Cancers of the Respiratory System

Question 1

Major risk factors for development of cancer of head and neck

Answer 1

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

Question 2

Risk factors specific to nasopharyngeal cancer

Answer 2

Endemic in Mediterranean and far East

EBV infection

Consumption of salted fish and indoor pollution

Question 3

Risk factors specific to oropharyngeal cancer

Answer 3

HPV 16, 18

Association with younger pt population, increased sexual partners, oral sexual practices

Question 4

Common complaints of pts with head and neck cancers

Answer 4

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

Question 5

What is trismus?

Answer 5

Inability to open the jaw d/t compression of trigeminal n. or muscle invasion by tumor

Question 6

Presenting signs/symptoms of nasopharyngeal cancer

Answer 6

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

Question 7

Presenting signs/symptoms of oropharyngeal cancer

Answer 7

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

Question 8

HPV related tumors frequently present with _______ as the first sign

Answer 8

Cervical LAD

Question 9

Laryngeal carcinoma usually presents with _____

Answer 9

Hoarseness

Question 10

Treatment of head and neck cancer when it is categorized as localized disease

Answer 10

Treated with curative intent either by surgery or radiation, depending on anatomic location and institutional expertise

Question 11

In terms of treating localized head and neck cancer, _______ is often preferred for laryngeal cancer to preserve voice function

Answer 11

Radiation therapy

Question 12

If laryngectomy is performed for laryngeal cancer, what are some ways in which voice function can be restored?

Answer 12

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

Question 13

In terms of treating localized head and neck cancer, _____ is preferred for small lesions in the oral cavity

Answer 13

Surgery

[radiation is avoided d/t complications of xerostomia and dental caries]

Question 14

Treatment of head and neck cancer when it is categorized as locally or regionally advanced disease

Answer 14

Combined-modality therapy including surgery, radiation, and chemotherapy

Question 15

Treatment of head and neck cancer when it is categorized as recurrent and/or metastatic disease

Answer 15

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

Question 16

Major risk factors for development of lung cancer

Answer 16

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

Question 17

Common presenting complaints in lung cancer

Answer 17

Hemoptysis
Pulmonary infections
Dyspnea
Cough
Chest pain

[evidence of extrathoracic spread may include weight loss, LAD, focal neurologic findings, bone tenderness, skin nodules, hepatomegaly]

Question 18

Paraneoplastic syndromes associated with small cell carcinoma

Answer 18

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

Question 19

What type of lung cancer occurs almost exclusively in smokers?

Answer 19

Small cell lung cancer

Question 20

Paraneoplastic syndrome associated with squamous cell carcinoma, and sometimes adenocarcinoma

Answer 20

Hypercalcemia (PTHrP)

Question 21

Paraneoplastic syndromes associated with adenocarcinoma of the lung

Answer 21

Hypertrophic pulmonary osteoarthropathy

Trousseau syndrome (migratory superficial thrombophlebitis)

Question 22

Physical findings associated with hypertrophic pulmonary osteoarthropathy

Answer 22

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]

Question 23

______ 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

Answer 23

Horner

Question 24

What is pancoast syndrome?

Answer 24

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

Question 25

Lung cancer may present with vocal cord paralysis due to entrapment of the ______ n.

Answer 25

Recurrent laryngeal

Question 26

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

Answer 26

A. Initial radiotherapy and chemotherapy, followed by surgery

Question 27

• 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

Answer 27

D. Refer the pt to a head and neck surgeon

Question 28

• 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

Answer 28

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]

Question 29

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

Answer 29

D. Low-dose spiral chest CT

Question 30

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

Answer 30

A. Chemotherapy and radiation