Lecture 8 (Lung CA)-Exam 3 Flashcards
Pulmonary Nodule
* What size is a solitary nodule? What size is a mass?
* What size is suspicious, what size requires a work up and what size is malgnant unless proven otherwise? ⭐️
* What is the shape?
* usually incidental findings in who?
* Can be what?
* Most likely bengin in who?
* Likeihood of malignacy increas with what?
- Solitary nodule <3 cm, >3 cm mass
- > 8mm (0.8cm) is suspicious, generally 1cm or greater requires at least some work-up, >3cm is malignant unless proven otherwise ⭐️
- Rounded opacity on CT scan, outlined by normal lung, not associated with infiltrate, atelectasis, or adenopathy
- Usually, incidental finding in pts >=35 without symptoms
- Can be malignant or benign
- Most likely benign with age <30
- Likelihood of malignancy increases with age and if smoker
under slide: Subcentimeter nodules are usually below the threshold of PET scan recognition.
Pulmonary Nodule: benign causes
* What are the infectious causes?
* What is the benign tumor?
* What is vascular? What do you NOT do?
* What are some other causes?
- Infectious: infectious granulomas (TB) cause 80%; endemic fungi (histoplasmosis, coccidioidomycosis) and mycobacteria (TB or non-TB), most common. Less common, abscess-forming bacteria (Staph)
- Benign tumors: pulmonary hamartomas 10%.
- Vascular: Pulmonary arteriovenous malformations (PAVMs)->Do not biopsy (dt bleeding, so do CTa instead)
- Other: inflammatory; granulomatosis RA, sarcoidosis, bronchogenic cyst
Pulmonary Nodule- Malignant causes:
* What is the primary lung cancer?
* What is the metastatic cancers?
* What are the carinoid tumors?
- Primary lung cancer: Adenocarcinoma most common
- Metastatic cancer: Most common malignant melanoma, sarcoma and carcinomas of the bronchus, colon, breast, kidney and testicle.
- Carcinoid tumors: Although most endobronchial, approx. 20% present as a peripheral, well-circumscribed pulmonary nodule
Solitary Nodules-Goals of evaluation
* Identify and resect what?
* Aviod what?
* Most bengin nodules are what?
* What accounts for under 5% of solitary nodules?
Identify & resect malignant tumors
Avoid invasive procedures in benign nodules
* Most benign nodules are infectious granulomas
* Hamartomas (benign neoplasms) only account for < 5% of solitary nodules
Solitary nodules:
* What are the Factors suggesting malignancy & need for resection?
- Cigarette smoking
- Age > 35
- Relatively large(> 2 cm) lesion
- Lack of calcification
- Chest symptoms
- Growth of lesion compared to old CXR
- Prior malignancy history increases the risk
Evaluation of nodule
* What is inital evaluation?
* Likeihood determines what?
* How do you asses risk?
* Often what?
- Initial evaluation uses clinical and radiographic features to determine likelihood of malignancy.
- Likelihood determines surveillance with CT or biopsy
- Assessing risk either clinically or predictive models, calculators
- Often intuitive
Evaluation of nodule
* What are the age associated risks?
* What are the other risk factors?
Age associated risks:
* 35 to 39 years: 3 percent
* 40 to 49 years: 15 percent
* 50 to 59: 43 percent
* ≥60 years: >50 percent
Other risk factors considered:
* Smoking
* Family history
* Female
* Emphysema
* Prior malignancy
* Asbestos
Pulmonary Nodule Characteristics
* What should you review?
* What is likely infection?
* Growth: what suggests benign? What is growth defined as?
* What are the size and malignancy rates (4)
Pulmonary Nodule Characteristics
* What is a characterisitcs of a benign process?
* What characterisitic suggests malignancy?
* What is highly associated malignancy on CT
* What type of pattern is in bengin nodules?
* What type of pattern is in malignant nodules?
* What types of walls are more likely malignant?
Evaluation of Pulmonary Nodules
* What are low probability patients? What do you need to do for work up?
