9/17- Clinical Presentations of Lung Cancer Flashcards
What are some primary tumors of the lung?
Other lung malignancies (non-lung parenchyma cells)?
- Squamous cell
- Adenocarcinoma
- Large cell
- Small cell
- Other
Other lung malignancies:
- Mesothelioma
- Sarcoma
- Lymphoma
- Lung cancer is the __ most diagnosed cancer in men and __ in women.
- In terms of mortality, lung cancer is the __ most fatal cancer in men and __ in women
- Lung cancer is the 2nd most diagnosed cancer in men and 2nd in women.
- In terms of mortality, lung cancer is the #1 most fatal cancer in men and #1 in women
T/F: Lung cancer kills more people than breast, colorectal, and prostate cancer combined
True
- Smokers are __x more likely to develop lung cancer
- Passive exposure?
- Over __% of lung cancer is related to smoking
- Smokers are 13x more likely to develop lung cancer
- Passive exposure: 1.5x greater
- Over 90% of lung cancer is related to smoking
- Risk is decreased when you stop smoking, but takes about 20 years to come near the same level as non-smoker
The risk of cancer is proportional to what smoking factors?
- Number of pack years
- Age at starting
- Depth of inhalation
- Amount of tar
- Less risk with cigars/pipes
- Quitting decreases your risk (20 years to come near non-smoker, but never equal)
T/F: Smoking rates have stabilized in the US (no more increases)
False
- Smoking is decreasing in the US
T/F: There are more male smokers than female
False
- About 24% of women and 23% of men (currently)
What population has the greatest percentage of smokers?
Adolescents
- Minorities and youth
- Increasing problem in 3rd world countries
What are non-smoking risk factors for cancer (occupational carcinogens)?
What proportion of lung cancers are due to these occupational exposures?
9-15% of lung cancers are due to occupational exposures
- Asbestos
- Arsenic
- Bis(cholormethyl)ether
- Chromium
- Coke oven emissions
- Iron and steel founding
- Mustard gas
- Nickel compounds
- Radiation
- Vinyl chloride
Suspected (not proven):
- Be
- Cd
- Crystalline silica
- Fibrous glass
- Formaldehyde
- Welding fumes
When is the peak incidence for asbestos-related cancer?
Peak 30-35 years after initial exposure
T/F: The risks of smoking and asbestos exposure is additive
False; multiplicative (not just independent)
What are other environmental risk factors for lung cancer?
Air pollution
- Indoor air pollution (developing world with cooking fuels): as bad as smoking!
- Atmospheric air pollution: urban effect (weak association)
Radiation
- Radiation that is a risk for lung cancer is the high-dose stuff involved in atomic bomb… not really x-rays and whatnot
What diets may effect lung cancer development?
Diet high in antioxidant nutrients may protect against oxidative DNA damage and protect against cancer
- Weak evidence showing protection with high fruit intake; better with increased veggies
- Dietary retinol may reduce risk
- Better evidence for carotenoids and vitamin C (Need to take them in naturally, not supplements)
Why do a minority of exposed persons with the mentioned environmental agents not get lung cancer?
Host factors
- Familial aggregation seen in case-control studies after being controlled for smoking
- Genetic factors may play a role in many stages of the multi-stage model of lung cancer development
- Previous acquired lung diseases: COPD and fibrotic lung disease (asbestosis)
Explain how lung cancer is a “multi-hit” problem
Body has many natural protective factors; tumor development requires:
- Persistence/miscoding
- Activation of dominant oncogenes
- Inactivation of tumor suppressors
What are the big (2) divisions of lung cancer types?
Subtypes? Percentages?
Non-small cell carcinomas ~ 70% (other lecture said 80%)
- Squamous
- Adenocarcinoma
- Large cell
Small cell carcinoma ~25% (other lecture said 20%): aka “oat-cell”
When is lung cancer commonly discovered? Peak?
- Majority between 35-75 years
- Peak = 60 yo
- 5-15% asymptomatic at diagnosis (detected through screening or incidentally by imaging done for other reasons)
T/F: Lung cancer normally presents like other diseases (non-specifically) with things like dyspnea, cough…
False; commonly asymptomatic
What is a solitary pulmonary nodule?
