Clin Med Pulm Neoplasms Flashcards
Which neoplasm is known as “coin lesion”?
Solitary pulmonary nodules
Define solitary pulmonary nodules
a < 3cm isolated, rounded opacity outlined by normal lung and not associated with infiltrate, atelectasis, or adenopathy
What factors increase risk of malignancy?
- Age > 30
- Smoking – risks increases with amount smoked
- H/o malignancy (breast cancer, etc.)
- Size > 2-5mm
Is SPN symptomatic or asymptomatic?
Asymptomatic
What do you do after spotting coin lesion on image?
- obtain chest CT (with contrast if not contraindicated)
- review old films
- assess doubling time
Which doubling time suggests infection?
Rapid progress = doubling time < 30 days
Which doubling time suggests benign?
Long term stability = doubling time > 465
Radiographic features consistent with benignicity (2)
- Smooth, well defined edge
2. Dense calcification in a central of laminated pattern
Radiographic features consistent with malignancy (5)
- Ill-defined margins
- Lobular appearance
- Spiculated margins and a peripheral halo
- Sparser calcifications, typically stippled or eccentric
- Cavitary lesions with thick walls
What characteristics are low probability SPN?
- < 5% chance of malignancy
- Age under 30
- stable for >2 years
- characteristic pattern of benign calcification
* Watchful waiting –> serial CT scans (can be done without contrast)
What are the characteristics of intermediate probability SPN?
- 5-60% chance of malignancy
- Controversial
- Traditionally obtain a biopsy if possible (FNA vs bronch)
- PET scans, sputum cytology, VATS
What are the characteristics of high probability SPN?
- > 60% chance of malignancy
- Proceed to resection if possible
- Neoplasm staging
What is the 3rd most common cause of cancer & leading overall cause of cancer deaths?
Primary pulmonary neoplasms (PPN)
What are the risk factors for PPN?
- SMOKING!
- Asbestos
- Environmental: metals and industrial gases (ex. Radon gas)
- H/o COPD, pulmonary fibrosis, or sarcoidosis
- A second primary lung CA is more common in a previous cancer pt
What is the mediate age of PPN diagnosis?
71 yrs
*Rare under 40 yrs
Which risk causes > 90% of lung cancers?
SMOKING!
- 40 pack year history increases risk by 20x that of non-smoker
- Despite smoking cessation, the risk increases with age faster in a previous smoker than in a lifetime non-smoker
- Delayed peak in women
Signs & symptoms of PPN
- New cough or change in chronic cough (60-75%)
- New onset of cough in smoker must be evaluated!
- Copious thin secretions
- Hemoptysis (35%) more common in squamous cell
- Dyspnea (60%)
- Change in voice, hoarseness (18%) recurrent laryngeal N involvement
- Anorexia, weight loss, asthenia (weakness) (55-90%)
* can also be seen with hepatic mets* - Neurologic s/s indicating brain mets HA, N/V, seizures, dizziness, AMS (10% NSCLC, 20-30% SCLC)
- Bone pain or chest pain (35%)
When do symptoms present in PPN? Implications?
- Symptoms usually present later in the disease process
- Typically a poorer prognosis if symptomatic at diagnosis
What are signs of local spread for PPN?
- Change in voice, hoarseness (18%) recurrent laryngeal N involvement
- Anorexia, weight loss, asthenia (weakness) (55-90%)
* can also be seen with hepatic mets* - Neurologic s/s indicating brain mets HA, N/V, seizures, dizziness, AMS (10% NSCLC, 20-30% SCLC)
- Bone pain or chest pain (35%)
What are 4 common morbidities related to PPN?
- Atelectasis
- Post-obstructive pneumonia
- Pleural effusions
- Clubbing of the nails
What is superior vena cava syndrome?
Obstruction of SVC by tumor
S/Sx of SVC
- Feeling of fullness in head, neck, and or upper extremities
- Dilated veins on chest and neck, +/- JVD
- Increased facial edema and plethoric appearance
- HA, dizziness
- usually sudden onset
What is Paraneoplastic Syndromes?
patterns of organ dysfunction related to immune-mediated or secretory effects of neoplasms
Characteristics of paraneoplastic syndromes
- May occur before, during, or after diagnosis
- Does not necessarily indicate mets
Common paraneoplastic syndromes
- SIADH
- Cushings
- Horner Syndrome
What are the 2 types of primary lung cancers?
Non-small cell (NSCLC) Small cell (SCLC)
What are the 3 NSCLC?
- Squamous cell (20%)
- Adenocarcinoma (30-40%)
- -Bronchioalveolar Cell Carcinoma (2%) - Large Cell Carcinoma (3-5%)
Squamous Cell Carcinoma
- Approx. 25-35% of lung cancers
- Arises from bronchial epithelium
- Located centrally as an intraluminal sessile or polypoid mass
- Spread locally
- Often see hilar adenopathy and mediastinal widening
S/Sx of Squamous cell carcinoma
- Hemoptysis (do sputum cytology - positive in 20%)
- Hypercalcemia (10%)
What % of squamous cell carcinoma patients have metastasis?
