Clin Med Pulm Neoplasms Flashcards
1
Q
Which neoplasm is known as “coin lesion”?
A
Solitary pulmonary nodules
2
Q
Define solitary pulmonary nodules
A
a < 3cm isolated, rounded opacity outlined by normal lung and not associated with infiltrate, atelectasis, or adenopathy
3
Q
What factors increase risk of malignancy?
A
- Age > 30
- Smoking – risks increases with amount smoked
- H/o malignancy (breast cancer, etc.)
- Size > 2-5mm
4
Q
Is SPN symptomatic or asymptomatic?
A
Asymptomatic
5
Q
What do you do after spotting coin lesion on image?
A
- obtain chest CT (with contrast if not contraindicated)
- review old films
- assess doubling time
6
Q
Which doubling time suggests infection?
A
Rapid progress = doubling time < 30 days
7
Q
Which doubling time suggests benign?
A
Long term stability = doubling time > 465
8
Q
Radiographic features consistent with benignicity (2)
A
- Smooth, well defined edge
2. Dense calcification in a central of laminated pattern
9
Q
Radiographic features consistent with malignancy (5)
A
- Ill-defined margins
- Lobular appearance
- Spiculated margins and a peripheral halo
- Sparser calcifications, typically stippled or eccentric
- Cavitary lesions with thick walls
10
Q
What characteristics are low probability SPN?
A
- < 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)
11
Q
What are the characteristics of intermediate probability SPN?
A
- 5-60% chance of malignancy
- Controversial
- Traditionally obtain a biopsy if possible (FNA vs bronch)
- PET scans, sputum cytology, VATS
12
Q
What are the characteristics of high probability SPN?
A
- > 60% chance of malignancy
- Proceed to resection if possible
- Neoplasm staging
13
Q
What is the 3rd most common cause of cancer & leading overall cause of cancer deaths?
A
Primary pulmonary neoplasms (PPN)
14
Q
What are the risk factors for PPN?
A
- 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
15
Q
What is the mediate age of PPN diagnosis?
A
71 yrs
*Rare under 40 yrs
16
Q
Which risk causes > 90% of lung cancers?
A
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
17
Q
Signs & symptoms of PPN
A
- 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%)
18
Q
When do symptoms present in PPN? Implications?
A
- Symptoms usually present later in the disease process
- Typically a poorer prognosis if symptomatic at diagnosis
19
Q
What are signs of local spread for PPN?
A
- 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%)
20
Q
What are 4 common morbidities related to PPN?
A
- Atelectasis
- Post-obstructive pneumonia
- Pleural effusions
- Clubbing of the nails
21
Q
What is superior vena cava syndrome?
A
Obstruction of SVC by tumor
22
Q
S/Sx of SVC
A
- 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
23
Q
What is Paraneoplastic Syndromes?
A
patterns of organ dysfunction related to immune-mediated or secretory effects of neoplasms
24
Q
Characteristics of paraneoplastic syndromes
A
- May occur before, during, or after diagnosis
- Does not necessarily indicate mets
25
Common paraneoplastic syndromes
- SIADH
- Cushings
- Horner Syndrome
26
What are the 2 types of primary lung cancers?
```
Non-small cell (NSCLC)
Small cell (SCLC)
```
27
What are the 3 NSCLC?
1. Squamous cell (20%)
2. Adenocarcinoma (30-40%)
- -Bronchioalveolar Cell Carcinoma (2%)
4. Large Cell Carcinoma (3-5%)
28
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
29
S/Sx of Squamous cell carcinoma
- Hemoptysis (do sputum cytology - positive in 20%)
| - Hypercalcemia (10%)
30
What % of squamous cell carcinoma patients have metastasis?
60% at presentation
| -MC sites are liver, bone, brain, and adrenal glands
31
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
32
What is a pancoast tumor?
- usually squamous cell or adenocarcinoma
| - Round, opaque density in left lung apex with rib destruction
33
Pancoast tumor syndrome
1. Ipsilateral arm pain
2. Horner’s syndrome
- -ptosis (drooping eyelid)
- -miosis (narrow pupil)
- -anhidrosis
34
How does pancoast tumor spread?
From lungs to ribs
35
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
36
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
37
Spread of bronchoalveolar cell carcinoma
Spread aerogenously & usually metastasize to other areas of lungs
38
S/Sx of bronchoalveolar cell carcinoma
Copious thin, watery secretions is characteristic of advanced disease
39
High risk for bronchoalveolar cell carcinoma
Higher incidence in women and non-smokers
40
Carcinoid tumors
- Typically endobronchial
- Often central but can be peripheral
* approx. 1-6% of lung cancers
41
What paraneoplastic syndromes do carcinoid tumors produce?
SIAD, Cushings
42
What is the treatment for carcinoid tumors?
Best treatment is surgical resection if no evidence of metastasis
43
Large Cell Carcinoma
Heterogenous group of undifferentiated tumors sharing large cells (don’t fit in to other groups)
*Approx. 3-5% of lung cancers
44
Features of large cell carcinoma
- Rapid doubling times
- Aggressive
- Central or peripherally located
45
Which cancer is known as "oat cell"?
