Lung Cancer

Question 1

Lung Cancer

Answer 1

Lung Cancer is the leading cause of cancer death in the United States and accounts for 27% of all cancer deaths

1/4 of patients don’t have symptoms at diagnosis

3/4 of patients have a cough with blood or rust colored sputum

Question 2

Diagnosis of lung cancer

Answer 2

Typically seen on a chest X-ray

Cough with rust or bloody sputum

Question 3

Histological Types of lung cancer

Answer 3

Squamous cell (epidermoid)- bronchial lining
Small cell (oat cell) carcinoma
Large cell carcinoma
Adenocarcinoma-most prevalent carcinoma

Question 4

Small cell lung carcinomas

Answer 4

SCLC
OAT CELL, intermediate and combined
Very small cells with scant cytoplasm
Very rapid growing that usually metastasizes

Question 5

Epidemiology

Answer 5

86 percent of lung cancer patients die within 5 years
Death peaks in ages 55-65
Men have higher incidence
African-American men have higher risk


Question 6

Causes

Answer 6

Smoking

Environmental and occupation exposure to carcinogens

Question 7

Pathophysiology

Answer 7

Carcinogenic agents are deposited in the epithelial lining
Repeated carcinogenic insults to the bronchial epithelium may cause increased rates of cellular replication which result in hyperplasia dysplasia carcinoma in situ and invasive carcinoma

Question 8

Small Cell Lung Cancer

Answer 8

15 percent of lung cancers
Invades the submucosa and is centrally located, developing around a main bronchus as a whitish-gray growth that compromises surrounding structures

Grows more rapidly
Metastasizes earlier
More responsive to chemotherapy than NSCLC

Question 9

SCLC

Answer 9

Oat cell carcinoma- tumors are soft in consistency and have shiny gray cut surfaces on exam

Intermediate- cells with larger more vesicular or spindles nuclei

Combined- combination of small cell and other cell. Lacks sensitivity to radiation and chemotherapy

Question 10

NON SMALL CELL LUNG CANCER

Answer 10

85 percent of all primary lung carcinomas

P53 gene in about 60% of cases

Question 11

Squamous cell carcinoma

Answer 11

2nd most common lung cancer
Arose from basal cells of epithelium
Mass in segmental, lobar , or mainstem bronchi
Common in men
Three types well differentiated, moderately well differentiated, and poorly differentiated tumors
Metastasis in mediastinal lymph nodes, liver, adrenals, bones, and brain

Question 12

Adenocarcinoma

Answer 12

Most prevalent carcinoma
In non smokers
Slow growing
May invade lymphatic and blood vessels
Metastasizes in brain, liver,bone, and adrenal glands
Those with lung disease at increased risk

Question 13

Large cell carcinoma

Answer 13

Undifferentiated carcinoma
Least common lung cancer
Clear cell and giant cell
Large tumors, peripherally, very aggressive, highly malignant and usually found at later stages

Question 14

Clinical presentation

Answer 14

History of chronic lung problems
Exposure to environmental carcinogens
Smoking history( age, packs per day, how many years , type of tobacco)
Family history

Question 15

Signs and symptoms

Answer 15

Cough, sputum production, dyspnea, chest pain, hemoptysis, wheezing, pneumonia, pleural effusions,stridor, hoarseness, atelectasis, pericardial effusion, superior vena cava syndrome

Question 16

Horners syndrome

Answer 16

Unilateral ptosis, miosis, and ipsilateral anhidrosis (lack of sweating). Caused my tumor suppression of the cervical sympathetic nerve plexus
Often associated with the radiographic evidence of destruction of the first and second ribs

Question 17

Pancoast syndrome

Answer 17

Arm and shoulder pain Do you to invasion of the brachial nerve plexus by a superior sulcus tumor

Question 18

Nonspecific system signs and symptoms

Answer 18

Generalized weakness, fatigue, anorexia, cachexia, weight loss, and anemia fever

Question 19

Extra-thoracic involvement

Answer 19

Bone pain, headache, dizziness, lymphadenopathy, CNS disturbances, GI disturbances, jaundice, hepatomegaly, abdominal pain.
Spreads most often occur in the lymph nodes, brain, bones, liver, and super renal glands
Brain metastasis can cause Hema plegia, epilepsy, personality changes, confusion, speech deficits, gait disturbances and or only nonspecific headache

Question 20

Diagnostic test

Answer 20

CBC, CMP( Sodium, potassium, calcium, liver enzymes, prothrombin time, PTT), CHEST X-RAY, CT, Sputum sample (early morning), fine need aspiration, thorascopic surgery for staging, head ct and abdomen to rule out metastasizes

Question 21

Management

Answer 21

Annual screening for those with lose dose ct aged 55-80 who have a 30 pack year smoking history and currently smokes or quit within 15 years

Question 22

Surgery

Answer 22

Pneumonectomy- removed whole lung
Lobectomy- remove single lobe (most common)
Sleeve resection- main bronchus included in resection
Segmenectomy- removal of lung segment
Wedge resection- removal of small vshaped wedge of lung
Lumpectomy-lesion in lung removed by laser or cautery

Question 23

NSCLC chemo

Answer 23

Improves medial survival not curative
Multi drug based chemo
Widely used in stage 2-3
Improves survival 3 months at 5 years

Question 24

SCLC CHEMO

Answer 24

Combination chemo
Effective mostly in SCLC
80-100% response in limited stage disease
60-80 in extensive
Remission last 6-8 months
If cancer reoccurs survival is 3-4 months

Question 25

Radiation NSCLC

Answer 25

Commonly offered with inoperable cancer when it hasn’t spread beyond the thorax
Shrink tumor and control symptoms
Postop radiation to reduce reoccurrence

Question 26

SCLC Radiation

Answer 26

Sensitive to this and chemo
In limited stage, in adjunct with chemo can increase 5 year survival rate 11-20%
Thoracic radiation for tumor control

Question 27

Follow up and referral

Answer 27

Referred to specialist for staging and treatment decisions
Pulmonologist and oncology
Monitor patients with unresctablr lung cancer in complete remission
Many stage 3-4 don’t reach remission
-h& p every 3 months during 1st two years
-every 6 months through year 5
-no clear role for routine chest X-ray in asymptomatic
-yearly X-ray for metastasis for curable secondary cancers possibly
CBC, ct bad and chest, bronchoscope and routine chemistry only as indicated by patient symptoms

Question 28

Education

Answer 28

Smoking cessation
Support groups for cancer patients and family 
Patients have choice in treatment 
Lifestyle modifications 
Home or hospice for palliative care

Question 29

Paraneoplastic syndrome

Answer 29

SCLC is associated with paraneoplastic syndromes more frequently than NSCLS
CusHINGS SYNDROME
SIADH
Hypercalemia
Hypophosphatemia
Hormone issues
Eaton lambert  Myasthenic syndrome- autoimmune interferes with acetylcholine released causing muscle weakness, fatigue, dryness, double vision, ptosis dyplopia