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Pulmonology > Clin Med Pulm Neoplasms > Flashcards

Clin Med Pulm Neoplasms Flashcards

1
Q

Which neoplasm is known as “coin lesion”?

A

Solitary pulmonary nodules

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2
Q

Define solitary pulmonary nodules

A

a < 3cm isolated, rounded opacity outlined by normal lung and not associated with infiltrate, atelectasis, or adenopathy

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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
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4
Q

Is SPN symptomatic or asymptomatic?

A

Asymptomatic

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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
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6
Q

Which doubling time suggests infection?

A

Rapid progress = doubling time < 30 days

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7
Q

Which doubling time suggests benign?

A

Long term stability = doubling time > 465

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8
Q

Radiographic features consistent with benignicity (2)

A
  1. Smooth, well defined edge

2. Dense calcification in a central of laminated pattern

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9
Q

Radiographic features consistent with malignancy (5)

A
  1. Ill-defined margins
  2. Lobular appearance
  3. Spiculated margins and a peripheral halo
  4. Sparser calcifications, typically stippled or eccentric
  5. Cavitary lesions with thick walls
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10
Q

What characteristics are low probability SPN?

A
  1. < 5% chance of malignancy
  2. Age under 30
  3. stable for >2 years
  4. characteristic pattern of benign calcification
    * Watchful waiting –> serial CT scans (can be done without contrast)
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11
Q

What are the characteristics of intermediate probability SPN?

A
  1. 5-60% chance of malignancy
  2. Controversial
  3. Traditionally obtain a biopsy if possible (FNA vs bronch)
  4. PET scans, sputum cytology, VATS
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12
Q

What are the characteristics of high probability SPN?

A
  1. > 60% chance of malignancy
  2. Proceed to resection if possible
  3. Neoplasm staging
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13
Q

What is the 3rd most common cause of cancer & leading overall cause of cancer deaths?

A

Primary pulmonary neoplasms (PPN)

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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
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15
Q

What is the mediate age of PPN diagnosis?

A

71 yrs

*Rare under 40 yrs

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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
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17
Q

Signs & symptoms of PPN

A
  1. New cough or change in chronic cough (60-75%)
  2. New onset of cough in smoker must be evaluated!
  3. Copious thin secretions
  4. Hemoptysis (35%) more common in squamous cell
  5. Dyspnea (60%)
  6. Change in voice, hoarseness (18%) recurrent laryngeal N involvement
  7. Anorexia, weight loss, asthenia (weakness) (55-90%)
    * can also be seen with hepatic mets*
  8. Neurologic s/s indicating brain mets HA, N/V, seizures, dizziness, AMS (10% NSCLC, 20-30% SCLC)
  9. Bone pain or chest pain (35%)
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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

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19
Q

What are signs of local spread for PPN?

A
  1. Change in voice, hoarseness (18%) recurrent laryngeal N involvement
  2. Anorexia, weight loss, asthenia (weakness) (55-90%)
    * can also be seen with hepatic mets*
  3. Neurologic s/s indicating brain mets HA, N/V, seizures, dizziness, AMS (10% NSCLC, 20-30% SCLC)
  4. Bone pain or chest pain (35%)
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20
Q

What are 4 common morbidities related to PPN?

A
  1. Atelectasis
  2. Post-obstructive pneumonia
  3. Pleural effusions
  4. Clubbing of the nails
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21
Q

What is superior vena cava syndrome?

A

Obstruction of SVC by tumor

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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
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23
Q

What is Paraneoplastic Syndromes?

A

patterns of organ dysfunction related to immune-mediated or secretory effects of neoplasms

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24
Q

Characteristics of paraneoplastic syndromes

A
  • May occur before, during, or after diagnosis

- Does not necessarily indicate mets

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25
Q

Common paraneoplastic syndromes

A
  • SIADH
  • Cushings
  • Horner Syndrome
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26
Q

What are the 2 types of primary lung cancers?

A 
Non-small cell (NSCLC)
Small cell (SCLC)
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27
Q

What are the 3 NSCLC?

A
  1. Squamous cell (20%)
  2. Adenocarcinoma (30-40%)
    - -Bronchioalveolar Cell Carcinoma (2%)
  3. Large Cell Carcinoma (3-5%)
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28
Q

Squamous Cell Carcinoma

A
  • 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
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29
Q

S/Sx of Squamous cell carcinoma

A
  • Hemoptysis (do sputum cytology - positive in 20%)

- Hypercalcemia (10%)

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30
Q

What % of squamous cell carcinoma patients have metastasis?

