Lung Cancer

Question 1

Why do most lung cancer patients often dismiss their first symptoms?

Answer 1

Because they are almost all smokers! And the first symptoms (hemoptysis and cough) are usually not new to them.

Question 2

Tumors that originate in the airways

Answer 2

squamous cell carcinoma or small cell carcinoma

Patients may also have problems related to bronchial obstruction

Question 3

Tumors that originate in the periphery of the lung

Answer 3

Adenocarcinomas or large cell carcinomas

Patients tend not to have symptoms related to bronchial involvement, and their lesions are often found on imaging obtained for unrelated purposes

Question 4

When tumors involve ___ patients may have chest pain

Answer 4

When tumors involve the pleural surface patients may have chest pain

Question 5

Horner syndrome

Answer 5

Caused by disruption of the cervical sympathetic chain

Ptosis (drooping upper eyelid), miosis (constricted pupil), and anhidrosis (loss of sweat) over the forehead and face

May occur in lung cancer

Question 6

Involvement of mediastinal structures near the hilar lymph nodes of the lung and produced symptoms

Answer 6

phrenic nerve : diaphragmatic paralysis

recurrent laryngeal nerve : vocal cord paralysis

superior vena cava : edema of the face and upper extremities

Question 7

Paraneoplastic syndromes

Answer 7

Symptoms developing with neoplasm that are not anatomically related to the presence of the cancer

Frequently are due to either production of a hormone or a hormone-like substance by the tumor or the presence of autoantibodies stimulated by antigens on the tumor

Question 8

Paraneoplasm in lung cancer

Answer 8

Mostly just SCLC. Here ADH and ACTH may be elevated, precipitating hyponatremia. It can also precipitate immune-mediated neuropathic paraneoplasm against voltage-gated calcium channels at the NMJ.

Rarely squamous cell, in which case it is often hypercalcemia from parathyroid hormone–related peptide

Question 9

The initial test for detection and macroscopic evaluation of bronchogenic carcinoma is typically . . .

Answer 9

The initial test for detection and macroscopic evaluation of bronchogenic carcinoma is typically the posteroanterior and lateral chest radiograph.

Question 10

On a CXR, peripheral lesions are more likely to be___, whereas central lesions are statistically more likely to be ___

Answer 10

On a CXR, peripheral lesions are more likely to be adenocarcinoma or large cell carcinoma, whereas central lesions are statistically more likely to be squamous cell carcinoma or small cell carcinoma

Question 11

Basis for staging of non–small cell lung cancer includes the following:

Answer 11

1. Size, location, and local complications of the primary tumor
2. Hilar and mediastinal lymph node involvement
3. Distant metastasis

Question 12

Suprasternal mediastinoscopy

Answer 12

Mediastinum is visualized with a scope placed through an incision made just above the sternal notch. Biopsy specimens can be obtained by this technique

Question 13

parasternal mediastinotomy

Answer 13

Mediastinum is examined through a small incision made adjacent to the sternum, and samples of suspicious nodes can be taken

Question 14

Unlike non-small cell cancers, SCLC is typically staged as. . .

Answer 14

limited or extensive stage disease.

• Limited disease is defined as tumor that is limited to an ipsilateral thorax and regional lymph nodes.
• Extensive stage disease represents spread outside this region

Question 15

Genetic analysis of lung cancers features two genes prominently:

Answer 15

EGFR and ALK

Question 16

A patient may be unable to tolerate lobectomy if ____.

Answer 16

A patient may be unable to tolerate lobectomy if they already have extensive lung disease, i.e. if they have substantial COPD.

Question 17

The four major forms of treatment available for lung cancer

Answer 17

• Surgery
• Radiation
• Chemotherapy
• Targeted molecular therapy

Question 18

Treatment of Non–Small Cell Lung Cancer (in order of preference)

Answer 18

1. Surgery if viable - complete resection has high cure rate
2. Targeted therapies - if surgery not viable or any metastasis, including lymph nodes
   
   • Include tyrosine kinase inhibitors for EGFR
3. Chemotherapy
4. Radiation - purely palliative, unlikely to ever cure

• Immunotherapy is an emerging option, but too soon to be placed within the above. Probably preferable to chemo/radiation

Question 19

Treatment Small Cell Lung Cancer (in order of preference)

Answer 19

1. Chemotherapy
   
   • Cisplatin for early disease
   • Combination regimens for more extensive disease
2. Radiation

Question 20

SCLC has ___ at the time of diagnosis in almost all patients

Answer 20

SCLC has already disseminated at the time of diagnosis in almost all patients

Question 21

Restoration of Airway Patency

Answer 21

With either flexible or rigid bronchoscopy, using techniques such as laser, argon plasma coagulation, photodynamic therapy, cryotherapy, or electrocautery, diminish the size an endobronchial tumor and reestablish an effective lumen.

Question 22

Bronchial Carcinoid Tumors

Answer 22

aka bronchial neuroendocrine tumors, 5% of primary lung tumors

Low-grade malignancy, classified as either typical or atypical based on histologic features. Smoking is not a risk factor and patients tend to be younger at time of presentation. Arise mostly in central airways. Accompanied by carcinoid syndrome.

Most patients with these tumors have an excellent prognosis and are cured by surgical removal.

Question 23

Carcinoid syndrome

Answer 23

Accompanies a bronchial carcinoid tumor. A form of paraneoplastic syndrome.

Episodic flushing, diarrhea, and wheezing that results from the effects of serotonin produced by the tumor

Question 24

Malignant mesothelioma

Answer 24

Primarily involves the pleura.

Chest pain, dyspnea, and sometimes cough. Radiograph usually is most notable for the presence of pleural fluid and often irregular or lobulated thickening of the pleura. Diagnosis requires biopsy. Prognosis is poor, usually death due to respiratory failure.

Smoking is not a risk factor. History of exposure to abestos 30-40 years prior is biggest risk.

Question 25

Solitary pulmonary nodule

Answer 25

Common presentation of lung cancer, but has a broad differential. Estimating the likelihood of a malignant versus a benign lesion from its radiographic appearance on CT scan is based on six major factors:

1. Size
2. Growth
3. Attenuation
4. Calcification
5. Border appearance
6. Location (upper lobe more likely to be cancer)

Question 26

The ___ recurrent laryngeal nerve is more prone to paralysis in lung cancer.

Answer 26

The left recurrent laryngeal nerve is more prone to paralysis in lung cancer.

Question 27

Targetable mutations in lung adenocarcinoma

Answer 27

• EGFR
• KRAS
• ALK rearrangement
• ROS1 rearrangement
• NTRK fusion
• BRAF

Question 28

Osimertinib

Answer 28

EGFR inhibitor that is effective even for T790M mutation. Now a first-line therapy for EGFR+ lung cancers.

Question 29

___ are contraindicated for squamous cell carcinoma.

Answer 29

Angiogenesis inhibitors are contraindicated for squamous cell carcinoma.

They are associated with massive pulmonary hemorrhage, for unknown causes.

Question 30

Most common lung metastases

Answer 30

Bone

Brain

Liver

Adrenal