Lung Cancer and Mediastinal Masses Flashcards
What is the second most common type of cancer overall?
Lung cancer. Even though it is the second most common type, it is the most common malignancy that results in death in the United States and world-wide.
What is the most common cancer to metastasize to the brain?
Lung cancer.
What is the most common risk factor for lung cancer?
Smoking. Smoking is associated with an accelerated decline in pulmonary function, and smoking cessation slows this decline. Quitting smoking not only reduces the risk for chronic obstructive pulmonary disease (COPD), but also in patients with COPD, the risk for exacerbations reduce. Long-term smokers are estimated to be at a 10- to 30-fold increased risk of developing lung cancer, with the cumulative cancer risk approaching 30% in heavy smokers versus 1% in nonsmokers. The risk for lung cancer declines with cessation of smoking, and screening can be discontinued once a patient has not smoked for 15 years. Moreover, studies have shown that individuals who have not smoked for at least 15 years have an 80%-90% reduction in lung cancer risk compared to current smokers. However, the lung cancer risk remains elevated by 10%-80% in former smokers compared to individuals who have never smoked. Smoking cessation appears to be associated with a decrease in all-cause mortality rates at any age, even in long-term heavy smokers.
What is the most common lung cancer in non-smokers?
Adenocarcinoma.
What environmental exposures increase lung cancer risk?
Radon exposure (basements), secondhand smoke, and asbestos. Also chemicals like polycyclic aromatic hydrocarbons (from burning coal or wood), nickel, and chromium.
How is lung cancer screened?
Patients 50 to 80 with a 20 pack year history of smoking (or quit smoking less than 15 years ago). Screening generally should continue through age 80. However, it may be discontinued in patients who develop other conditions that significantly limit life expectancy or the ability to tolerate aggressive therapy, especially surgery, for lung cancer.
Where is small cell lung cancer typically located?
Centrally in the lung. Small cell lung cancer tends to have bulky adenopathy.
What demographic is most commonly affected by small cell lung cancer?
Older patients with a history of smoking.
Is small cell lung cancer surgically resectable?
No, it is treated with chemotherapy and radiation.
What paraneoplastic syndromes are associated with small cell lung cancer?
- SIADH (syndrome of inappropriate ADH), which leads to hyponatremia.
- Lambert-Eaton syndrome, which causes proximal muscle weakness that improves with use.
- Ectopic ACTH production (Cushing’s syndrome).
How are the MAJOR paraneoplastic syndromes secondary to small cell lung cancer managed?
Look at the image (lol).
How is SIADH managed when it is secondary to small cell lung cancer?
The hyponatremia that arises in SIADH is secondary to the combination of water retention and the loss of sodium and potassium. In chronic SIADH, the loss of sodium is more significant than the amount of water retained. Unless there are neurologic symptoms arising from the hyponatremia, it should be corrected slowly with water restriction. Once water restriction is initiated, the plasma sodium concentration will slowly begin to normalize. An ideal rate of increase is 0.5 mEq/h. Patients must be simultaneously monitored for volume depletion as a sodium deficit may become apparent, requiring concomitant administration of salt. Water restriction (with the possible inclusion of salt administration) is the preferred means of correcting mild to moderate hyponatremia associated with SIADH.
Alternative medications:
- Furosemide lowers the urine osmolality and blunts renal response to ADH, thereby increasing water excretion. Since loop diuretics decrease NaCl reabsorption in the loop of Henle, they should be administered concomitantly with hypertonic saline or salt tablets.
- Hydrochlorothiazide may induce hyponatremia, typically within a few weeks of starting therapy. Thiazides cause the loss of both sodium and water, and when the water is better replaced than the sodium, hyponatremia ensues.
- Demeclocycline and lithium work to blunt the response of the collecting tubule cells to ADH, ultimately increasing the excretion of water. These drugs are indicated in patients with persistent severe hyponatremia when water restriction, salt intake, or loop diuretics fail to resolve the condition. Although it is potentially nephrotoxic, demeclocycline is typically preferred to lithium because it is more effective and less toxic.
What oncogene is associated with small cell lung cancer?
MYC oncogene mutation. The cancer arises from Kulchitsky cells in the basal bronchial epithelium with neuroendocrine biomarkers positive for neuron-specific enolase, chromogranin A, synaptophysin and CD56.
Small cell has early metastasis to the … ?
brain, liver, and bone.
