Lung Cancer Flashcards
Radiation Pneumonitis Risk factors
- Age >50yo
- Concurrent chemotherapy and/or tamoxifen
- Solid tumor seems to be more likely to develop RP
- Supra-clavicular field
- Chest wall irradiation with electron therapy
- No difference in type of radiation received
- Dose dependent risk factor- high dose high risk however not everyone gets it so unclear other risk factors
Radiation Pneumonitis Clinical Course
Symptoms: Cough, dyspnea, fever (<10%), respiratory failure requiring intubation (can happen, less common)
Acute radiation Pneumonitis
- With 6m of Radiation
- Most within 12 weeks post treatment
CT: Straight line effect- abnormalities confined to the radiation field
Tx: Prednisone 40-60mg for 2 weeks then taper 12wks
Can progress to:
Chronic Radiation fibrosis
- >12m following treatment
- Fibrosis- localized usually to treatment area however can be outside
Treatment:
- 1mg/kg for 2-4 weeks, following by taper over 6-12weeks.
Characteristics of Squamous Cell
Centrally located
Cavitating
HyperCalcemia due to PrPTH
HPO
More commonly in smokers
Characteristics of Adenocarcinoma
More common in never smoker
peripherally located
Metastatic on diagnosis
Paraneoplastic: HPO
Characteristic of Small Cell
Diagnosed in just smokers
Centrally located
Metastatic at presentation
Paraneoplastic
— Cushing
— Eaton Lamberts
— SIADH
Bronchoalveolar Cell
Adenocarcinoma in-situ
Non smokers, female
Solitary nodule, consolidation, or multiple nodules
- Slow growing
- negative on PET
- Think of in patient with lobar consolidation and has been treated with Antibiotics however not improving.
- Bronchorrhea (copius secretions)
—- Mucinous or non-mucinous
—- Salty sputum
Indications for wedge (sublobar resection)
- Elderly
- Poor cardiopulmonary reserve
- Small tumor
- BAC
- 2nd site of primary tumor
Treatment for Stage 1 NSCLC
Resection
- VATs or thoracotomy
—- Same operative mortality rate
—- Lower complications with VATs
—- Same long term outcomes
For stage IA, if CT/PET negative - no need for invasive staging.
Resection preferred however if unable to undergo surgery due to co-morbid conditions-
SBRT can be done. Similar outcomes, less complications.
Treatment for stage 2 NSCLC
- Definition
Stage II disease:
- N1 with <5cm
-or N0 with >5cm
Resection with adjuvant chemotherapy
- High risk or recurrence therefore will benefit from adjuvant chemotherapy with a 5% mortality improvement.
- Distal recurrence possible (ex: brain mets)
Pancoast tumor treatment
Resection if possible
Chemoradiation induction PRIOR to surgery however.
Look for Horner syndrome (PAM is horny)
Treatment of NSCLC stage III
N1 + >5cm
N2 disease
2 cancerous nodules in the same lobe
Chemoradiation + immunotherapy
Can do Neoadjuvant chemoradiotherapy followed by surgery for non-bulky disease but not by yourself- need tumor board.
Add EGFR (osimertinib) if positive. Can improve 2 year mortality
Staging of
- cancer in the main carina with or without atlectasis
- Cancer invading the diaphragm
- 2 nodule same lung - same lobe
- 2 nodules same lung - different lobe
- T2a
- T4
- T3
- T4
Benign Tracheo-bronchial Tumors
Hamartoma
Squamous cell Papillomatosis
Papilloma (HPV 6 and 11)
Leiomyoma
Lipoma
Chondroma
Neurogenic tumor
Granular cell tumor (neuro cells- S100 vermentin stains, PAS positive)
Malignant Tracheo-bronchial tumors
SCC
Adeno
Small Cell
Carcinoid Tumor
Mucoepidermoid carcinoma
Direct invasion
Mets
Inflammatory Myoblastic Tumor
- rare mesenchymal neoplasm in adults
—- Spindle cell proliferation with lymphocytes and plasma cells - present as well circumscribed peripheral lesion in the lung, lower lobes
- Indolent course
- Resection is curative
- Anaplastic lymphoma kinase
Malignant Mesothelioma
Sx:
- chest wall pain
- dyspnea (pleural effusion)
Imaging:
- Pleural effusion
- Pleural thickening with extension along the fissures
- May have calfications however not malignant (support the diagnosis)
Pleural fluid:
- Usually not helpful in dx
- need tissue diagnosis
Tumor marker:
- Loss of BAP-1 protein
Type of Mesothelioma:
- Epitheloid - best prognosis
- Sarcomatoid - worst prognosis
- biphasic
Stage I and II disease:
- local invasion into the lung parenchyma and/or diaphragm without spread to the mediastinum or distant sites.
Stage III disease
- mediastinal and/or hilar lymph nodes.
Stage IV disease
- distant metastases and/or the presence of N3 lymph node involvement
Tx:
- resection (if possible)
- Nivolumab plus ipilimumab
poor prognosis
Mesothelioma markers
- pleural fluid
Calretinin
CK 5/6
D2-40
WT-1
Adenocarcinoma Tumor Markers
CEA
B27.3
Bg8
BerEP4
MOC 31
Napsin +
TTF +
Squamous Cell Markers
P40
P63
CK5/6
CK 7 negative
Radiation induced organizing PNA
Women undergoing breast cancer
Symptoms within 1-12months (usually 6m) after completing therapy
Patchy alveolar infiltrates outside the radiation field
Tx:
- steroids
- may recur once discontinued. Need prolonged taper
Prognosis: Good- most resolve without steroids.
Lung NET
Neuroendocrine cells with malignant differentiation
No association with smoking
- Low grade - indolent course, nodal spread uncommon (good 5 year survival)
- Intermediate - aggressive with common nodal spread (bad 5 year survival)
- High grade - aggressive small cell and large cell lung (really bad 5 year survival)
Commonly intrabronchial- trachea or main bronchi
Sx:
Bronchial obstruction or from carcinoid syndrome (wheezing, flushing). Can have cushing and acromegaly
CT: mass or obstructive PNA
Somatostatin scan
Low uptake on PET if low grade
Treatment:
-Surgical resection
- If unresectable
—– Chemo/radiation/endobronchial
- If metastatic:
—– SSA, everolimus, chemotherapy, radiolabeled SSA
Mucoepidermoid Carcinoma
Intrabronchial- cough, wheeze
Diagnosed with asthma/COPD etc
Salivary gland carcinoma
- Mucus secreting
- squamous cells
Endo-bronchial lesion
Children to eldery
T(11:19)(q21:p13) Chromosomal translocation
Tx: surgical resection
Good prognosis
Adenoid Cystic Carcinoma
Intrabronchial lesion
Dx with asthma due to wheeze - will have flattening on FV curve
Tx: surgical resection
Will recur**
If un-resectable then radiation and laser