- Solitary pulmonary nodule = “coin lesion”
- Spherical mass surrounded by lung parenchyma
What is the differential for a solitary pulmonary nodule (SPN)?
- Malignant
- Benign
Large differential (benign -> malignant)
Malignant:
- Bronchogenic cancer
- Metastasis: breast, head/neck, colon, kidney, germ cell
- Bronchial carcinoid
- Other
Benign:
- Infectious granuloma: TB, Histo, Cocci
- Hamartoma
- Wegener’s
- Rheumatoid nodule
- A-V malformation
- Pulmonary infarction
What are certain features of solitary pulmonary nodules that help distinguish between benign and malignant?
More commonly malignant if:
- Very large
- Irregular margin
- Intermediate doubling time (30-490 days)
Less commonly malignant if:
- More calcified
- Fat present (hamartoma)
- Doubling time under 30 or > 490 days
What is seen here?
Benign nodule (probably… can’t depend only on appearance)
- Smooth boundary
- Calcification
What should be the next step for a mass found in a high risk patient?
Removal!
- Get diagnosis at the same time… but don’t waste time getting biopsy
What should be the next step for mass in intermediately-risky patient?
- Wait and watch
- Can do a PET scan (lights up metabolically active cells)
What are signs and symptoms of lung cancer (assuming pt isn’t asymptomatic)- broadly?
Constitutional symptoms: important prognostic implications regardless of “stage” of disease
- Weight loss (may be 1st seen)
- Fatigue
- Anorexia
- Weakness
What are some symptoms/signs related to primary tumor?
- Cough: most common
- Dyspnea: 60% of pts (so not too common; think, 2 cm tumor not affecting lung function too much)
- Hemoptysis: rarely severe (esp if peripheral tumor- not gonna happen)
- Wheeze and stridor (if obstructing airway)
- Post-obstructive pneumonia symptoms (pneumonia distal to tumor and cant clear, so pneumonia symptoms that persist)
- Chest discomfort: common, up to 50%, ill-defined
What are some signs/symptoms related to intrathoracic spread?
- Tracheal obstruction
- Dysphagia due to esophageal compression
- Hoarseness due to recurrent laryngeal nerve palsy; more on left side
- Phrenic nerve paralysis (elevated hemi-diaphragm and dyspnea)
- Sympathetic nerve paralysis (Horner syndrome)
- Pancoast syndrome
- Superior vena cava syndrome
What is Horner’s syndrome?
Symptoms/what causes it
- Involvement of sympathetic chain at the thoracic inlet at the apex of the lung
Syndrome:
- Enophthalmos
- Ipsilateral anhydrosis (no sympathetic innervation of sweat glands)
- Ptosis (droopy eyelid b/c sympathetics innervate superior tarsal muscle that elevate eyelid?)
- Miosis (constricted pupils; sympathetics normally work on dilator muscle to dilate eye)
What is Pancoast syndrome?
- From local extension of tumor at apex of lung.
- Usual cause of Horner’s syndrome
- Also shoulder pain that radiates in ulnar distribution
What is Superior Vena Cava Syndrome? - Common cause - Mechanism - Signs/symptoms
Most common cause: lung cancer
Mechanism: compression of the thin walled vessel -> obstructed drainage of the upper thorax, head, and neck
Signs and symptoms:
- Swelling and plethora of the head and neck
- Distended venous collaterals
- Epistaxis
- Headache
- Confusion, and even coma
What are malignant pleural effusions?
- Causes
- Characteristics
Either:
- Secondary to tumor involvement of the pleura
- Paramalignant (due to tumor involvement elsewhere)
- Unrelated to lung cancer, i.e. coincident process
Characteristics of malignant effusion:
- Typ moderate - large effusion
- May be bloody
- Lymphocytes predominate
- Low pH and glucose predict shorter survival
What are symptoms related to extra-thoracic spread?
- Bone: Bone pain present in up to 25% at initial presentation
- Liver, Adrenals: Usually normal LFTs until late; produce weakness and weight loss
- Brain and spine: 10% of patients at presentation have intracranial mets, headache, nausea, vomiting
What are paraneoplastic syndromes (broadly)?