What are the major types of non-small cell lung cancer (NSCLC)?
Squamous cell carcinoma, adenocarcinoma, and large cell carcinoma.
Where is squamous cell lung cancer typically located?
Centrally in the lung, arising from the bronchus.
What radiologic feature is associated with squamous cell carcinoma?
Cavitation (usually if peripheral).
What paraneoplastic syndrome is associated with squamous cell carcinoma?
PTHrP (parathyroid hormone-related peptide) leading to hypercalcemia.
What mutation is associated with squamous cell carcinoma?
p53 mutation and P450 activation.
What is the most common type of lung cancer overall?
Adenocarcinoma. Commonly occurs with females. This type of lung cancer is common is both smokers and non-smokers and is associated with EGFR, ALK, and KRAS mutations (targetable mutations in some cases).
Where is adenocarcinoma typically located?
Peripheral lung.
What is a distinct histologic subtype of adenocarcinoma with better prognosis?
Bronchoalveolar carcinoma.
What paraneoplastic syndrome is associated with adenocarcinoma?
Hypercoagulability (DVTs, thromboembolism, and migratory thrombophlebitis).
What genetic mutations are associated with adenocarcinoma?
EGFR, KRAS, and ALK mutations. Usually stain positive for mucin.
What additional conditions are associated with adenocarcinoma?
Strong association with smoking. Hypercoagulability, Hypertrophic osteoarthropathy, and non-bacterial verrucous endocarditis (marantic endocarditis). Common to have distant metastasis.
Which form of adenocarcinoma has the best prognosis?
Lepidic. Bronchoalveolar has improved prognosis.
Where is large cell carcinoma typically located?
Peripheral lung.
What paraneoplastic syndrome is associated with large cell carcinoma?
Increased β-hCG leading to gynecomastia.
What is the prognosis of large cell carcinoma?
Poor prognosis due to undifferentiated nature.These are poorly differentiated, a diagnosis of exclusion and require surgical resection.
Where is bronchial carcinoid tumor located?
Can be central or peripheral.
What is the prognosis of bronchial carcinoid tumor?
Excellent prognosis, rare metastasis.
What symptoms are associated with carcinoid syndrome?
Flushing, diarrhea, and wheezing due to serotonin secretion.
What are common clinical symptoms of lung cancer?
Cough, hemoptysis, wheezing, dyspnea, recurrent pneumonia, weight loss, and fever.
What are complications of lung cancer due to mass effect?
Hoarseness (recurrent laryngeal nerve compression), superior vena cava syndrome, Horner syndrome, and pleural effusion.
What is the first step in evaluating a lung nodule found on chest X-ray?
Compare with previous imaging and perform a chest CT.
What is the best imaging study is for suspected lung cancer?
Chest CT.
How is lung cancer confirmed?
Biopsy via bronchoscopy (central tumors) or CT-guided biopsy (peripheral tumors).
What procedure is used for mediastinal lymph node sampling?
Endobronchial ultrasound (EBUS).
What is the primary treatment for small cell lung cancer?
Chemotherapy with prophylactic cranial radiation. Immunotherapy also used.
What is the primary treatment for non-small cell lung cancer?
Surgery with or without chemotherapy and radiation.
Are non-small cell lung cancers sensitive to chemotherapy?
No, they are primarily treated with surgical resection. A solitary lesion that metastases to the brain would require surgical removal.
What FEV1 level is required for surgical resection of non-small cell lung cancer?
FEV1 >800 mL.
What radiological features increase the risk of lung cancer?
Certain patterns of calcification within the pulmonary nodule are strongly suggestive of benign lesions, including popcorn, concentric or laminated, central, and diffuse homogeneous calcifications. Popcorn calcification is characteristically seen on radiographic imaging in patients with pulmonary hamartoma. Eccentric calcification (area of asymmetric calcification), as well as reticular or punctate calcification, should raise suspicion for malignancy.
What size lung nodules require no follow-up?
Nodules <0.6 cm with benign features (smooth, calcified, evidence of fat), and low risk profile (Age < 40, a never smoker)
What features increase suspicion for malignancy in lung nodules?
Age older than 40, History of smoking, size >2 cm, upper lobe location, scalloped or spiculated appearance (Irregular borders).
How is a lesion 0.6 to 0.8 cm managed?
serial CT
How is a lesion 0.8 cm or larger managed?