* What are intermediate probability patients? What do you need to do for work up?
* What are high probability patients? What do you need to do for work up?
- Low probability patients: age under 30, lesions stable for more than 2 years, characteristic pattern of benign calcification -> watchful waiting with serial CT scans or CXR
- Intermediate probability patients -> biopsy via bronchoscopy or CT guided biopsy
- High probability patients -> surgical resection (if surgical risk is acceptable).
Lung Cancer
* Leading cause of what?
* What is the genetic predisposition?
* Most people are how old at dx?
* Combined relative 5-year survival rate for all stages is what?
- Leading cause of cancer deaths in both men (>40yo) and women (>60yo) in US-> Surpassed breast CA in 1987
- Genetic Predisposition: ATM, CXCR2, CYP1A1, CYP2E1, ERCC1, ERCC2, FGFR4, SOD2, TERT, and TP53
- Most people over 65 at time of diagnosis in US; average 70, unusual under the age of 40
- Combined relative 5-year survival rate for all stages is currently 19%
Risk Factors of lung cancer:
* What is the primiary risk factor of cancer? ⭐️⭐️⭐️⭐️
* What are some other ones?
KNOW CIGSSSSSS
Risk factors of lung cancer:
* What are the comorbid conditions?
* What are the infections?
* What is the diet?
- Comorbid conditions: COPD, Alpha1-antitrypsin
- Infections: HPV, EB virus, CMV, HIV, chlamydia pneumonia
- Diet: red meat, dairy products, saturated fats, and lipids have been suggested to increase the risk for lung cancer.
Uncertain or unproven effect on lung cancer risk: Marijuana
* Marijuana smoke contains what?
* Inhaled deeply and held for a long time, gives what?
* Due to illegal in many places, may not be possible to what?
Uncertain or unproven effect on lung cancer risk:
* What is a cig alternative?
Uncertain or unproven effect on lung cancer risk:
* What type of powder ? why?
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What is the most common independ risk factor for lung CA after smoking?
COPD
* Most common independent risk factor for Lung CA after smoking
* Most COPD from smoking; however, independent risk factor
* 2-to-5-fold increase in risk of lung CA
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Pul fibrosis increases the risk of lung cancer by how much?
Pulmonary fibrosis
* Fivefold increase in lung CA in pts with IPF; independent from smoking
* (more people have COPD for statistical comparison
What is the median age of a patient being dx with lung cancer?
Five Main Histologic Categories of Bronchogenic Carcinoma
- Squamous cell
- Adenocarcinoma
- Adenocarcinoma in situ (previously bronchioalveolar cell carcinoma)
- Large cell carcinoma
- Small cell carcinoma
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For purposes of staging and treatment, bronchogenic carcinomas are divided into two categories, what are they?
Small cell lung cancer (SCLC)
Non-small cell lung cancer (NSCLC)
* Squamous cell, adenocarcinoma, adenocarcinoma in situ, Large cell carcinoma
* 80-85% of lung CA is NSCLC
Adenocarcinoma
* Common or rare?
* Arises from what?
* How does it present in the lungs?⭐️
* What is Adenocarcinoma in situ?
Adenocarcinoma
* Who does it often occur more in?
* Said to occur in association with what?
* Grows fast or slow? What is the prognosis?
- Occurs more often in non-smokers & in smokers who have quit.
- Said to occur in association with old trauma, scars, TB & infarctions
- Grows more slowly than SCC or undifferentiated carcinomas & tends to have a better prognosis
Bronchioalveolar Carcinoma
* Varient of what?
* What does it present as?
* What is in large ares of the lung parenchyma?
* Better or worst prognosis?
- Variant of adenocarcinoma, arising from epithelium of distal bronchioles.
- Clinical picture & imaging mimic pneumonia
- Intra-alveolar spreading, infiltrates large areas of lung parenchyma
- Better prognosis than most other primary lung cancers.
