patient.
Reference:

Brunicardi, F. C. (2016). Schwartzs principles of surgery . Place of publication not identified:

Mcgraw-Hill.

Fauci, A., Braunwald, E., Kasper, D., Hauser, S., Longo, D., Jameson, J., . . . Houston, B.
(2018). Harrisons principles of internal medicine. New York: McGraw-Hill Education.

Travis, W, Brambilla, E., Muller-Hermelink, H., Harris, C. (2004). WHO pathology and Genetics of
Tumor of the Lung, Pleura, Thymus and Heart. New York: WHO Publications Center.