Lec 23 Lung Cancer Flashcards
What is epidemiology of lung cancer?
leading cause of cancer death in US and the world
What is risk of cancer smokers vs non-smokers?
smokers 20x increase risk
What are some smoking related carcinogens?
- polycyclic aromatic hydrocarbons
- tobacco specific nitrosamines
What percent of lung cancers occur in non-smoking females vs males?
9-13% of lung cancer in females is non-smokers
2-6% of lung cancer in males is non-smokers
What are some other risk factors for cancer besides active cigarette smoking?
- environmental/passive tobacco smoke
- radiation/radon gas exposure
- air pollution
- cooking oil fumes and indoor coal/biomass burning
- prior lung disease [COPD]
- family history
What are some occupational exposures associated with lung cancer?
- asbestos
- silica
- arsenic
What are genetic determinants of lung cancer susceptibility?
- locus at 15q24-25
- gene codes for nicotinic ACh receptor subunits
- confers 30% increased risk of lung cancer
What is most common presentation of lung cancer?
pulmonary nodules
What should you think if pulm nodule in smoker?
cancer until proven otherwise
Are majority of pulm nodules cancer or benign?
mostly benign
What are some possible causes of small pulm nodules?
- lung cancer
- bronchial carcinoid tumor
- hamartoma
- metastasis
- granuloma
- abscess
- inflammatory nodule
How can you tell benign from cancerous nodule?
- stability vs growth over time
- calcification pattern if present
- appearance of lesion
- metabolic characteristics
What does calcification of a nodule tell you?
tells you the nodule is old/has been around for a while
What does a perfectly round nodule suggest?
suggests benign
What does a popcorn calcification pattern suggest?
hamartoma
What does dense central calcification suggest?
granuloma
What does a spiculated border of small pulm nodule suggest?
suggets lung cancer
What does a cavitated pulm nodule tell you?
can be benign or malignant
How do you diagnose primary lung cancer?
-cytology on sputum, bronchoscopy, transthoracic needle aspiration
biopsy
What are two main histologic types of cancer?
small cell = 15%
non-small cell = 85%
What are 3 types of non small cell lung cancer?
- squamous cell carcinoma
- adenocarcinoma
- large cell carcinoma
What type of non small cell lung cancer is most common?
adenocarcinoma
What are features of squamous cell carcinoma?
- central location – mainstem or lobar bronchi
- may be cavitary
- strong association with smoking
- often bulky; fast doubling time
What are features of adenocarcinoma?
- peripheral location
What is most common type of lung cancer in non-smokers?
adenocarcinoma
What is new name for bronchioalveolar carcinoma?
lepidic adenocarcinoma
What are features of lepidic adenocarcinoma?
- non-mucinous adenocarcinoma
- lines alveolar spaces
- slow progression
- looks like pneumonia
What should you think if non-resolving pneumonia?
might be lepidic adenocarcinoma
What are features of large cell lung cancer?
- may present as bulky tumors
- aggressive w/ poor prognosis
What are features of carcinoid tumors?
- well differentiated
- neuroendocrine tumor
- arise in central airways
What are features of small cell carcinoma?
- poorly differentiated
- neuroendocrine tumor
- central
- perihilar masses; mediastinal lymphadenopathy
- paraneoplastic syndromes
How do carcinoid tumors present?
wheezing, cough, obstructive pneumonia
What is prognosis carcinoid vs other tumors?
carcinoid = better survival than small cell or non small cell
Which lung cancer has the highest association with smoking?
small cell carcinoma
What type of cells does small cell carcinoma arise from?
pulmonary neuroendocrine cells
What is survival for small cell carcinoma?
poor –> 5 year survival rate 6.2%
How do lung cancers usually present?
- often present at advanced stage
- early lung cancers often asymptomatic
What are airway symptoms of lung cancer? Most common w/ what type?
most common with squamous cell
- cough
- hemoptysis
- dyspnea
What are symptoms of mediastinal spread of cancer?
- hoarseness [recurrent laryngeal nerve involvement]
- diaphragm paralysis [phrenic nerve]
- SVC syndrome
What are symptoms of distant spread of lung cancer?
- headache
- localized weakness
- seizure
- bone pain
- abdominal pain
What is a pancoast tumor? signs?
lung cancer originating in apex of lung
signs = arm pain/weakness due to brachial involvement; horner’s
What cancer should you think if have hypercalcemia?
squamous cell carcinoma
hyper-Ca from ectopic PTH
What cancer should you think if have clubbing?
non small cell lung cancer
What cancer should you think if have cushing’s syndrome?
due to cortisol production by small cell carcinoma
What cancer should you think if have SIADH?
due to ADH production by small cell carcinoma
What cancer should you think if have Eaton-lambert syndrome?
SCC due to autoantibodies to voltage sensitive Ca channels
What does sputum cytology tell you about lung cancer?
tells you cellular diagnosis
What does bronchoscopy tell you about lung cancer? best for what kind of tumor?
tells you tissue diagnosis and extent/location of tumor
best for central tumors
CT guided biopsy is best for what type of lung tumors?
peripheral lesions
What are the 3 TNM stages of non small cell lung cancer?
T = site, size, local invasion of primary tumor
N = whether spread to local or regional lymph nodes
M = whether or not spread of lung cancer to distant metastatic sites
How do you stage small cell lung cancer?
limited stage = confined to single hemothorax
extensive stage = spread beyond hemithorax
How do you stage cancer non-invasively?
CT = assess size, location of tumor and sites of metastasis
PET = metabolic activity that could represent sites of metastatic disease
Is positive or negative PET most helpful?
negative most helpful = tells you probably not cancer;
positive is less specific
What is stage 1 NSCLC?
- no nodes
- no metastases
- no local invasion
What is prognosis of stage 1 NSCLC post resection?
60-70% 5 year survival post resection
What is stage 2 NSCLC cancer?
ipsilateral peribronchial or hilar nodes
or limited local invasion w/ no nodal involvement
What is 5 year survival stage 2 NSCLC?
30-50%
What is stage 3 NSCLC?
positive ipsilateral mediastinal nodes; greater local invasion
What is 5 year survival stage 3 NSCLC?
10-20%
What is stage 4 NSCLC?
distant metastases or metastasis to any lung lobe other than lobe w/ primary tumor
What is 5 year survival stage 4 NSCLC?
< 10%
What is treatment of NSCLC?
surgery is only cure
chemo is life extending by months
What is treatment of small cell lung cancer?
chemo +/- radiation
dramatic initial response then often recurs
What is treatment stage 1/2 NSCLC?
resection of area or entire lobe
What is treatment stage 3a NSCLC?
surgery and adjuvant chemo + radiation
What is treatment stage 3b NSCLC?
chemo +/- radiation
What is treatment stage 4 NSCLC?
chemo or palliative care
What is treatment limited vs extensive small cell lung cancer?
limited = chemo + radiation extensive = chemo
Who gets EGFR mutation? What does it predict?
more common in non smokers
predicts response to EGFR tyroskine kinase inhibitor [gefitinib, erlotinib]
Who gets KRas mutation? What does it predict?
more common in smokers
predicts poor response to TKI/chemo and poor prognosis
EML4-ALK mutation predicts what?
predicts response to ALK inhibitors
