Lung Cancer Flashcards
What are the risks for lung cancer?
Smoking
Secondhand smoke
Genetic predispostion
Asbestos, radon, arsenic, radiation, polycyclic aromatic hydrocarbons
Do cancer cells do apoptosis
No they avoid it thats why they grow so much
What is another name for a Solitary Pulmonary Nodule?
“Coin Lesion”
What is a solitary pulmonary nodule (SPN)?
An isolated lung nodule that is less than 3cm and round
Are most SPNs benign or malignant?
Benign
What do benign SPNs look like?
Smooth, well-defined edges
Dense central calcification
Most benign SPNs end up being________
Infectious granulomas
If a lesion is spiculated, it is (good/bad)
Bad
If a nodule is calcified, it is (good/bad)
Good
What is the difference between a nodule and a mass?
A mass is greater than 3cm
How does size of a lung mass relate to its chance for malignancy?
The bigger the mass, the more likely it’s malignant
Other than infectious granulomas, what are other possible causes of benign SPNs?
Hamartoma (tumor of cells from somewhere else like hair cells)
Vascular
Inflammation
Who is more likely to have a lung malignancy: males or females
Females
How does age relate to likelihood of malignancy
Older = higher risk
Most SPNs in Arizona are _____
Cocci (valley fever)
Most SPNs in patient who have had cancer before are ______
Metastasis
If an SPN is 5cm or bigger, what are the chances its cancerous
90%
What is the 1st step in evaluating an SPN?
Review old films
Malignant nodules grow FAST
Minimal growth in 2 years suggests a benign lesion
Smooth, well defined edges on an SPN indicate that it is most likely (benign/malignant)
Benign
What kind of chest CT do you need to do to evaluate a suspicious SPN?
Without contrast
Low radiation
Thin 1mm slices
What should you do if you find a solid nodule that is over 8mm?
You determine the probability of it being malignant and then go from there
Low probability <5%
Intermediate probability 5-65%
High probability >65%
What should you do if you find a solid nodule that is over 8mm and has a LOW probability of being malignant?
Get a CT 3 months later
No growth= serial CTs at 9-12 months and 18-24 months
Growth= needs Pathologic evaluation
What should you do if you find a solid nodule over 8mm and there is an intermediate probability of it being malignant?
Do an FDG PET/CT and/or biopsy
If “FDG avid”= biopsy/excision
If PET/CT unavailable, negative, or indeterminate= you can do individualized management based on suspicion (??)
CT scans at 3, 9-12, and 18-24 months is an acceptable alternative to biopsy
I hate this
What does “FDG avid” mean?
It means the PET/CT showed that it was abnormal
FDG is fluorodeoxyglucose
What should you do if you find a solid nodule that is over 8mm and there is HIGH probability that it is malignant?
Biopsy/excision
What should you do if you find a solid nodule that is smaller than 8mm?
6-8mm= do a CT in 6-12 months
<6mm do not require follow up
What are the 3 types of NSCLC?
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
What is another name for small cell lung cancer?
Oat cell carcinoma
Where does Small Cell LC show up
Central airways
*******
Was in red
What does small cell LC look like?
Large hilar mass with bulky mediastinal adenopathy
Is small cell lung cancer aggressive?
HIGHLY aggressive. THE MOST aggressive. 70% of patients have metastatic disease when they are first diagnosed.
6-18 WEEK survival without treatment
What are the 2 categories of Small Cell Lung Cancer?
Limited- one lung and nodes on same side
Extensive- both sides of chest
What should you be really worried about if you have a small cell lung cancer in the right side?
(Other than dying…. 😞)
SVC syndrome
What is the most common form of non small cell lung cancer
Adenocarcinoma
What kind of tissue gives rise to adenocarcinoma?
Mucous glands
Epithelial cells in or distal to terminal bronchioles
Where do adenocarcinomas metastasize to?
Distant organs
Where in the lung does adenocarcinoma show up?
Periphery
Where in the lung does squamous cell carcinoma show up?
Centrally or in main bronchus
Intraluminal growth inside the bronchus)*
What kind of tissue gives rise to squamous cell carcinoma?
Bronchial epithelium
What kind of non small cell LC is most likely to cause hemoptysis?
Squamous cell carcinoma
It’s often INSIDE the main bronchi
What is the most likely cause of hemoptysis?
BRONCHITIS*****
She said this 7386 times
Where does squamous cell carcinoma metastasize to?
Nearby lymph nodes
Which kind of lung cancer did she say “cavitates?”
