Lung Cancer Overview and Preop Eval

Question 1

The overall chance of developing lung ca (men and women)

Answer 1

Men: 8%
Women: 6%

Question 2

At risk patient populations for lung ca

Answer 2

Men
African Americans
Low SE class

Question 3

Most important RF for lung ca

Answer 3

Smoking (~85% of cases)

Question 4

Active smoker has _ fold increase in risk of developing lung ca?

Answer 4

16-fold increase

(risk directely correlated to quanitity and duration of smoking)

Question 5

% reduction in lung cancer mortatity risk with smoking cessation > 10 years

Answer 5

30-50% reduction

Question 6

Enviornmental carcinogens account for _ % of lung cancers

Answer 6

10%

(asbestos, radon, tar, soot, arsenic, chromium, nickel)

Question 7

Inherited lung ca susceptibility may be linked to what chromosome

Answer 7

chromosome 6

Question 8

Genetic markers linked to lung ca

Answer 8

k-ras (earlier distant mets and worse NSCLC prognosis)

EGFR ( linked to adenoca)

c-myc (linked to SCLC)

Question 9

Results of National Lung Screening Trial

Answer 9

20% reduction in lung cancer deaths among high-risk patients screened with low-dose helical CT compared to CXR

Question 10

3 major WHO categories for lung ca

Answer 10

1. NSCLC (most common, ~ 85%)
2. SCLC
3. Mixed epithelial lung ca

Question 11

NSCLC types (3)

Answer 11

1. Adenocarcinoma (MC)
2. SCC
3. Large cell ca (10-15%)

Question 12

Characteristics of lung adenocarcinoma

Answer 12

1. MC histologic type in non-smokers
2. Peripheral distribution
3. Cytokeritin 7 and thyroid transcription factor-1 (TTF-1)

Question 13

What is bronchoalveolar ca

Answer 13

indolant, non-invasive, variant of adenocarcinoma

Question 14

Characteristics of lung SCC

Answer 14

1. Usually arise in major bronchi
2. Discrete smoking dose-response relationship
3. Assoc with necrosis and cavitary lesions
4. Cytokeratin pearls on histology

Question 15

Characteristics of large cell lung ca

Answer 15

1. 10-15% of lung ca
2. Large, peripheral mass on CXR

Question 16

Characteristics of SCLC

Answer 16

1. 15-20% of lung ca
2. Usually metastatic at time of dx
3. Poor prognosis
4. Neuroendocrine type of lung ca

Question 17

2 neuroendocrine tumor associated lung cancers

Answer 17

1. SCLC
2. Carcinoid

Question 18

Most common presenting symptoms of lung ca

Answer 18

Weight loss
Fatigue
Cough
Dyspnea
Hemoptysis

Question 19

Paraneoplastic syndroms MC with what lung cancer types

Answer 19

SCLC (SIADH)
SCC (hypercalcemia, PTHRP)

Question 20

SVC synrome MC with what lung cancer type

Answer 20

SCLC (bulky upper lobe tumor)

Question 21

MC metastatic symproms

Answer 21

Neurologic (headache)
Bone pain

Question 22

General approach to cancer management

Answer 22

Name
Stage
Treat

Question 23

Approach to diagnosis (Name) of lung ca

Answer 23

Histologic confirmation (Name) mandatory:

1. Sputum cytology
2. Bronch with bx
3. EBUS with bx
4. FNA
5. CT guided FNA
6. Surgical bx

Question 24

Lung cancer staging based on

Answer 24

TNM classification

Question 25

Lung ca (T-stage)

Answer 25

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

Question 26

Lung ca (N-stage)

Answer 26

N1: Ipsilateral peribronchial, hilar, intrapulmonary LN N2: Ipsilateral mediastinal/subcarinal LN N3: - Contralateral mediastinal/hilar LN - Ipsilateral/contraleral scalene or supraclavicluar LN

Question 27

Lung ca (M-stage)

Answer 27

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)

Question 28

AJCC lung cancer staging

Answer 28

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)