If low risk, repeat CT in 3 months
If high risk, preform biopsy
What is the management of a high-risk pulmonary nodule (>2 cm, speculated, smoker)?
Biopsy or surgical resection.
What are the most common risk factors for developing mesothelioma?
Mesothelioma is strongly associated with occupational exposure:
- Shipbuilding
- Cement workers
- Brake pad workers
What is the most common lung cancer following asbestos exposure?
Bronchogenic carcinoma, not mesothelioma.
Where do the tumors of mesothelioma tend to develop, what type of processes ensue?
Mesothelioma is a rare neoplasm arising from the mesothelial surface of the pleural cavity. Tumors primarily form on the pleura, but other mesothelial surfaces can be affected including the peritoneum, tunica vaginalis, and pericardium. Mesothelioma also commonly presents with pleural effusion and pleural thickening or calcifications. Malignant pleural mesotheliomas tend to present after weeks or months of nonspecific symptoms including cough, dyspnea, weight loss, night sweats, and fatigue. Pleural effusion is almost always present and is typically noted on physical examination (eg, dullness to percussion) and chest x-ray. Pleural fluid analysis often shows an exudative effusion that tends to have low pH and glucose levels; cytology may be negative. Most patients also have pleural thickening, calcifications, and/or mass.
At what point in time do symptoms of mesothelioma typically appear?
The symptoms of mesothelioma tend to manifest years after exposure. Symptoms of mesothelioma typically appear 20 to 50 years after asbestos exposure due to its long latency period. This delayed onset is a hallmark of the disease, often leading to late-stage diagnosis when symptoms like dyspnea, pleuritic chest pain, and pleural effusions become clinically apparent. Malignant pleural mesotheliomas with an exudative effusion often present after weeks or months of nonspecific symptoms including cough, dyspnea, weight loss, night sweats, and fatigue.
What imaging findings suggest mesothelioma?
Unilateral pleural thickening, pleural calcifications, or pleural effusion on CT.
How is a diagnosis established for mesothelioma?
Pleural effusion is almost always present and is typically noted on physical examination (eg, dullness to percussion) and chest x-ray. Pleural fluid analysis often shows an exudative effusion that tends to have low pH and low glucose levels; cytology may be negative. Most patients also have pleural thickening, calcifications, and/or mass. Definitive diagnosis can sometimes (~35%) be made using thoracentesis with cytology, but most cases require video-assisted thorascopic biopsy or open thoracotomy.
What is the treatment for mesothelioma?
Pleurectomy or radical pneumonectomy with chemotherapy. Treatment with surgery, systemic chemotherapy, and/or radiotherapy is often palliative, as cures are uncommon.
What is the prognosis for mesothelioma?
Median survival is 9-13 months.
What targeted therapies are used for lung cancer?
PD-L1 inhibitors (immunotherapy), EGFR inhibitors, KRAS inhibitors, and ALK inhibitors.
What type of lung cancer is commonly treated with EGFR inhibitors?
Adenocarcinoma with EGFR mutation.
What is the role of immunotherapy in lung cancer?
PD-1/PD-L1 inhibitors improve survival in advanced non-small cell lung cancer.
What is a Pancoast tumor?
A tumor that arises in the superior sulcus of the lung, often invading nearby structures such as the brachial plexus, sympathetic chain, and cervical/thoracic nerves.
What type of lung cancer is most commonly associated with Pancoast tumors?
Non-small cell lung cancer (NSCLC), particularly squamous cell carcinoma and adenocarcinoma.
Can small cell lung cancer (SCLC) cause Pancoast tumors?
SCLC can rarely cause Pancoast tumors, but NSCLC is more commonly implicated.
What are the classic symptoms of a Pancoast tumor?
Shoulder pain, arm pain, weakness, paresthesias (due to brachial plexus involvement), Horner syndrome (ptosis, miosis, anhidrosis), and possible phrenic nerve palsy (leading to diaphragmatic paralysis).
What is the mechanism of shoulder and arm pain in Pancoast tumors?
Compression or invasion of the brachial plexus (C8-T2 nerve roots), causing pain, weakness, and sensory deficits in the ulnar nerve distribution.
How does Pancoast tumor cause Horner syndrome?
Compression of the stellate ganglion (part of the sympathetic chain) leads to ptosis, miosis, and anhidrosis on the affected side.
What is superior vena cava (SVC) syndrome, and how is it related to Pancoast tumors?
