Lung CA Flashcards
“coin lesion”
solitary pulmonary nodule (SPN)
Characteristics of SPN
< 3cm isolated, rounded opacity
completely surrounded by pulmonary parenchyma
not associated w/ infiltrate, atelectasis or adenopathy
most are benign
Signs of benign
smooth, well-defined edges
dense central calcification
Most common SPN
infectious granulomas
Mass characteristics
> 3 cm in size
greater chance of malignancy
CA until proven otherwise
Goal:
- determine which needs resection
- limit invasive procedures for benign disease
Causes of benign nodules
infectious (80%): TB, Cocci, abscess
Hamartoma
vascular
inflammatory
Risk factors for malignancy
tobacco female FHx emphysema previous malignancy asbestos exposure
PE findings
unexplained weight loss
supraclavicular LAD
fixed or localized wheeze
joint tenderness
Approach to SPN
- Review old films: malignant nodules typicallyd ouble in 20-400 days; minimal growth = benign
- Calcification = benign
- Shape: smooth, well defined = benign
- Size: >5cm = 90% CA
Imaging for SPN
CT w/o contrast w/ low radiation (thin 1 mm slices)
Low probability <5% management nodule >8 mm
get CT @ 3 mo
- no growth = serial CT at 9-12 and 18-24
- growth = patho eval
Intermediate probability (5-65%) nodule > 8 mm
FDG PET/CT and/or Bx
CT survellience at 3,9-12 and 18-34 mo (alt. to bx)
High probabilty >65% nodule > 8 mm
biopsy or excision (staging with PET/CT may be helpful)
Nodule <8 mm step
6-8 mm: follow w/ CT @ 6-12 mo then repeat as indicated
<6mm: doesn’t usually require f/u; CT @ 12 mo optional
Lung malignancy types
SCLC: oat cell carcinoma NSCLC: -adenocarcinoma (42%) - squamous cell carcinoma (22%) - large cell carcinoma (2%)
Oat cell lung cancer (SCLC) location
CENTRAL airways
Presentation of SCLC
large hilar mass w/ bulky mediastinal adenopathy
cough, dyspnea, weight loss, debility
HIGHLY AGGRESSIVE
Prognosis of SCLC
6-18 weeks w/o tx
Categories for SCLC
limited (ipsilateral hemithorax and regional ndoes)
extensive (70%)
Adenocarcinoma etiology
arises from mucous glands or any epithelial cell in or distal to the terminal bronchioles
Location of adenocarcinoma
peripheral (distal or in terminal bronchioles)
Squamous cell carcinoma location
centrally or in main bronchus
Squamous cell carcinoma etiology
bronchial epithelium
Characteristics of squamous cell carcinoma
intraluminal growth in bronchi may detect by sputum cytology more likely to cause hemoptysis likely to metastasize to regional lymph nodes can cavitate
More likely to cause hemoptysis
squamous cell
Found in bronchial tube
squamouss
found centrally
SCLC
Found distal to terminal bronchioles
Adenocarcinoma
Large cell carincoma location
central or peripheral masses
Characteristics of large cell
metastazes to distant organs
relatively undifferentiated
AGGRESSIVE - rapid doubling time
Metastasized to lymph nodes
squamous
metastasizes to distal organs
adeno and large cell
Sx result from
paraneoplastic syndromes
metastasis: may have no lung complains
paraneoplastic syndrome
altered immune system response to neoplasm (ataxia, eye movements, etc)
Most common sx of lung canger
cough
Cough is most frequent with
squamous and small cell
poor prognosis for lung CA
weight loss
Hemoptysis
squamous cell
What is the most common cause of hemoptysis
bronchitis
Sx of intrathoracic pread
PE (direct pleural extention, mediastinal node involvement, lymph obstruction)
pericardial effusion
hoarseness (compression of laryngeal nerve; > w. left sided tumors)
Cause of SVC syndrome
patho process of: right lung lymph nodes other mediastinal structure thrombosis of devices
Most common to cause SVC
SCLC
Sx of SVC syndrome
dyspnea!
facial swelling/head fullness (worse w/ forward bend)
arm swelling, cough, chest pain, dysphagia
PE for SVC syndrome
facial edema
dilated neck veins
prominent venous pattern on chest
Dx for SVC syndrome
CXR
Duplex U/S (initial for indwelling devises or arm swelling)
CT w/ contrast (level and extent of block)
Superior vena cavogram (GOLD STANDARD) - identify and extent of thrombus formation
Gold standard for dx SVC syndrome
superior vena cavogram
Tx goals for SVC syndrome
alleviate sx and underlying disease
Tx options for SVC syndrome
Emergency RT
venous stent
chemo if indicated
removal of devices and anticoag
Indications for emergency RT (radiation)
stridor from central airway obstruction or laryngeal edema
coma from cerebral edema
Pancoast syndrome
tumor involving superior sulcus (apical chest); compresses brachial plexus and cervical sympathetic nerves
Horner’s Syndrome
injury of sympathetic nerves of the face
Pancoast syndrome sx
right shoulder > forearm, scapula and finger pain ipsilateral to side of tumor miosis anhidrosis ptosis rib destruction atrophy of hand mm. pain C8, T1, T2 nerve roots
Most common to cause pancoast syndrome
Squamous cell
Sx of paraneoplastic syndrome
anorexia weight loss cachexia fever suppressed immunity
Hematologic dysfunction in paraneoplastic syn.