Question 29

Staging options for lung ca

Answer 29

1. Mediastinoscopy with LN bx (gold standard for N2 disease) 2. PET-CT 3. EBUS and esophageal US-guided bx 4. MRI brain (brain mets) [T1b (2cm) or greater] 5. Bone scan (bone mets) 6. Abdominal CT and LFTs (liver and adrenal mets)

Question 30

MC site for NSCLC distant mets

Answer 30

Brain

Question 31

Preoperative risk assessment for lung cancer includes

Answer 31

Overall functional status (Zubrod) Comorbidities Pulmonary function Cardiac evaluation

Question 32

Classic spiromety findings used to determine lung cancer resectability

Answer 32

Moratlity \< 5% when: FEV1 \> 1.5L (lobectomy) FEV \> 2L (pneumonectomy)

Question 33

Postoperative Predicted Pulmonary Function should be determined when

Answer 33

Preoperative FEV1 or DLCO \< 80% predicted

Question 34

Determination of Postoperative Predicted Pulmonary Function

Answer 34

1. Anatomic calculation 2. Quantitative CT 3. Ventilation and/or perfusion scan

Question 35

Patients with Postoperative Predicted FEV1 or DLCO less than \_% are at increased risk of perioperative death or cardiopulmonary complicaitons

Answer 35

PPFEV1 or PPDLCO \< 40% Should undergo preoperative cardiopulmonary exercise testing (CPET)

Question 36

Most specific predictor of postoperative pulmonary complicatations related to lung resection

Answer 36

Maximal oxygen consumption (VO2 max) measurement VO2 max \> 15ml/kg/min \>\> low risk FEV1/DLCO \< 40% and VO2 max \< 15 \>\> very high risk

Question 37

Alternatives to CPET to evaluate cardiopulmonary reserve preop

Answer 37

1. Shuttle walk test 2. Stair-climb test 3. 6-minute walk test

Question 38

Lung cancer screening guidelines 2021

Answer 38

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.

Question 39

Fleischner Society pulmonary nodule recommendations: Single solid nodule \<6 mm (\<100 mm3)

Answer 39

* 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)

Question 40

Fleischner Society pulmonary nodule recommendations: Solitary solid nodule 6-8 mm (100-250 mm3)

Answer 40

* 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

Question 41

Fleischner Society pulmonary nodule recommendations: Solitary solid nodule \>8 mm

Answer 41

low-risk and high-risk patients: consider CT at 3 months, PET/CT, or tissue sampling.

Question 42

Fleischner Society pulmonary nodule recommendations: Multiple solid nodules \<6 mm

Answer 42

* low-risk patients: no routine follow-up required * high-risk patients: optional CT at 12 months

Question 43

Fleischner Society pulmonary nodule recommendations: Multiple solid nodules \>6 mm

Answer 43

* 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.

Question 44

Fleischner Society pulmonary nodule recommendations: Single ground glass nodule \<6 mm

Answer 44

no routine follow-up required

Question 45

Fleischner Society pulmonary nodule recommendations: Single ground glass nodule ≥6 mm

Answer 45

CT at 6-12 months, then if persistent, CT every 2 years until 5 years

Question 46

Fleischner Society pulmonary nodule recommendations: Single part-solid nodule ≥6 mm

Answer 46

CT at 3-6 months, then if persistent and solid component remains \<6 mm, annual CT until 5 years

Question 47

Fleischner Society pulmonary nodule recommendations: Multiple subsolid nodules \<6 mm

Answer 47

CT at 3-6 months, then if stable consider CT at 2 and 4 years in high-risk patients

Question 48

Fleischner Society pulmonary nodule recommendations: Multiple subsolid nodules ≥6 mm

Answer 48

CT at 3-6 months, then subsequent management based on the most suspicious nodule(s).

Question 49

Fleischner Society pulmonary nodule recommendations: Guideline Exclusions

Answer 49

* 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

Question 50

Fleischner Society pulmonary nodule recommendations: Risk Assessment

Answer 50

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.