60% at presentation
-MC sites are liver, bone, brain, and adrenal glands
Adenocarcinoma
-Approx. 30-40% lung cancers
-Arise from mucus glands
-Typically present as a peripheral nodule or mass
80% have metastasis on presentation
*Associated with brain metastasis
What is a pancoast tumor?
- usually squamous cell or adenocarcinoma
- Round, opaque density in left lung apex with rib destruction
Pancoast tumor syndrome
- Ipsilateral arm pain
- Horner’s syndrome
- -ptosis (drooping eyelid)
- -miosis (narrow pupil)
- -anhidrosis
How does pancoast tumor spread?
From lungs to ribs
Bronchoalveolar Cell Carcinoma (subtype of adenocarcinoma)
- Arise from epithelial cell within or distal to the terminal bronchioles
- -Tumor cells fill alveoli
- -Do not invade parynchema
- Relatively rare - approx. 2-5% of lung cancers
Appearance of bronchoalveolar cell carcinoma
Can appear as a single nodule, multiple nodules, or diffusely (infiltrates, ground glass, etc)
- Hilar and mediastinal lymphadenopathy is uncommon
- Usually peripheral
- Slow growing
Spread of bronchoalveolar cell carcinoma
Spread aerogenously & usually metastasize to other areas of lungs
S/Sx of bronchoalveolar cell carcinoma
Copious thin, watery secretions is characteristic of advanced disease
High risk for bronchoalveolar cell carcinoma
Higher incidence in women and non-smokers
Carcinoid tumors
- Typically endobronchial
- Often central but can be peripheral
- approx. 1-6% of lung cancers
What paraneoplastic syndromes do carcinoid tumors produce?
SIAD, Cushings
What is the treatment for carcinoid tumors?
Best treatment is surgical resection if no evidence of metastasis
Large Cell Carcinoma
Heterogenous group of undifferentiated tumors sharing large cells (don’t fit in to other groups)
*Approx. 3-5% of lung cancers
Features of large cell carcinoma
- Rapid doubling times
- Aggressive
- Central or peripherally located
Which cancer is known as “oat cell”?
Small Cell Carcinoma
Where does small cell carcinoma arise from?
Bronchioles - infiltrates the submucosa to cause narrowing or obstruction without intraluminal loss
Where does small cell carcinoma begin?
centrally - hilar and mediastinal changes are common
Small cell carcinoma characteristics
- Very aggressive
- Prone to early hematogenous spread
- Rarely amendable to surgery
Common paraneoplastic syndromes related to small cell carcinoma
SIADH - evaluate unexplained hyponatremia in a smoker
Cushings
Diagnosis of lung cancer
- Any abnormal CXR must be followed up with CT (often obtain a PET scan to look for metastasis)
- FNA (fine needle aspiration)
- bronchoscopy
- mediastinoscopy
- VATS
- thoracotomy
- sputum cytology
- thoracentesis of pleural effusion
What directs treatment in lung cancer?
Staging
What staging does NSCLC use?
TNM
T = size and location of primary tumor
N = presence and location of involved lymph nodes
M = distant metastasis
What is assumed on diagnosis of SCLC?
Micrometastasis
What are the 2 categories of SCLC?
- Limited disease – limited hemithorax and contralateral hilum (survival 20-40%)
- Extensive disease – disease beyond hemithorax or with pleural effusion (survival < 5%)
What 2 organs do you not want to us PET/CT for?
Brain and bladder - take up too much contrast.
When is a mediastinoscopy indicated?
Prior to resection, to evaluate for nodal disease.
If positive lymph nodes, may signal more advanced disease and resection is not indicated.
NSCLC Treatment
Lower chance of cure without surgical resection
- -Complete lobectomy if possible
- -All patients considered for surgery should get PFTs
Surgical resection based on stages
- Stage I/II – usually able to cure with surgery
- Stage III-B/IV – minimal benefit from surgery (if any)
- Stage III-A – benefit of surgery depends on case
3 categories of chemotherapy
- Platinum containing drugs
- Erlotinibn (Tarceva)
- Nivolumab (Opdivo)
What are platinum-containing drugs?
