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Clin Med II Unit II > 6 Lung Cancer > Flashcards

6 Lung Cancer Flashcards

1
Q

Leading cause of CA related deaths

A

Lung cancer

80% are either smokers or former smokers

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2
Q

Risk factors for lung cancer

A

SMOKING

Passive smoking (ie living with a smoker) has a 20-30% increased risk

Other exposures: asbestos, radon, arsenic, radiation, polycyclic aromatic hydrocarbons

Genetic predisposition

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3
Q

What is a solitary pulmonary nodule (SPN)

A

“Coin lesion”

<3 cm isolated, rounded opacity

Completely surrounded by pulmonary parenchyma

Not associated with infiltrate, atelectasis, or adenopathy

Most are benign

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4
Q

Signs that a SPN is benign

A

Smooth, well-defined edges
Dense central calcification
Most common are infectious granulomas

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5
Q

Signs of malignancy with SPNs

A

Speculated coin lesion (spiky)

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6
Q

Nodules vs masses

A

> 3cm in size = mass

Mass = greater chance of malignancy (the larger something is, the more likely to be malignant)

Nodule or mass is CA until proven otherwise

Goals: determine which need resection, limit invasive procedures for benign disease

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7
Q

Examples of benign SPNs

A

Infections (80%) - TB, Cocci, Pulmonary abscess

Hamartoma

Vascular

Inflammatory

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8
Q

Examples of malignant SPNs

A

Lung cancer

Carcinoid tumor

Metastatic cancer

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9
Q

Likelihood of malignancy of an SPN increases with _____

A

Age (35-39 y/o is 3%, >60 is 50%)

Other risk factors:
Tobacco use
Family Hx
Female>males
Emphysema
Previous malignancy
Asbestos exposure
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10
Q

PE signs of possible malignancy

A

Unexplained weight loss

Supraclavicular LAD

Fixed or localized wheeze

Joint tenderness

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11
Q

Malignant nodules typically double in ________

A

20-400 days

Minimal growth in 2 years suggests benign lesion

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12
Q

Preferred imaging for evaluating possible lung CA

A

CT of the chest without contrast, thin 1mm slices

Most reliable for assessing nodule size, growth, lobar location, visualization of density and borders

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13
Q

Evaluating solid nodule >8mm

A

Low probability - get CT at 3 months, then if no growth, serial CT at 9-12 months and 18-24 months

Intermediate probability - FDG PET/CT and/or biopsy, with serial CTs at 3, 9-12, and 18-24 months

High probability - Biopsy or excision, staging with PET/CT

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14
Q

Evaluating solid nodule ≤ 8 mm

A

6-8 mm follow with CT at 6-12 months then repeat as indicated

< 6mm do not usually require follow-up (CT at 12 months optional)

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15
Q

Indications for referral in SPN cases

A

New or enlarging lesion

Lesion that is not stable, not calcified, not rounded, or >3cm

Lesion that is indeterminate

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16
Q

Four primary cell types in lung CA

A

Small cell carcinoma (13%)
• Oat cell carcinoma

Non-small cell types
• Adenocarcinoma (42%)
• Squamous cell carcinoma (22%)
• Large cell carcinoma (2%)
• Other NSCLC (16%)

Others (5%)

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17
Q

Small cell lung cancer usually arises in ….

A

Central airways - presents as large hilar mass with bulky mediastinal adenopathy

Extrinsic compression of airway can lead to SVC syndrome

Also will have cough, dyspnea, weight loss and debility

Highly aggressive - 70% with metastatic disease

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18
Q

Prognosis for small cell lung cancer

A

6-18 week survival without treatment

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19
Q

Adenocarcinoma arises from …

A

Mucous glands or any epithelial cell in or distal to the terminal bronchioles

Metastasizes to distant organs

Presents as PERIPHERAL nodules or masses

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20
Q

Squamous cell carcinoma arises from …

A

Bronchial epithelium - occurs centrally or in the main bronchus

Seen as an INTRALUMINAL growth in the bronchi

May be able to detect by sputum cytology

More likely to cause hemoptysis

Likely to metastasize to regional lymph nodes

Can cavitate - grapelike clusters

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21
Q

Most common cause of hemoptysis?