A

60% at presentation

-MC sites are liver, bone, brain, and adrenal glands

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31
Q

Adenocarcinoma

A

-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

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32
Q

What is a pancoast tumor?

A
  • usually squamous cell or adenocarcinoma

- Round, opaque density in left lung apex with rib destruction

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33
Q

Pancoast tumor syndrome

A
  1. Ipsilateral arm pain
  2. Horner’s syndrome
    - -ptosis (drooping eyelid)
    - -miosis (narrow pupil)
    - -anhidrosis
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34
Q

How does pancoast tumor spread?

A

From lungs to ribs

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35
Q

Bronchoalveolar Cell Carcinoma (subtype of adenocarcinoma)

A
  • 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
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36
Q

Appearance of bronchoalveolar cell carcinoma

A

Can appear as a single nodule, multiple nodules, or diffusely (infiltrates, ground glass, etc)

  • Hilar and mediastinal lymphadenopathy is uncommon
  • Usually peripheral
  • Slow growing
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37
Q

Spread of bronchoalveolar cell carcinoma

A

Spread aerogenously & usually metastasize to other areas of lungs

38
Q

S/Sx of bronchoalveolar cell carcinoma

A

Copious thin, watery secretions is characteristic of advanced disease

39
Q

High risk for bronchoalveolar cell carcinoma

A

Higher incidence in women and non-smokers

40
Q

Carcinoid tumors

A
  • Typically endobronchial
  • Often central but can be peripheral
  • approx. 1-6% of lung cancers
41
Q

What paraneoplastic syndromes do carcinoid tumors produce?

A

SIAD, Cushings

42
Q

What is the treatment for carcinoid tumors?

A

Best treatment is surgical resection if no evidence of metastasis

43
Q

Large Cell Carcinoma

A

Heterogenous group of undifferentiated tumors sharing large cells (don’t fit in to other groups)
*Approx. 3-5% of lung cancers

44
Q

Features of large cell carcinoma

A
  • Rapid doubling times
  • Aggressive
  • Central or peripherally located
45
Q

Which cancer is known as “oat cell”?

A

Small Cell Carcinoma

46
Q

Where does small cell carcinoma arise from?

A

Bronchioles - infiltrates the submucosa to cause narrowing or obstruction without intraluminal loss

47
Q

Where does small cell carcinoma begin?

A

centrally - hilar and mediastinal changes are common

48
Q

Small cell carcinoma characteristics

A
  1. Very aggressive
  2. Prone to early hematogenous spread
  3. Rarely amendable to surgery
49
Q

Common paraneoplastic syndromes related to small cell carcinoma

A

SIADH - evaluate unexplained hyponatremia in a smoker

Cushings

50
Q

Diagnosis of lung cancer

A
  • 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
Q

What directs treatment in lung cancer?

A

Staging

52
Q

What staging does NSCLC use?

A

TNM
T = size and location of primary tumor
N = presence and location of involved lymph nodes
M = distant metastasis

53
Q

What is assumed on diagnosis of SCLC?

A

Micrometastasis

54
Q

What are the 2 categories of SCLC?

A
  1. Limited disease – limited hemithorax and contralateral hilum (survival 20-40%)
  2. Extensive disease – disease beyond hemithorax or with pleural effusion (survival < 5%)
55
Q

What 2 organs do you not want to us PET/CT for?

A

Brain and bladder - take up too much contrast.

56
Q

When is a mediastinoscopy indicated?

A

Prior to resection, to evaluate for nodal disease.

If positive lymph nodes, may signal more advanced disease and resection is not indicated.

57
Q

NSCLC Treatment

A

Lower chance of cure without surgical resection

  • -Complete lobectomy if possible
  • -All patients considered for surgery should get PFTs
58
Q

Surgical resection based on stages

A
  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
Q

3 categories of chemotherapy

A
  1. Platinum containing drugs
  2. Erlotinibn (Tarceva)
  3. Nivolumab (Opdivo)
60
Q

What are platinum-containing drugs?

