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X Clin Med II Exam 2 > Bronchogenic Carcinoma > Flashcards

Bronchogenic Carcinoma Flashcards

1
Q

Identifier of solitary pulmonary nodule (SPN)

A

Coin lesion

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2
Q

Describe an SPN

A

<3 cm isolated, rounded opacity
Completely surrounded by pulmonary parenchyma
Not associated with infiltrate, atelectasis or adenopathy
Most are benign

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3
Q

What makes you think an SPN is benign?

A

Well-defined edges
Dense central calcification
(most common are infectious granulomas)

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4
Q

Difference between a nodule and a mass

A

> 3 cm means mass
Greater change of malignancy
Both are cancer until proven otherwise
Determine if needs resection because limit invasiveness if benign

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5
Q

Reasons for benign SPN

A

Infectious mostly (TB, cocci, abscess)
Hamartoma- abnormal cells from place of origin
Vascular
Inflammatory

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6
Q

Reasons for malignant SPN

A

Lung cancer
Carcinoid tumor
Metastatic cancer

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7
Q

Likelihood of malignancy for SPN

A

When over 60, greater than 50% are

40-49 is 15% etc

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8
Q

Risk factors of SPNs

A

Tobacco, FHx, female more (for once), emphysema, previous malignancy, asbestos exposure

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9
Q

Physical exam sxs of SPN

A

Unexplained weight loss
Supraclavicular LAD
Fixed or localized wheeze
Joint tenderness

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10
Q

1st step in imaging for SPN

A

Review old films (malignant nodules usually double in 20-400 days)
**minimal growth in 2 yrs suggests benign

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11
Q

What is the preferred imaging study?

A

CT of chest without contrast with low radiation
(thin 1 mm slices)
Reliable for size, growth, lobar location and density/borders

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12
Q

What to do for a solid nodule >8 mm that has low probability of being malignant?

A

Get CT at 3 mos–if no growth then serial CT at 9-12 and 18-24 mos
If growth, then eval for pathologic

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13
Q

What to do for a solid nodule >8 mm that has intermediate probability of being malignant?

A

Fluorodeoxy glucose PET/CT and/or biopsy
FDG avid: need biopsy or excision
CT surveillance at 3, 9-12 and 18-24 mos (alternative to biopsy)

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14
Q

What to do for a solid nodule >8 mm that has high probability of being malignant?

A

Biopsy or excursion

Might need to stage with PET/CT

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15
Q

What to do or a solid nodule <8 mm?

A

If 6-8 mm, CT at 6-12 mos then repeat prn

If <6mm, usually don’t need f/u and CT at 12 mos is optional

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16
Q

Indications for referral with SPN

A

New or enlarging lesion
Lesion is not stable, calcified or rounded and greater than 3 cm
Indeterminate lesion

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17
Q

Primary types of lung malignancies

A

Small cell carcinoma (oat cell-13%)

Non small cell carcinomas- adenocarcinoma (42%), squamous cell (22%), large cell (2%) and other NSCLC

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18
Q

Where does SCLC usually arise?

A

Central airways

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19
Q

Presentation of SCLC

A

Large hilar mass with bulky mediastinal adenopathy (extrinsic compression of airway and surrounding tissues)
Cough, dyspnea, weight loss, debility
Highly aggressive
*not good prognosis without tx

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20
Q

Categories of SCLC

A 
Limited disease (ipsilateral hemothorax and regional nodes)
Extensive disease- mostly
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21
Q

Where does adenocarcinoma occur?

A

Arises from mucous glands or any epithelial cell in or distal to terminal bronchiles
Presents as peripheral nodules or masses
Metastasis to distant organs

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22
Q

Where does squamous cell carcinoma occur?

A

Centrally or in main bronchus (arise from bronchial epithelium)
*more likely to cause hemoptysis (but bronchitis is most likely to)
Likely to metastasize to regional lymph nodes (can cavitate)

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23
Q

How to detect squamous cell carcinoma

A

Seen as intraluminal growth in bronchi

Detect by sputum cytology

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24
Q

Where does large cell carcinoma occur?

