L14 Lung Cancer Flashcards
solitary pulmonary nodule aka
coin lesion
solitary pulmonary nodule definition
<3 cm, isolated, rounded opacity with dense central calcification completely surrounded by pulmonary parenchyma
a mass is
> 3 cm in size→ greater chance of malignancy
nodules or masses in lungs are
considered cancer until proven otherwise
benign solitary nodule causes
Infectious granulomas (most common): TB, cocci, pulmonary abscess
Hamartoma
Vascular
Inflammatory
Fungal infection: multiple calcified lesions
malignant solitary nodule causes
lung cancer, carcinoid tumor, metastatic cancer
age/gender of solitary pulmonary nodule risk
> 60 years old = 50% risk of it being malignant
FEMALES
60% of solitary pulmonary nodules in arizona
cocci
if your patient has had cancer in the past and now presents with a solitary pulmonary nodule, regardless of their other risk factors, you are thinking it’s
malignant, metastasis
60% of the time
your patient has a mass >5 cm, what’s their prognosis
90% of the time it is cancer
malignant vs benign nodules monitored by CXR
malignant double in 20-400 days
benign show minimal growth in 2 years
preferred imaging of solitary pulmonary nodule
low radiation CT of chest without contrast, 1mm slices
Imaging for nodule 6-8 mm
follow up CT 6-12 months, repeat
Imaging for nodule <6 mm
no follow up required, optional at 6 months
Imaging for nodule >8 mm Low probability (<5%)
CT at 3 months
→ no growth→ serial CT a 9-12, 18-24 months
→ growth→ pathologic evaluation
Imaging for nodule >8 mm Intermediate probability (5-65%)
FDEG: avid→ biopsy or excision
PET/CT: if negative, unavailable, or indeterminate→ individualized management
CT surveillance: 3, 9-12, 18-24 months: alternative to biopsy
Management for nodule >8 mm High probability (>65%)
biopsy/excision +/- PET/CT for staging
oat cell carcinoma aka
small cell lung cancer
small cell lung cancer presentation
large hilar mass with bulky mediastinal adenopathy→ compression of airway, cough, dyspnea, weight loss, debility
Highly aggressive, metastasizes, short survival without treatment
small cell lung cancer arises from
From central airways
most are extensive
most common lung cancer
adenocarcinoma
adenocarcinoma arise from
mucous glands or any epithelia cell in/distal to terminal bronchioles
metastasizes to distant organs
adenocarcinoma presents as
peripheral nodules or masses
squamous cell carcinoma arises from
Arises from bronchial epithelium→ centrally or main bronchus→ intraluminal growth in bronchi
can cavitate
lung cancer most likely to present with hemoptysis
squamous cell carcinoma
sputum cytology can detect
squamous cell carcinoma
large cell carcinoma
Central or peripheral masses with rapid doubling times that metastasize to distant organs
can a clear chest x ray rule out cancer
NO
signs/symptoms of intrathoracic spread
Pleural effusion: Pericardial effusion Hoarseness Superior vena cava syndrome Pancoast syndrome
what causes hoarseness in lung cancer patients?
intrathoracic spread:
compression of recurrent laryngeal nerve with left sided tumors
lung cancer most commonly associated with superior vena cava syndrome
SCLC
superior vena cava syndrome causes
Compression or direct invasion from right lung, lymph nodes, or thrombosis (intravascular devices), intrathoracic malignancy
superior vena cava syndrome symptoms used to make a clinical diagnosis
symptoms of central venous obstruction: dyspnea, swelling of head/face worse when bending forward, laying down, arm swelling, cough, chest pain, dysphagia, dilated neck veins, prominent venous pattern on chest
initial study with indwelling devices and arm swelling (SVC syndrome)
duplex ultrasound
why use a CT with contrast for SVC syndrome
level and extent of blockage, map collateral pathways, identify underlying cause
gold standard imaging of SVC syndrome
superior vena cavogram
identify obstruction and extent of thrombus formation
treatment of SVC syndrome
emergency RT: stridor from central airway obstruction or laryngeal edema, coma from cerebral edema venous stents \+/- chemo removal of devices anticoagulation
pancoast syndrome
Tumor involving superior sulcus of apical chest→ compresses brachial plexus and cervical sympathetic nerves
Right shoulder, forearm, scapula, finger pain
Signs on ipsilateral side of tumor: miosis, anhidrosis, ptosis
Rib destruction
Atrophy of hand muscles
C8, T1, T2 nerve pain (down arms)
Horner’s syndrome
injury of sympathetic nerves of face
under pancoast syndrome?