Squamous cell carcinoma
Where does large cell carcinoma appear?
Anywhere
Central or peripheral
Where does Large cell carcinoma metastasize to?
Distant organs
What is the most aggressive non small cell lung cancer?
Large cell carcinoma
Small cell is the most aggressive lung cacner though
Are most patients symptomatic at the time of lung cancer diagnosis?
Yes
What is the most common symptom of lung cancer?
Cough
*******
What are the symptoms that lung cancer patients may present with at diagnosis?
Cough
Weight loss
Dyspnea
Chest pain
Hemoptysis
Bone pain
Hoarseness** DO NOT FORGET
Cough is the most common symptom of lung cancer, but what 2 types does it most frequently occur with?
Squamous cell
Small cell
If a patient has weight loss, what does it mean for their prognosis?
BAD NEWS
Does a CXR rule out lung cancer?>
No
Idk this had an exclamation point
What causes hoarseness in lung cancer patients?
Left sided tumors compression the recurrent laryngeal nerve
**SHE REALLY HARPED ON THIS
What is the most common cause of intrathoracic malignancy that causes SVC syndrome?
Small Cell Lung Cancer *****
What are the symptoms of SVC syndrome?
Dyspnea #1
Facial swelling
Head fullness (worse when bending forward/supine)
Arm swelling
Cough
Chest pain
Dysphagia
What will you find on physical exam in a pt with SVC syndrome?
Facial edema
Dilated neck veins
Prominent venous pattern on chest
What is the GOLD STANDARD of diagnosing SVC syndrome?
Superior vena cavogram
taking pictures inside the SVC
What kind of imaging can be done to diagnose SVC syndrome?
CXR
Duplex ultrasound
CT scan WITH contrast
Superior vena cavogram
What kind of imaging for SVC syndrome will allow you to see the level of blockage, map collateral pathways, and ID the underlying cause?
CT with contrast
BUT superior vena cavogram is still the gold standard for diagnosing SVC syndrome
How do you treat SVC syndrome?
Emergency Radiation Therapy
Venous stents
Chemo
Removal of cardiac devices and anticoagulation (if caused by thrombosis)
Which patients with SVC syndrome require emergency radiation therapy?
Stridor from central airway obstruction
Laryngeal edema
Coma from cerebral edema
What causes Pancoast syndrome?
A tumor in the superior sulcus (apical chest) compressing the brachial plexus and cervical sympathetic nerves
What is Horner’s syndrome and what condition is it associated with?
Injury to the sympathetic nerves of the face
Associated with Pancoast syndrome
What kinds of Sx will a pt with Pancoast syndrome have?
Right shoulder pain A LOT
Forearm, scapula and finger pain
One pupil constricted
Not sweating on one side
Eyelid drooping on one side
Rib destruction
Atrophy of hand muscles
Pain in C8, T1, T2 nerve roots
(Signs are going to be on the same side as the tumor)
What kind of lung cancer is most likely to cause Pancoast syndrome?
Squamous cell
What are paraneoplastic syndromes?
Sx that occur as a result of organ/tissue damage at locations remote from the site of the primary tumor/metastases
Ex: hypercalcemia due to bone destruction and SIADH
What kinds of hematologic effects can occur due to paraneoplastic syndromes?
Hypercalcemia due to bone destruction
Anemia
Leukocytosis -poor prognosis
Thrombocytosis
Hypercoagulabilty
What are the 4 endocrine effects caused by paraneoplastic syndromes?
PTH-like substance causing bone erosion=hypercalcemia
Excess HCG production- gynecomastia, milky nipple discharge
SIADH- hyponatremia
Cushing’s syndrome- ectopic ACTH.
What kind of lung cancer causes a PTH-like substance to be secreted?
Squamous cell
What kind of lung cancer causes excess HCG production?
Large Cell
What kind of lung cancer causes SIADH and Cushing’s syndrome?
Small cell lung cacner
What causes patients with Small Cell LC to develop Cushing’s syndrome?
Tumor secretes ectopic ACTH leading to lots of cortisol
VERY BAD PROGNOSIS
What is Eaton-Lambert syndrome?
An immune mediated attack of antibodies at the NMJ causing:
Acetylcholine release
Muscle weakness
What kind of cancer causes Eaton Lambert syndrome?
Small cell lung cancer
What are the most common sites of distant metastases?
Liver
Bone
Adrenal glands
Brain (especially Small cell)
What kinds of symptoms will someone with liver metastasis have
Elevated LFTs
What kinds of symptoms will someone with bone metastases have
Back, chest, extremity pain
Elevated alkaline phosphate (from bone growth)
What kinds of symptoms will someon with metastasis to the adrenal glands have?
