Lung Cancer NM Flashcards
Lung cancer T
Lung cancer N
N1 - peribronchial or hilar or intrapulmonary
N2 - mediastinal or subcarinal
N3 - contralateral
Lung cancer M
Liver
Adrenal
Bone
Brain
M1a - separate nodule in contralateral lobe
M1b - single extra thoracic MTS
M1 multiple extra thoracic MTS
Central tumor
Cough
Dyspnea
Atelectasis
Post obstructive pneumonia
Wheezing
Hemoptysis
Peripheral tumor
Cough
Dyspnea
Severe pain (parietal pleura)
Superior vena cava syndrome
Facial edema
Dusky skin color
Conjunctival edema
Upper extremity edema
Upper chest wall veins retrograde flow
Pancoast syndrome
Compression of brachial plexus root
Intense radiating pain in hand
Horner syndrome
Ipsilateral ptosis, miosis, enophtalmos, anhidrosis
NSCLC 85-90%
Adenocarcinoma - - peripheral solitary nodule or mass
SCC - smoking, large central tumor
Large cell carcinoma
SCLC 15%
Men >60y, 99% smokers
Central location - - main bronch - - obstruction
Larger tumor - - cavitation - - aggressive with early mediastinal LN - - 80% respond to chemo
Never smoke
15% men
>50% women
EGFR mutation 15% adenocarcinoma
Non smokers
62% Asian - - good prognosis
Lung cancer risk
Smoking 80%. Passive smoking 25%
Asbestos - - 5-fold increase risk
Radon 2-3% annually
HIV - 6.5-fold increase risk
Emphysema, chronic bronchitis - - impact on treatment
Idiopathic pulmonary fibrosis - 3-7-fold increase risk, 20% develop cancer
Paraneoplastic syndrome
SCLC
SIADH,
Parat hormone - - hyperparathyroidism
Cushing - - ACTH
Hyponatremia - - ADH
Hypocalcemia - - Calcitonin
gynecomastia - - gonadotropins
Carcinoid - - serotonin
Encephalomyelitis
Lambert - Eaton sy
Sensory neuropathy
Paraneoplastic syndrome
Adenocarcinoma
Clubbing
Hypertrophic pulmonary osteoarthropathy
Trousseau sy of hypercoagulopathy
Dermatomyositis / polimyositis
Surgery
Lung cancer
No mediastinal disease or invasion
Stage I and II only NSCLC
Lobectomy
Poor pulmonary reserve or peripheral nodule <2 cm, >50% GGO or doubling time >400 days - - wedge resection
NSCLC treatment
Stage I-II - - surgical resection
Resectable stage III - - surgery, chemo, radio or combi
Unresectable stage IIIA - - chemo radio
Stage IV - - chemo, palliative radio
SCLC treatment
Chemo radio
Neoadjuvant chemo and Surgery for 5% T1-2N0-1M0
Adenocarcinoma
Consolidation with air bronchogram
Peripheral nodule with pleural tail
SCC
15% cavitation
Central/perihilar
Large cell carcinoma
Large peripheral mass with necrosis
CT
Extent of primary tumor
Chest wall invasion - - >3 cm contact
Mediastinal invasion - - >3 cm contact
Pleural/pericardial effusion
Separate nodules
Important for staging - around tumor, same lobe, other lobes, contralateral
CT
Nodal disease
Mediastinal >10 mm
Subcarinal >13-15 mm
Lymphangitic carcinomatosis - - mimic interstitial lung disease
CT distant MTS
Lung - - contralateral, pleural nodules, effusion
Adrenal - - >3 cm, HU>10, Irregular rim enhancement
Bone - - vertebra, ribs, pelvis
Lytic>blastic
Elevated Ca, AlcPhos
CT special scenario
2 separate lesions - - separate staging
Part-solid nodule - - adenocarcinoma with lepidic component
Patchy GGO, consolidation - - mucinous/lepidic adenocarcinoma
PET CT
Lung cancer
Most accurate
Limited for brain, can detect unexpected brain MTS >1.5 cm
Patients selected for Operation - - 24% MTS
Adrenal - - uptake >liver
Lepidic adenocarcinoma - -Tis - - minimal uptake
RECIST response criteria
Lung cancer
Unidimensional measurements
At least 1 measurable lesion at baseline
Min size 10 mm
After radio - - 3 months
MRI
Lung cancer
Most sensitive for brain MTS
Chest - - cardiac invasion, brachial plexus, vertebra
Subclavian vessels and carotid/vertebral artery - - precludes surgical resection
MRI
Lung cancer
Abs Contra surgery
Invasion of brachial plexus roots/trunks above T1
>50% vertebral body
Esophagus / trachea
NSCLC
Left hilar mass