lung cancer most likely to present with pancoast syndrome
squamous cell carcinoma
Paraneoplastic syndromes
Organ dysfunction due to immune mediated or secretory effects: hematologic, endocrine, neurologic
Paraneoplastic syndromes symptoms
anorexia, weight loss, cachexia, fever, suppressed immunity
cachexia
weakness/wasting of the body due to severe chronic illness
hematologic paraneoplastic syndrome labs
Hypercalcemia Anemia: fatigue, dyspnea Leukocytosis: poor prognosis Thrombocytosis: poor prognosis Hypercoagulability
endocrine paraneoplastic syndrome
PTH-like substance secreted
or
Excess HCG production
Excess HCG production endocrine paraneoplastic syndrome most commonly seen in
large cell
Excess HCG production endocrine paraneoplastic syndrome symptoms
gynecomastia
milky nipple discarge
PTH-like substance secreted endocrine paraneoplastic syndrome most commonly seen in
squamous cell NSCLC
PTH-like substance secreted endocrine paraneoplastic syndrome causes
hypercalcemia
SIADH or Cushing’s syndrome endocrine paraneoplastic syndromes is most commonly seen in
small cell
SIADH symptoms
Hyponatremia
irritability, restlessness, personality changes, confusion, coma, seizure, respiratory arrest
Cushing’s syndrome (ectopic ACTH) symptoms
muscle weakness, weight loss, HTN, hirsutism, osteoporosis
eaton-lambert syndrome
neurologic paraneoplastic syndrome
Immune mediated antibodies at neuromuscular junction –> defective release of ACh–> muscle weakness
cancer most likely to present with eaton-lambert syndrome
small cell
signs of liver metastasis
elevated LFTs, seen on CT/PET scan
signs of adrenal metastasis
asymptomatic
signs of bone metastasis
elevated alkaline phosphatase
back, chest, extremity pain
signs of brain metastasis
neuro sx: HA, N/V, seizures, confusion, personality change
staging of SCLS
Limited: ipsilateral hemithorax, regional nodes
Extensive (most): extends beyond hemithorax + pleural effusions
staging of NSCLC
T-primary tumor
N-nodal involvement
M-distant metastasis
stages of cancer
Stage 1: localized
Stage 2: spread in lymph nodes at top of lung
Stage 3: spread into chest wall
Stage 4: spread to another part of the body
performance status staging
0= fully active
1=strenuous physical activity restricted
2=capable of all self care, no work activity, up and about > 50% of waking hours
3=capable of only limited self care, confined to bed/chair >50% of waking hours
4= completely disabled
strongest indicator of post-op complications
FEV1 <60% predicted
how is PET done and why is it helpful
aids diagnosis and staging
Uses fluorodeoxyglucose which lights up in metabolically active cancer cells
→ better than CT for metastasis
→ false positives: infections
→ does not detect all cancer: bronchoalveolar
treatment of choice for NSCLC
surgical resection (if adequate pulmonary function)
Drainage for malignant effusions
Thoracocentesis
pleurodesis
pleurx catheters
which small cell cancers can get surgery
VERY FEW <5%
Small primary lung cancer with no evidence of spread
Cytoxic Chemotherapy side effects
anemia, neutropenia (infection risk), nephrotoxicity, cutaneous toxicity, N/V anorexia, weight loss, neurotoxicity (only partially reversible), fatigue, chemo brain
Radiation side effect
fatigue
who can get surgical resection without chemo
stage 1 NSCLC (but not 1B)
lobectomy
stage 3 NSCLC treatments
resected NSCLC with clear margin: nothing? no chemo
resected NSCLC without clear margin: radiation
unresected: chemotherapy
stage 4 cancer treatment
not curable, palliative car, chemo, trials, resection of metastasis, targeted therapy
which group of cancer has the worst prognosis
all small cell lung cancers
how to screen for lung cancer
Low dose helical CT (LDCT) noncontrast, high resolution thin slice
who to screen for lung cancer
every patient with suspected lung cancer
High risk patients:
55-74 with 30 year pack history/quit within 15 years/20 year pack history+1 risk factor
the problems with zyban
Avoid EtOH
Black box: increased suicide risk in children, adolescents, young adults
Adverse rxns: seizures, agitation, weight loss
zyban/wellbutrin/bupropion MOA and use
Inhibits neuronal uptake of NE and DA
antidepressant
smoking cessation
OTC nicotine replacement
Nicoderm CQ
Nicorette gum
Commit lozenge
the problems with varenicline or nicotrol
Precautions: unstable cardiovascular disease
Adverse reactions: dizziness, htn, palpitations, GI
nicotrol is
prescription nicotine replacement nasal spray or inhaler
varnicline MOA
Blocks alpha4-beta2 nicotinic acetylcholine receptors
Smoking cessation: after 7 days, continue prescription 12-24 weeks