None
What is necessary to diagnose Lung cancer?
Tissue biopsy
Sputum, bronchoscopy, thoracentesis, etc
How is Non small cell LC staged?
With the TNM staging system
T- Tumor
N- Nodal involvement
M-Metastasis
How is small cell LC staged?
Limited vs Extensive
What kind of tissue sample is best for central lesions?
Sputum culture
How is performance status graded?
Don’t know if you have to know this?
0= no restriction
1= strenuous physical activity restricted
2= capable of all self care but unable to do work
3= capable of only limited self care, confined to bed or chair more than 50% of waking hrs
4= completely disabled, no self care, totally bed or chair confined
What is the strongest indicator of post-op complications?
FEV1 less than 60%
Which is better to detect metastasis:
PET or CT
PET
What kind of radioactive isotope is used in PET scans?
fluorodeoxyglucose (FDG)
What kind of tissue may show as a false positive on a PET scan?
Infections
What tissue is NORMAL to light up in a PET scan?
Heart
Kidneys
Bladdder
What is the treatment of choice for non small cell LC?
Surgical resection (if the disease is localized)
Do we do surgery for Small Cell LC?
Not usually an option
Only if its very small primary lesion with no spread
What is the treatment for Small Cell LC?
Chemotherapy
Radiation
Prophylactic cranial radiation
How do you treat malignant effusions?
Thoracentesis
Pleurodesis (fusing pleura to lung tissue)
Pleura Catheter
What are the side effects of chemotherapy?
Fatigue
Chemo brain
N/V
Anorexia, weight loss
Anemia
Neutropenia
Nephrotoxicity
Neurotoxicity
How do you treat stage 1 Non small cell LC
Surgical resection
How do you treat stage 2 non small cell LC
Surgical resection + chemo
How do you treat Stage 3 non small cell LC?
Uncertain:
Dont do surgery and do chemo+ radiation
Do surgery and do chemo and add radiation if you didn’t get clear margins from surgery
How do you treat stage 4 non small cell lung cancer
Palliative :(
Chemo, clinical trials
Resection of metastases
“Targeted therapy”
Every patient with suspected lung cancer needs this kind of imaging screening:
Low dose helical CT
This was in orange idk
Who needs a low dose helical CT to screen for lung Cancer?
Every pt with suspected lung cancer
Age 55-74 with 30 pack year history
20 pack-year history with one additional risk factor (other than secondhand smoke)
What drugs can you prescribe to help your patients quit smoking?
Zyban aka Wellbutrin (Bupropion)
Chantix (Varenicline)
Nicotrol (Rx nicotine inhaler/nasal spray)
How should you instruct your patent to take Zyban/Wellbutrin/Bupropion to quit smoking?
Start taking it and keep smoking
Quit smoking after 5-7 days
What are the what does your patient need to avoid doing when taking Zyban/Wellbutrin/Bupropion?
Alcohol (to prevent seizures)
What is the black box warning for zyban/Wellbutrin/bupropion?
Suicidal risk in children, young adults, and adolescents
What are the adverse reactions of Zyban/Wellbutrin/bupropion?
Seizures***
Agitation
Weight loss
How should you instruct your patient to take Chantix (varenicline) to quit smoking?
Start taking med
Stop smoking after 7 days
Keep taking it for 12-24 weeks
What is the biggest thing you can do to help your patient quit smokiong?
Positive support! 🥳
Which paraneoplastic syndromes are associated with SMall Cell Lung Cancer
SIADH
Cushings
Eaton-Lambert
What parts of the lungs are usually affected by Small Cell lung cancer
Central lung
Hilar and mediastinal lymphadenopathy
Thrombophlebitis and clubbing are associated with this type of cancer:
Adenocarcinoma
What is the most common NSCLC
Adenocarcinoma
Adenocarcinoma usually arises (centrally/peripherally)
Peripherally
Which kind of LC is slower growing and metastasizes later?
Squamous cell
Squamous cell LC usually arises in what part of the lung
Central bronchi
Which kind of lung cancer is associated with excess PTH, which causes hypercalcemia?
Squamous cell
Which kind of LC may cause cavitations?
Squamous cell
Which kind of LC is associated with hemoptysis?
Squamous cell
Who should get CXR screening for lung cancer?
NO ONE.
We don’t screen with CXRs, only CT
True or false:
Every nodule requires a CT
True
What is the most common presenting symptom of lung cacner?
Cough
