Lung Cancer - Clinical and Smoking Cessation Flashcards
What are the major occupational and environmental carcinogens predisposing to lung cancer?
Asbestos
Radon
Indoor smoke from cooking / heating
Air pollution / diesel exhaust
Why does lung cancer tend to present so late in its course?
The lungs are not innervated, so often there is no pain until you have parietal pleural pain
What is the best form of smoking cessation therapy and what are the best drugs for this?
Combination therapy - including behavioral and pharmacologic intervention
Drugs:
- Nicotine replacement - i.e. Chantix
- Varenicline
- Bupropion
Who should be screened for lung cancer?
Those over age 55 who have a 30 pack-year history of smoking, and if they quit they’ve done so within the past 15 years
What is the protocol for lung cancer screening and its main problem?
Serial CT scans annually for three years
problem: high false positive rate
How can lung cancer cause hoarseness?
Malignancy involves recurrent laryngeal nerve alongs its course under the arch of the aorta or the subclavian artery (right side) back to the larynx
If a patient has what appears to be a malignancy with pleural involvement and your thoracentesis comes back negative for malignancy, what is your next step? What’s the prognosis for patients with pleural involvement?
Do the tap again -> it has a limited sensitivity and may be found on a second one
Prognosis -> very poor if you have malignant effusions. Goal will be palliative care.
A patient has severe lung cancer, and presents with dilated neck veins, prominent veins on their chest, and facial edema. What is their likely condition?
Superior vena cava syndrome
-> due to obstructing SVC causing a sensation of fullness in the head and dyspnea
What is Pancoast syndrome? What two neurologic conditions are associated it?
Condition caused by lung cancers arising in the superior sulcus (apex of the lung) which interrupts the sympathetic trunk or brachial plexus nearby.
Sympathetic trunk - superior cervical ganglion interruption - Horner’s syndrome
Brachial plexus pain - pain of shoulder, forearm, scapula, and fingers
What are the most frequent sites where lung cancer metastasizes to?
Liver, adrenal glands, bones, and brain
What lung cancers are known for causing hypercalcemia and how do they do it?
Squamous cell carcinoma > Adenocarcinoma > small cell carcinoma
Caused by secreted of parathyroid hormone-related protein (PTHrP), or straight calcitriol
What endocrine paraneoplastic syndromes are most commonly associated with small cell carcinoma and how do these manifest clinically?
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) -> causes hyponatremia
Excessive secretion of ACTH causing Cushing’s syndrome
-> moon facies, fluid retention, buffalo hump
What cancer is associated with autoantibodies to presynaptic Ca+2 channels for ACh neurons and what is this called?
Lambert-Eaton myasthenic syndrome
Associated with small cell carcinoma
How does the presentation of Lambert-Eaton myasthenic syndrome differ from Myasthenia gravis?
Lambert-Eaton will actually get better throughout the day, and also causes autonomic symptoms (dry mouth, impotence)
Cannot be reversed by an ACh inhibitor
What lung cancer is especially associated with hypertrophic osteoarthropathy? What is it?
Adenocarcinoma
New bone formation on distal long bones causing arthritis, as well as clubbing of fingers
How can small cell cancer cause neurological issues other than just ACh problems?
Formation of auto-antibodies to neurons
-> paraneoplastic myelitis, cerebellar ataxia, etc
What two random musculoskeletal / skin conditions are associated with lung cancer and can reciprocally predispose to cancer?
Polymyositis and Dermatomyositis
If you see lesions in lung, liver, and brain, where should you biopsy?
Liver -> want to get the most distal & safe biopsy
- if you see small cell lung cancer in the liver, you can instantly assign the appropriate stage
- lung biopsy can do the patient harm
How are biopsies typically done for lung cancer now, and what is the risk of the old way?
Typically be bronchoscopy or endobronchial ultrasound (small probe with needle put down the trachea)
Old procedure - transthoracic needle biopsy - high risk of pneumothorax
Surgical biopsy - high risk in general
How is NSCLC vs SCLC staged?
NSCLC - TNM scale (size, LN involvement, metastasis)
SCLC - limited or extensive.
Limited = confined to one hemithorax. Extensive = beyond one hemithorax.
What should every patient with an NSCLC have done?
CT scan of chest and upper abdomen to evaluate extend of primary tumor and spread to mediastinum, liver, and adrenal glands
How are early, middle, and advanced NSCLCs treated?
Early stage - surgical resection
Middle stage - resection + chemotherapy
Late - palliative chemotherapy
How is SCLC treated?
Systemic chemotherapy, since it is pretty disseminated at presentation for most patients
If at limited stage -> use radiation in combination with chemotherapy
Prognosis is poor no matter what
What is the treatment response pattern of SCLC to chemotherapy?
Initially responds very quickly and may even disappear, then comes back strong (like Mendy)
What is the definition of a solitary pulmonary nodule (SPN) and some of the possible causes?
Spherical opacity on Xray that measures up to 3cm in diameter
Causes: lung cancer, metastases, scars, infections, other benign lesions
What is the recommendation if you have an SPN, and what clinical factors are tied to highest risk of malignancy?
Non-contrast CT scan of chest. If low-risk, follow by CT for 2 years. If high risk, excise it
Increased risk -> advanced patient age and significant smoking
What CT features make an SPN more likely to be malignant?
Large size, irregular border, lack of pattern of calcification, rapid growth (it is VERY important to look at old radiology in making this diagnosis)
