A 45-year-old asymptomatic white man with a 60-pack-year history of cigarette abuse presented with an upper lobe pulmonary nodule apparent on the right side on a routine chest roentgenogram. Physical examination was unrevealing. Computed tomography demonstrated an irregular noncalcified mass suggestive of neoplasm. Results oftransbronchial biopsy were positive for adenocarcinoma. Evaluation for metastases, including a computed tomographic scan of the head, radionuclide bone scan, and serum liver function tests, yielded negative results. The patient subsequently underwent upper lobectomy of the right lung with curative intent and was pathologically staged as having stage I (T2N0)1 adenocarcinoma of the lung.The patient did well until 14 months after surgery, when he developed cough, dyspnea, and hemoptysis. A few days later, he noted a right-sided facial droop, clumsiness of the right hand, blurring of vision, and a severe headache. He presented in the emergency department, where physical examination revealed facial swelling, bilateral jugular venous distention, an engorged venous pattern over the upper part of the chest, bilat¬ eral papilledema, and right-sided cen¬ tral facial nerve paresis. A chest roentgenogram demonstrated a superior mediastinal mass on the right, and multiple enhancing lesions in bilateral cerebral and left cerebellar hemispheres were From the National noted on computed tomographic scan of the patient's head. A diagnosis of re¬ current lung cancer with superior vena cava syndrome and brain métastases was made. Irradiation to the thorax and brain and dexamethasone were ad¬ ministered, which provided symptom¬ atic relief. However, 2 months later, severe hip and shoulder pain oc¬ curred, and lytic bone lesions were documented in the acetabulum and scapula. Despite further radiother¬ apy, followed by treatment with com¬ bination chemotherapy with etoposide and cisplatin, the patient died 5 months after initial tumor recurrence.
COMMENTLung cancer continues to occur in ep¬ idemic proportions in the United States. According to American Cancer Society estimates for 1991,2 it is the second most common cancer among men and women combined. It is second only to prostate cancer as the most frequently occurring cancer in men and trails only breast and colorectal malignancies in women. Fur¬ thermore, because it is seldom diagnosed early, when prospects for cure are high, lung cancer is the most common cause of cancer death in both men and women.2The cause of this epidemic is not mys¬ terious. About 95% of lung cancers in men and 80% to 85% of lung cancers in women result from cigarette smoking, as was almost certainly true in the pa¬ tient whose case history was just de¬ scribed. There is a dose-dependent re¬ lationship between the degree of ciga¬ rette abuse and relative risk of death from lung cancer, which in prospective epidemiologie studies has increased up to 25-fold for men who smoke 25 to 40 cigarettes per day compared with ne versmokers.3 Both cigarette consumption per capita and the percentage o...