Lecture 11: Thoracic Neoplasms Flashcards
What is the superior mediastinum?
Anything above the heart.
What are the common etiologic masses within the anterior mediastinum?
- Terrible T’s (Thymoma, Teratoma, Thyroid/Parathyroid)
- Foramen of Morgagni hernia
- Mesenchymal tumors (lipoma, fibroma)
- Giant lymph node hyperplasia, lymphoma
- Germ cell tumor (seminoma/teratoma)
What are the MC etiologic masses within the middle mediastinum?
- Granulomatous or metastatic LAN
- Cysts (pleuropericardial, bronchogenic, enteric)
- Masses of vascular origin (pulmonary artery enlargement, aortic aneurysm)
Grainy Central Masses
What are the MC etiologic masses within the posterior mediastinum?
- Neurogenic tumors, meningocele, meningomyelocele
- Gastroenteric cysts, esophageal diverticula/tumor
- Hiatal hernia, hernia through foramen of Bochdalek
- Extramedullary hematopoiesis
Neuro = posterior mediastinum
How are mediastinal masses usually found?
Incidentally in half of all cases.
Do full H&P if found!!!!!!!!
If a mediastinal mass sits upon the sympathetic chain within the chest, what is likely to occur?
Horner’s syndrome
Ptosis, Anhidrosis, Miosis
Miosis is smaller than mydriasis, so miosis is pupillary constriction, while mydriasis is dilation.
If systemic/constitutional symptoms are occurring in relation to a medistinal mass, what does that tell us about the mass?
Most likely malignant.
What is the initial imaging for a suspected mediastinal mass?
CXR PA/Lateral
CT w/ con for f/u
If we suspect esophageal disease, what secondary imaging should we order?
Barium swallow
What is a good option for imaging for vascular etiologies?
CT or MR angiography or Doppler US
What imaging modality might be best for lymphoma/malignancy?
PET scan/PET-CT
What imaging modality is best to locate the origin of a germ cell tumor?
Testicular/ovarian US
What tumor markers are associated with thymic tumors, germ cell tumors, or seminomas/lymphomas?
- Thymic: Anti-acetylcholine receptor antibodies
- Germ cell tumors: alpha-fetoprotein and beta-hCG
- Seminomas/lymphomas: serum LDH
When a mediastinal mass is to be biopsied, what is the main concern?
Malignant seeding
For a tumor sitting very close to the bronchus, what might be the best approach to biopsy it?
Endobronchial approach with US guidance
For a tumor located centrally within the mediastinum, what might be the best way to biopsy it?
Mediastinoscopy
What size is a pulmonary nodule?
<= 3cm (30mm)
What are the characteristics of a solitary pulmonary nodule?
- <= 3cm
- Isolated and round opacity
- Surrounded by normal lung
- Usually benign
What is the MC non-malignant cause of solitary pulmonary nodules?
Infectious granulomas caused by fungi or mycobacteria
Well-demarcated and well-calcified
Describe a hamartoma on CXR and CT.
- CXR: Popcorn calcification
- CT: Areas of fat or alternating fat/calcifications
What benign cause of SPNs should we AVOID biopsy of?
Pulmonary AV formations (vascular)
How does pulmonary metastases typically present?
Multiple nodules.
What are the 4 primary lung cancers that can cause SPNs?
- Small cell carcinoma: SCLC (centrally)
- Adenocarcinoma (peripherally)
- Squamous cell carcinoma (centrally)
- Large cell cancer (anywhere but usually peripherally)
Where is the MC malignant cause of SPNs that present as carcinoid tumors?
Endobronchial
What are the biggest cancer risks for SPN development?
- Smoking, increasing with pack year history.
- Increasing age past 35.
What would cause us to repeat a CXR prior to doing a CT?
- Suspected nodule is a nipple shadow
- Evidence of infection
- Nodule looks like a benign lesion.
What is the preferred advanced imaging modality for SPN?
CT Chest w/o contrast
What are the 4 things that a CT scan gives us to determine malignancy risk factors?
- Size
- Location
- Attenuation
- Calcification
What characteristics of a nodule on CT imaging make it more suspicious for malignancy?
- Size > 20mm = 50%
- Upper lobes = malignant
- Subsolid = higher likelihood of malignancy
- Ill-defined borders, lobular or spiculated, with peripheral halo.
- Rapidly growing
- Sparse calcification with stippled or eccentric patterns.
What are the two subsolid nodules?
- Ground-glass
- Part-solid
What is considered growth of a SPN for determining malignancy?
- Solid: stable for 2 years is fine.
- Part-solid: stable for 5 years at minimum.
What is considered low-risk and high-risk in the SPN calculator?
- Low < 5%
- High > 60%
Only need to calculate if size is less than 30mm.
Estimates the probability that a lung nodule will be diagnosed as cancerous within a 2-4 year f/u period.
What do we do for low-risk SPN patients?
Serial CT scanning.
