Lung Cancer - Clinical and Smoking Cessation

Question 1

What are the major occupational and environmental carcinogens predisposing to lung cancer?

Answer 1

Asbestos
Radon
Indoor smoke from cooking / heating
Air pollution / diesel exhaust

Question 2

Why does lung cancer tend to present so late in its course?

Answer 2

The lungs are not innervated, so often there is no pain until you have parietal pleural pain

Question 3

What is the best form of smoking cessation therapy and what are the best drugs for this?

Answer 3

Combination therapy - including behavioral and pharmacologic intervention

Drugs:

1. Nicotine replacement - i.e. Chantix
2. Varenicline
3. Bupropion

Question 4

Who should be screened for lung cancer?

Answer 4

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

Question 5

What is the protocol for lung cancer screening and its main problem?

Answer 5

Serial CT scans annually for three years

problem: high false positive rate

Question 6

How can lung cancer cause hoarseness?

Answer 6

Malignancy involves recurrent laryngeal nerve alongs its course under the arch of the aorta or the subclavian artery (right side) back to the larynx

Question 7

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?

Answer 7

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.

Question 8

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?

Answer 8

Superior vena cava syndrome

-> due to obstructing SVC causing a sensation of fullness in the head and dyspnea

Question 9

What is Pancoast syndrome? What two neurologic conditions are associated it?

Answer 9

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

Question 10

What are the most frequent sites where lung cancer metastasizes to?

Answer 10

Liver, adrenal glands, bones, and brain

Question 11

What lung cancers are known for causing hypercalcemia and how do they do it?

Answer 11

Squamous cell carcinoma > Adenocarcinoma > small cell carcinoma

Caused by secreted of parathyroid hormone-related protein (PTHrP), or straight calcitriol

Question 12

What endocrine paraneoplastic syndromes are most commonly associated with small cell carcinoma and how do these manifest clinically?

Answer 12

Syndrome of Inappropriate Antidiuretic Hormone (SIADH) -> causes hyponatremia

Excessive secretion of ACTH causing Cushing’s syndrome
-> moon facies, fluid retention, buffalo hump

Question 13

What cancer is associated with autoantibodies to presynaptic Ca+2 channels for ACh neurons and what is this called?

Answer 13

Lambert-Eaton myasthenic syndrome

Associated with small cell carcinoma

Question 14

How does the presentation of Lambert-Eaton myasthenic syndrome differ from Myasthenia gravis?

Answer 14

Lambert-Eaton will actually get better throughout the day, and also causes autonomic symptoms (dry mouth, impotence)

Cannot be reversed by an ACh inhibitor

Question 15

What lung cancer is especially associated with hypertrophic osteoarthropathy? What is it?

Answer 15

Adenocarcinoma

New bone formation on distal long bones causing arthritis, as well as clubbing of fingers

Question 16

How can small cell cancer cause neurological issues other than just ACh problems?

Answer 16

Formation of auto-antibodies to neurons

-> paraneoplastic myelitis, cerebellar ataxia, etc

Question 17

What two random musculoskeletal / skin conditions are associated with lung cancer and can reciprocally predispose to cancer?

Answer 17

Polymyositis and Dermatomyositis

Question 18

If you see lesions in lung, liver, and brain, where should you biopsy?

Answer 18

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

Question 19

How are biopsies typically done for lung cancer now, and what is the risk of the old way?

Answer 19

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

Question 20

How is NSCLC vs SCLC staged?

Answer 20

NSCLC - TNM scale (size, LN involvement, metastasis)

SCLC - limited or extensive.
Limited = confined to one hemithorax. Extensive = beyond one hemithorax.

Question 21

What should every patient with an NSCLC have done?

Answer 21

CT scan of chest and upper abdomen to evaluate extend of primary tumor and spread to mediastinum, liver, and adrenal glands

Question 22

How are early, middle, and advanced NSCLCs treated?

Answer 22

Early stage - surgical resection
Middle stage - resection + chemotherapy
Late - palliative chemotherapy

Question 23

How is SCLC treated?

Answer 23

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

Question 24

What is the treatment response pattern of SCLC to chemotherapy?

Answer 24

Initially responds very quickly and may even disappear, then comes back strong (like Mendy)

Question 25

What is the definition of a solitary pulmonary nodule (SPN) and some of the possible causes?

Answer 25

Spherical opacity on Xray that measures up to 3cm in diameter

Causes: lung cancer, metastases, scars, infections, other benign lesions

Question 26

What is the recommendation if you have an SPN, and what clinical factors are tied to highest risk of malignancy?

Answer 26

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

Question 27

What CT features make an SPN more likely to be malignant?

Answer 27

Large size, irregular border, lack of pattern of calcification, rapid growth (it is VERY important to look at old radiology in making this diagnosis)