lung cancer Flashcards
more pts die of lung ca than..
colorectal, breast, prostate ca combined
this causes 85-90% lung ca
smoking
over past 30 years: mortality dec or inc in MEN? why?
dec, change in tobacco use
Females: started falling in 2003
median age of dx
70
worldwide, this % of M/F lung ca pts are nonsmokers
why?
15% men, 50% women
biomass cooking
other risk factors
radon gas
asbestos
metals (arseninc, chromium, Ni, iron oxide)
industrial carcinogens
familial predis.
preexisting disease: pulm. fibrosis, COPD (4x inc.), sarcoidosis
lung ca breakdown: 30-40% 22% 13-20% 16% 2%
adenocarcinoma SqCC SmCC non-small cell large cell
SqCC
From the bronchial epithelium, centrally located, can be intraluminal sessile or polyps
More likely to present with hemoptysis; can cavitate
Highly associated with smoking history
Tend to spread locally and may be associated with hilar adenopathy
adenocarcinoma
From mucous glands or epithelial cells in terminal bronchioles
Never smokers, higher rate of metastatic disease
Peripheral nodules/masses
Adenocarcinoma in Situ (previously Bronchoalveolar cell carcinoma)
Spreads along preexisting alveolar structures without evidence of invasion
large cell carcinoma
Relatively undifferentiated cancers that do not fit into other categories but share large cells
Aggressive clinical course with rapid doubling times
Central OR peripheral masses
non-small cell carcinoma
Can’t be better differentiated on pathological review
SmCC
Bronchial origin typicall centrally located
Highly associated with smoking
Infiltrates submucosa causing narrowing or obstruction of the bronchus without discrete luminal mass
Often involves lymph nodes
for staging, divided into
SmCC vs non-SmCC (included other 4)
what type is more prone for hematogenous spread and rarely approp. for surg. resection
more or less aggressive course?
median survival?
SmCC
MORE aggressive
only 6-18 wk survival
s/s lung ca
anorexia, wl, asthenia new/change in cough hemoptysis pain (bony, nonsp. chest) postobstr. pneumonia pleural effusion (12-33%) change in voice (rec. lary. n) SVC syndrome Horner's invol. inf cervical ganglion, paravert. symp. chain
brain metastasis more common in these lung ca
and cause ???
adenocarcinoma, SmCC
cause ha, nausea, seizures, dizziness, AMS
paraneoplastic syndrome caused by
occurs in what %
immune-med. or secretory effects of neoplasms
in 10-20% lung ca pts
PNP syndrome comps
SIADH (10-15% SmCC)
hypercalcemia (10% SqCC)
inc. ACTH, anemia, hypercoag, peripheral neuropathy, labert eaton myasthenic syndrome
lung ca dx
sputum cytology thoracentesis thoracoscopy fine needle aspiration fiberoptic bronchoscopy mediastinoscopy video assisted thorascopic surgery (VATS) open thoracotomy
sputum cytology: sp or sn?
more like to be positive if ??? lesion
highly specific, v. insensitive
central lesion
thoracentesis used for..
sens. of ??
do this to inc. yield
malignant pleural effusion
sn 50-60%
repeat 3x
thorascoscopy for..
preferred over ??
malignant pleural effusion
pref. over blind pleural biopsy
what is fine needle aspirated?
supraclavicular LNs
fiberoptic bronchoscopy allows visualization of ??
accompanies…
major airways
w/ BAL of lung segs + cytology/biopsy
can also FNA ??
blindly or with ??
mediastinal LNs
endobronchial US guidance (EBUS)
this helps properly biopsy peripheral nodules
electromagnetic navigational bronchoscopy
this is a high risk for pts (peripheral nodules) esp. with ??
pneumothorax!
underlying emphysema
this can be used then less invasive techniques fail
mediastinoscopy, VATS, open thoracotomy
-wedge biopsy-imm. analysis on simult. tx/lobectomy
(wait on management as frozen sects. can be inaccurate?)
if multiple nodules on imaging, be more suspicious for ??? than ???
metastatic disease
primary lung ca
TNM staging used for..
tx guidance, prognosis, to standardize trials
TNM…
T: tumor (primary) size/location (where, how big?)
