Lung Cancer — DCE Clinical Case

Approach — what the examiner is watching

This is a targeted respiratory examination with malignancy in the differential from the first second: the marks are in finding the peripheral clues deliberately (hands, face, nodes) before the chest, and in presenting a unifying diagnosis with a next step, not a laundry list [1].

The examination — in the order that finds the money

• Hands: clubbing (loss of nail-bed angle, increased longitudinal curvature, boggy nail bed) — in a smoker with a chest mass it raises squamous/NSCLC probability and may accompany hypertrophic pulmonary osteoarthropathy; nicotine staining frames exposure but diagnoses nothing [1].
• Face and neck: Horner syndrome (ptosis, miosis, anhidrosis) for apical disease; facial plethora, conjunctival suffusion and non-pulsatile distended neck veins suggesting SVC obstruction — check Pemberton sign if suspected [2].
• Nodes: supraclavicular and cervical chains, carefully — a hard left supraclavicular node is both a staging finding and the kindest biopsy target [1].
• Chest: tracheal position first (deviation toward volume loss); then inspection, palpation, percussion, auscultation. The expected pattern here is left upper-lobe collapse: reduced expansion, dull percussion, diminished breath sounds over the upper zone, possibly with post-obstructive crackles.
• Complete the survey: cachexia and performance status, calves (VTE complicates malignancy), and a statement that you would examine the abdomen for hepatomegaly and review observations.

Presentation template (deliver this to the examiner)

"Mr Papas is a 68-year-old man with a heavy smoking history and constitutional symptoms. On examination he has finger clubbing and a firm 2 cm left supraclavicular node. His trachea is central. There are signs of left upper-lobe collapse — reduced expansion, dullness and diminished breath sounds in the upper zone — without signs of pleural effusion. There is no Horner syndrome and no evidence of SVC obstruction. In a smoker with weight loss, these findings are most consistent with a central bronchogenic carcinoma causing proximal obstruction, with nodal involvement. I would confirm with contrast CT and PET, and obtain tissue — the supraclavicular node may be the safest diagnostic and staging specimen — ensuring enough material for molecular testing." [1] [3].

Differentials to hold while presenting

• Bronchogenic carcinoma with post-obstructive collapse — the unifying diagnosis the station is built around [1].
• Tuberculosis or other granulomatous disease — apical disease with weight loss; the node biopsy answers it.
• Lymphoma — nodal disease can dominate; again a tissue question.
• Benign obstruction (foreign body, carcinoid) — why 'malignancy until proven otherwise' still ends in histology [3].

Probing questions

"Why did you examine the supraclavicular nodes before the chest?" — "Two reasons: a positive node changes the stage, and it offers the least invasive tissue — fine-needle or core biopsy of a palpable node can give diagnosis, staging and molecular material in one procedure, sparing him a bronchoscopy as the first invasive step." [3].

"What signs of SVC obstruction would you look for, and why does it matter?" — "Facial and upper-limb swelling, venous engorgement of the neck and chest wall, conjunctival suffusion, and headache on bending; Pemberton sign on arm elevation. It matters because it is an oncological emergency — management is tissue first, stenting for severe obstruction, then disease-directed therapy — and because it localises disease to the mediastinum." [2].

"Clubbing — what is its significance here?" — "In this context it supports a thoracic malignancy and, with bony tenderness, hypertrophic pulmonary osteoarthropathy — a paraneoplastic phenomenon classically of non-small-cell disease. It is not specific: suppurative lung disease, interstitial fibrosis, cyanotic cardiac disease and cirrhosis share it. Its exam value is as a red flag that commits you to a cancer pathway." [1].

"Your CT confirms a central left upper-lobe mass with the node involved. What does the biopsy need to achieve beyond 'cancer'?" — "Histotype first — small-cell versus non-small-cell changes everything. If non-squamous NSCLC, enough material for molecular testing — EGFR, ALK, ROS1, KRAS and PD-L1 at minimum — because first-line treatment in advanced disease is chosen by genotype, and the 2021 WHO classification treats that molecular layer as integral to the pathology report." [3].