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Pulm > Lecture 11: Thoracic Neoplasms > Flashcards

Lecture 11: Thoracic Neoplasms Flashcards

1
Q

What is the superior mediastinum?

A

Anything above the heart.

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2
Q

What are the common etiologic masses within the anterior mediastinum?

A
  • 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)
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3
Q

What are the MC etiologic masses within the middle mediastinum?

A
  • Granulomatous or metastatic LAN
  • Cysts (pleuropericardial, bronchogenic, enteric)
  • Masses of vascular origin (pulmonary artery enlargement, aortic aneurysm)

Grainy Central Masses

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4
Q

What are the MC etiologic masses within the posterior mediastinum?

A
  • Neurogenic tumors, meningocele, meningomyelocele
  • Gastroenteric cysts, esophageal diverticula/tumor
  • Hiatal hernia, hernia through foramen of Bochdalek
  • Extramedullary hematopoiesis

Neuro = posterior mediastinum

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5
Q

How are mediastinal masses usually found?

A

Incidentally in half of all cases.

Do full H&P if found!!!!!!!!

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6
Q

If a mediastinal mass sits upon the sympathetic chain within the chest, what is likely to occur?

A

Horner’s syndrome

Ptosis, Anhidrosis, Miosis

Miosis is smaller than mydriasis, so miosis is pupillary constriction, while mydriasis is dilation.

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7
Q

If systemic/constitutional symptoms are occurring in relation to a medistinal mass, what does that tell us about the mass?

A

Most likely malignant.

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8
Q

What is the initial imaging for a suspected mediastinal mass?

A

CXR PA/Lateral

CT w/ con for f/u

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9
Q

If we suspect esophageal disease, what secondary imaging should we order?

A

Barium swallow

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10
Q

What is a good option for imaging for vascular etiologies?

A

CT or MR angiography or Doppler US

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11
Q

What imaging modality might be best for lymphoma/malignancy?

A

PET scan/PET-CT

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12
Q

What imaging modality is best to locate the origin of a germ cell tumor?

A

Testicular/ovarian US

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13
Q

What tumor markers are associated with thymic tumors, germ cell tumors, or seminomas/lymphomas?

A
  • Thymic: Anti-acetylcholine receptor antibodies
  • Germ cell tumors: alpha-fetoprotein and beta-hCG
  • Seminomas/lymphomas: serum LDH
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14
Q

When a mediastinal mass is to be biopsied, what is the main concern?

A

Malignant seeding

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15
Q

For a tumor sitting very close to the bronchus, what might be the best approach to biopsy it?

A

Endobronchial approach with US guidance

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16
Q

For a tumor located centrally within the mediastinum, what might be the best way to biopsy it?

A

Mediastinoscopy

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17
Q

What size is a pulmonary nodule?

A

<= 3cm (30mm)

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18
Q

What are the characteristics of a solitary pulmonary nodule?

A
  • <= 3cm
  • Isolated and round opacity
  • Surrounded by normal lung
  • Usually benign
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19
Q

What is the MC non-malignant cause of solitary pulmonary nodules?

A

Infectious granulomas caused by fungi or mycobacteria

Well-demarcated and well-calcified

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20
Q

Describe a hamartoma on CXR and CT.

A
  • CXR: Popcorn calcification
  • CT: Areas of fat or alternating fat/calcifications
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21
Q

What benign cause of SPNs should we AVOID biopsy of?

A

Pulmonary AV formations (vascular)

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22
Q

How does pulmonary metastases typically present?

A

Multiple nodules.

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23
Q

What are the 4 primary lung cancers that can cause SPNs?

A
  1. Small cell carcinoma: SCLC (centrally)
  2. Adenocarcinoma (peripherally)
  3. Squamous cell carcinoma (centrally)
  4. Large cell cancer (anywhere but usually peripherally)
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24
Q

Where is the MC malignant cause of SPNs that present as carcinoid tumors?

A

Endobronchial

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25
Q

What are the biggest cancer risks for SPN development?

A
  • Smoking, increasing with pack year history.
  • Increasing age past 35.
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26
Q

What would cause us to repeat a CXR prior to doing a CT?

A
  • Suspected nodule is a nipple shadow
  • Evidence of infection
  • Nodule looks like a benign lesion.
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27
Q

What is the preferred advanced imaging modality for SPN?

A

CT Chest w/o contrast

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28
Q

What are the 4 things that a CT scan gives us to determine malignancy risk factors?

A
  1. Size
  2. Location
  3. Attenuation
  4. Calcification
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29
Q

What characteristics of a nodule on CT imaging make it more suspicious for malignancy?

A
  • 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.
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30
Q

What are the two subsolid nodules?

A
  • Ground-glass
  • Part-solid
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31
Q

What is considered growth of a SPN for determining malignancy?

