Lung Cancer Flashcards
What are the important aspects of the history of cough SOB and occasional hemoptysis
Age - more elderly patients more likely
Chronic illnesses - COPD, Immunocompromising illnesses like HIV, other cancers
cough- when, during certain activities, more at night productive/non-productive
hemoptysis - color, amount, how often
Occupation - exposure to asbestos
Constitutional symptoms - weight loss, rigors, night sweats
Chest pain - Lung cancers are associated with chest pain due to invasion of the tumor into the chest wall specifically invasion of the intercostal nerves
Hoarseness- invasion of the recurrent laryngeal nerve - most likely to be on the left because it goes around the ligamentum arteriosum on this side because that is a chest lesion
Paralysis of the phrenic nerve - causing SOB and diaphragmatic issues
Compression of the superior vena cava leading to congestion of blood in the head and neck - known as SVC syndrome.
Compression of the oesophagus - patients presents with dysphagia
Horners syndrome- ptosis, invasion of the superior cervical celiac ganglion which leads to ptosis ,
Invasion of subclavian vein
Metastatic symptoms - headache, seizures
Drug Hx -
Family hx - lung cancer
What are some differentials for lung CA
Tuberculosis Pneumonia Bronchiectasis (more significant hemoptysis) Fungal infection Pulmonary embolism (SOB and hemoptysis)
What lung cancers typically metastasize to the brain
adenocarcinoma
and small cell carcinoma
WHere does lung cancer like to metastasize to?
brain, liver, adrenals, bone
Why is hypercalcemia seen in lung cancer patients
- paraneoplastic syndromes
- bony mets
What are some Paraneoplastic syndromes asscociated with lung cancer?
- Lambert Eatons syndrome - Proximal muscle weakness
- Cushings syndrome
- SIADH
- gynacoemastia
- hypercalcemia
What type of lung cancer ususally presents paraneoplastic syndromes
seen in the small cell carcinomas
What blood investigations would you order and what derangement would you expect?
- CBC - anemia, WBC count infection, platelets
- U&E - if patient has
- LFTs- mets to liver will cause derangements/coagulaopathy, transaminases
If patient has SIADH, what do you expect to see in his U&Es?
Sodium would be decreased - hyponatremic
What do you look for in the mediastinum on xray of an individual with a lung mass?
Normal width of the superior mediastinum is
you look for widening of the superior mediastinum
What is the most appropriate investigation after x-ray when a lesion is seen in the lung?
CT chest and upper abdoemen with IV contrast . - we need to look at the LIVERRR for mets !!!!!
On CT of the chest which lung nodule is more suggestive of malignancy? well circumscribed or irregular margins?
IRREGULAR MARGINS
Which of these features of the lung nodule is more suggestive of malignancy? heterogenous or homogenous?
HETEROGENOUS
Which feature of a lung nodule is more suggestive of malignancy? no calcification OR densely calcified?
NO CALCIFICATIONS
malignancies are not densely calcified
What other features on CT scan are important to look out for?
- Size and Shape of tumor - necessary for staging
- Mediastinal lymph node involvement - enlargement may be seen, lymph nodes are matted and you lose their usual architecture
- presence of an effusion
- invasion to the chest wall
- loss of the fat plane between the mediastinum and the lung
- squamous and small cell are more central tumors while adeno is peripheral
What is the most appropriate next radiological investigation after CT shows 2cm lesion with irregular margins?
PET SCAN - a functional scan
In PET scan what does SUV mean?
standardized uptake value - ratio comparing the uptake in the target area when compared to the surrounding tissue. SUV>4 suggests malignancy
How would you confirm the diagnosis of lung cancer in a patient after malignancy is suggested with PET SCAN?
Peripheral Transthoracic needle biopsy, when closer to the periphery of the lung
OR
ENdobronchial ultrasound and biopsy when the lesion is more central
How would you confirm the diagnosis of lung cancer in a patient after malignancy is suggested with PET SCAN?
Peripheral Transthoracic needle biopsy, when closer to the periphery of the lung
OR
ENdobronchial ultrasound and biopsy when the lesion is more central
What is the most likely histology of a lung cancer seen in a 68yr old male smoker with no mets on PET or CT and a mass closer to the periphery
LIKELY to be ADENOCARCINOMA
- unlikely to be small cell, these tend to present with metastases
- Large cell carcinomas are rare
- Adenosquamous carcionomas are very rare so not likely
What is the WHO classification for lung adenocarcinoma?
- Pre invasive
1. Atypical adenamatous hyperplasia
2. Adenocarcinoma in situ, non mucinous/mucinous - minimally invasive
non mucinous or mucinous - Invasive
1. lepidic predominant -bronchioalveolar best prognosis
2. Acinar predominant
3. Papillary predominant
4. Micropapillary predominane - worst prognosis
5. Solid predominant - worst prognosis
-
What biomarkers may be useful in adenocarcinomas?
ALK, BRAF, EGFR, ROS1
If patient has level 7 - subcarinal lymph nodes, how are they sampled?
- cervical mediastinoscopy
- transbronchial needle aspiration
- endobronchial ultrasound
- endoscopic ultrasound
What does N1, N2 and N3 mean?
N1- within the pleural envelope
N2- spread to mediastinal nodes on the same side
N3- contralateral disease
How is lung cancer staged?
Lung cancer is staged using the TNM system - Tumor, Nodes, Metastasis
Stage 1A2 lung adenocarcinoma is treated using
Ans - SURGERY ONLY
Immunotherapy usually for patients with mets
Chemoradiotherapy ised for advaned disease
Stereotactic body radiotherapy used for patients who cannot do surgery
Adjuvant chemotherapy has no role is STAGE 1 lung cancer
Which of the following tests is not useful in the determining the suitability of a patient for pulmonary resection?
Stress ECG - tells about the patients heart
Tests that should be done include:
SPIROMETRY - FEV1 >2L patient can have pneumonectomy FEV1>%L can undergo a lobectomy
DIFFUSE CAPACITY OF CARBON MONOXIDE
CRDIOPULMONARY EXERCISE TESTING
VENTILATION PERFUSION SCAN
What is the best surgical option for a stage 1A2 adenocarcinoma in the right lung?
Need to remove the nodule and the draining lymphatics
Ans - Right lower lobectomy with lymph node dissection
Wedge resection is reserved for patients with mets to the lung
Is adjuvant therapy needed in adenocarcinoma if dissected lymph nodes are histologically negative?
NO
How do you follow up patients after surgery?
follow up with CT scan every 3- 6 months to see if there is local recurrence then at a year and then eveyr 2 years for 5 years
What histology is associated with hyperglycemia
Squamous cell due to PRODUCTION of parathyroid related protein it produces