N: nodal metastasis presence/location (+/-, where?)
M: metastasis (distant) presence/absence (+/-)
TNM stages grouped into prognostic categories
stages I-IV
need to ?? in order to stage
evaluate LNs
if no LNs on imaging larger than 1 cm…
resection of primary tumor and sample mediastinum at thoracotomy
if suspect metastatic disease, LNs > 1-2 cm
CT guided FNA, mediastinoscopy, EBUS, EUS, limited thoracotomy to eval. LNs (prior to decision about thoracotomy?)
PET scanning uses ??? to identify ???
specificity depends on ??
18F fluoro-2-deoxyglucose (FDG) to ID metastatic foci
size of mediastinal LN
freq. obtain this to eval. for metastatic disease and determine surgical candidates
limited resolution if ???
false positive if ???
whole body fusion PET-CT imaging
if nodule
with PET, need separate ??? to r/o brain metastasis in pts with at least Stage ??? disease
MRI of brain
Stage II
periop. assessment for tumor resection is necessary b/c most pts have ???
most pts req ??? to evaluated how tolerate post-resection ???
other chronic lung diseases
spirometry
pulmonary insufficiency
if pre-op. FEV1 is ??? have low risk of compl. from lobectomy/pneumonectomy
> 2L
if FEV1 ??? need to calculate an est. ???
if ??? have low incident peri-op complications
800mL
if borderline spirometry, can do ??? to determine if resection is an option
??? is desired
cardiopulmonary exercise testing
high max. O2 uptake
national lung screening trial done on..
former heavy smokers
USPSTF recommends annula screening for lung ca w/ ???
for ages ??? who have ??? smoking hx or ???
low-dose CT (LDCT)
55-80 yo
30 pk-yr hx and currently smoke or have quit w/in past 15 years
screening should discontinue once person has not smoked in ??? OR develops ???
15 years
health problem that subst. limits life expectancy or willingness to have curative lung surgery
ddx for solitary pulmonary nodule
non-sp. healed granuloma hamartoma lymphoma fibroma lunc abscess round atelectasis AVM (art-ven malform.) hematoma granulomatosis w/ polyangiitis
radiological prob. of ca increases if…
inc. diameter
spiculation
upper lobe location
if ??? zero likelihood of ca
calcified completely
non-SmCC (NSCLC) tx:
first ID if ??? is feasible and if pt can tolerate it
complete surgical resection
these prevent surgery
Extrathoracic metastases, malignant pleural effusion, tumor involving heart, pericardium, great vessels, esophagus, trachea, contralateral mediastinal LNs
NSCLC Stage I and II
surgical resection (when possible)
NSCLC IB and II
adjuvant chemotherapy
NSCLC Stage IIIA
resection and chemo and/or radiotherapy
NSCLC Stage IV
chemotherapy and palliation
??? for early stage primary NSCLC -non-surg. candidate
stereotactic body radiotherapy (Cyberknife)
??? gives antineoplastic drugs in advance of sx or radiation
used in stages ???
neoadjuvent chemotherapy (NSCLC) Stage IIIA/B (no impact I/II)
??? admin antineoplastic drugs FOLLOWING sx, radiation
??? regimens for stages ???
adjuvent chemotherapy (NSCLC) Cisplatin, Stage II or IB
chemo in Stages IIIB and IV (NSCLC): curative?
improves survival from ?? to ??
also improves ??
not curative
5 mos–>7-11 mos
improved quality of life and symptom control
chemo drugs for NSCLC Stage IIIB, IV
cisplatin or carboplatin combined with pemetrexed, gemcitabine, taxane or vinorelbine
NSCLC advanced molecular profiling: target tx for these mutations
EGFR, EML4-ALK, more
SCLC tx: response to ??? are excellent (80-90%) in ??? and 60-80% partial response in ???
cisplatin and etoposide
limited stage disease
extensive disease
SCLC tx: remission is ?? and if recurred med. survival is ??
short-lived
3-4 mos
overall 2 yr survival ??? in limited stage and ?? in extensive stage
20-40%
5%
pallliative tx relieves ??? and also ???
endobronchial obstruction
improves dyspnea, contols hemoptysis
this improves quality of life if no evidence of other metastatic disease
resection for solitary brain metastasis
