Lung Cancer Overview and Preop Eval Short

Question 1

Characteristics of lung adenocarcinoma

Answer 1

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

Question 2

What is bronchoalveolar ca

Answer 2

indolant, non-invasive, variant of adenocarcinoma

Question 3

Characteristics of lung SCC

Answer 3

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 4

Characteristics of large cell lung ca

Answer 4

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

Question 5

Characteristics of SCLC

Answer 5

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

Question 6

2 neuroendocrine tumor associated lung cancers

Answer 6

1. SCLC
2. Carcinoid

Question 7

Most common presenting symptoms of lung ca

Answer 7

Weight loss
Fatigue
Cough
Dyspnea
Hemoptysis

Question 8

Paraneoplastic syndroms MC with what lung cancer types

Answer 8

SCLC (SIADH)
SCC (hypercalcemia, PTHRP)

Question 9

SVC synrome MC with what lung cancer type

Answer 9

SCLC (bulky upper lobe tumor)

Question 10

MC metastatic symproms

Answer 10

Neurologic (headache)
Bone pain

Question 11

General approach to cancer management

Answer 11

Name
Stage
Treat

Question 12

Approach to diagnosis (Name) of lung ca

Answer 12

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 13

Lung cancer staging based on

Answer 13

TNM classification

Question 14

Lung ca (T-stage)

Answer 14

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 15

Lung ca (N-stage)

Answer 15

N1: Ipsilateral peribronchial, hilar, intrapulmonary LN

N2: Ipsilateral mediastinal/subcarinal LN

N3:

• Contralateral mediastinal/hilar LN
• Ipsilateral/contraleral scalene or supraclavicluar LN

Question 16

Lung ca (M-stage)

Answer 16

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 17

AJCC lung cancer staging

Answer 17

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 18

Staging options for lung ca

Answer 18

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 19

MC site for NSCLC distant mets

Answer 19

Brain

Question 20

Preoperative risk assessment for lung cancer includes

Answer 20

Overall functional status (Zubrod)
Comorbidities
Pulmonary function
Cardiac evaluation

Question 21

Classic spiromety findings used to determine lung cancer resectability

Answer 21

Moratlity < 5% when:

FEV1 > 1.5L (lobectomy)
FEV > 2L (pneumonectomy)

Question 22

Postoperative Predicted Pulmonary Function should be determined when

Answer 22

Preoperative FEV1 or DLCO < 80% predicted

Question 23

Determination of Postoperative Predicted Pulmonary Function

Answer 23

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

Question 24

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

Answer 24

PPFEV1 or PPDLCO < 40%

Should undergo preoperative cardiopulmonary exercise testing (CPET)

Question 25

Most specific predictor of postoperative pulmonary complicatations related to lung resection

Answer 25

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

Question 26

Alternatives to CPET to evaluate cardiopulmonary reserve preop

Answer 26

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

Question 27

Lung cancer screening guidelines 2021

Answer 27

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 28

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

Answer 28

* 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 29

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

Answer 29

* 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 30

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

Answer 30

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

Question 31

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

Answer 31

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

Question 32

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

Answer 32

* 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 33

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

Answer 33

no routine follow-up required

Question 34

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

Answer 34

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

Question 35

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

Answer 35

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

Question 36

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

Answer 36

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

Question 37

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

Answer 37

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

Question 38

Fleischner Society pulmonary nodule recommendations: Guideline Exclusions

Answer 38

* 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 39

Fleischner Society pulmonary nodule recommendations: Risk Assessment

Answer 39

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.