277. Lung Cancer

Question 1

Lung Cancer

• Epi
• RFs
• Carcinogenesis

Answer 1

Epi: 1st leading cause of death, 2nd most dx cancer, worst 5 year survival (21%), most likely to present late/distant disease

RF: SMOKING (but can occur in non-smokers), asbestos, radiation

Carcinogenesis

• activated by carcinogens
• DNA adduct formation
• mutations, epigenetic gene inactivation
• growth suspension evasion, apoptotic resistance, sustained proliferation, angiogenesis

Question 2

Lung Cancer: CPs and complications

• early stage
• other presenting syndromes (3)
• sites of mets (5)

Answer 2

Early Stage: Asx
- maybe cough, weight loss, dyspnea, chest pain, hemoptysis

SVC syndrome: vessel obstruction = facial plethora, dilated veins on chest, extremity edema, HA

Pancoast Tumor: nerve impingement: shoulder pain, brachial plexus abnormality, Horner’s Syndrome (ptosis, miosis, anhidrosis) [can vary]

Hoarseness: laryngeal nerve compression

Mets: pleura, brain, bone, adrenal gland, liver

Question 3

What paraneoplastic syndromes are associated with lung cancer (4)? Which types of lung cancer?

Answer 3

1. SIADH = euvolemic hyponatremia, low serum osmolarity, high urine osmolarity (ectopic ADH production) = SCLC
2. Cushings syndrome (ectopic ACTH production) = SCLC
3. HyperCa (hypoPhosphate) (stones, bones, groans, overtones) = bone mets (Bone destruction = CA release) or Squamous cell lung cancer (ectopic PTHrp production)
4. Lambert-Eaton Myasthenic Syndrome (Ab development against tumor crosses over to presynaptic Ca channels = proximal muscle weakness to due blocked ACh release = IMPROVES with use) = SCLC

Question 4

Dx of Lung Cancer

• what is REQUIRED to make dx, where?
• 4 types, most common, cell of origin, location, biopsy findings, pt demo, unique sx

Answer 4

Dx: REQUIRES TISSUE SAMPLING (distant site biopsy preferred if metastatic dz suspected = confirm BOTH dx AND stage)

1. Adenocarcinoma (NSCLC)
   - most common of all, most common NSCLC (A LOT)
   - origin: gland/mucus cells
   - bx: glandular structures
   - location central or periphery (ANYWHERE)
   - pts: smokers or nonsmokers (ANYONE)
2. Squamous Cell Carcinoma (NSCLC)
   - 2nd most common NSCLC
   - bx: Keratin pearls, intercellular bridges
   - location: Central tumors, Cavitary lesions
   - pts: smokers (Cigarettes)
   - sx: PTHrp = hyperCalcemia
3. Small Cell Lung Cancer (SCLC)
   - Aggressive (poor prognosis)
   - Neuroendocrine tumor
   - pt: smokers
   - location: central
   - bx: small densely packed blue cells
   - sx: paraneoplastic syndromes (SIADH, Cushing’s, LEMS)
4. Large Cell Lung Cancer (NSCLC)
   - Poor prognosis

Question 5

Treatment of NSCLC

• based on stage
• stage IV tx

Answer 5

Stage I - curative intent (surgery)
Stage II - curative intent (surgery + chemotx)
Stage III - curative intent (multidisciplinary tx - combos)
Stage IIIc/IV - PALLIATIVE, personalized tx

Stage IV tx

• chemotx - target rapidly growing cells
• targeted - specific mLc targets (ex: EGFR TKIs)
• immunotherapy: does not allow tumor to hide, can further stim immune system against cancer (ex: PD1/PDL1-i, Pembrolizumab/nivolumab)
• remember: stage 4 not always distant! includes mets to contralateral side, pericardium, pleural effusion, and distant mets

Question 6

Small Cell Lung Cancer

• epi
• pt demo
• behavior
• staging: what we do, limited vs. extensive
• tx by “stages”

Answer 6

15% all lung cancers dx
pts: almost exclusively smokers
behaviors: rapid growth, AGGRESSIVE Dz, paraneoplastic syndromes
Staging: TNM or historical limited/diffuse
Limited: confined to single hemithorax - one side of chest, used for single radiation port
Diffuse: extends BEYOND single hemithorax (anything outside chest) - cannot fit into one radiation field (historically then could not be cured)
Tx: Surgery if T1, T2 and N0
Limited: combo chemo and radiation (Curative intent, cisplatin/carboplatin + etoposide)
Extensive: combo chemo and immunotherapy (palliative intent, cannot be cured - no fit into one radiation field), cisplatin/carboplatin + etoposide with atezolizumab/durvalumab

Question 7

Carcinoid Tumor

• origin
• types
• sx

Mesothelioma

• what it is
• RF

Answer 7

Carcinoid

• Neuroendocrine tumor
• Typical Carcinoid: well differentiated
• Atypical Carcinoid: intermediate grade tumor
• sx: Carcinoid syndrome (overproduce serotonin = flushing, cough, diarrhea)

Mesothelioma

• disease of pleura (may include peritoneal cavity, tunica vaginalis, pericardium)
• RF: asbestos exposure

Question 8

What is the #1 thing to do to prevent lung cancer?

Answer 8

SMOKING CESSATION