Cancer Flashcards
Incidence of Small cell lung cancer (SCLC)
15-25% of lung cancers
SCLC
chemo is primary treatment (Cisplatin, etoposide); surgery can rarely impact survival. Partial response to chemo may be amenable to surgery. Radiation is reserved for localized lesions without evidence of metastasis.
Radiation induced osteosarcoma. Radiologic and pathologic findings
Radiology: “sunburst”, periosteal reaction
Biopsy: malignant spindle cells, mitosis, and excess osteoid. Rib and sternum account for 5% of osteogenic sarcomas
Radiation induced osteosarcoma rx
Neoadjuvant protocols. Complete wide local excision. Radiation is reserved for palliation.
Fleischner recommendations for < 4mm (Low risk and High risk pts)
Low risk: no follow up needed
High risk: F/u in 12 months. If unchanged, no further f/u
Fleischner recommendations for 4-6 mm (Low risk and High risk pts)
Low risk: F/u in 12 months, if unchanged, no further f/u
High risk: f/u in 6-12 mon, then 18-2 mo if no change
Fleischner recommendations for <6-8 mm (Low risk and High risk pts)
Low risk: f/u in 6-12 mo, then 18-24 mo if no change
High risk: CT at 3-6 mo, then 9-12 mo, and 24 months if no change
Fleischner recommendations for >8 mm (Low risk and High risk pts)
Low risk: f/u CT at 3, 9, 24, dynamic contrast enhanced CT, PET, and/or biopsy
High risk: f/u CT at 3, 9, 24, dynamic contrast enhanced CT, PET, and/or biopsy
What size nodule is a PET scan considered sensitive and specific
Purely solid lesion > 7 mm
S/p pneumonectomy, c/o cough with serosanguineous sputum/hemoptysis, fever, CXR with air fluid level. Dx? Next step?
Post-pneumonectomy bronchopleural fistula with empyema. Next step is thoracentesis with culture –> chest tube placement –> bronchoscopy. Avoid bronchoscopy until pt is drained to minimize infection of the contralateral lung
S/p RU Lobectomy, fever + tachycardia 4 days later. CXR shows atelectactic middle lobe. Dx? Next Step?
Torsion of the lung. Next Step is flex bronch (will appear “fish mouth” on bronch) –> surgical emergency
Risk factors for lobar torsion (4)
division of inferior pulm ligament
failure to reexpand lung prior to closure
residual pneumothorax and pleural effusion
a remaining complete fissure
How to avoid lobar torsion after lobectomy
Ensure remaining lobes are inflated in neutral and anatomic position
anchoring lung tissue at 2 points (the hilum and somewhere else (e.g. suturing or stapling middle lobe to the lower lobe)
According to National Lung Screening Trial (NLST), what patient factors must be present to justify use of CT screening for lung cancer
age 55-74
> 30 pack year smoking
active smoker or quit < 15 years ago
Pt with SCC of RUL. Right hilar and level 4 lymph node with FDG avidity on PET, SUV (standardized uptake values) of 7 and 4, respectively. Next step?
EBUS with lymph node biopsy
What value of SUV (standardized uptake values) is associated with high probability of malignancy
2.5
What factor affect the accuracy of SUB
weight blood glucose leng of uptake period partial volume effect recovery coefficient type of region of interest
50 obese F with HTN and hirsutism, presented with hypokalemia, elevate urine/plasma cortisol and serum ACTH. MRI shows normal pituitary gland. CT shows LLL nodule. Whats the syndrome? Ddx? Next step?
- Cushing syndrome
- Ddx: bronchial carcinoid, islet cell cancer, small cell lung CA, medullary thyroid ca, neuroendocrine tumor, thymic carcinoid, pheochromocytoma, (of note, pituitary adenoma causing cushing syndrome is known as cushing disease)
- next step: Somatostatin receptor scintigraphy with octreotide to identify hypersecreting tumors or FDG-PET
Patient with resected stage III non-small cell lung cancer. Next step?