- Binds DNA to form adducts that inhibit their synthesis and function
- Cisplatin or Carboplatin
Erlotinib (Tarceva)
- Tyrosine kinase inhibitor of EGFR (epidermal growth factor receptor)
- More often used in women, non-smokers, Asians, adenocarcinomas, bronchoalveolar carcinomas, and with EGFR mutations
Nivolumab (Opdivo)
2nd line therapy in advanced disease for those that have tried or are currently being treated with platinum containing drugs
SCLC Treatment: Limited Stage
Chemotherapy + thoracic radiation + prophylactic brain radiation
- -Blood brain barrier limits chemotherapy’s effect on brain mets
- -Whole brain radiation helps control CNS disease but does not effect overall survival
SCLC Treatment: Extensive Stage
Often chemotherapy alone
- -Brain radiation if good response to chemo
- -Little benefit from radiation therapy
SCLC Treatment
Use platinum containing drugs
Palliate Therapy
- Drainage of pleural effusions
- Photoresection
- Intracranial resection (accompanied brain radiation therapy)
- Brachytherapy – intraluminal radiation (alternative for endobronchial lesions)
- Pain control
- Symptom control
Prognosis
Overall 5 year survival rate for lung cancer is 16%
SCLC Prognosis
- Limited disease: remission is short with recurrence often in 6-8 months (2 year survival rate is 20%)
- Extensive disease: median survival is 6-12 months (2 year survival rate is 20%, 5 year survival rate is < 5%)
Secondary Pulmonary Neoplasm - Metastases
kidney, breast, colon, cervix, malignant melanoma, lymphoma (thyroid colon renal and breast)
Secondary Pulmonary Neoplasm appearance
- Appear as pulmonary nodules or masses, or malignant pleural effusions
- More common in lower lung zones
- < 5cm
- Often spherical
- Bilateral
- Pleural or subpleural
S/Sx of secondary pulmonary neoplasms
S/Sx of that specific kind of cancer, but can have pulmonary symptoms
Secondary pulmonary neoplasm diagnosis
- Imaging - CT, PET-CT
1. Cavitation –> think squamous carcinoma
2. Calcification –> think osteosarcoma
3. Extremely large multiple masses –> sarcoma
4. Large, anterior mediastinal mass +/- hilar lymphadenopathy –> think lymphoma - Biopsy if able
Define lymphangitic carcinomatosis
- diffuse involvement of the pulmonary lymphatic network
- can be a primary or secondary cancer (breast and stomach CA)
- can have streaky or linear infiltrates throught
Secondary pulmonary neoplasm surgical resection
only if the primary cancer can be controlled
–Resection not helpful if there is pleural involvement or in cases of malignant melanoma
Malignant Pleural Effusions
Most frequent initiating cause - direct involvement of the serous surface with the tumor
Diff dx of malignant pleural effusions
include other causes of effusion - must send fluid for analysis to make diagnosis
Malignant pleural effusion characteristics
- Typically exudative
- Bloody effusions usually due to cancer (can also be bloody with PE or trauma)
- Lymphomas can cause chylous effusion
Why is malignant pleural effusion considered uncurable?
Usually end-stage manifestation of disease
Malignant pleural effusion s/sx
- SHOB, orthopnea
- decreased breath sounds (esp. on side of PE), egophony, percussion dullness
Malignant pleural effusion treatment
- Treat underlying cancer
- Thoracentesis
- Pleurodesis if reasonable life expectancy
- Pleurex catheter, typically for short life expectancy or if they do not respond to pleurodesis
Mesothelioma characteristics
- Primary tumor from the surface lining of the pleura (80%) or peritoneum (20%)
- Most present as a diffuse tumor & are malignant
- ¼ are a localized tumor & are benign
- can also occur in peritoneum, pericardium, & testicles
Sex and age of mesothelioma
Men 3:1
Age 60 yrs
Mesothelioma survival
4-16 months (5 yr survival rate < 5%)
3 types of mesothelioma
- Epithelial (50-60%)
- Sarcomatoid (10%) – more resistant to tx, worse prognosis
- Biphasic (30-40%)
Mesothelioma is due to…
Asbestos exposure
- 60-80% of patients have h/o exposure
- latent periods 20-40 years between exposure and development
Is there correlation with mesothelioma and smoking?
No, but pt with asbestos exposure typically has a more significant course
What do mesothelioma pts die of?
Most die from respiratory failure and complications from local extension
Mesothelioma s/sx
- Insidious with rapid progression after presentation
- SHOB, non-pleuritic CP, weight loss
- Decreased breath sounds, dullness to percussion, clubbing
- Local invasion:
- -Dysphagia, hoarseness
- -SVC syndrome
- -Abdominal pain
- -Horner’s syndrome
- -Arrhythmias
Mesothelioma paraneoplastic syndromes
- Acidemia
- Hemolytic anemia
- DIC
- Hypercalcemia
- Migratory thrombophlebitis
Mesothelioma radiologic findings
\+/- Nodular Irregular Unilateral pleural thickening 60% lesions right sided 5% lesions bilateral
Mesothelioma pleural effusion
Exudative
May be hemorrhagic
Often negative cytology
Mesothelioma treatment
- Generally unsuccessful
- Surgery
- -Pleurectomy & decortication
- -Extrapleural pneumonectomy (radical approach)
- Chemotherapy
- -Usually palliative
- -2 drug therapy, including platinum based drug
