Approach to Lung Cancer Flashcards
- 72F, smoker
- Referred to you because she has an abnormal chest x-ray
Relevant positives:
• Active smoker, >70py
• Mild SOBOE. Mild expiratory wheezing, no lymphadenopathy.
Relevant negatives:
- No hemoptysis, chronic cough
- Weight unchanged, appetite preserved
- No new bony pains
- No new headache, gait disturbances or other neurological changes
What’s your approach to this CXR?
Looks like a Solitary Pulmonary Nodule: A lung lesion that is a discrete opacity, 3cm or
less in size, completely surrounded
by lung parenchyma, does not touch the
hilum or mediastinum, and is not associated
with adenopathy, atelectasis, or pleural
effusion
definition of solitary pulmonary nodule
A lung lesion that is a discrete opacity, 3cm or
less in size, completely surrounded
by LUNG PARENCHYMA, does not touch the
hilum or mediastinum, and is not associated
with adenopathy, atelectasis, or pleural
effusion
t/f a solitary pulmonary nodule can is a discrete opacity and can infiltrate the hilum
false. does not touch the
hilum or mediastinum, and is not associated
with adenopathy, atelectasis, or pleural
effusion
T/F a solitary pulmonary nodule is associated wtih adenopathy infiltration
false. is not associated
with adenopathy, atelectasis, or pleural
effusion
DDX of solitary pulmonary nodule.
outline the types of lung cancer and the subtypes
- small cell
- non small cell
- adenocarcinoma
- squamous cell
- large cell
___ cell carcioma is a highly aggressive cancer that arisses from ___ cells.
SMALL CELL CARCINOMA. Arises from neuroendocrine cells. majority are central and metastasize early. poor prognosis. there’s a 15% long term survival rate. treated with chemotherapy and radiotherapy.
Tx for small cell carcinoma
SMALL CELL CARCINOMA. Arises from neuroendocrine cells. majority are central and metastasize early. poor prognosis. there’s a 15% long term survival rate. treated with chemotherapy and radiotherapy.
usual stage of small cell carcinoma at diagnosis
most are at stage 4. basically incurable.
usual stage of non-small cell carcinoma at time of diagnosis
usually stage 4 too, but stage 1 and 2 are also detected at a higher rate compared to small cell
• Physiologic Evaluation of lung cancer
– Cardio Pulmonary function testing
• PFTs/Spirometry
- Sometimes echocardiogram
- Rarely exercise tolerance test – VO2max
LOCAL symptoms of lung cancer
resp: cough, hemoptysis, shortness of breath
tumor: pain, obstruction
METASTATIC causes of lung cancer
Common sites: CNS, MSK, adrenal, can go anywhere.
- weightloss, anorexia, fatigue, pain, neurologic
diagnostic staging tools (3 non-invasive, 2 invasive)
T/F lung cancer surgery makes the patient feel better
false. unlike other cancers where a patient has many symptoms alleviated afterwards, cutting out lung makes a patient feel worse.
The gold standard diagnostic tetst for LC
chest CT
- provides info about lesion and structures
- size, spiculation, calcification, nodes, other organs.
sensitivity and specificty of PET scan
95% sensitivity and 80%
specificity
___ imaging is done on the brain for Stage II and higher
CT/MRI. looks for extrathoracic mets.
tissue diagnosis:
Bronchoscopy: valuable in
__ lesions.
Bronchoscopy: valuable in
central lesions. Not good for small noduesl on the periphery, you wouldn’t see it.
a bronchoscopy can assess ___ invation and look at __- lesions. it can determine mainstem/carina involvement. Allows you to obtain a tissue diagnosis as well as biopsy lymph nodes via needle aspiration
a bronchoscopy can assess PROXIMAL invation and look at CENTRAL lesions.