Squamous Cell Carcinoma (Epidermoid cell)
* Arises from what?
* Most closely associated with what? ⭐️
* Usually presents how? ⭐️
- Arise from the bronchial epithelium and often present as intraluminal masses
- Most closely associated with cigarette smoking in men
- Usually centrally located and can present with hemoptysis
23% of cases
Epidermoid Cancer Obstructing R Bronchus
* Frequently silent until it causes what?
* Amendable to early detection (sputum) due to what?
- Frequently silent until it causes narrowing of bronchi, collapse of parenchyma with obstruction, & consequent pneumonia distal to obstruction
- Amendable to early detection (sputum) due to tendency to originate in central bronchi.
Large Cell Carcinoma (Anaplastic)
* What is that?
* Typically what? Good or bad prognosis?
* Present how?
* What make up about 14% of cases?
Small Cell Carcinoma
* Almost always associated with what? ⭐️⭐️⭐️
* Tumors of bronchial origin that typically begin how?
* Aggressive cancers that often involves what?
* Often associated with what?
* More amenable to what?
do biospy-> ID cancer type-> pick therapy type
Histological Classification/Clinical Utility
* Small cell versus non-small cell types major determinant of what?
* What is the difference between small cell and non-small on?
* Epidermoid amendable to what? Why?
* Epidermoid & large cell cavitate in how many patients?
* Adenocarcinoma & large cell tend to originate how?
Clinical Manifestations of Lung cancer
* Over half of patients diagnosed with lung cancer present with what?
* Majority present with signs and symptoms or laboratory abnormalities that can be attributed to what?
* Hx of?
- Over half of patients diagnosed with lung cancer present with locally advanced or metastatic disease at time of diagnosis
- Majority present with signs and symptoms or laboratory abnormalities that can be attributed to the primary lesion, local tumor growth, invasion or obstruction of adjacent structures
- History of chronic cough, hemoptysis, wheeze, stridor, dyspnea, or postobstructive pneumonia
Physical Exam of lung cancer
* Lung:
* HEENT:
* Fundi:
* Cardiac:
* Abdomen:
* Lymph
Signs and Symptoms on Presentation
* What happens to the pt’s weight?
* New what?
* Cough?
* What type of pain?
- Anorexia, weight loss in 55-90%
- New cough or change in chronic cough 60%
- Hemoptysis 6-31%
- Pain* 25-40%
* Nonspecific chest pain
* Pain from bony metastases to the vertebrae, ribs, or pelvis
* Remember this with pts presenting with bony pain and no trauma
Signs and Symptoms on Presentation of lung cancer:
* Local spread may cause what?
What are these?
- Right: pleural effusion
- left: pericardial effusion
Superior Vena Cava Syndrome
* What is this?
* What are the sxs?
* Treatable if what?
- Blood flow through the SVC is blocked or compressed
- Face/neck swelling, distended neck veins, cough, dyspnea, orthopnea, upper extremity swelling, distended chest vein collaterals, and conjunctival suffusion.
- Treatable if able to relieve compression
What is this?
SVC Syndrome
Symptoms metastaes to liver and brain?
What are the primary sites of metastasis?
- Liver
- Bone
- Adrenal
- Brain
Paraneoplastic Syndromes
* What is it?
* Occurs in who?
* When can it occur?
* Recognition is important because why?
- Patterns of organ dysfunction related to immune-mediated or secretory effects of neoplasms
- Occur in 10-20% of lung cancer pts
- May precede, accompany or follow diagnosis of Lung Cancer
- Recognition is important because treatment of the primary tumor may improve or resolve symptoms even when the cancer is not curable
Paraneoplastic Syndromes
* What are the different one and which cancers are they more common in?
What is this?
clubbing
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Lambert-Eaton Myasthenic Syndrome
* What is the pathophysio?
* What is the sx?
* If you know the clinical features early then you may do what?
Diagnosing LEMS
* How can you tell clinically?
* How is it tricky?
* LEMS occurs ouside of what?
* Associated with what?