What are the risk factors for SPN malignancy?
- Size
- Age
- Tumor Hx
- Smoking Hx
- Hx of smoking cessation
- COPD
- Asbestos exposure
- Nodule characteristics
What is the pattern for 4-8mm SPN on a low-risk patient?
- Starts with no risk factors = selective.
- With risk factors = the same as nodule 2mm bigger without risk factors.
Essentially the initial f/u time for a scan gets halved, and then it becomes more frequent until 8mm.
What are the options for a intermediate risk SPN patient with a central lesion?
Sputum cytology
Highly specific test, but not sensitive.
AKA it can tell you with good certainty that your SPN is not malignant.
High specificity = high true negative
What are the surgical procedures to help determine if a SPN needs full surgery?
- Biopsy
- VATS with frozen tissue sampling.
What should we do if a patient has multiple pulmonary nodules?
Test each nodule individually!!!!!!!!!!!!
What are the 6 hallmark characteristics of a cancer cell?
- Self-sufficient growth
- Insensitive to anti-growth signals
- Evades apoptosis
- Limitless replicative potential
- Sustained angiogenesis
- Tissue invasion and metastasis
What parts of the lungs falls under bronchogenic carcinoma?
- Bronchi
- Bronchioles
- Alveoli
Respiratory epithelium
How much does smoking cessation decrease lung cancer risk?
- 90% of the risk attributable to tobacco if you stop by middle age.
- In general, decreases 50% risk of lung cancer
What are the 5 criteria for annual lung cancer screening via low-dose CT?
- 50-80 in good health
- Current smoker or in past 15 years.
- 20-year pack history (advise cessation)
- Inform/shared decision making about pros/cons of the screening.
- Access to a lung center that can screen and treat.
You need all of the first 3 to qualify for testing!!!!!!!!!!!!!!!!!!!!!!
What are the top 3 symptoms of lung cancer?
- Cough
- Weight loss
- Dyspnea
What are the 3 intrathoracic complications common in lung cancer?
- Malignant pleural effusions
- SVC syndrome
- Pan coast tumor
What is the prognosis of malignant pleural effusions?
Incurable and managed palliatively.
Need cytology of pleural fluid!
What type of lung cancer is most likely to cause SVC syndrome?
Small cell lung cancer (SCLC)
Describe the S/S of SVC syndrome.
- Head fullness
- Facial edema
- Dilated neck veins
- Prominent veins on the chest
- Pemberton’s sign (Facial plethora with arm extension)
- Mediastinal widening/right hilar mass on CXR.
What is a pan coast tumor?
Tumor in the apex, resulting in compression of surrounding structures.
What are the symptoms of a pan coast tumor?
- Shoulder pain (brachial plexus)
- Horner’s syndrome (sympathetic chain)
- Bone destruction (bones surrounding)
- Atrophy of hand muscles (C8, T1 nerve roots)
What would indicate us to do a CT chest w/ contrast for lung cancer after a CXR?
- New or enlarging lesion
- Pleural effusion
- Pleural nodularity
- Enlarged hilar or paratracheal nodes
- Endobronchial lesion
- Post-obstructive pneumonia
- Segmental or lobar atelectasis
What is the main purpose of CT and PET imaging for lung cancer?
Staging and biopsy planning.
DOES NOT DEFINITIVELY DIAGNOSE
Integrated CT/PET is best for lymph node staging.
What cancer metastases usually elevate ALP?
Bone or liver mets.
What labs may be elevated in MSK paraneoplastic syndromes?
CK & ANA
What are the 4 MC organs that lung cancer tends to metastasize to?
- Liver
- Adrenal glands
- Bones
- Brain
What suggests that we have liver mets from lung cancer?
Elevated LFTs tends to be the only sign.
Use CT w/o con or CT/PET.
What suggests we have bone mets from lung cancer?
- Pain in the back, chest, or extremity
- Elevated ALP
- Elevated Ca in severe cases
- Preferred imaging modality: PET
MC in SCLC
If we need to check for bone mets, what is the alternative to PET and MRI?
Bone scintigraphy
How are most adrenal mets typically found?
Incidentally. Need a PET to differentiate if it is metastatic or not.
How does brain mets typically present?
- HA, vomiting, seizures
- Papilledema, visual field loss, hemiparesis, cranial/focal nerve deficit
Need MRI w/ contrast.
What is the only definitive way to diagnose malignancy?
Biopsy of EVERY SINGLE NODULE YOU SUSPECT
How do we biopsy centrally and peripherally located lung tumors?
- Central: endobronchial US bronchoscopy
- Peripherally: Transthoracic percutaneous FNA with CT guidance.
What are the indications for alternative biopsy options for lung cancer?
Alternatives as in VATS or mediastinoscopy.
- Resection prior to biopsy results
- Inadequate specimen or undiagnosed with previous methods.
What are the NSCLCs?
- Adenocarcinoma
- Squamous cell carcinoma
- Large cell carcinoma
Describe SCLC.