A

Occur as central or peripheral masses
Metastasis to distant organs
Undifferentiated
Aggressive with rapid doubling times

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25
What do sxs of lung cancer result from?
Primary lesion Intrathoracic spread (pleural/pericardial effusion, hoarseness, SVC syndrome, pancoast syndrome) Paraneoplastic syndromes Metastasis (no lung complaints)
26
Most common symptom of lung cancer
Cough
27
Sxs of the primary lesion in lung cancer
Cough (most frequent with squamous and small cell)- change in character of chronic cough Nonspecific sputum Weight loss (poor prognosis-metastasis or paraneoplastic syndrome) Dyspnea (airway obstruction, effusion, pneumonitis) Chest pain Hemoptysis (bronchitis!!!!)- greater in squamous cell
28
Does a clear CXR rule out lung cancer?
NOPE
29
When does hoarseness result in lung cancer?
Compression of recurrent larygneal nerve (greater with left sided tumors)
30
What causes SVC syndrome?
Compression of SVC or direct invasion: Pathologic process of right lung, lymph nodes or other mediastinal structures Thrombosis (from devices)
31
Most common malignancy associated with SVC syndrome
SCLC
32
How to diagnosis SVC syndrome
Clinical diagnosis based on characteristic sxs of central venous obstruction
33
Sxs of SVC syndrome
Mostly dyspnea Facial swelling/head fullness (worse with forward bend) Arm swelling, cough, chest pain, dysphagia
34
What is seen on the exam for SVC syndrome?
Facial edema Dilated neck veins Prominent venous pattern on chest
35
Diagnostics used in SVC syndrome
CXR Duplex ultrasound CT scan with contrast Superior vena cavogram (gold standard)
36
What is the initial study for indwelling devices and arm swelling?
Duplex u/s
37
Tx options for SVC syndrome
``` Emergency RT (stridor from central obstruction or laryngeal edema, coma from cerebral edema) Venous stents, chemo, removal of devices and anticoagulation ```
38
What is pancoast syndrome?
Tumor involving superior sulcus that compresses brachial plexus and cervical sympathetic nerves *more with NSCLC (squamous cell)
39
Presentation of pancoast syndrome
Horners (injury of sympathetic nerves of face) | More pain in right shoulder than forearm, scapula or finger
40
Where are the signs for pancoast syndrome?
Ipsilateral side of tumor (miosis, anhidrosis, ptosis, rib destruction, atrophy of hand muscles, pain C8, T1 and T2 nerve roots)
41
What is paraneoplastic syndrome?
Organ dysfunction related to immune mediated or secretory effects (heme, endocrine or neuro)
42
Sxs of paraneoplastic syndrome
Anorexia, weight loss, cachexia (look like skin and bones), fever, suppressed immunity Tx to reduce effects (but may be temporary)
43
Hematologic sxs of paraneoplastic syndromes
``` Hypercalcemia (bone destrusction) Anemia Leukocytosis Thrombocytosis Hypercoagulability ```
44
Endocrine sxs of paraneoplastic syndromes
If due to PTH-like substance then hypercalcemia (more NSCLC-squamous) If due to HCG production then gynecomastia or milky nipple discharge (large cell) If due to SIADH, then hyponatremia (small cell) If due to Cushings, then ectopic ACTH (worse prognosis-small cell)
45
Presentation of SIADH
Irritability, restlessness, personality changes, confusion, coma, seizure, respiratory arrest
46
Presentation of Cushings
Muscle weakness, weight loss, HTN, hirsutism, osteoporosis
47
Neurologic sxs paraneoplastic syndrome
Eaton-Lambert syndrome
48
What is Eaton Lambert syndrome?
Immune mediated Antibodies at NMJ (defective release of acetylcholine and muscle weakness) Almost always small cell!
49
Most common sites of distant metastases