A

BRONCHITIS

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22
Q

Large cell carcinoma typically occurs as…

A

Central or peripheral masses that metastasize to distant organs

Relatively undifferentiated

Aggressive clinical course - rapid doubling times

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23
Q

Symptoms of lung cancer result from…

A

Primary lesion

Intrathoracic spread (pleural effusion, pericardial effusion, hoarseness, SVC syndrome, pancoast syndrome)

Paraneoplastic syndromes

Metastasis

24
Q

Most common symptoms of primary lung cancer lesions

A

Cough (present 45-75%), most frequent with squamous cell and small cell

Can also have non-specific Sx

Change in character of chronic cough

Sputum non-specific

25
Q

Sx with a poor prognosis in lung CA

A

Weight loss

26
Q

Dyspnea in lung CA typically due to …

A

Airway obstruction

Pneumonitis

Pleural or pericardial effusion

27
Q

Lung cancer most likely to cause hemoptysis

A

Squamous cell

28
Q

Symptoms of intrathoracic spread of lung cancer

A

Pleural effusion (direct pleural extension, mediastinal node involvement, lymphatic obstruction)

Pericardial effusion (direct extension of tumor into pericardium)

Hoarseness (from compression of recurrent laryngeal nerve with left sided tumors)

29
Q

SVC syndrome is more common with _______ sided lung tumors

A

Right sided

SVC syndrome is due to compression or direct invasion

30
Q

Lung cancer that is the most common cause of intrathoracic malignancy

A

Small cell lung cancer

31
Q

Clinical presentation of SVC syndrome

A

Dyspnea

Facial swelling/head fullness, worse with forward bend or laying down

Arm swelling, cough, chest pain, dysphagia

PE: facial edema, dilated neck veins, prominent venous pattern on chest

32
Q

SVC Diagnostics

A

CXR

Duplex ultrasound (initial study with indwelling devices and arm swelling)

CT scan with contrast and w/o for comparison

Superior vena cavogram = GOLD STANDARD

33
Q

Treatment options for SVC syndrome

A

Goals: alleviate Sx and treat underlying disease

Emergency RT
• Stridor from central airway obstruction or laryngeal edema, coma from cerebral edema

Other options:
Venous stents
Chemo if indicated
Removal of devices and anticoagulation

34
Q

What is pancoast syndrome?

A

Tumor involving superior sulcus (apical chest) that compresses the brachial plexus and cervical sympathetic nerves

Leads to Horner’s syndrome (sympathetic nerve injury to face)

Right shoulder pain > forearm, scapula, and finger pain

Signs are on ipsilateral side of tumor

Can also have rib destruction, atrophy of hand muscles

35
Q

Signs of pancoast syndrome

A

Ptosis
Miosis
Anhidrosis (lack of sweating)

36
Q

Common cause of pancoast syndrome

A

Squamous cell

37
Q

Organ dysfunction related to immune mediated or secretory effects

A

Paraneoplastic syndromes (hematologists, endocrine, neurologic)

Constellation of:
Anorexia
Weight loss
Cachexia
Fever
Suppressed immunity

Treatment can reduce effects

38
Q

Hematologists signs of paraneoplastic syndrome

A

Hypercalcemia - from bone destruction

Anemia (fatigue, dyspnea)

Leukocytosis (indicates poor prognosis)

Thrombocytosis (predictor of shortened survival)

Hypercoagulability

39
Q

Endocrine signs of paraneoplastic syndromes

A

PTH-like substance —> Hypercalcemia (seen with squamous cell)