* What is depressed or absent?
* What are some sxs?
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Unique Feature of LEMS
* What is Postexercise facilitation?
* Therefore – reflexes and muscle testing best done when?
* This feature may lead clinicians to suspect what?
- Postexercise facilitation – recovery of lost deep tendon reflexes and improvement in muscle strength with vigorous brief muscle activation
- Therefore – reflexes and muscle testing best done after a period of rest
- This feature may lead clinicians to suspect malingering
How does LEMS manifest?
- Abnormal gait
- Hard to stand from sitting position
- Difficulty in climbing, or coming down the stairs
- Muscle testing may not match with functional loss
- Typically symmetrical, but may be regional
Pancoast Syndrome?
Pancoast syndrome
* Rare type of what?
* Where is pain?
* What type of syndrome? ⭐️⭐️⭐️⭐️
* What happens to hand muscles?
* Most commonly caused by what?
What is Horner’s syndrome?
Horner’s syndrome (inferior cervical ganglion) – enophthalmos, ptosis, miosis, unilateral anhydrosis
Clinical Manifestations of Lung Cancer
Radiographic Findings of pancoast’s syndrom?
Radiographic Findings/Superior Sulcus Tumor
* Pancoast’s syndrome (local extension with CN VIII and T1/2 involvement) – shoulder pain with ulnar distribution
Screening of lung cancer:
* There is research that indicates CT screening of high-risk patients (active smokers) improves what?
* What is the diagnosis txt?
* No lung cancer screening test has yet been shown to prevent what?
- There is research that indicates CT screening of high-risk patients (active smokers) improves morbidity and mortality, likely due to early detection.
- LDCT: low-dose computed tomography (yearly)
- No lung cancer screening test has yet been shown to prevent people from dying of this disease.
Imaging for lung cancer:
* 85% are what at time of dx?
* Nearly all patients with lung cancer have what?
* Rarely what?
* May request CT scan of chest if what? ⭐️⭐️⭐️
- 85% are symptomatic at time of diagnosis
- Nearly all patients with lung cancer have abnormal findings on CXR or CT scan
- Rarely specific
- May request CT scan of chest if chest x-ray reveals potential pulmonary nodule
Radiographic Features Suggesting Malignancy
* Absence of a benign pattern of what?
* A nodule or mass that is what?
* A nodule with what type of border?
* Size?
* Wall?
- Absence of a benign pattern of calcification in detected lesion
- A nodule or mass that is growing
- A nodule with a spiculated or lobulated border
- A larger lesion > 8 mm is suspicious (>3 cm is considered malignant unless proven otherwise)
- A cavitary lesion that is thick walled
CXR findings in Lung CA Types
* Adenocarcinoma: In who? Where are the masses?
* Small Cell Carcinoma: In who? What type of carcinoma?
* Squamous cell carcinoma commonly produces what?
Adenocarcinoma (people who don’t smoke)
* Commonly produces small peripheral masses.
Small Cell Carcinoma (only in smokers)
* Oat cell carcinoma (central)
Squamous cell carcinoma(Epidermoid)
* Commonly produces a hilar mass, mediastinal widening, and cavitation (central)
CXR findings in Lung CA Types
* Mesothelioma (asbestosis): Always what? Presents with what?
* Large cell tumors: Produce what?
Mesothelioma (asbestosis) always fatal
* presents with pleural thickening
Large cell tumors
* Produce large peripheral masses
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Cancer Diagnosis
* What needs to be obtained to confirm diagnosis of cancer? How does it happen?
Cancer Diagnosis
* Thoracentesis: What is the sensitivity? Used in patients with what?
* Fine-needle aspiration: Aspiration of what? Also done with what?
* What are other tests?
Fiberoptic Bronchoscopy
* Visual what?
* What do you need to brush?
* Lavage what?
* Direct biopsy of what?
* Blind transbronchial biopsy of what?
* FNA biopsy of what?
* Fluorescence bronchoscopy improves the ability to identify what?
