Page 176 Guide to Pain Management in Low-Resource Settings

164 Th omas Jehser

How does lung cancer start? the pain medication was suspected to be responsible.
After the completion of radiotherapy, Mr. K. experi-
Bronchial carcinomas mostly start in the central airway enced much better breathing and almost no pain, al-
region and less often in the more peripheral smaller though the medication had been reduced to metamizol
bronchi. Th e fi rst and most noticeable symptom is a q.i.d. and tramadol p.r.n.
nonproductive persistent cough (suspicious when last-
ing longer than 6 weeks). Other primary symptoms are
What are the disease trajectory
hemoptysis, dyspnea or chest pain, and rarer symptoms and treatment options?
are hoarseness, anxiety, fever, and mucoid expectoration
or paraneoplastic syndromes or signs following any kind Tumor diseases may cause local, regional, and systemic
of early metastasis (Box 1). Th e histological analysis dif- functional disorders, symptoms, and complications. Th e
ferentiates small-cell (13%) from non-small-cell (81%) local eff ects of lung cancer are airway obstruction and
carcinomas. Six percent of analyses deliver no distinct infi ltration of neighboring tissues. Th is may lead to mu-
result (anaplastic carcinoma). Other malignancies or coid impaction, retrostenotic pneumonia, hemorrhage,
space-consuming processes of the thorax are pleural or pleural eff usion. Th e regional spreading of the tumor
mesotheliomas, thymomas, metastases of extrathoracic follows continuous infi ltration of the mediastinum, the
tumors, or infectious diseases (Box 2). An accurate dif- pleura, or the axilla or spreads via local lymph vessels.
ferential diagnosis of thoracic discomfort therefore has Symptoms of regional spreading are weakness;
to consider tumorous illnesses. loss of appetite and weight; congestion of head and
neck vessels; infi ltration into the mediastinum, axilla,
Case report—part two and chest wall with mixed pain in the arm, shoulder,
chest and upper back; dysphagia; or neurological dis-
Unfortunately, tumor metastasis was detected at the orders (palsy of the arm, Horner syndrome, or para-
moment of initial diagnosis, and the primary growth plegia). Th e systemic dissemination of primary lung
was located in a very central position. Breathing ca- tumors via the bloodstream or lymphatic pathways
pacity—when tested—was limited to a FEV of 1.1 causes symptoms and disorders according to the quan-
1
L. Th erefore it was decided that a surgical resection tity and location of the metastases. Patients may now
would be impossible. For symptomatic treatment, Mr. suff er from neurological, metabolic, cardiovascular or
K. was treated by radiotherapy at the tumor region gastrointestinal disorders (Box 3). Common locations
(cumulative dose of 46 Gy) following radiation of the of dissemination of lung cancer are thoracic and cer-
bone metastasis at the spine (36 Gy) and the knee (8 vical lymph nodes, bone, pleura, the brain and its lin-
Gy). In the course of treatment, blood testing revealed ings, the liver, and the adrenal glands. Very seldom are
elevated hepatic transaminases. Since no hepatic me- the spleen, heart, skin, eye (choroid coat), kidney, or
tastasis was found, the carbamazepine component of pancreas affl icted.

Box 1. Common symptoms of beginning Box 2. Common extrathoracic diseases and
lung cancer infections with pulmonary manifestation
Persistent cough Breast cancer
Hemoptysis Rectal cancer
Dyspnea Renal cancer
Chest pain Malignant melanoma
Hoarseness Sarcomas
Fever, mucoid impaction Aspergillosis
Other pain locations Tuberculosis
Loss of appetite, weight, and strength Helminthiasis
Paraneoplastic syndromes
Cushing syndrome
Herpes zoster
Peripheral neuropathy
Venous thrombosis