- Abnormalities due to production of substances by the tumor
- Occur in ~ 10% of pts with lung cancer
- Not related to extent of disease and can precede lung cancer diagnosis
- Often relieved with successful treatment of the tumor
What are common specific paraneoplastic syndromes?
- Endocrine
- Neurologic-myopathic
- Vascular
- Skeletal
- Dermatologic
- Hematologic
Endocrine (most common)
- Ectopic ACTH
- Hypercalcemia
- SIADH
- Acromegaly
- Gynecomastia
What are common specific paraneoplastic syndromes?
- Endocrine
- Neurologic-myopathic
- Vascular
- Skeletal
- Dermatologic
- Hematologic
Neurologic- myopathic (1%)
- Eaton Lambert Syndrome
- Retinal Blindness
- Subacute Cerebellar Degeneration
- Polymyositis Vascular
- Trausseau’s syndrome
What are common specific paraneoplastic syndromes?
- Endocrine
- Neurologic-myopathic
- Vascular
- Skeletal
- Dermatologic
- Hematologic
Vascular
- Trausseau’s syndrome
What are common specific paraneoplastic syndromes?
- Endocrine
- Neurologic-myopathic
- Vascular
- Skeletal
- Dermatologic
- Hematologic
Skeletal
- Clubbing (30%)
- Pulmonary Hypertrophic Osteoarthropathy
What are common specific paraneoplastic syndromes?
- Endocrine
- Neurologic-myopathic
- Vascular
- Skeletal
- Dermatologic
- Hematologic
Dermatologic
- Acanthoses Nigricans
What are common specific paraneoplastic syndromes?
- Endocrine
- Neurologic-myopathic
- Vascular
- Skeletal
- Dermatologic
- Hematologic
Hematologic
- Anemia
- Leukemoid reaction (elevated WBCs without identifiable cause)
What are common specific paraneoplastic syndromes?
ALL TOGETHER NOW
- Endocrine
- Neurologic-myopathic
- Vascular
- Skeletal
- Dermatologic
- Hematologic
Endocrine (most common)
- Ectopic ACTH
- Hypercalcemia
- SIADH
- Acromegaly
- Gynecomastia
Neurologic- myopathic (1%)
- Eaton Lambert Syndrome
- Retinal Blindness
- Subacute Cerebellar Degeneration
- Polymyositis Vascular
- Trausseau’s syndrome
Skeletal
- Clubbing (30%)
- Pulmonary Hypertrophic Osteoarthropathy
Dermatologic
- Acanthoses Nigricans
Hematologic
- Anemia
- Leukemoid reaction (elevated WBCs without identifiable cause)
What causes ectopic ACTH paraneoplastic syndromes?
Typ small cell carcinoma
- More electrolyte disturbances than frank Cushing’s syndrome
What causes hypercalcemia paraneoplastic syndrome?
Squamous cell carcinoma (only endocrine one that is not small cell!!)
- Due to bony metastasis (osteolysis), production of PTH-like substances or PGE2
What causes SIADH paraneoplastic syndrome?
(Syndrome of inappropriate antidiuretic hormone)
More in small cell carcinoma
- Hyponatremia with inappropriately concentrated osmolality
Describe Eaton Lambert paraneoplastic syndrome?
- Presents with weakness, fatigability, and aching (similar to myasthenia gravis)
- Differs from MG in that muscle strength gets better with repetitive exercise
- Due to development of anti-voltage-gated calcium channel antibodies
- More with SMALL CELL
What lung cancer is most commonly associated with retinal blindness?
Small cell carcinoma
What is Trousseau’s Syndrome?
Vascular paraneoplastic syndrome
- Migratory recurrent thrombophlebitis
What is Pulmonary Hypertrophic Osteoarthropathy (PHO)?
Skeletal paraneoplastic syndrome
- Sub-periosteal new bone formation in distal joints/bones with edema and pain
What is acanthoses nigricans?
Dermatologic paraneoplastic syndrome
- Hyperpigmented/hypertrophic skin
- Usually in the axilla, intertriginous areas, neck
What is seen here?
Mass way up in apex; Pancoast
What is seen here?
Looks like pneumonia
In what ways can lung cancer look like pneumonia on CXR?
