Cancers of the Respiratory System Flashcards
Major risk factors for development of cancer of head and neck
Alcohol and tobacco (synergistic)
Male>female
Occupational exposure — nickel refining, exposure to textile fibers, woodworking
Dietary — low consumption of fruits and vegetables; vitamin supplementation with carotenoids may be protective
Supplements of retinoids (such as cis-retinoic acid) may increase risk in active smokers
Risk factors specific to nasopharyngeal cancer
Endemic in Mediterranean and far East
EBV infection
Consumption of salted fish and indoor pollution
Risk factors specific to oropharyngeal cancer
HPV 16, 18
Association with younger pt population, increased sexual partners, oral sexual practices
Common complaints of pts with head and neck cancers
Difficulty swallowing, choking, trismus, ear pain, weight loss
Advanced head and neck cancers in any location can cause severe pain, otalgia, airway obstruction cranial neuropathies, trismus, odynophagia, dysphagia, decreased tongue mobility, fistulas, skin involvement, and massive cervical LAD
What is trismus?
Inability to open the jaw d/t compression of trigeminal n. or muscle invasion by tumor
Presenting signs/symptoms of nasopharyngeal cancer
Usually does not cause initial symptoms
May cause unilateral serous otitis media d/t eustachian tube obstruction, or unilateral or bilteral nasal obstruction
Epistaxis
When advanced, can cause neuropathy of cranial nerves d/t involvement of the skull base
Presenting signs/symptoms of oropharyngeal cancer
Rarely cause early symptoms, but may cause sore throat and/or otalgia
May present as nonhealing ulcers, changes in fit of dentures, painful lesions, leukoplakia, erythroplakia
Tumors of the tongue base or oropharynx can cause decreased tongue mobility and/or alterations in speech
HPV related tumors frequently present with _______ as the first sign
Cervical LAD
Laryngeal carcinoma usually presents with _____
Hoarseness
Treatment of head and neck cancer when it is categorized as localized disease
Treated with curative intent either by surgery or radiation, depending on anatomic location and institutional expertise
In terms of treating localized head and neck cancer, _______ is often preferred for laryngeal cancer to preserve voice function
Radiation therapy
If laryngectomy is performed for laryngeal cancer, what are some ways in which voice function can be restored?
Electrolarynx can be placed in submandibular region which vibrates at constant pitch to allow speech
-Or-
“Talking tracheostomy” — provides set of synthetic “vocal cords” to allow partial speech
In terms of treating localized head and neck cancer, _____ is preferred for small lesions in the oral cavity
Surgery
[radiation is avoided d/t complications of xerostomia and dental caries]
Treatment of head and neck cancer when it is categorized as locally or regionally advanced disease
Combined-modality therapy including surgery, radiation, and chemotherapy
Treatment of head and neck cancer when it is categorized as recurrent and/or metastatic disease
Usually treated with palliative intent
Some may require local or regional radiation for pain control, but most are given chemotherapy
Chemotherapy response rates are usually 30-50% and last a short duration
Major risk factors for development of lung cancer
Smoking — increased risk based on number of years smoked, how many packs per day, length of cigarette, depth of inhalation, and tar content
Second-hand smoke exposure
Occupational hazards — uranium miners (radon gas alpha particles damage DNA in bronchial epithelium), coal tars for coal miners, nickel, arsenic, mustard gas, petrochemical exposure in oil field workers
Common presenting complaints in lung cancer
Hemoptysis Pulmonary infections Dyspnea Cough Chest pain
[evidence of extrathoracic spread may include weight loss, LAD, focal neurologic findings, bone tenderness, skin nodules, hepatomegaly]
Paraneoplastic syndromes associated with small cell carcinoma
Acromegaly (GHRH)
Cushing syndrome (ACTH)
Hyponatremia (SIADH)
Lambert-Eaton myasthenic syndrome
SVC syndrome — extrinsic compression of SVC causes distention of superficial vv. and edema of face/neck
What type of lung cancer occurs almost exclusively in smokers?
Small cell lung cancer
Paraneoplastic syndrome associated with squamous cell carcinoma, and sometimes adenocarcinoma
Hypercalcemia (PTHrP)
Paraneoplastic syndromes associated with adenocarcinoma of the lung
Hypertrophic pulmonary osteoarthropathy
Trousseau syndrome (migratory superficial thrombophlebitis)
Physical findings associated with hypertrophic pulmonary osteoarthropathy
Clubbing of distal phalanges and hypertrophy of joints
Arthralgias, synovitis, periostitis
Characteristic facies with furrowing of the brow can develop
[cause is unclear, likely growth factors and inflammatory cytokines]
______ syndrome may present with pancoast tumor, usually squamous cell carcinoma, resulting in ipsilateral anhydrosis of the face, ptosis of the eyelid, and pupillary constriction d/t compression or involvement of stellate ganglion
Horner
What is pancoast syndrome?