* Endobronchial and transesophageal endoscopic US for what?
* Electromagnetic navigational bronchoscopy allows what?
Explain the fluorescence bronchoscopy
Bronchoalveolar Lavage (BAL)
* Performed during what?
* Minimally invasive method to provide information about what?
- Performed during flexible bronchoscopy
- Minimally invasive method to provide information about immunologic, inflammatory, and infectious processes taking place at the alveolar level
Bronchoalveolar Lavage (BAL)
* Equal to what?
* What is usually adequate?
* How much saline is instilled?
* Samples how much?
- Equal to open lung biopsy
- One site is usually adequate
- ~ 100 mL saline is instilled
- Samples ~ one million alveoli (1.5 to 3% of lung)
Bronchoalveolar Lavage (BAL)
* What are the different components?
Lymphocyte subpopulations and immunohistochemistry
* What is it helpful for?
Immunofluorescent and immunocytochemical techniques helpful in the diagnosis of certain interstitial lung diseases and pulmonary lymphomas
Essentials of Diagnosis of lung cancer
* Cough?
* What are other sxs?
* Enlarging what? what else on cxr/ct?
* Cytologic or histologic findings of lung cancer in what?
- New cough or change in chronic cough
- Dyspnea, hemoptysis, anorexia, weight loss
- Enlarging nodule or mass; persistent opacity, atelectasis, or pleural effusion on CXR or CT scan
- Cytologic or histologic findings of lung cancer in sputum, pleural fluid or biopsy specimen
LUNG CANCER SCREENING
* Low dose CT to who?
* What type of swab? What does it identify?
* LIQUID BIOPSY?
* What are the genetic testing?
* FOR NSCLC THE MOST COMMON MUTATIONS WITH SPECIFIC THERAPEUTIC DRUGS?
Staging of lung cancer
* Accurate staging is crucial: Provides what? (2) Standardizes what?
- Provides clinician information to guide treatment
- Provides patient with accurate information regarding prognosis
- Standardize entry criteria for clinical trials to allow interpretation of results
Staging of lung cancer
* the more extensive the disease=
* Surgical resection offers what?
Two essential principles of staging NSCLC
* The more extensive the disease, the worse the prognosis
* Surgical resection offers the best chance for cure
Staging of lung cancer
* Staging begins with what?
* PE to exclude obvious what?
* Detailed history because why?
Staging begins with a thorough history and physical examination!
* PE to exclude obvious metastatic disease to lymph nodes, skin, and bone
* Detailed history because pt’s performance status is a powerful predictor of disease course
Staging of lung cancer
* What labs
CBC, serum electrolytes, calcium, creatinine, liver biochemical tests, lactate dehydrogenase, and albumin
Staging of lung cancer:
* What are the tests for antomic (where it has it spread)
Staging of lung cancer
* how do you determine the physiologic stages?
- Assessment of patient’s ability to withstand antitumor treatment or surgery
- Pulmonary function tests
Patients who smoke, they get many what along with lung cancer?
Patients who smoke, they get many head and neck cancers along with lung cancer.
PET scan in Lung Cancer
* What can it show?
Primary lung cancer, with hilar, liver, & bone metastases.
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TNM International Staging System:Attempts a physical description of the non-small cell neoplasm
* What is T, N, M
- T describes the size and location of the primary tumor
- N describes the presence and location of nodal metastases
- M refers to the presence of absence of distant metastases
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TNM stages are grouped into summary stages I-IV, these are used to guide therapy
* explain
- Stage I and II are cured through surgery
- IIIB and IV do not benefit from surgery
- IIIA locally invasive diagnosis that may benefit from surgery in selected cases as part of multimodality therapy
Tumor:
* What is T1, T2, T3, T4?
Node
* What is N0, N1, N2, N3
Metastasis
* What is M0, M1?
- M0 - Local or regional disease, no distant metastases
- M1 - Disseminated disease, distant metastases present
Most common primary cancer sites associated with lung metastasis?
