Lung Cancer Overview and Preop Eval Flashcards
The overall chance of developing lung ca (men and women)
Men: 8%
Women: 6%
At risk patient populations for lung ca
Men
African Americans
Low SE class
Most important RF for lung ca
Smoking (~85% of cases)
Active smoker has _ fold increase in risk of developing lung ca?
16-fold increase
(risk directely correlated to quanitity and duration of smoking)
% reduction in lung cancer mortatity risk with smoking cessation > 10 years
30-50% reduction
Enviornmental carcinogens account for _ % of lung cancers
10%
(asbestos, radon, tar, soot, arsenic, chromium, nickel)
Inherited lung ca susceptibility may be linked to what chromosome
chromosome 6
Genetic markers linked to lung ca
k-ras (earlier distant mets and worse NSCLC prognosis)
EGFR ( linked to adenoca)
c-myc (linked to SCLC)
Results of National Lung Screening Trial
20% reduction in lung cancer deaths among high-risk patients screened with low-dose helical CT compared to CXR
3 major WHO categories for lung ca
- NSCLC (most common, ~ 85%)
- SCLC
- Mixed epithelial lung ca
NSCLC types (3)
- Adenocarcinoma (MC)
- SCC
- Large cell ca (10-15%)
Characteristics of lung adenocarcinoma
- MC histologic type in non-smokers
- Peripheral distribution
- Cytokeritin 7 and thyroid transcription factor-1 (TTF-1)
What is bronchoalveolar ca
indolant, non-invasive, variant of adenocarcinoma
Characteristics of lung SCC
- Usually arise in major bronchi
- Discrete smoking dose-response relationship
- Assoc with necrosis and cavitary lesions
- Cytokeratin pearls on histology
Characteristics of large cell lung ca
- 10-15% of lung ca
- Large, peripheral mass on CXR
Characteristics of SCLC
- 15-20% of lung ca
- Usually metastatic at time of dx
- Poor prognosis
- Neuroendocrine type of lung ca
2 neuroendocrine tumor associated lung cancers
- SCLC
- Carcinoid
Most common presenting symptoms of lung ca
Weight loss
Fatigue
Cough
Dyspnea
Hemoptysis
Paraneoplastic syndroms MC with what lung cancer types
SCLC (SIADH)
SCC (hypercalcemia, PTHRP)
SVC synrome MC with what lung cancer type
SCLC (bulky upper lobe tumor)
MC metastatic symproms
Neurologic (headache)
Bone pain
General approach to cancer management
Name
Stage
Treat
Approach to diagnosis (Name) of lung ca
Histologic confirmation (Name) mandatory:
- Sputum cytology
- Bronch with bx
- EBUS with bx
- FNA
- CT guided FNA
- Surgical bx
Lung cancer staging based on
TNM classification
Lung ca (T-stage)
T1: < 3 cm (T1a: < 2cm, T1b 2-3 cm)
- surrounded by visceral pleura
- involvment of lobar (not main) bronchus
T2: 3-7cm (T2a: 3-5 cm, T2b: 5-7 cm)
- involvement of main bronchus (> 2cm from carina)
- invasion of visceral pleura
- atelectaiss or obstructive pneumonitis (< entire lung)
T3: > 7 cm
- invasion of CW, diaphragm, phrenic n, mediastinal pleura, parietal pleura
- involvement of main bronchus (< 2cm from carina, not involving carina itself)
- atelectasis or obstructive pneumonitis (entire lung)
- separate tumor nodules in same lobe
T4:
- invasion of mediastinum, heart, great vessels, trachea, RLN, esophagus, vertebral body
- involvement of carina
- separate tumor nodules in different, ipsilateral lobes
Lung ca (N-stage)
N1: Ipsilateral peribronchial, hilar, intrapulmonary LN
N2: Ipsilateral mediastinal/subcarinal LN
N3:
- Contralateral mediastinal/hilar LN
- Ipsilateral/contraleral scalene or supraclavicluar LN
Lung ca (M-stage)
M1: Distant mets
M1a:
- Separate tumor nodule in contralateral lobe
- Tumor with pleural nodules
- Malignant pleural or pericardial effusion
M1b: distant mets (liver, bone, brain, adrenal)
AJCC lung cancer staging
Stage I: T1-T2, N0, M0
Stage II:
- T1-2 with N1 disease (MO)
- T2b or T3 alone (NO, MO)
Stage III:
- N2 or N3 disease
- T3 with LN (N1-3)
- T4 alone
Stage IV: M1 disease (M1a or M1b)
Staging options for lung ca
- Mediastinoscopy with LN bx (gold standard for N2 disease)
- PET-CT
- EBUS and esophageal US-guided bx
- MRI brain (brain mets) [T1b (2cm) or greater]
- Bone scan (bone mets)
- Abdominal CT and LFTs (liver and adrenal mets)
MC site for NSCLC distant mets
Brain
Preoperative risk assessment for lung cancer includes
Overall functional status (Zubrod)
Comorbidities
Pulmonary function
Cardiac evaluation
Classic spiromety findings used to determine lung cancer resectability
