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Neoplasms, Lung: Differential Diagnoses & Workup
Updated: Oct 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Metastatic cancer
Granuloma
Hamartoma
Workup
Laboratory Studies
- Generally, a CBC is not helpful in the initial evaluation.
- Obtain a CBC in patients with widely metastatic disease to aid in determining if an infiltrate is potentially infectious.
- Obtain a CBC in patients with fever with recent history of chemotherapy to check for neutropenia (absolute neutrophil count <1000).
- Tests for electrolyte, BUN, creatinine, calcium, and magnesium levels are not helpful, except when specific paraneoplastic syndromes (eg, hypercalcemia, Cushing syndrome, syndrome of inappropriate antidiuretic hormone) are being considered.
- Can check serum levels of parathyroid hormone (PTH) or parathyroid hormone – related peptide (PTH-rP).
- Liver function tests (AST, ALT, GGT, PT/INR) and alkaline phosphatase are usually not helpful initially, but elevated results may be an indication of hepatic metastasis and bone metastasis, respectively.
- ABG levels are useful in the detection of respiratory failure (eg, acidosis, hypercarbia, hypoxia) in sick patients. Obtain ABG levels in patients with active systemic diseases or abnormal labored breathing.
- Sputum cytology is suggested for high-risk patients in which semi-invasive procedures such as bronchoscopy or transthoracic needle aspiration might pose a higher risk. The diagnostic accuracy of sputum cytology, however, is dependent on rigorous specimen sampling (at least 3 specimens) and preservation techniques, as well as on the location (central vs peripheral) and size of the tumor.13
- The test detects 71% of central tumors but less than 50% of peripheral tumors; therefore, further testing must always follow a negative result.
- Several large studies have not revealed that screening with sputum cytology and chest radiography is cost-effective in early detection.
Imaging Studies
- The percentage of patients found to have lung cancer incidentally through chest radiographs has been consistently low. Clues from the chest radiograph may suggest the diagnosis of lung cancer, but may not be helpful in identifying a histologic subtype. Chest radiographs may show the following:
- Pulmonary nodule, mass, or infiltrate
Non–small cell lung cancer. Bronchoscopy. A large central lesion was diagnosed as non–small cell carcinoma.
- Mediastinal widening
- Atelectasis
- Hilar enlargement
- Pleural effusion
Non–small cell lung cancer. Left pleural effusion and volume loss secondary to non–small cell carcinoma of the left lower lobe. The pleural effusion was sampled and found to be malignant; therefore, the lesion is inoperable.
- A chest CT scan is the standard for staging. The findings of CT scans of the chest and clinical presentation usually allow a presumptive differentiation between SCLC and NSCLC. Massive lymphadenopathy and direct mediastinal invasion are commonly associated with small cell carcinoma. A mass in or adjacent to the hilum is a particular characteristic of small cell cancer and is seen in about 78% of cases.14
Lung cancer, small cell. Contrast-enhanced CT scan of the chest shows a large left lung and a hilar mass, with invasion of the left pulmonary artery.
- PET scanning using fluoro-18–2-deoxyglucose (FDG) has proven to be an excellent modality for evaluating solitary pulmonary nodules. The average sensitivity and specificity of FDG-PET scanning for detecting a malignancy was reported to be 0.97 and 0.78, respectively.15
Lung cancer, small cell. Coronal positron emission tomogram shows abnormal areas of increased metabolic activity in the left hilar and left adrenal regions consistent with a hilar tumor with left adrenal metastasis.
- Obtain head CT scans, in patients with mental status change, when applicable.
- Bone scanning, when applicable.
Lung cancer, small cell. Whole-body nuclear medicine bone scanning with anterior and posterior images reveal multiple abnormal areas of increased radiotracer activity in the pelvis, spine, ribs, and left scapula. These findings are consistent with bony metastatic disease. The bones are commonly affected in patients with small-cell lung cancer.
- Experience with MRI is limited. Generally, an MRI is used only when findings of superior sulcus and brachial plexus tumors are equivocal on CT scans.
Other Tests
- Electrocardiography
- An ECG is helpful in establishing baseline findings and differentiating clinical symptoms (eg, chest pain, dyspnea).
- Changing lung hemodynamics often alter ECG wave patterns.
- Spirometry
- Bedside tests for peak expiratory flow provide good indicators of significant airflow obstruction.
- Lung cancer is more closely linked to chronic obstructive pulmonary disease with airflow compromise than to the disease without significant airway obstruction.
Procedures
- Excisional biopsy of an accessible node, or biopsy of accessible bone lesion
- Needle thoracentesis (ultrasound guided)
- Needle thoracentesis is both diagnostic and therapeutic in patients presenting with respiratory distress. Thoracentesis has a sensitivity of only 80% with a specificity greater than 90%. In patients suspected of having lung cancer who have an accessible pleural effusion, if the pleural fluid cytology finding is negative (after at least 2 thoracenteses), thoracoscopy is recommended as the next step to aid in diagnosis.
- Video-assisted thoracoscopy
- Video-assisted thoracoscopy is a newer modality that may be used to sample small peripheral tumors (less than 2 cm in diameter), pleural tumors, or pleural effusions for diagnostic or staging purposes.16
- Safe and can provide a definitive diagnosis with a high degree of accuracy and minimal risk to the patient. The reported sensitivity rate ranges between 0.80 and 0.99, the specificity rate ranges between 0.93 and 1, and the negative predictive value ranges between 0.93 and 0.96.16
- Flexible bronchoscopy
- The decision about whether to pursue a diagnostic bronchoscopy for a lesion that is suspected of being lung cancer largely depends on the location of the lesion (central vs peripheral).17 This is the study of choice in patients with central tumors, with a combined sensitivity of 88% with this type of tumor. The addition of transbronchial needle aspiration with endobronchial ultrasound to obtain cytology or histology samples when there is submucosal tumor spread or peribronchial tumor causing extrinsic compression further increases the sensitivity of bronchoscopy.16
- Transthoracic needle biopsy
- CT or fluoroscopically guided transthoracic biopsy is best for peripheral lung lesions. A positive finding for cancer is reliable; however, the false-negative rate is high at 26%, and, thus, transthoracic biopsy is generally not useful in ruling out cancer.
- Mediastinoscopy may be used to obtain tissue from cancer that has infiltrated into the mediastinum.18
- Thoracotomy is indicated only for diagnosis and treatment of clearly resectable NSCLC.
More on Neoplasms, Lung |
| Overview: Neoplasms, Lung |
 Differential Diagnoses & Workup: Neoplasms, Lung |
| Treatment & Medication: Neoplasms, Lung |
| Follow-up: Neoplasms, Lung |
| Multimedia: Neoplasms, Lung |
| References |
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Further Reading
Keywords
lung neoplasm, bronchogenic carcinoma, lung cancer, lung malignancy, adenocarcinoma, squamous cell carcinoma, SCC, oat cell carcinoma, large cell carcinoma, smoking, tobacco, passive smoke, secondhand smoke, SCLC, NSCLC