Endobronchial US:
Very useful for evaluating for ___ nodes
• done if nodes enlarged,___on PET or stage II or higher –
Needle biopsy of abnormal nodes can be done
under direct vision
Very useful for evaluating for mediastinal nodes
• done if nodes enlarged, hot on PET or stage II or higher – Needle biopsy of abnormal nodes can be done
under direct vision
Schema for most Cancer Treatment
early stage treatment goals are ___, and advanced stage treatment goals are ___
early stage treatment goals are CURATIVE, and advanced stage treatment goals are PALLIATIVE
curative therapy options
- Surgical Resection
- Radiotherapy
- Stereotactic radiotherapy
- Conventional radiotherapy
mechanism of stereotactic RT curative radiotherapy
Multiple convergent beams,
precisely targeted,
concentrated, high dose of
RT
pros and cons of stereotactic RT
pros:less collateral damage and side effects because of precise targeting. 37% survival rate.
cons; limited by size and location of lesion typically 4 cm or less.
SBRT has a limitation by tumor size and location of lesion typically 4 cm or less. What is now offered for lesions too large for SBRT?
Conventional external beam RT. also a type of radio therapy for curative goals. It’s less targeted with more damage. 5 year survival of 15-35%.
pros and cons of surgery for lung cancer
surgery procedures offered for curative therapy.
Lobectomy is the general standard of care
for lung cancer resection
__ ___ ___ surgery is the Majority of lung cancer resections these days
video-assisted thoracic surgery
a ___ ____ is done when VAT surgery is not suitable or safe
Lateral Thoracotomy. requires opening the chest.
type of resection that has the lowest morbidity rates
wedge resections. removal of a piece of lung around the nodule.
Anatomical Resection
• one segment - __
• one lobe - __
• two lobes - __
• whole lung – ___
Anatomical Resection
• one segment - segmentectomy
• one lobe - lobectomy
• two lobes - bilobectomy
• whole lung – pneumonectomy
Survival for NSCLC is ___ dependent
stage dependent
treatment of stage III disease
In general terms treatment is combined
Chemo + RT
Most complicated/nuanced stage in terms of
management
– Difficult to summarize as many subtleties and
options
Stage 4 advanced disease;
Objectives of treatment are ___ -> to
preserve quality of life, potentially improve
quantity of life and minimize side effects
• ~ 5yr survival ~__%
• Options include ___/conventional
chemotherapy OR a ___ targeted therapy
OR immunotherapy OR a combination thereof
• In rare cases targeted treatment of limited
metastatic deposits with surgery or SBRT (ie.
Single brain met, single adrenal met)
Stage 4 advanced disease;
Objectives of treatment are PALLIATIVE -> to
preserve quality of life, potentially improve
quantity of life and minimize side effects
• ~ 5yr survival ~5%
• Options include CYTOTOXIC/conventional
chemotherapy OR a MUTATION targeted therapy
OR immunotherapy OR a combination thereof
• In rare cases targeted treatment of limited
metastatic deposits with surgery or SBRT (ie.
Single brain met, single adrenal met)
removal of which lung has a higher chance of death?
right lung. it’s larger and will put more strain on the heart
decision tree for palliative chemotherapy
- Do the tumor have a “driver mutation” (EGFR, ALK, ROS)?
• Yes –“targeted therapy” directed at mutation - No— Do the tumor have PDL expression?
• Yes—immunotherapy - No—Cytotoxic Chemotherapy
palliative radiation: Generally given for ____ or to prevent imminent symptoms
4 types of anterior mediastinal tumors
Workup for suspeced mediastinal mass
- PE (nodal basins, ocular movements)
- Lab work (Beta HcG, Alpha fetoprotein)
• Imaging
– CT scan, sometimes MRI, scrotal U/S
• Tissue Confirmation
– If diffuse/infiltrative – core biopsy
– If encapsulated - resection
systemic history problems that are associated with mediastinal masses
• Hx
– Local Compression (pain, cough, dyspnea, orthopnea)
– Systemic (Myasthenic sx [ocular, bulbar, muscular], wt. loss, lethargy)
pt presents with profound orthopnea, shortness of breath. What tumor is here?
very large anterior mediastinal mass.
• Neurogenic Tumors are mostly __
benign