A
  • Solid: stable for 2 years is fine.
  • Part-solid: stable for 5 years at minimum.
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32
Q

What is considered low-risk and high-risk in the SPN calculator?

A
  • 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.

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33
Q

What do we do for low-risk SPN patients?

A

Serial CT scanning.

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34
Q

What are the risk factors for SPN malignancy?

A
  • Size
  • Age
  • Tumor Hx
  • Smoking Hx
  • Hx of smoking cessation
  • COPD
  • Asbestos exposure
  • Nodule characteristics
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35
Q

What is the pattern for 4-8mm SPN on a low-risk patient?

A
  • 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.

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36
Q

What are the options for a intermediate risk SPN patient with a central lesion?

A

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

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37
Q

What are the surgical procedures to help determine if a SPN needs full surgery?

A
  • Biopsy
  • VATS with frozen tissue sampling.
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38
Q

What should we do if a patient has multiple pulmonary nodules?

A

Test each nodule individually!!!!!!!!!!!!

39
Q

What are the 6 hallmark characteristics of a cancer cell?

A
  • Self-sufficient growth
  • Insensitive to anti-growth signals
  • Evades apoptosis
  • Limitless replicative potential
  • Sustained angiogenesis
  • Tissue invasion and metastasis
40
Q

What parts of the lungs falls under bronchogenic carcinoma?

A
  • Bronchi
  • Bronchioles
  • Alveoli

Respiratory epithelium

41
Q

How much does smoking cessation decrease lung cancer risk?

A
  • 90% of the risk attributable to tobacco if you stop by middle age.
  • In general, decreases 50% risk of lung cancer
42
Q

What are the 5 criteria for annual lung cancer screening via low-dose CT?

A
  1. 50-80 in good health
  2. Current smoker or in past 15 years.
  3. 20-year pack history (advise cessation)
  4. Inform/shared decision making about pros/cons of the screening.
  5. Access to a lung center that can screen and treat.

You need all of the first 3 to qualify for testing!!!!!!!!!!!!!!!!!!!!!!

43
Q

What are the top 3 symptoms of lung cancer?

A
  1. Cough
  2. Weight loss
  3. Dyspnea
44
Q

What are the 3 intrathoracic complications common in lung cancer?

A
  1. Malignant pleural effusions
  2. SVC syndrome
  3. Pan coast tumor
45
Q

What is the prognosis of malignant pleural effusions?

A

Incurable and managed palliatively.

Need cytology of pleural fluid!

46
Q

What type of lung cancer is most likely to cause SVC syndrome?

A

Small cell lung cancer (SCLC)

47
Q

Describe the S/S of SVC syndrome.

A
  • 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.
48
Q

What is a pan coast tumor?

A

Tumor in the apex, resulting in compression of surrounding structures.

49
Q

What are the symptoms of a pan coast tumor?

A
  • Shoulder pain (brachial plexus)
  • Horner’s syndrome (sympathetic chain)
  • Bone destruction (bones surrounding)
  • Atrophy of hand muscles (C8, T1 nerve roots)
50
Q

What would indicate us to do a CT chest w/ contrast for lung cancer after a CXR?

A
  • New or enlarging lesion
  • Pleural effusion
  • Pleural nodularity
  • Enlarged hilar or paratracheal nodes
  • Endobronchial lesion
  • Post-obstructive pneumonia
  • Segmental or lobar atelectasis
51
Q

What is the main purpose of CT and PET imaging for lung cancer?

A

Staging and biopsy planning.

DOES NOT DEFINITIVELY DIAGNOSE

Integrated CT/PET is best for lymph node staging.

52
Q

What cancer metastases usually elevate ALP?

A

Bone or liver mets.

53
Q

What labs may be elevated in MSK paraneoplastic syndromes?

A

CK & ANA

54
Q

What are the 4 MC organs that lung cancer tends to metastasize to?

A
  • Liver
  • Adrenal glands
  • Bones
  • Brain
55
Q

What suggests that we have liver mets from lung cancer?

A

Elevated LFTs tends to be the only sign.

Use CT w/o con or CT/PET.

56
Q

What suggests we have bone mets from lung cancer?

A
  • Pain in the back, chest, or extremity
  • Elevated ALP
  • Elevated Ca in severe cases
  • Preferred imaging modality: PET

MC in SCLC

57
Q

If we need to check for bone mets, what is the alternative to PET and MRI?

A

Bone scintigraphy

58
Q

How are most adrenal mets typically found?

A

Incidentally. Need a PET to differentiate if it is metastatic or not.

59
Q

How does brain mets typically present?

A
  • HA, vomiting, seizures
  • Papilledema, visual field loss, hemiparesis, cranial/focal nerve deficit

Need MRI w/ contrast.

60
Q

What is the only definitive way to diagnose malignancy?