hypercalcemia (bone destruction) anemia (fatigue, dyspnea) leukocytosis (poor prognosis) thrombocytosis (shortened survival) hypercoagulability
Poor prognosis in paraneoplastic
leukocytosis and thrombocytosis
Endocrine dysfunction in paraneoplastic
PTH-like substance: hypercalcemia
Excess HCG production: gynecomastia, milky nipple d/c
Most likely to cause hypercalcemia due to PTH
Squamous
Most likely to cause gynecomastia and nipple d/c
large cell
SIADH causing hyponatremia
small cell
Presentation of SIADH
irritable restlesss personality changes confusion coma seizure resp. arrest
Cushing syndrome due to ectopic ACTH
small cell
Small cell can cause what effects in paraneoplastic syndrome
SIADH and Cushings (ACTH) and Eaton-Lambert
Presentation of cushings
muscle weakness weight loss HTN Hirsuitism Osteoporosis
Neuro sign in paraneoplastic
Eaton-Lambert Syndrome
Eaton-Lambert Syndrome
immune mediated
antibodies at NMJ: defective release of Ach, mm. weakness
Causes Eaton-Lambert
small cell
Most common sites of metastases
Liver (elevated LFT)
bone (elevated ALP)
adrenal (rarely symptomatic)
brain
What is most likely to metastasize to brain
SCLC
1 cause of brain metastasis
lung CA
Sx of brain metastasis
HA N/V seizures confusion personality chagnes
Staging of SCLC
limited vs extensive
Staging of NSCLC
T - primary tumor
N - nodal involvement
M- distant metastases
Dx of Lung CA
bx
Obtaining tissue sample for tissue bx
sputum (central lesion- squamous)
Bronchoscopy w/ bx
thoracentesis (remove fluid from pleural space)
fine needle aspiration/CT-guided needle bx
transbronchial aspiration
VATS
Thoracotomy
Performance status
0- fully active
1- strenous activity restricted
2- capable of all self-care; can’t carry out work activities; up >50% of walking hours
3= limited self care; confined to bed or chair
4 = completely disabled; no self-care
PFT
<60% = strongest indicator of post-op complications
used for staging
PET
used in PET
fluorodeoxyglucose (FDG)
Limitations of PET
does not detect all CA (bronchoalveolar CA)
infections may be +
Normally light up in PET
kidneys
bladder
heart
Tx for NSCLC
surgical resection (I-IIIA) IIIB-IV = palliative radiation or combo chemo
Tx for SCLC
chemo regardless of stage (cisplatin + etoposide) limited disease: chemo + radiation radiation prophylactic cranial radiation relapse commo surgery option <5%
Main tx for NSCLC
resection
Main tx for SCLC
chemo +/- radiation
Malignant effusion tx
thoracentesis
pleurodesis (chem agent)
pleurx catheter
SE of surgery
pain
SE of radiation
fatigue
SE of chemo
anemia, neutropenia nephrotoxicity cutaneous toxicity n/v, anorexia, weightloss fatigue, "chemo brain"
Stage 1 NSCLS tx
resection (lobectomy)
alt: radiation
1B NSCLC tx
resection + chemo
Stage 2 NSCLC tx
surgical resection + chemo
Stage 3 NSCLC
unresected: chemo
resected: adjuvant chemo; RT if uncertain resection margin
Stage 4 NSCLC tx
palliative (sx baed)
chemo, clinical trials
resection of metastasis
“targeted therapy” - EGF-R inhibitors
Used for lung cancer screening
Low-dose helical CT (LDCT)
Who should get screened?
age 55-74 w/ 30 pack/yr history
or quit w/i 15 yrs
or 20 pack/yr hx with one more risk factor
Smoking cessation drugs
Zyban (wellbutrin)
Chantix (varenicline)
Nicotine replacement
chantix MOA
blocks alpha-4-beta-2 nicotinic acetylcholine receptors
Effects of chantix
stop smoking in 7 days
Rx 12-24 weeks
Precaution of chantix
unstable CVD
drug interrxns with chantix
synergistic w/ nicotine
Adverse rxns of chantix
dizziness, HTN, palpitations, GI upset
zyban MOA
inhibits neuronal uptake of NE and dopamine
Effects of zyban
stop smoking 5-7 days
precaution of zyban
avoid EtOh
Black box warning
zyban;
increased suicide in children, young adults, adolescents
Adverse rxns of zyban
seizures*, agitation, wt. loss
Nicotine replacement
nicotrol NS (nasal spray) nicotrol inhaler
Precautions of nicotine replacemetn
unstable CVD
Adverse rxns of nicotine replacement
dizziness, HTN, palpitations, GI upset
OTC nicotine replacement
nicoderm CQ
nicorette
commit lozenge
thrombophlebitis
adenocarcinoma
most common NSCLC
adenocarcinoma
central bronchi
squamous cell
associated with PTH
squamous
slow growing, late metastasis
squamous
dx of exclusion
large cell
main cause of adenocarcinoma
smoking
associated with SCLC
cushing, eaton-lambert, SIADH