- Obstructive pneumonia (pneumonia distal to mass)
- Bronchoalveolar subtype of adenocarcinoma (just looks like pneumonia on CXR)
What is seen here?
- Pleural effusion
- Tumor encroaching into heart, mediastinum…
Use contrast or not to find met in brain?
Use contrast
Bone scan done to pick up what?
Bone metastases
- PET scan used more commonly
What is seen here?
PET scan
- Bright = high metabolic activity
- PET scan looks at entire body
What are some diagnostic techniques for lung cancer?
- Sputum cytology (if pt coughing up blood)
- Superficial lymph node or mass biopsy
- Thoracentesis (if pt has pleural effusion)
- Transthoracic needle aspiration (if tumor very close to chest wall)
- Bronchoscopy
- Endobronchial Ultrasound/Mediastinoscopy
- Exploratory thoracotomy, VATS
What is the staging system for small cell tumors?
Limited disease (30%)- disease confined to one hemithorax and regional LNs (1 radiation portal)
Extensive disease (70%)- disease beyond the hemithorax
What is the prognosis for small cell lung cancer?
Very aggressive; commonly diagnosed in extensive stage
If untreated, median survival is:
- Limited disease: 12 wks
- Extensive disease: 5-7 wks
This tumor is sensitive to CTX
What is the staging for non-small cell cancer?
TNM Classification:
- T (primary tumor): T0-T4
- N (lymph node): N0-N3
- M (distant metastasis): M0-M1
On what does treatment of lung cancer depend?
- Cell-type (small vs. non-small; adeno vs. squamous)
- Stage of tumor
- Resectability of tumor
- Patient’s “operability” status: FEV1, other co-morbidities
- Performance status
What is the treatment for small cell lung cancer?
Chemo +/- radiation
Stages:
- IA, IB: surgical resection/curative radiation if nonoperable
- IIA, IIB: surgical resection and adjuvant chemo
- some IIIA: surgical resection and consideration fo neoadjuvant chemo and postop radiation
- IIIA, IIIB: combined chemo/radiation
- IV: symptomatic thearpy; palliative chemo if good performance status
What is the treatment for non small cell lung cancer?
- Defined by stage AND functional status, other medical problems
- Surgery is mainstay
- Radiation +/- chemo if surgery is not an option
STAGES:
- IA, IB: surgical resection/curative XRT if non-operable
- IIA, IIB: surgical resection + adjuvant chemo
- Some IIIA: surgical resection and consideration of neoadjuvant chemo and postop radiation
- IIIA, IIIB: combo chem/radiation
- IV: symptomatic therapy; palliative chemo if good performance status
What are some contraindications to surgery?
- Advanced stage disease: extra-thoracic metastases, superior vena cava syndrome, malignant pleural effusion
- Poor operability: recent MI, major arrhythmias
—- Poor FEV1 status
What does the prognosis of lung cancer depend on?
- Stage (most important!)
- Cell type
- Therapeutic options
- Performance status
Screening guidelines for lung cancer?
New guidelines recommend screening with low dose CT scanning in high risk pts (20 pack years?)
What is mesothelioma?
- Affects what tissue
- Associated with what
- Timeline
- Prognosis
- Malignancy of pleura
- Strong association with asbestos exposure
- Latency of 35-40 yrs
- Very poor prognosis with mortality within 12 mo
What tumors frequently metastasize to the lung?
- Breast
- Thyroid
- Germ-cell tumors
- Renal cell carcinoma
- Colon carcinoma
- Melanoma
What are patterns of metastases in the lung?
- Solitary lung mass
- Multiple lung masses (most common)
- Lymphangitic spread
What are common benign lung masses?
Benign lung masses = under 5% of primary tumors
90% of benign lung tumors are either:
- Hamartomas
- Bronchial adenomas
What is a hamartoma?
- Contains normal pulmonary tissue elements in a disorganized fashion (muscle and collagen)
- Peripheral, silent
- Popcorn calcification
What is a bronchial adenoma?
- Mainly slow-growing endobronchial masses
- Carcinoid is a type of neuroendocrine mass
- Usually diagnosed with bronchoscopy
- Bleed easily
- Should be resected
