Lung Cancer Flashcards
Overall, e-cigarettes are a new source of ____
Voltaile Organic Compounds (VOCs) and ultrafine/fine particles in the indoor environment
Compared to other cancers (except notably pancreatic cancer), ____ has seen the least improvement in 5 year survival compared to other common cancers
lung cancer (17%)
Causes and risk factors for cancer
• Smoking – the vast majority of all lung cancer is attributable to this single factor (up to 85-90% of lung cancers) = 85-87%
- Passive/Environmental smoke inhalation
- Radon Gas
- Asbestos
- Metals (chromium, arsenic, iron oxide)
- Industrial chemicals
- Polycyclic aromatic hydrocarbons
- Genetic causes
Over 2/3 of patients present with ___
stage IIIA cancer or worse
Risk assessment of lung cancer patient
Bach Index
1) age
2) gender
3) asbestos exposure history or coal miner or radon history
4) smoking history
5) previous history of tobacco related cancer (head and neck, renal, esophagus cancer, colon
6) airflow obstruction
7) serum cytologic atypia
yearly incidence = 2% in highest risk
higher GOLD 3 or 4 is assoc with higher risk of ___
lung cancer
–> subset of smokers exhibit accelerated loss of FEV1
if your parents or 1st degree relative, do you have incr risk of lung cancer
yes!! family history
SEQUENCE OF lung cancer development
1) normal epithelium
2) hyperplasia
3) dysplasia
4) CIS
5) invasive carcinoma
INcidence based on initials putum
Precision medicine
Methylation of tumor suppressors –> tumor formation
Look at # of genes methylated
good at diagnosis within 18 months
Types of lung cancer
and subtypes
NSCLC (87%)
- adenocarcinoma
- adenocarcinoma in situ
- squamous cell
- large cell
Small cell lung cancer (13%
small cell lung cancer histology
findings
1) high N:C ratio
2) large cytoplasm
3) neuroendocrine marker (NCAM) = diagnostic
4) TTF-1 = positive in lung cancer
high rate of paraneoplastic = may lead to endocrinopathies and weakness
History/Physical of lung cancer
symptoms of lung cancer
1) weight loss
2) cough
3) hemoptysis
4) neuro symptoms
5) lymphadenopathy
lab studies indicative of lung cancer
suggest metastases
high alk phos
Ca2+
anemia
cytopenias
CT/pet scans
why use?
CT/PET scans
N2 nodes/upper abdomen
why use fiberoptic or needle biopsy
fiberoptic bronchoscopy or needle biopsy to establish histology (SCLC vs NSCLC)
proximety to carina, mediastinal staging
purpose of mediastinal biopsy
mediastinal biopsy = confirm status of mediastinal nodes
biopsy of lymph nodes
T classification for T1a, T1b, T2a, T2b
tumor 2, 7 cm and invades pareital pleura, mediastinum, pericardium, diaphragm
T4 = invade mediastinum and heart and apical tumors
why use thoracentesis
Pleural effusions
thoracentesis = to stage and make diagnosis
3 samples
symptoms of upper lobe tumor (apical)
upper lobe tumor = apical = involve brachial plexus and upper extremity
N classification
N0 = no regional nodes N1 = ipsilateral intrapumonary/peribronchial/hilar N2 = contralateral (less surgical and more radiation/chemo) N3 = node in neck
M classification
M1a= malignant pleural effusion
malignant pericardial effusion
contralateral pulm nodes
M1b = more distant mets= liver, adrenals, bone, brain
NSCLC
EGFR (ERB-1)
% of NSCLC vs. SCLC
drugs to use?
50-80% NSCLC
Her-2/neu (ERB-2)
drugs to use?
10% NSCLC (
EGFR leads to…
1) prolif
2) invasion
3) inhib of metastasiss
vEGF in lung cancer
what drug?
overexpressed
bevacizumab (Avastin)
Ras mutations
found in what cancers?
mutations assoc with resistance to?
2-30% NSCLC, adenocarcinoma
mutations assoc with resistance to TKIs and EGFRi
Precision medicine of NSCLC
50% adenocarcinoma
30% squamous cell
Using specific drugs to target types of cancer
Paradigm for precision medicine in lung cancer
Initial presentation
Genetic testing
Platinum doublet +/- Bevacizumab or target therapy
if recur then go on to pemetrexed, docetaxel erlotinib or 2nd line targeted
3rd line chemotherapy or 3rd line
Squamous cell cancer compared to adenocarcinoma for therapies
compared to lung adenocarcinoma = no proven genomically targeted therapy for lung squamous cell
Immunotherapy for targeting lung cancer
why use them?
