6 Lung Cancer Flashcards
Leading cause of CA related deaths
Lung cancer
80% are either smokers or former smokers
Risk factors for lung cancer
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
What is a solitary pulmonary nodule (SPN)
“Coin lesion”
<3 cm isolated, rounded opacity
Completely surrounded by pulmonary parenchyma
Not associated with infiltrate, atelectasis, or adenopathy
Most are benign
Signs that a SPN is benign
Smooth, well-defined edges
Dense central calcification
Most common are infectious granulomas
Signs of malignancy with SPNs
Speculated coin lesion (spiky)
Nodules vs masses
> 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
Examples of benign SPNs
Infections (80%) - TB, Cocci, Pulmonary abscess
Hamartoma
Vascular
Inflammatory
Examples of malignant SPNs
Lung cancer
Carcinoid tumor
Metastatic cancer
Likelihood of malignancy of an SPN increases with _____
Age (35-39 y/o is 3%, >60 is 50%)
Other risk factors: Tobacco use Family Hx Female>males Emphysema Previous malignancy Asbestos exposure
PE signs of possible malignancy
Unexplained weight loss
Supraclavicular LAD
Fixed or localized wheeze
Joint tenderness
Malignant nodules typically double in ________
20-400 days
Minimal growth in 2 years suggests benign lesion
Preferred imaging for evaluating possible lung CA
CT of the chest without contrast, thin 1mm slices
Most reliable for assessing nodule size, growth, lobar location, visualization of density and borders
Evaluating solid nodule >8mm
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
Evaluating solid nodule ≤ 8 mm
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)
Indications for referral in SPN cases
New or enlarging lesion
Lesion that is not stable, not calcified, not rounded, or >3cm
Lesion that is indeterminate
Four primary cell types in lung CA
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%)
Small cell lung cancer usually arises in ….
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
Prognosis for small cell lung cancer
6-18 week survival without treatment
Adenocarcinoma arises from …
Mucous glands or any epithelial cell in or distal to the terminal bronchioles
Metastasizes to distant organs
Presents as PERIPHERAL nodules or masses
Squamous cell carcinoma arises from …
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
Most common cause of hemoptysis?
BRONCHITIS
Large cell carcinoma typically occurs as…
Central or peripheral masses that metastasize to distant organs
Relatively undifferentiated
Aggressive clinical course - rapid doubling times
Symptoms of lung cancer result from…
Primary lesion
Intrathoracic spread (pleural effusion, pericardial effusion, hoarseness, SVC syndrome, pancoast syndrome)
Paraneoplastic syndromes
Metastasis
Most common symptoms of primary lung cancer lesions
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
Sx with a poor prognosis in lung CA
Weight loss
Dyspnea in lung CA typically due to …
Airway obstruction
Pneumonitis
Pleural or pericardial effusion
Lung cancer most likely to cause hemoptysis
Squamous cell
Symptoms of intrathoracic spread of lung cancer
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)
SVC syndrome is more common with _______ sided lung tumors
Right sided
SVC syndrome is due to compression or direct invasion
Lung cancer that is the most common cause of intrathoracic malignancy
Small cell lung cancer
Clinical presentation of SVC syndrome
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
SVC Diagnostics
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
Treatment options for SVC syndrome
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
What is pancoast syndrome?
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
Signs of pancoast syndrome
Ptosis
Miosis
Anhidrosis (lack of sweating)
Common cause of pancoast syndrome
Squamous cell
Organ dysfunction related to immune mediated or secretory effects
Paraneoplastic syndromes (hematologists, endocrine, neurologic)
Constellation of: Anorexia Weight loss Cachexia Fever Suppressed immunity
Treatment can reduce effects
Hematologists signs of paraneoplastic syndrome
Hypercalcemia - from bone destruction
Anemia (fatigue, dyspnea)
Leukocytosis (indicates poor prognosis)
Thrombocytosis (predictor of shortened survival)
Hypercoagulability
Endocrine signs of paraneoplastic syndromes
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)
Neurologic paraneoplastic syndromes
Eaton-Lambert Syndrome
Immune mediated, antibodies at NMJ —> defective release of ACh and muscle weakness
Almost exclusively small cell
Most common sites of distant metastases in lung cancer
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!)
Signs of brain metastasis
HA
N/V
Seizures
Confusion
Personality changes
SCLC divided into 2 stages:
- Limited disease (35-40%) - tumor limited to ipsilateral hemithorax
- Extensive disease (60-65%) - tumor extends beyond hemithorax, includes pleural effusions
Components of staging for NSCLC
“T” - primary tumor
“N” - nodal involvement
“M” - distant metastases
Categories of performance status
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
PFTs and performance status
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
How is positive emission tomography used?
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)
Management of NSCLC
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
Management of SCLC
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%
Prognosis for lung cancer
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)
Best prevention for lung cancer?
Smoking cessation
Screening
low dose CT for lung cancer screening should be conducted in the following high-risk individuals:
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
How does Welbutrin work?
Inhibits neuronal uptake of norepinephrine and dopamine (increasing norepinephrine and dopamine levels)
Typical stops smoking after 5-7 days
Precautions for welbutrin use
Avoid EtOH
Increased risk for suicide in children/young adults
Adverse reactions: seizures, agitation, wt loss
How does Chantix work?
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
Rx nicotine replacement
Nicotrol NS spray, Nicotrol inhaler
Precautions: unstable CVD
Adverse reactions: dizziness, HTN, palpitations, GI upset
Examples of OTC nicotine replacement
Nicoderm CQ
Nicolette gum
Commit lozenge
Positive support