According to the LACE (lung adjuvant cisplatin evaluation) meta-analysis, adjuvant cisplatin-based chemotherapy had survival benefit over observation
Staging: any metastasis
At least stage IV-A
T classification for tumor size < 1 cm
T1a
T classification for tumor size 1-2 cm
T1b
T classification for tumor size 2-3 cm
T1c
T classification for tumor size 3-4 cm
T2a
T classification for tumor size 4-5 cm
T2b
T classification for tumor size 5-7 cm
T3
T classification for tumor size >7 cm
T4
N1 nodes
ipsilateral, bronchopulmonary/hilar nodes (double digit, 10-15)
N2 noes
1-9 mediastinal nodes, subcarinal or ipsilateral internal mammary nodes
N0
No lymph node mets
N3
Contralateral mediastinal, internal mammary or hilar nodes or any subclavicular or scalene lymph nodes
Staging: N1 involvement
At the very least is a stage II B
Staging: T4, N0
Stage IIIA
Staging: T3, N1
Stage IIIA
Staging T2b, N0
Stage IIA (this is the only permutation of stage IIA)
Staging: T2a, N0
Stage I B (This is the only permutation of stage 1B)
Staging: T1, N0
Stage I A (subcategory of 1,2,3, based on tumor size)
Staging: T3, N2
Stage IIIB
Staging: T4, N2
Stage IIIB
Staging: T1, N3
Stage IIIB
Staging: T3, N3
Stage IIIC
Staging T1, N1
Stage IIB
Staging T1, N2
Stage IIIA
Staging: any N2 involvement
At least a stage IIIA
Staging: any N3 involvement
At least a stage IIIB
Findings of LACE meta analysis
Survival benefit for adjuvant cisplatin based chemo over observation in patients with resected stage II and III NSCLS.
Intergroup trial INT0139 findings
Patients with Stage IIIA (N2) disease had no significant difference in overall survival to chemorad with or without surgical resection. However, in an exploratory analysis, post-induction lobectomy had superior survival.
Management of pancoast tumor
According to the intergroup trial (INT 0160), treat with induction chemoradiation therapy, followed by complete resection including en-bloc chest wall resection, (may include subclavian vessels if involved)
Eligibility criteria for INT 0160
T3 or T4 superior sulcus tumors with either N0 or N1 disease, no distant metastasis
When is a sublobar resection oncologically sound?
Tumors <2cm in maximal diameter
T classification if tumor involves main bronchus (not carina), invades visceral pleura, or associated with atelectasis or obstructive pneumonitis that extends to the hilar region
T2a
T classification if tumor invades the parietal pleura and superior sulcus tumors, phrenic nerve, or parietal pericardium
T3
T classification if tumor is associated with a separate tumor nodule in a DIFFERENT ipsilateral lobe
T4
T classification if tumor is associated with a separate tumor nodule in the SAME ipsilateral lobe
T3
T classification if tumor involves with CARINA, diaphragm, mediastinum, heart, great vessels, trachia, recurrent largyneal nerve, esophagus, vertebra
T4
Patients with lung cancer with primary tumors > 4 cm or pos lymph nodes can be treated with?
adjuvant platinum-based chemo. This shows improved survival in a meta analysis of a large prospective randomized studies
Definition of R0 resection
Microscopically margin-negative resection
Definition of R1 resection
Indicates removal of all macroscopic disease, but microscopic margins are positive for tumor.
65F w/ T2N2 adenoCA and neoadj chemorads s/p RULobectomy. Post op, developed SOB, hypoxemia on PEEP 8. CXR with b/l fluffy infiltrate. Dx? Next step?
Post-resection pulmonary edema. Usually occurs after pneumonectomy, but may happen after lobectomy or sublobar resections.
Tx: supportive. Ventilation with management analogous to tx of ARDS, i.e. high PEEP. If refractory, consider ECMO.
Risk factors for post op ARDS / post resection pulm edema. (10)
Older age Male Chronic suppurative lung disease reduced DLCO Low predicted post-op lung perfusion Prior irradiation or chemo Concurrent cardiac disease High blood loss/blood transfusion Excessive periop IVF Reoperation
Definition of persistent air leak per STS
Air leak that last for 5 days.
Risk factors for persistent air leak
COPD
Low preop lung function