Excess HCG production —> Gynecomastia, milky nipple discharge (seen with large cell)

SIADH —> hyponatremia (seen with small cell)

Cushing’s syndrome —> ectopic ACTH (seen with small cell - indicates worse prognosis)

40
Q

Neurologic paraneoplastic syndromes

A

Eaton-Lambert Syndrome

Immune mediated, antibodies at NMJ —> defective release of ACh and muscle weakness

Almost exclusively small cell

41
Q

Most common sites of distant metastases in lung cancer

A

Liver (50% on autopsy)
• Elevation of LFTs, seen on CT/PET scan

Bone (pain in back, chest, extremities, elevated ALP)

Adrenal glands (rarely symptomatic)

Brain (20-30% of patients - SCLC!)

42
Q

Signs of brain metastasis

A

HA

N/V

Seizures

Confusion

Personality changes

43
Q

SCLC divided into 2 stages:

A
  1. Limited disease (35-40%) - tumor limited to ipsilateral hemithorax
  2. Extensive disease (60-65%) - tumor extends beyond hemithorax, includes pleural effusions
44
Q

Components of staging for NSCLC

A

“T” - primary tumor
“N” - nodal involvement
“M” - distant metastases

45
Q

Categories of performance status

A

0 = fully active, no restrictions

1 = strenuous physical activity restricted

2 = capable of all self-care

3 = capable of only limited self-care

4 = completely disabled

46
Q

PFTs and performance status

A

FEV1 < 60% predicted: strongest indicator of post-op complications

Considerations:
Size, age, gender
Severity of underlying lung disease
Amount of lung tissue to be resected

47
Q

How is positive emission tomography used?

A

Aid to diagnosis and staging

Utilizes short-lived radioactive isotope (FDG)

Superior to CDT to detect metastasis

Limitations: does not detect all CA, infections may be positive)

48
Q

Management of NSCLC

A

Surgical resection is treatment of choice in localized disease

Stage I to IIIA disease, with adequate pulmonary function, can proceed to surgery

Stage IIIB to IV, palliative radiation or combo therapy

49
Q

Management of SCLC

A

Chemotherapy regardless of stage

80% response rate to platinum-based regimen (cisplatin)

Limited disease: chemo w/ concurrent radiation beneficial

Radiation therapy

Prophylactic cranial radiation

Relapse common

Surgery is option for <5%

50
Q

Prognosis for lung cancer

A

5 year survival rates:

NSCLC - 15% for all stages combined

SCLC:
Limited - 10-13% (median survival 15-20 months)
Extensive - 1-2% (median survival 8-13 months)

51
Q

Best prevention for lung cancer?

A

Smoking cessation

Screening

52
Q

low dose CT for lung cancer screening should be conducted in the following high-risk individuals:

A

Ages 55-74 with 30 pack year history

Those who have quit in the last 15 years

20 pack year history with one additional risk factor

53
Q

How does Welbutrin work?

A

Inhibits neuronal uptake of norepinephrine and dopamine (increasing norepinephrine and dopamine levels)

Typical stops smoking after 5-7 days

54
Q

Precautions for welbutrin use

A

Avoid EtOH

Increased risk for suicide in children/young adults

Adverse reactions: seizures, agitation, wt loss

55
Q

How does Chantix work?

A

Blocks alpha-4-beta-2 nicotinic ACh receptors

Stops smoking after 7 days

Precautions: unstable CVD

Drug interactions: synergistic effects with nicotine

Adverse reactions: dizziness, HTN, palpitations, GI

56
Q

Rx nicotine replacement

A

Nicotrol NS spray, Nicotrol inhaler

Precautions: unstable CVD

Adverse reactions: dizziness, HTN, palpitations, GI upset

57
Q

Examples of OTC nicotine replacement

A

Nicoderm CQ
Nicolette gum
Commit lozenge

Positive support

Clin Med II Unit II (7 decks)

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