Liver (elevated LFTs) Bone (pain in back, chest, extremities and elevated alk phos) Adrenal glands Brain (greater in SCLC)
50
Where is the primary site of brain metastasis?
Lung (when symptomatic)
51
Neurologic sxs of brain metastasis
HA, n/v, seizures, confusion, personality changes
52
Use of tissue biopsy in diagnosis of lung cancer
NSCLC vs SCLC Rule out non malignant process Rule out mets from another primary tumor
53
Staging of NSCLC
T- primary tumor N- nodal involvement M- distant metastases
54
What is the best way to diagnose central lesions?
Sputum culture biopsy
55
What is limited disease (SCLC)?
Tumor limited to ipsilateral hemothorax
56
What is extensive disease (SCLC)?
Tumor extends beyong hemithorax, includes pleural effusions
57
General classifications of stages of lung cancer
1: localized cancer 2: cancer in lymph nodes at top of lung 3: cancer spread into chest wall 4: cancer spread to another part of body
58
Performance status and lung cancer
0: fully active, no restrictions 1: strenuous physical activity restricted 2: capable of all self care 3: capable of only limited self-care (confined to chair) 4: completely disabled
59
What is the strongest indicator of post-op complications with lung cancer?
FEV1 < 60% predicted
60
What is superior to CT to detect metastasis?
Positive Emission Tomography (PET)
61
What is a PET scan?
Utilizes short-lived radioactive isotope that is incorporated into metabolically active molecule (usually fluorodeoxyglucose) Metabolically active cells show increased accumulation of FDG
62
Treatment of choice in localized non-small cell lung cancer
Surgical resection Stage I-IIIa can proceed to surgery Stage IIIb-IV have palliative radiation or combo chemo
63
Choices for treatment of small cell lung cancer
Chemo regardless of stage Platinum based regiment (limited disease is chemo with concurrent radiation) Prophylactic cranial radiaiton Relapse is common because highly aggressive Surgery only option for small percentage
64
Management for malignant effusions
Thoracentesis Pleurodesis Pleurx catheters
65
Side effects of surgery
Pain
66
Side effects of radiation
Fatigue
67
Side effects of systemic therapy
Cytotoxic chemo- anemia, nephrotoxicty, cutaneous toxicity, n/v, heme toxicity, chemo brain
68
Management of Stage 1 NSCLC
Surgical resection (lobectomy)-- may also need chemo/radiation
69
Management of Stage 2 NSCLC
Surgical resection and chemo | advanced primary tumors/mets to ipsilateral nodes
70
Management of Stage 3 NSCLC
Optimal tx uncertain Unresected: concurrent chemo Resected: adjuvant chemo, if uncertain resection margin do radiation
71
Management of Stage 4 NSCLC
Not curable Symptom based Resection of metastasis if primary or new primary
72
Prognosis of NSCLC vs SCLC
SCLC prognosis is always worse
73
Who should be screened with low dose helical CT?
``` Every pt with suspected lung CA High risk: Ages 55-74 with 30 pack yr history Or quit within 15 yrs or 20 pack year history with one additional risk factor (other than second hand smoke exposure) ```
74
Drugs for smoking cessation
Zyban Chantix Rx nicotine replacement
75
Zyban
Inhibits neuronal intake of NE and dopamine Avoid EtOh while using Increased risk of suicide in kids, young adults and adolescents Adverse: seizures, agitation, wt loss
76
Chantix (varenicline)
Block acetylcholine receptors Precaution: unstable CV disease Drug interactions with synergistic effects with nicotine Adverse: dizzy, HTN, palpitations, GI upset
77
Rx nicotine replacement
Nasal spray or inhaler Precaution: unstable CV disease Adverse: dizzy, HTN, palpitations, GI upset

X Clin Med II Exam 2 (6 decks)

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