- Almost exclusively in smokers.
- Small cells, rapidly growing, with early mets.
- Generally starts centrally in the bronchi.
- Often seen as a large hilar mass with bulky mediastinal adenopathy
Only makes up 15% of lung cancers.
Smokers Catch Lung Cancer
Describe adenocarcinoma.
- Slow growing
- Periphery
- MC form of lung cancer in NONsmokers
Abstaining smokers get Adenocarcinoma
Describe squamous cell carcinoma.
- Center of lungs
- Smokers
Both central lung cancers have SC in their abbreviation
Describe large cell carcinoma.
- Rapidly growing mass
- Anywhere, but usually periphery
How do I differentiate between limited and extensive SCLC?
- Limited: Ipsilateral hemithorax, with the entire thing being contained within a radiation field.
- Extensive: Overt metastatic disease. Often includes Cardiac tamponade, malignant pleural effusions, and bilateral involvement.
How should limited SCLC be treated vs extensive?
- Limited: Platinum based Chemo + Thoracic radiation treatment to try and CURE the cancer. Can also consider surgical resection per chest physicians guidelines in the text.
- Extensive: Chemo only to CONTROL the cancer.
Limited Disease includes contralateral supraclavicular nodes, recurrent laryngeal nerves, and SVC obstruction.
What is physiologic staging?
- An assessment of a patient’s ability to withstand various antitumor treatments.
- Using PFTs and ASCVD risk calculations, along with VO2max estimates.
Mainly for NSCLC
What is anatomic staging?
Determining the location of a tumor and possible metastatic sites.
Mainly for NSCLC
What does x mean in TNM?
Cannot be assessed
What size is T1 for a lung cancer?
< 3cm
Every increase goes up by 2 cm, until T4 = 7cm.
When does N staging include contralateral lymph nodes for lung cancer?
N3.
Prior to this is ipsilateral only.
At what M stage does lung cancer include extrathoracic mets?
M1b
Describe stage 0 for NSCLC.
- Only finding is malignant cells on cytology.
- Need bronchoscopy to identify.
- Surgery is usually curative.
Describe stage 1 for NSCLC.
- Still no nodal or mets
- Surgery is generally the only treatment needed
- Radiation only indicated for positive surgical margins or refuses/poor candidate for surgery.
Positive surgical margins = still cancerous at the edges.
Describe stages 2 and 3 for NSCLC.
- Surgery
- Adjuvant chemo, esp if lymph nodes are involved.
- Post-op radiation for positive surgical margins, nodal involvement, or poor/refuses surgery.
Describe stage 4 for NSCLC.
- Distant mets
- Systemic chemo + molecular therapy +/- immunotherapy
- Palliative radiation/surgery
- Isolated mets can be excised
Describe the limited stage of SCLC.
- No distant mets or mediastinal disease = resection + chemo
- Evidence of disease = chemoradiotherapy
Describe the extensive stage of SCLC.
- Systemic chemo
- Prophylactic irradiation of the cranial and thoracic areas.
Extension past the hemithorax
What is the most common abnormality seen in paraneoplastic syndrome?
- Hypercalcemia due to secretion of PTHrP by proteins and Vit D-1,25.
- Often suggests advanced disease (stage 3-4)
What type of lung cancer is SIADH usually associated with and what symptoms does it present with?
- SCLC.
- Symptoms are correlated with the severity of hyponatremia.
What is the MC neurologic paraneoplastic syndrome due to SCLC?
Lambert-Eaton myasthenic syndrome (LEMS)
Describe LEMS.
- Autoantibody formation impairs release of ACh.
- Requires electrodiagnostic studies and antibody testing.
- Often can precede a Dx of SCLC.
50% of LEMS pts have SCLC.
What XRAY finding is indicative of hypertrophic osteoarthropathy due to paraneoplastic syndrome?
Periosteal new bone formation
Clubbing of digits can appear too.
What are the two MSK paraneoplastic syndromes associated with lung cancer?
- Dermatomyositis
- Polymyositis
Elevated CK and ANA
What lyte abnormalities does Cushing’s cause?
- HypoK
- Hyperglycemia
When do bronchial carcinoid tumors tend to appear?
Before age 60
Not linked to smoking!!!!!!!!
How does bronchial carcinoid tumors present?
- Hemoptysis
- Cough
- Focal wheezing
- Recurrent pneumonia
- Carcinoid syndrome (rare)
What is carcinoid syndrome?
- Flushing
- Diarrhea
- Wheezing
- Hypotension
What does a bronchial carcinoid tumor look like on bronchoscopy?
Central airway will show a pink/purple tumor.
Biopsy will cause severe bleeding ):
Highly vascularized
How do we manage a bronchial carcinoid tumor?
- Observe with serial CT scans
- F/u if symptomatic, could require excision
- MC complication: tumor bleeding and airway obstructions
Generally a good prognosis.
