In a patient with epidermoid carcinoma of the right lung, the finding which indicates the worst prognosis is
a. Pulmonary symptoms result from the direct effect of the tumor on the bronchus or lung tissue.
b. Symptoms (in order of frequency) include
1. Cough (secondary to irritation or compression of a bronchus),
2. Dyspnea (usually due to central airway obstruction or compression, with or without atelectasis),
3. Wheezing (with narrowing of a central airway of greater than 50%), hemoptysis (typically, blood streaking of mucus that rarely is massive, and indicates a central airway location),
4. Pneumonia (usually due to airway obstruction by the tumor), and lung abscess (due to necrosis and cavitation, with subsequent infection.
c. Nonpulmonary thoracic symptomsresult from invasion of the primary tumor directly into a contiguous structure (e.g., chest wall, diaphragm, pericardium, phrenic nerve, recurrent laryngeal nerve, superior vena cava, and esophagus), or from mechanical compression of a structure (e.g., esophagus or superior vena cava) by enlarged tumor-bearing lymph nodes.
d. Recurrent laryngeal nerve (RLN) involvement most commonly occurs on the left side, given the hilar location of the left RLN as it passes under the aortic arch.
e. Symptoms include voice change, often referred to as hoarseness, but more typically a loss of tone associated with a breathy quality, and coughing, particularly when drinking liquids.
f. Superior vena cava (SVC)syndrome most frequently occurs with small-cell carcinoma, with bulky enlargement of involved mediastinal lymph nodes and compression of the SVC. Occasionally, a medially-based right upper lobe (RUL) tumor can produce the syndrome with direct invasion. Symptoms include variable degrees of swelling of the head, neck, and arms; headache; and conjunctival edema.
g. Pericardial invasion may lead to pericardial effusions (benign or malignant), associated with increasing levels of dyspnea and/or arrhythmias, and with the potential to develop pericardial tamponade.
h. Diagnosis requires a high index of suspicion in the setting of a medially-based tumor with symptoms of dyspnea, and is confirmed by CT scan or echocardiography.