- Breast
- Colon
- Cervix
- Prostate
- Head and Neck
- Renal
Metastatic Adenocarcinoma of Prostate
* Famous for metastasizing to lungs in what type of pattern?
Famous for metastasizing to lungs in a “lymphangitic” pattern in which streaks of tumor appear between lung lobules & beneath pleura in lymphatic spaces.
SCLC Staging
* What are the two cateogories? Explain them?
* How is it staged?
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Treatment Principles
* What is the txt of SCLC?
* What is the txt of early NSCLC?
* What is the of advance NSCLC?
* In considering all these procedures, need to think of what?
Treatment NSCLC
* What offers the best chance for cure?
* Initial approach is to answer what two questions?
* Clinical features that preclude complete resection include what (2)?
Treatment NSCLC
* What happens in Stage 1 and 2
* stage 2 and 1B are additionally recommended to do what?
* Stage IIIA have poor outcomes if what? What should they get?
* Inoperable IIA and IIIB treated with what?
* Stage IV tx with what?
- Stage I and II surgical resection where possible
- Stage II and select IB are additionally recommended to receive adjuvant chemotherapy
- Stage IIIA have poor outcomes if treated with resection alone. They should get multimodality treatment that includes chemo, radiotherapy or both.
- Inoperable IIA and IIIB treated with chemo and radiation therapy have improved survival
- Stage IV tx with systemic therapy (targeted therapy, chemo, or immunotherapy) or symptom-based palliative therapy or both
What responds better to radiation in NSCLC?
THE ABSENCE OF PD-L1 EXPRESSION RESPOND BETTER TO RADIATION
What are the Contraindications to Surgery?
- Extrathoracic metastases – already spread
- SVC Syndrome
- Phrenic nerve paralysis
- Malignant pleural effusions
- Mets to contralateral lung
- Histological diagnosis of small cell cancer
Treatment SCLC
* What is the standard mode of therapy? What are the response rates?
* Response after what?
* Remission short lived with what?
* Once dx recurred, median survival is what?
* Overall 2-year survival is what in limited and extensive?
* Thoracic radiation improves survival in what?
- Combination chemotherapy (cisplatin and etoposide) is Standard mode of therapy
* Limited-stage disease response rates are 80-90% (50-60% complete response)
* Extensive-stage disease 60-80% (15-20% complete response) - Response after 6-12 weeks predicts median & long-term survival
- Remissions short lived with a median duration of 6-8 months
- Once dx recurred, median survival 3-4 months
- Overall 2-year survival is 20-40% in limited-stage disease and 5% in extensive-stage disease
- Thoracic radiation improves survival in limited SCLC given concurrently with chemo
Treatment SCLC
* What can still happen with good response to chemo?
* Prophylactic cranial irradiation concurrently with chemo to decrease what?
High risk of brain mets even with good response to chemo
* Prophylactic cranial irradiation concurrently with chemo to decrease incidence of CNS dx and to improve survival with limited SCLC and extensive with excellent response to chemo
Radiation Therapy Used For what?
Bronchial Carcinoid Tumors
* Classifed as what?
* Carcinoid tumors 6 x more common than what?
* Most occur as what? What are they?
* Who is affected (gender and age)
Bronchial Carcinoid Tumors
* What does it secrete?
* What are the symptoms?
* What is carcinoid syndrome?
Bronchial Carcinoid Tumors
* Dx with what?
* What does it look like? May be complicated by what?
Dx with bronchoscopy
* Pink or purple tumor in a central airway
* Well-visualized stroma
* Bx may be complicated by significant bleeding
Bronchial Carcinoid Tumors
* How do these tumors grow?
* Complications involve what?
* Surgical excision of what?
* Prognosis?
* Most are resistant to what?
- These tumors grow slowly and rarely metastasize
- Complications involve bleeding and airway obstruction
- Surgical excision of clinically symptomatic lesions
- Prognosis favorable
- Most are resistant to radiation and chemo