Moratlity < 5% when:
FEV1 > 1.5L (lobectomy)
FEV > 2L (pneumonectomy)
Postoperative Predicted Pulmonary Function should be determined when
Preoperative FEV1 or DLCO < 80% predicted
Determination of Postoperative Predicted Pulmonary Function
- Anatomic calculation
- Quantitative CT
- Ventilation and/or perfusion scan
Patients with Postoperative Predicted FEV1 or DLCO less than _% are at increased risk of perioperative death or cardiopulmonary complicaitons
PPFEV1 or PPDLCO < 40%
Should undergo preoperative cardiopulmonary exercise testing (CPET)
Most specific predictor of postoperative pulmonary complicatations related to lung resection
Maximal oxygen consumption (VO2 max) measurement
VO2 max > 15ml/kg/min >> low risk
FEV1/DLCO < 40% and VO2 max < 15 >> very high risk
Alternatives to CPET to evaluate cardiopulmonary reserve preop
- Shuttle walk test
- Stair-climb test
- 6-minute walk test
Lung cancer screening guidelines 2021
Adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years:
- Screen for lung cancer with low-dose computed tomography (CT) every year.
- Stop screening once a person has not smoked for 15 years or has a health problem that limits life expectancy or the ability to have lung surgery.
Fleischner Society pulmonary nodule recommendations:
Single solid nodule <6 mm (<100 mm3)
- low-risk patients: no routine follow-up required
- high-risk patients: optional CT at 12 months (particularly with suspicious nodule morphology and/or upper lobe location; see “risk assessment” below)
Fleischner Society pulmonary nodule recommendations:
Solitary solid nodule 6-8 mm (100-250 mm3)
- low-risk patients: CT at 6-12 months, then consider CT at 18-24 months
- high-risk patients: CT at 6-12 months, then CT at 18-24 months
Fleischner Society pulmonary nodule recommendations:
Solitary solid nodule >8 mm
low-risk and high-risk patients: consider CT at 3 months, PET/CT, or tissue sampling.
Fleischner Society pulmonary nodule recommendations:
Multiple solid nodules <6 mm
- low-risk patients: no routine follow-up required
- high-risk patients: optional CT at 12 months
Fleischner Society pulmonary nodule recommendations:
Multiple solid nodules >6 mm
- low-risk patients: CT at 3-6 months, then consider CT at 18-24 months
- high-risk patients: CT at 3-6 months, then CT at 18-24 months
When multiple nodules are present, the most suspicious nodule should guide further individualized management.
Fleischner Society pulmonary nodule recommendations:
Single ground glass nodule <6 mm
no routine follow-up required
Fleischner Society pulmonary nodule recommendations:
Single ground glass nodule ≥6 mm
CT at 6-12 months, then if persistent, CT every 2 years until 5 years
Fleischner Society pulmonary nodule recommendations:
Single part-solid nodule ≥6 mm
CT at 3-6 months, then if persistent and solid component remains <6 mm, annual CT until 5 years
Fleischner Society pulmonary nodule recommendations:
Multiple subsolid nodules <6 mm
CT at 3-6 months, then if stable consider CT at 2 and 4 years in high-risk patients
Fleischner Society pulmonary nodule recommendations:
Multiple subsolid nodules ≥6 mm
CT at 3-6 months, then subsequent management based on the most suspicious nodule(s).
Fleischner Society pulmonary nodule recommendations:
Guideline Exclusions
- patients aged 35 years or younger
- considered to have an overall low risk for pulmonary malignancy
- in this age group, nodules are most likely to be infectious rather than cancer
- management of incidentally-found pulmonary nodules in this group should be individualized
- patients with known malignancy
- an incidentally-detected pulmonary nodule is more likely to be cancer-related than in the general population
- immunocompromised patients
- higher risk for opportunistic pulmonary infections
- lung cancer screening population
- these patients are on active screening due to a high-risk for lung cancer development, usually current and former smokers, and, therefore, should have their scans reported accordingly to Lung-RADS
Fleischner Society pulmonary nodule recommendations:
Risk Assessment
The guidelines recommend considering high-risk as an estimated risk of cancer >5%.
Suggested risk factors to consider include older age, heavy smoking, irregular or spiculated margins, and upper lobe location.