A

Biopsy of EVERY SINGLE NODULE YOU SUSPECT

61
Q

How do we biopsy centrally and peripherally located lung tumors?

A
  • Central: endobronchial US bronchoscopy
  • Peripherally: Transthoracic percutaneous FNA with CT guidance.
62
Q

What are the indications for alternative biopsy options for lung cancer?

Alternatives as in VATS or mediastinoscopy.

A
  • Resection prior to biopsy results
  • Inadequate specimen or undiagnosed with previous methods.
63
Q

What are the NSCLCs?

A
  • Adenocarcinoma
  • Squamous cell carcinoma
  • Large cell carcinoma
64
Q

Describe SCLC.

A
  • 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

65
Q

Describe adenocarcinoma.

A
  • Slow growing
  • Periphery
  • MC form of lung cancer in NONsmokers

Abstaining smokers get Adenocarcinoma

66
Q

Describe squamous cell carcinoma.

A
  • Center of lungs
  • Smokers

Both central lung cancers have SC in their abbreviation

67
Q

Describe large cell carcinoma.

A
  • Rapidly growing mass
  • Anywhere, but usually periphery
68
Q

How do I differentiate between limited and extensive SCLC?

A
  • 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.
69
Q

How should limited SCLC be treated vs extensive?

A
  • 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.

70
Q

What is physiologic staging?

A
  • 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

71
Q

What is anatomic staging?

A

Determining the location of a tumor and possible metastatic sites.

Mainly for NSCLC

72
Q

What does x mean in TNM?

A

Cannot be assessed

73
Q

What size is T1 for a lung cancer?

A

< 3cm

Every increase goes up by 2 cm, until T4 = 7cm.

74
Q

When does N staging include contralateral lymph nodes for lung cancer?

A

N3.

Prior to this is ipsilateral only.

75
Q

At what M stage does lung cancer include extrathoracic mets?

A

M1b

76
Q

Describe stage 0 for NSCLC.

A
  • Only finding is malignant cells on cytology.
  • Need bronchoscopy to identify.
  • Surgery is usually curative.
77
Q

Describe stage 1 for NSCLC.

A
  • 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.

78
Q

Describe stages 2 and 3 for NSCLC.

A
  • Surgery
  • Adjuvant chemo, esp if lymph nodes are involved.
  • Post-op radiation for positive surgical margins, nodal involvement, or poor/refuses surgery.
79
Q

Describe stage 4 for NSCLC.

A
  • Distant mets
  • Systemic chemo + molecular therapy +/- immunotherapy
  • Palliative radiation/surgery
  • Isolated mets can be excised
80
Q

Describe the limited stage of SCLC.

A
  • No distant mets or mediastinal disease = resection + chemo
  • Evidence of disease = chemoradiotherapy
81
Q

Describe the extensive stage of SCLC.

A
  • Systemic chemo
  • Prophylactic irradiation of the cranial and thoracic areas.

Extension past the hemithorax

82
Q

What is the most common abnormality seen in paraneoplastic syndrome?

A
  • Hypercalcemia due to secretion of PTHrP by proteins and Vit D-1,25.
  • Often suggests advanced disease (stage 3-4)
83
Q

What type of lung cancer is SIADH usually associated with and what symptoms does it present with?

A
  • SCLC.
  • Symptoms are correlated with the severity of hyponatremia.
84
Q

What is the MC neurologic paraneoplastic syndrome due to SCLC?

A

Lambert-Eaton myasthenic syndrome (LEMS)

85
Q

Describe LEMS.

A
  • 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.

86
Q

What XRAY finding is indicative of hypertrophic osteoarthropathy due to paraneoplastic syndrome?

A

Periosteal new bone formation

Clubbing of digits can appear too.

87
Q

What are the two MSK paraneoplastic syndromes associated with lung cancer?

A
  • Dermatomyositis
  • Polymyositis

Elevated CK and ANA

88
Q

What lyte abnormalities does Cushing’s cause?

A
  • HypoK
  • Hyperglycemia
89
Q

When do bronchial carcinoid tumors tend to appear?

A

Before age 60

Not linked to smoking!!!!!!!!

90
Q

How does bronchial carcinoid tumors present?

A
  • Hemoptysis
  • Cough
  • Focal wheezing
  • Recurrent pneumonia
  • Carcinoid syndrome (rare)
91
Q

What is carcinoid syndrome?

A
  • Flushing
  • Diarrhea
  • Wheezing
  • Hypotension
92
Q

What does a bronchial carcinoid tumor look like on bronchoscopy?

A

Central airway will show a pink/purple tumor.

Biopsy will cause severe bleeding ):

Highly vascularized

93
Q

How do we manage a bronchial carcinoid tumor?

A
  • Observe with serial CT scans
  • F/u if symptomatic, could require excision
  • MC complication: tumor bleeding and airway obstructions

Generally a good prognosis.

Pulm (12 decks)

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