A
  • Binds DNA to form adducts that inhibit their synthesis and function
  • Cisplatin or Carboplatin
61
Q

Erlotinib (Tarceva)

A
  • 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
Q

Nivolumab (Opdivo)

A

2nd line therapy in advanced disease for those that have tried or are currently being treated with platinum containing drugs

63
Q

SCLC Treatment: Limited Stage

A

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
Q

SCLC Treatment: Extensive Stage

A

Often chemotherapy alone

  • -Brain radiation if good response to chemo
  • -Little benefit from radiation therapy
65
Q

SCLC Treatment

A

Use platinum containing drugs

66
Q

Palliate Therapy

A
  • Drainage of pleural effusions
  • Photoresection
  • Intracranial resection (accompanied brain radiation therapy)
  • Brachytherapy – intraluminal radiation (alternative for endobronchial lesions)
  • Pain control
  • Symptom control
67
Q

Prognosis

A

Overall 5 year survival rate for lung cancer is 16%

68
Q

SCLC Prognosis

A
  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
Q

Secondary Pulmonary Neoplasm - Metastases

A

kidney, breast, colon, cervix, malignant melanoma, lymphoma (thyroid colon renal and breast)

70
Q

Secondary Pulmonary Neoplasm appearance

A
  • Appear as pulmonary nodules or masses, or malignant pleural effusions
  • More common in lower lung zones
  • < 5cm
  • Often spherical
  • Bilateral
  • Pleural or subpleural
71
Q

S/Sx of secondary pulmonary neoplasms

A

S/Sx of that specific kind of cancer, but can have pulmonary symptoms

72
Q

Secondary pulmonary neoplasm diagnosis

A
  • 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
Q

Define lymphangitic carcinomatosis

A
  • 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
Q

Secondary pulmonary neoplasm surgical resection

A

only if the primary cancer can be controlled

–Resection not helpful if there is pleural involvement or in cases of malignant melanoma

75
Q

Malignant Pleural Effusions

A

Most frequent initiating cause - direct involvement of the serous surface with the tumor

76
Q

Diff dx of malignant pleural effusions

A

include other causes of effusion - must send fluid for analysis to make diagnosis

77
Q

Malignant pleural effusion characteristics

A
  • Typically exudative
  • Bloody effusions usually due to cancer (can also be bloody with PE or trauma)
  • Lymphomas can cause chylous effusion
78
Q

Why is malignant pleural effusion considered uncurable?

A

Usually end-stage manifestation of disease

79
Q

Malignant pleural effusion s/sx

A
  • SHOB, orthopnea

- decreased breath sounds (esp. on side of PE), egophony, percussion dullness

80
Q

Malignant pleural effusion treatment

A
  • 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
Q

Mesothelioma characteristics

A
  • 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
Q

Sex and age of mesothelioma

A

Men 3:1

Age 60 yrs

83
Q

Mesothelioma survival

A

4-16 months (5 yr survival rate < 5%)

84
Q

3 types of mesothelioma

A
  1. Epithelial (50-60%)
  2. Sarcomatoid (10%) – more resistant to tx, worse prognosis
  3. Biphasic (30-40%)
85
Q

Mesothelioma is due to…

A

Asbestos exposure

    • 60-80% of patients have h/o exposure
    • latent periods 20-40 years between exposure and development
86
Q

Is there correlation with mesothelioma and smoking?

A

No, but pt with asbestos exposure typically has a more significant course

87
Q

What do mesothelioma pts die of?

A

Most die from respiratory failure and complications from local extension

88
Q

Mesothelioma s/sx

A
  • 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
Q

Mesothelioma paraneoplastic syndromes

A
  • Acidemia
  • Hemolytic anemia
  • DIC
  • Hypercalcemia
  • Migratory thrombophlebitis
90
Q

Mesothelioma radiologic findings

A 
\+/- Nodular
Irregular
Unilateral pleural thickening
60% lesions right sided
5% lesions bilateral
91
Q

Mesothelioma pleural effusion

A

Exudative
May be hemorrhagic
Often negative cytology

92
Q

Mesothelioma treatment

A
  • Generally unsuccessful
  • Surgery
  • -Pleurectomy & decortication
  • -Extrapleural pneumonectomy (radical approach)
  • Chemotherapy
  • -Usually palliative
  • -2 drug therapy, including platinum based drug

Pulmonology (11 decks)

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