Superior sulcus tumor — located at lung apex that compresses or invades the brachial plexus causing shoulder pain and paresthesias along the C7 or T1 dermatome
Lung cancer may present with vocal cord paralysis due to entrapment of the ______ n.
Recurrent laryngeal
A 65 y/o pt presents with progressive difficulty swallowing. His PMH is negative. PE is significant for a mass at the base of the tongue measuring 7 cm in size. Bx confirms SCC and CT of the neck demonstrates locally advanced disease without evidence of LN involvement. The staging exam is otherwise negative. The head and neck surgeon feels that adequate surgical margins will not be obtained with surgery alone. Which of the following is the most reasonable approach to the treatment of this patient?
A. Initial radiotherapy and chemotherapy, followed by surgery
B. Subtotal surgery with resection of as much tumor as possible, followed by radiation therapy
C. Chemotherapy alone
D. Total glossectomy, laryngectomy, tracheostomy, and bilateral radical neck dissection
E. Radiotherapy alone
A. Initial radiotherapy and chemotherapy, followed by surgery
• A 25 y/o male presents to your office with a 4-week hx of sore throat. He has tried salt water gargles without relief. He was seen in a local ED 10 days ago and was prescribed a 7-day course of abx without improvement. He additionally notes some progressive hoarseness over the last week. He smokes 3 packs of cigarettes per day, drinks a case of beer every 1-2 days, and is employed at a woodworking shop. On exam, the pt has minimal posterior pharyngeal erythema without exudate. There are no other abnormalities. The most appropriate treatment at this point would be…
A. 7-day trial of an alternative antibiotic
B. Encourage smoking cessation
C. Reassurance, with symptomatic treatment only
D. Refer the pt to a head and neck surgeon
E. Encourage smoking and alcohol cessation, and re-examine in 4 weeks
D. Refer the pt to a head and neck surgeon
• A 50 y/o man is evaluated because of blood-tinged sputum for the past 2 weeks. He has smoked 1.5 packs of cigarettes per day for the past 35 years and has had a chronic morning cough productive of clear or yellow sputum for many years. Although he has not had any change in the nature of the cough, he has noticed some streaks of blood in his usual sputum. He has no complaints of SOB, fever, or weight loss. His medical hx is otherwise negative, and he takes no medications. On PE, his vitals are normal, decreased breath sounds throughout the thorax but no other symptoms. A chest radiograph is normal. The rest of the exam is negative. Which of the following is the most appropriate next step in management?
A. Chest CT B. PFTs C. Sputum culture and cytology D. Reevaluation in 3 months E. Fiberoptic bronchoscopy
A. Chest CT
[note that at this point, chest CT and fiberoptic bronchoscopy probably need to get done, likely to do CT first to see where bronchoscopy should be directed. Fiberoptic bronchoscopy has largely supplanted sputum culture/cytology for this purpose]
65 y/o woman seeks consultation regarding lung cancer screening. She has a 40-pack year hx of smoking and continues to smoke. Her only active medical problem is COPD, tx with daily tiotropium inhaler and an albuterol inhaler prn. On PE, vital signs are normal, and breath sounds distant with occasional wheezing; remainder of exam is normal. Which of the following screening tests can be recommended?
A. Annual CXR
B. Annual sputum cytology
C. Combination annual CXR and sputum cytology
D. Low-dose spiral chest CT
E. Low-dose spiral chest CT and annual sputum cytology
D. Low-dose spiral chest CT
63 y/o man evaluated for fatigue and persistent cough of 7 weeks duration. He has a 60 pack year smoking history. PE and vital signs are normal. Chest radiograph shows a right hilar mass. CT scan of the thorax confirms the presence of a right perihilar mass and enlarged hilar and mediastinal LNs. An endobronchial mass is identified by bronchoscopy; brushings and biopsy reveal small cell lung cancer. A CT scan of the abdomen is negative. A bone scan and MRI of the brain are negative. Which of the following is the most appropriate next step in the management of this patient?
A. Chemotherapy and radiation B. Mediastinoscopy C. Radiation therapy D. Resection for cure E. Endobronchial ultrasonography
A. Chemotherapy and radiation
