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Spr2015_Week7 > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

Overall, e-cigarettes are a new source of ____

A

Voltaile Organic Compounds (VOCs) and ultrafine/fine particles in the indoor environment

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2
Q

Compared to other cancers (except notably pancreatic cancer), ____ has seen the least improvement in 5 year survival compared to other common cancers

A

lung cancer (17%)

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3
Q

Causes and risk factors for cancer

A

• 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
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4
Q

Over 2/3 of patients present with ___

A

stage IIIA cancer or worse

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5
Q

Risk assessment of lung cancer patient

A

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

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6
Q

higher GOLD 3 or 4 is assoc with higher risk of ___

A

lung cancer

–> subset of smokers exhibit accelerated loss of FEV1

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7
Q

if your parents or 1st degree relative, do you have incr risk of lung cancer

A

yes!! family history

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8
Q

SEQUENCE OF lung cancer development

A

1) normal epithelium
2) hyperplasia
3) dysplasia
4) CIS
5) invasive carcinoma

INcidence based on initials putum

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9
Q

Precision medicine

Methylation of tumor suppressors –> tumor formation

A

Look at # of genes methylated

good at diagnosis within 18 months

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10
Q

Types of lung cancer

and subtypes

A

NSCLC (87%)

  • adenocarcinoma
  • adenocarcinoma in situ
  • squamous cell
  • large cell

Small cell lung cancer (13%

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11
Q

small cell lung cancer histology

findings

A

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

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12
Q

History/Physical of lung cancer

symptoms of lung cancer

A

1) weight loss
2) cough
3) hemoptysis
4) neuro symptoms
5) lymphadenopathy

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13
Q

lab studies indicative of lung cancer

A

suggest metastases

high alk phos
Ca2+
anemia
cytopenias

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14
Q

CT/pet scans

why use?

A

CT/PET scans

N2 nodes/upper abdomen

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15
Q

why use fiberoptic or needle biopsy

A

fiberoptic bronchoscopy or needle biopsy to establish histology (SCLC vs NSCLC)
proximety to carina, mediastinal staging

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16
Q

purpose of mediastinal biopsy

A

mediastinal biopsy = confirm status of mediastinal nodes

biopsy of lymph nodes

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17
Q

T classification for T1a, T1b, T2a, T2b

A

tumor 2, 7 cm and invades pareital pleura, mediastinum, pericardium, diaphragm

T4 = invade mediastinum and heart and apical tumors

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18
Q

why use thoracentesis

A

Pleural effusions
thoracentesis = to stage and make diagnosis

3 samples

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19
Q

symptoms of upper lobe tumor (apical)

A

upper lobe tumor = apical = involve brachial plexus and upper extremity

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20
Q

N classification

A 
N0 = no regional nodes
N1 = ipsilateral intrapumonary/peribronchial/hilar
N2 = contralateral (less surgical and more radiation/chemo)
N3 = node in neck
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21
Q

M classification

A

M1a= malignant pleural effusion
malignant pericardial effusion
contralateral pulm nodes

M1b = more distant mets= liver, adrenals, bone, brain

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22
Q

NSCLC

EGFR (ERB-1)
% of NSCLC vs. SCLC

drugs to use?

A

50-80% NSCLC

23
Q

Her-2/neu (ERB-2)

drugs to use?

A

10% NSCLC (

24
Q

EGFR leads to…

A

1) prolif
2) invasion
3) inhib of metastasiss

25
Q

vEGF in lung cancer

what drug?

A

overexpressed

bevacizumab (Avastin)

26
Q

Ras mutations
found in what cancers?
mutations assoc with resistance to?

A

2-30% NSCLC, adenocarcinoma

mutations assoc with resistance to TKIs and EGFRi

27
Q

Precision medicine of NSCLC
50% adenocarcinoma
30% squamous cell

A

Using specific drugs to target types of cancer

28
Q

Paradigm for precision medicine in lung cancer

A

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

29
Q

Squamous cell cancer compared to adenocarcinoma for therapies

A

compared to lung adenocarcinoma = no proven genomically targeted therapy for lung squamous cell

30
Q

Immunotherapy for targeting lung cancer

why use them?

A

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

31
Q

Solitary Pulm nodules

define

A

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

32
Q

SPN usually _____ and common on CXR

Goals of SPN evaluation

A

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%

33
Q

Not all large nodules are ___

A

cancer (only 1/3 malignant)

follow up with biopsy

34
Q

what makes pleura calcified?

define rounded atelectasis

A

asbestos

pleural calcifications twist with tail and invaginate part of lung and gets trapped in lung

35
Q

What should we do for solitary pulm nodules

A

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

36
Q

what do you do to treat benign, central calcification

A

no eval (granulomas = near river valley)

37
Q

what do you do for nodule > 8 mm

A

estimate a pretest probability for cancer

38
Q

what do you do for SPN in marginal candidates (poor lung fxn

A

PET

if negative CT repeat in 3 months

39
Q

if you have growth on serial imaging

A

proceed to non-surgical biopsy and resection

40
Q

all resections should include ___

A

lymph node dissection

41
Q

___ is preferred over wedge or segmentectomy

A

lobectomy

42
Q

if nodule size 8 mm

A

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

43
Q

GGN (ground glass nodule) are typically what type of cancer

A

adenocarcinoma

44
Q

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 __

A

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

45
Q

Methods of lung ancer screen

A

1) CXR
2) sputum cytology
3) spiral CT
4) autofluorescence bronchoscopy

46
Q

Mayo Lung project

males > 45 and smoking 1 ppd in last year

A

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

47
Q

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

A

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

48
Q

Final medicare decision

Medicare B now covers which patients

Must include?

Risks of low dose CT?

A

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

49
Q

PET scans

1) evaluate for?
2) look for?
3) in patients with peripheral stage T1 A tumors a PET scan may ___

A

1) evaluate for mediastinal and extrathoracic metastases in all patients with NSCLC being treated with curative
2) look for ground glass opacities

50
Q

effect of beta carotene (because smokers probably eat low fruits and vegetables) so give them beta carotene

A

got more lung cancer than those that didn’t get beta carotene

51
Q

Chemoprevention

current agents to reverse, suppress or prevent carcinogenesis

A

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

52
Q

Staged chemoprevention

A

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

53
Q

strategy for early stage cancer

A

personalized
tertiary
chemoprevention/Stage 1A therapy such as apsirin use for colorectal cancer

Spr2015_Week7 (10 decks)

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