Small Cell Carcinoma
46
Where does small cell carcinoma arise from?
Bronchioles - infiltrates the submucosa to cause narrowing or obstruction without intraluminal loss
47
Where does small cell carcinoma begin?
centrally - hilar and mediastinal changes are common
48
Small cell carcinoma characteristics
1. Very aggressive
2. Prone to early hematogenous spread
3. Rarely amendable to surgery
49
Common paraneoplastic syndromes related to small cell carcinoma
SIADH - evaluate unexplained hyponatremia in a smoker
| Cushings
50
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
51
What directs treatment in lung cancer?
Staging
52
What staging does NSCLC use?
TNM
T = size and location of primary tumor
N = presence and location of involved lymph nodes
M = distant metastasis
53
What is assumed on diagnosis of SCLC?
Micrometastasis
54
What are the 2 categories of SCLC?
1. Limited disease – limited hemithorax and contralateral hilum (survival 20-40%)
2. Extensive disease – disease beyond hemithorax or with pleural effusion (survival < 5%)
55
What 2 organs do you *not* want to us PET/CT for?
Brain and bladder - take up too much contrast.
56
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.
57
NSCLC Treatment
Lower chance of cure without surgical resection
- -Complete lobectomy if possible
- -All patients considered for surgery should get PFTs
58
Surgical resection based on stages
1. Stage I/II – usually able to cure with surgery
2. Stage III-B/IV – minimal benefit from surgery (if any)
3. Stage III-A – benefit of surgery depends on case
59
3 categories of chemotherapy
1. Platinum containing drugs
2. Erlotinibn (Tarceva)
3. Nivolumab (Opdivo)
60
What are platinum-containing drugs?
- Binds DNA to form adducts that inhibit their synthesis and function
- Cisplatin or Carboplatin
61
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
62
Nivolumab (Opdivo)
2nd line therapy in advanced disease for those that have tried or are currently being treated with platinum containing drugs
63
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
64
SCLC Treatment: Extensive Stage
Often chemotherapy alone
- -Brain radiation if good response to chemo
- -Little benefit from radiation therapy
65
SCLC Treatment
Use platinum containing drugs
66
Palliate Therapy
- Drainage of pleural effusions
- Photoresection
- Intracranial resection (accompanied brain radiation therapy)
- Brachytherapy – intraluminal radiation (alternative for endobronchial lesions)
- Pain control
- Symptom control
67
Prognosis
Overall 5 year survival rate for lung cancer is 16%
68
SCLC Prognosis
1. Limited disease: remission is short with recurrence often in 6-8 months (2 year survival rate is 20%)
2. Extensive disease: median survival is 6-12 months (2 year survival rate is 20%, 5 year survival rate is < 5%)
69
Secondary Pulmonary Neoplasm - Metastases
kidney, breast, colon, cervix, malignant melanoma, lymphoma (thyroid colon renal and breast)
70
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
71
S/Sx of secondary pulmonary neoplasms
S/Sx of that specific kind of cancer, but can have pulmonary symptoms
72
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
73
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
74
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
75
Malignant Pleural Effusions
Most frequent initiating cause - direct involvement of the serous surface with the tumor
76
Diff dx of malignant pleural effusions
include other causes of effusion - must send fluid for analysis to make diagnosis
77
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
78
Why is malignant pleural effusion considered uncurable?
Usually end-stage manifestation of disease
79
Malignant pleural effusion s/sx
- SHOB, orthopnea
| - decreased breath sounds (esp. on side of PE), egophony, percussion dullness
80
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
81
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
82
Sex and age of mesothelioma
Men 3:1
| Age 60 yrs
83
Mesothelioma survival
4-16 months (5 yr survival rate < 5%)
84
3 types of mesothelioma
1. Epithelial (50-60%)
2. Sarcomatoid (10%) – more resistant to tx, worse prognosis
3. Biphasic (30-40%)
85
Mesothelioma is due to...
Asbestos exposure
- - 60-80% of patients have h/o exposure
- - latent periods 20-40 years between exposure and development
86
Is there correlation with mesothelioma and smoking?
No, but pt with asbestos exposure typically has a more significant course
87
What do mesothelioma pts die of?
Most die from respiratory failure and complications from local extension
88
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
89
Mesothelioma paraneoplastic syndromes
- Acidemia
- Hemolytic anemia
- DIC
- Hypercalcemia
- Migratory thrombophlebitis
90
Mesothelioma radiologic findings
```
+/- Nodular
Irregular
Unilateral pleural thickening
60% lesions right sided
5% lesions bilateral
```
91
Mesothelioma pleural effusion
Exudative
May be hemorrhagic
Often negative cytology
92
Mesothelioma treatment
* Generally unsuccessful
* Surgery
- -Pleurectomy & decortication
- -Extrapleural pneumonectomy (radical approach)
* Chemotherapy
- -Usually palliative
- -2 drug therapy, including platinum based drug