Tumors make PD-L1 in periphery that kill the immune response
so harness inhibitors for PD-L1 or CTLA-4
because allows body’s own immune system
Solitary Pulm nodules
define
1) less than 3cm in diameter
2) Surrounded by normal, aerated lung tissue
3) Has round, smooth contours
4) Lacks satellite lesions
5) Has no associated atelectasis, pnuemonitis, or regional adenopathy
SPN usually _____ and common on CXR
Goals of SPN evaluation
SPN usually asymptomatic and common on CXR (10-20% = bronchogenic carcinomas or pulm masses)
1) expedite resection potentially curable lung cancer
2) minimize resection of benign nodules
3) morbidity of nodule evaluation = 5-10%
Not all large nodules are ___
cancer (only 1/3 malignant)
follow up with biopsy
what makes pleura calcified?
define rounded atelectasis
asbestos
pleural calcifications twist with tail and invaginate part of lung and gets trapped in lung
What should we do for solitary pulm nodules
1) look at all previous CXRs
2) stable for >2 years = no eval
3) benign, central calcification = no eval (granulomas = near river valley)
4) spiral chest CT with contrast
5) if nodule > 8 mm estimate a pretest probability
6) SPN in marginal candidates (poor lung fxn and CT) –> , PET, if negative repeat CT in 3 months
7) If growth on serial imaging, proceed to non-surgical biopsy and resection
8) all resections include lymph node dissection
9) lobectomy is preferred over wedge or segmentectomy
what do you do to treat benign, central calcification
no eval (granulomas = near river valley)
what do you do for nodule > 8 mm
estimate a pretest probability for cancer
what do you do for SPN in marginal candidates (poor lung fxn
PET
if negative CT repeat in 3 months
if you have growth on serial imaging
proceed to non-surgical biopsy and resection
all resections should include ___
lymph node dissection
___ is preferred over wedge or segmentectomy
lobectomy
if nodule size 8 mm
follow up optional if no risk factors
follow up at 12 mo if risk factors
follow up at 12 mo
follow up at 6-12 month; then at 18-24 mo
follow up at 6-12 then 18-24 mo
follow up at 3-6, 9-12, 24
do PET or biopsy regardless
Low risk = minimal or absent history
high risk = history of smoking
nown risk = hx of lung cancer in 1st degree and exposure to asbestos, radon or uranium
GGN (ground glass nodule) are typically what type of cancer
adenocarcinoma
things to note on imaging:
Size= as SPN gets larger, more likely ___
if stable for > 2 years, it is likely ___
central clacification types
enhance with contract more common in ___
incr PET activity is more likely __
1) malignant
2) benign
3)
o Bull’s eye lamination (granulomas)
o Popcorn or chondroid (hamartomas)
o Dense central core of calcification
4) malignancies due to incr blood supply
more common in malignancies
Methods of lung ancer screen
1) CXR
2) sputum cytology
3) spiral CT
4) autofluorescence bronchoscopy
Mayo Lung project
males > 45 and smoking 1 ppd in last year
No difference in two groups if received CXR every 4 or 12 month
sputum cytology = no reduction in lung cancer mortality
CXR = no reduction in lung cancer mortality
reduction in lung cancer fatality
Results?
NLST = prospective comparing low-dose helical CT compared to CXR
55-74 y/o
30 PPD
Former smoker quit within 15 years
received 3 annual screeens and followed for 5 years
Those who received spiral CT scan = more lung cancer, 20% decr rate of lung cancer
Number to screen for 1 death = 219
292 lung cancers diagnosed in CT group and 190 in CXR
difference accounted for by higher incidence of stage 1A
no difference in # of IIB through IV
so CT IS GREAT FOR LOOKING AT EARLIER STAGE LUNG CANCERS
more adenocarcinoma in0situ and adenocarcinoma
Final medicare decision
Medicare B now covers which patients
Must include?
Risks of low dose CT?
Meidcare B = convers lung cancer screen with low dose CT onceper year (55-77)
current or former smoker who quit in last 15 years at least 30 PP year
must include visit for counseling and shared-decision making
Risk of overdiagnosis bias, radiation exposure, false positive scans
Smoking cessation discussions
PET scans
1) evaluate for?
2) look for?
3) in patients with peripheral stage T1 A tumors a PET scan may ___
1) evaluate for mediastinal and extrathoracic metastases in all patients with NSCLC being treated with curative
2) look for ground glass opacities
effect of beta carotene (because smokers probably eat low fruits and vegetables) so give them beta carotene
got more lung cancer than those that didn’t get beta carotene
Chemoprevention
current agents to reverse, suppress or prevent carcinogenesis
Iloprost- benefit for former smokers = improvement in areas of damage in airway
Selenium- no benefit in prevention of patinets with resected NSCLC
COX-2- PGI2= decr in # of tumors in mice
future = EGFR inhibitors
Rosigliatzone
VEGFR/EGFR antagonists
Angiogenesis modulators
Staged chemoprevention
Stage 1 = stop smoking
Stage 2 = identify highest risk groups (gene expression pattern in buccal or nasal mucosa, blood, sputum atypia, FHx, tobacco exposure)
Stage 3 = presence of pre-malignant lesions with specific alterations
strategy for early stage cancer
personalized
tertiary
chemoprevention/Stage 1A therapy such as apsirin use for colorectal cancer