Compression of the SVC leads to facial/arm edema, venous distension in the neck and upper chest, and dyspnea. Pancoast tumors can cause SVC syndrome, but it is more commonly associated with small cell lung cancer (SCLC).
What are the diagnostic tests for Pancoast tumor?
Chest X-ray (initial test, may show apical mass), CT or MRI (for detailed assessment of local invasion), and biopsy (bronchoscopy or percutaneous approach for histologic diagnosis).
What is the treatment for Pancoast tumors?
Multimodal approach: Chemoradiation followed by surgical resection (if resectable). In advanced cases, palliative radiation and chemotherapy are used.
What is the prognosis for Pancoast tumors?
Better prognosis compared to other lung cancers if detected early and surgically resectable, but poor if brachial plexus or vertebral bodies are extensively involved.
What are the three compartments of the mediastinum?
Anterior, middle, and posterior mediastinum.
What are the primary structures located in the anterior mediastinum?
Thymus, internal mammary arteries, lymph nodes.
What are the primary structures located in the middle mediastinum?
Pericardium, heart, aorta, trachea, esophagus, lymph nodes.
What are the primary structures located in the posterior mediastinum?
Spinal column, nerves, spinal ganglia.
What are the most common masses in the anterior mediastinum?
The ‘4 T’s’: Thymoma, Teratoma, Thyroid masses, and (T-cell) Lymphoma.
What is the most common anterior mediastinal tumor?
Thymoma.
What paraneoplastic syndrome is associated with thymoma?
Myasthenia gravis (autoantibodies against the acetylcholine receptor).
What imaging modality is best for evaluating a mediastinal mass?
Contrast-enhanced CT scan.
What marker is elevated in non-seminomatous germ cell tumors?
Alpha-fetoprotein (AFP) and β-hCG. These are midline tumors (Yolk sac tumors, choriocarcinoma, embryonal carcinoma, and mixed germ cell tumor)
Which mediastinal mass is associated with elevated β-hCG?
Germ cell tumors (teratoma, seminoma, choriocarcinoma).
What are common masses found in the middle mediastinum?
Bronchogenic cysts, lymphadenopathy, pericardial cysts, and enteric cysts.
What is a bronchogenic cyst?
A congenital cyst arising from abnormal budding of the foregut during development, typically found in the middle mediastinum.
What imaging findings are seen in a bronchogenic cyst?
A well-circumscribed, fluid-filled lesion on CT scan.
What are common causes of lymphadenopathy in the middle mediastinum?
Sarcoidosis, tuberculosis, lymphoma, and metastatic cancer.
What are the most common tumors in the posterior mediastinum?
Neurogenic tumors, including schwannomas, neurofibromas, and ganglioneuromas.
What pediatric tumor is commonly found in the posterior mediastinum?
Neuroblastoma. These tumors arise from primitive sympathetic ganglion cells most commonly adrenal, paravertebral, or in the posterior mediastinum. They are the most common neoplasm and infants where more than half of the patients present before 2 years old.
What syndrome is associated with neuroblastoma?
Opsoclonus-myoclonus syndrome (‘dancing eyes, dancing feet’). Often however they are asymptomatic. They can present with an abdominal mass with pain, constipation, bone pain and periorbital ecchymosis. The preferred imaging is with ultrasound and the screening test involves urine or serum catecholamines (increased VMA or HVA). A biopsy is informatory with small basophilic cells in rosettes. Treatment is surgical resection with or without chemo radiation and immunotherapy. The prognosis is variable and depends on histology and genetic factors (NMyc). There is a strong association with NF-1 and Beckwith Wiedemann.
What imaging findings are seen with neurogenic tumors?
Well-defined paraspinal masses that may extend into the spinal canal (dumbbell-shaped).
What are symptoms of a posterior mediastinal mass?
Back pain, Horner syndrome, and compressive myelopathy if spinal involvement occurs.
What symptom is common in mediastinal masses due to compression of the superior vena cava?
Facial swelling, dilated neck veins, and upper extremity swelling (SVC syndrome).
What is the best diagnostic step for a suspected mediastinal mass?
Contrast-enhanced CT to assess location, size, and involvement of adjacent structures.
When is biopsy indicated for a mediastinal mass?
If imaging suggests malignancy, biopsy via CT-guided, mediastinoscopy, or surgical excision.
What is the treatment for symptomatic mediastinal masses?
Surgical resection, chemotherapy, or radiation depending on histology.