Elevated left hemidiaphragm - - phrenic nerve involvement - - stage T3
Pancoast tumor
At least T3
T4 if invade brachial plexus, spine or great vessels
Paraneoplastic syndrome SCC
Hypercalcemia due to parathyroid like hormone
Cushing
Immunotherapy
Tumor shrinkage later than after chemo or targeted therapy
Temporal increase in tumor size - - pseudo progression
N2 treatment
Lung cancer
Most undergo mediastinoscopy
N2 negative after neoadjuvant - - critical for selection for thoracotomy
EUS-FNA - - no adequate visualization of lower paratracheal LN
Better - repeat FDG for restaging after neoadjuvant
Mesothelioma N
N1 - bronchopulmonary, hilar, mediastinal
N2 - contralateral mediastinal or supraclavicular LN
Nodal spread - - poor prognosis
Mesothelioma M
Lung
Peritoneum
Bone
Subcutaneous tissue
Liver
Mesothelioma presentation
Dyspnea
Unexplained Pleural effusion
Chest pain
Mesothelioma type
Epithelioid 55-65% - - best prognosis
Sarcomatoid 10-15% - - poor prognosis
Biphasic 20-35%
Desmoplastic 10%
Mesothelioma risk
Arise from mesothelium (peritoneum, pericardium, tunica Vaginalis)
Asbestos 80% - - latency >20 y
Prior radio
SV40 virus
Intrapleural Thorotrast
Mesothelioma surgery
Non Sarcomatoid (biopsy proven)
T1-3N0-1M0
Sufficient respiratory reserve
Fit to chemo radio
EPP = extrapleural pneumonectomy - - pleura, lung, pericardium, diaphragm
Pleurectomy / decortication - - symptom control, not cure
Mesothelioma treatment
Stage I, II, III - - EPP + chemo + postop radio
Stage III and IV unresectable - - palliative chemo and pleurodesis (sterile talc)
Chemo - - cisplatin, premetrexed
Immunotherapy - - pebrolizumab
Mesothelioma CT
Unilateral Pleural effusion 95%
Tumoral encasement of lung
Interlobular fissure thickening
Calcified pleural plaque 20%
Volume loss hemithorax
Pleural thickness >1 cm
Mesothelioma CT treatment response
Measure tumor thickness perpendicular to chest wall or mediastinum in 2 locations
Mesothelioma PET CT
High avid
SUV cutoff 3.0
Higher uptake - - shorter survival time
SUV >2.0 - - biopsy
>50% of circumference of vascular structure surrounded - - invasion
Recurrent SUV 8.9
Mesothelioma MRI
Assess local disease
Invasion of diaphragm, fascia, chest wall
Mesothelioma T1
Mesothelioma T1
Rind around lung
Mesothelioma T4
Mesothelioma T4N2
Thymus carcinoma M
Pleura
Lung
LN
Mediastinum (thymoma)
Bone (thymic cancer)
Liver (thymic cancer)
Thymoma
> 40 y
Slow grow
Risk of B lymphoma, GIT cancer, sarcoma after resection
Paraneoplastic - - 30% myasthenia gravis (10% наоборот), 30-50% pure red cell aplasia, 3-6% Good sy (hypogammaglobulinemia), glomerulonephritis, autoimmune hepatitis
Thymic carcinoma
50 y
More aggressive
Worse prognosis
Thymic NET
2-5%
Carcinoid
MEN1
Paraneoplastic - - Cushing, Lambert Eaton, carcinoid
Thymus biopsy
Not recommended
Seeding
Thymus CT
No dd thymoma vs thymic carcinoma
No matter size
Thymoma more homogenous
Thymoma - - encapsulated
Thymic carcinoma - - larger, with necrosis
Thymus PET CT
SUV >5.0 - - thymic carcinoma or lymphoma
SUV 2.0-4.0 benign
Thymus resectable
Invasion of innominate vein
Heart
Great vessels
Phrenic nerve
Thymus unresectable
Pleural or pericardial MTS
Distant disease
Chemo radio
Pulmonary nodule + high likelihood for malignancy by CT
Next step
Trans thoracic needle aspiration or thoracoscopy with wedge resection
Pulmonary nodule + low likelihood for malignancy by CT or Indeterminate
Next step
PET CT FDG
SUV mean cut off benign vs malignant pulmonary nodule
2.5
Negative PET
Excludes high grade lung carcinoma
% of nodules negative on PET that are malignant
5-10%
Normal size nodal MTS
15%
PET in mediastinal nodules
Negative - - no LN MTS
Positive - - still need diagnostic mediastinoscopy
Uptake of FDG correlates with
Tumor grade
Adenocarcinoma
Multifocal lung adenocarcinoma
Slow growth
Women, non smokers
Longer median survival
Sarcoidosis
