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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
Q

What do sxs of lung cancer result from?

A

Primary lesion
Intrathoracic spread (pleural/pericardial effusion, hoarseness, SVC syndrome, pancoast syndrome)
Paraneoplastic syndromes
Metastasis (no lung complaints)

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26
Q

Most common symptom of lung cancer

A

Cough

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27
Q

Sxs of the primary lesion in lung cancer

A

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

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28
Q

Does a clear CXR rule out lung cancer?

A

NOPE

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29
Q

When does hoarseness result in lung cancer?

A

Compression of recurrent larygneal nerve (greater with left sided tumors)

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30
Q

What causes SVC syndrome?

A

Compression of SVC or direct invasion:
Pathologic process of right lung, lymph nodes or other mediastinal structures
Thrombosis (from devices)

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31
Q

Most common malignancy associated with SVC syndrome

A

SCLC

32
Q

How to diagnosis SVC syndrome

A

Clinical diagnosis based on characteristic sxs of central venous obstruction

33
Q

Sxs of SVC syndrome

A

Mostly dyspnea
Facial swelling/head fullness (worse with forward bend)
Arm swelling, cough, chest pain, dysphagia

34
Q

What is seen on the exam for SVC syndrome?

A

Facial edema
Dilated neck veins
Prominent venous pattern on chest

35
Q

Diagnostics used in SVC syndrome

A

CXR
Duplex ultrasound
CT scan with contrast
Superior vena cavogram (gold standard)

36
Q

What is the initial study for indwelling devices and arm swelling?

A

Duplex u/s

37
Q

Tx options for SVC syndrome

A 
Emergency RT (stridor from central obstruction or laryngeal edema, coma from cerebral edema)
Venous stents, chemo, removal of devices and anticoagulation
38
Q

What is pancoast syndrome?

A

Tumor involving superior sulcus that compresses brachial plexus and cervical sympathetic nerves
*more with NSCLC (squamous cell)

39
Q

Presentation of pancoast syndrome

A

Horners (injury of sympathetic nerves of face)

More pain in right shoulder than forearm, scapula or finger

40
Q

Where are the signs for pancoast syndrome?

A

Ipsilateral side of tumor (miosis, anhidrosis, ptosis, rib destruction, atrophy of hand muscles, pain C8, T1 and T2 nerve roots)

41
Q

What is paraneoplastic syndrome?

A

Organ dysfunction related to immune mediated or secretory effects (heme, endocrine or neuro)

42
Q

Sxs of paraneoplastic syndrome

A

Anorexia, weight loss, cachexia (look like skin and bones), fever, suppressed immunity
Tx to reduce effects (but may be temporary)

43
Q

Hematologic sxs of paraneoplastic syndromes

A 
Hypercalcemia (bone destrusction)
Anemia
Leukocytosis
Thrombocytosis
Hypercoagulability
44
Q

Endocrine sxs of paraneoplastic syndromes

A

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
Q

Presentation of SIADH

A

Irritability, restlessness, personality changes, confusion, coma, seizure, respiratory arrest

46
Q

Presentation of Cushings

A

Muscle weakness, weight loss, HTN, hirsutism, osteoporosis

47
Q

Neurologic sxs paraneoplastic syndrome

A

Eaton-Lambert syndrome

48
Q

What is Eaton Lambert syndrome?

A

Immune mediated
Antibodies at NMJ (defective release of acetylcholine and muscle weakness)
Almost always small cell!

49
Q

Most common sites of distant metastases

A

Liver (elevated LFTs)
Bone (pain in back, chest, extremities and elevated alk phos)
Adrenal glands
Brain (greater in SCLC)

50
Q

Where is the primary site of brain metastasis?

A

Lung (when symptomatic)

51
Q

Neurologic sxs of brain metastasis

A

HA, n/v, seizures, confusion, personality changes

52
Q

Use of tissue biopsy in diagnosis of lung cancer

A

NSCLC vs SCLC
Rule out non malignant process
Rule out mets from another primary tumor

53
Q

Staging of NSCLC

A

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

54
Q

What is the best way to diagnose central lesions?

A

Sputum culture biopsy

55
Q

What is limited disease (SCLC)?

A

Tumor limited to ipsilateral hemothorax

56
Q

What is extensive disease (SCLC)?

A

Tumor extends beyong hemithorax, includes pleural effusions

57
Q

General classifications of stages of lung cancer

A

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
Q

Performance status and lung cancer

A

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
Q

What is the strongest indicator of post-op complications with lung cancer?

A

FEV1 < 60% predicted

60
Q

What is superior to CT to detect metastasis?

A

Positive Emission Tomography (PET)

61
Q

What is a PET scan?

A

Utilizes short-lived radioactive isotope that is incorporated into metabolically active molecule (usually fluorodeoxyglucose)
Metabolically active cells show increased accumulation of FDG

62
Q

Treatment of choice in localized non-small cell lung cancer

A

Surgical resection
Stage I-IIIa can proceed to surgery
Stage IIIb-IV have palliative radiation or combo chemo

63
Q

Choices for treatment of small cell lung cancer

A

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
Q

Management for malignant effusions

A

Thoracentesis
Pleurodesis
Pleurx catheters

65
Q

Side effects of surgery

A

Pain

66
Q

Side effects of radiation

A

Fatigue

67
Q

Side effects of systemic therapy

A

Cytotoxic chemo- anemia, nephrotoxicty, cutaneous toxicity, n/v, heme toxicity, chemo brain

68
Q

Management of Stage 1 NSCLC

A

Surgical resection (lobectomy)– may also need chemo/radiation

69
Q

Management of Stage 2 NSCLC

A

Surgical resection and chemo

advanced primary tumors/mets to ipsilateral nodes

70
Q

Management of Stage 3 NSCLC

A

Optimal tx uncertain
Unresected: concurrent chemo
Resected: adjuvant chemo, if uncertain resection margin do radiation

71
Q

Management of Stage 4 NSCLC

A

Not curable
Symptom based
Resection of metastasis if primary or new primary

72
Q

Prognosis of NSCLC vs SCLC

A

SCLC prognosis is always worse

73
Q

Who should be screened with low dose helical CT?

A 
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
Q

Drugs for smoking cessation

A

Zyban
Chantix
Rx nicotine replacement

75
Q

Zyban

A

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
Q

Chantix (varenicline)

A

Block acetylcholine receptors
Precaution: unstable CV disease
Drug interactions with synergistic effects with nicotine
Adverse: dizzy, HTN, palpitations, GI upset

77
Q

Rx nicotine replacement

A

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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