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Pulmonology and Thoracic surgery > Lung cancer, Pleural Disorders > Flashcards

Lung cancer, Pleural Disorders Flashcards

1
Q

Lung cancer

  • risk factors
  • prevention
A
  • main one: cigarette smoking
  • occupational factors: radon, asbestos, arsenic, chromium, vinyl chloride…
  • no smoking
  • screening as early as possible –> low dose spiral CT
  • problem: symptoms only begin when disease has already progressed a lot
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2
Q

Lung cancer

-2 major types

A
  1. Non-small cell (87%)
    - most cases tumor is only found when the disease has already progressed –> prognosis is bad
  2. Small cell
    - surgery is not possible
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3
Q

Lung cancer

  • symptoms
  • metastasis
A
  • non-specific
  • persistent cough, sputum with some blood, chest pain, voice change, recurrent pneumonia or bronchitis

-CNS, pleura, liver, bone, adrenals

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4
Q

Lung cancer

-diagnostics

A
  • bronchoscopy, transthoracic CT guided needle biopsy, radical probe EBUS
  • PET-CT –> if radical treatment is considered
  • Diagnosis should only be made after biopsy and pathologist’s confirmation
  • MRI of the head for SCLC, if symptoms, for stage 3 NSCLC
  • mediastinal staging
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5
Q

Lung cancer

-treatment options

A
  • surgery
  • never do surgery if the staging of lymph nodes came back positive
  • radiation
  • systemic therapy: chemo, immunotherapy…
  • much more effective to operate a person that has no symptoms –> prognosis is much better
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6
Q

Lung cancer

-treatment strategies for NSCLC

A
  • resectable –> stage I, II, and some III
  • unresectable –> stage III
  • surgery with or without chemo
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7
Q

Lung cancer

-Anaplastic lymphoma kinase

A
  • receptor tyrosine kinase that is normally not expressed in the lung
  • found in 4% of patients with NSCLC
  • more frequently in young and non-smoking patients
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8
Q

Lung cancer

-EGFT mutations

A
  • more commonly in severe smokers, adenocarcinomas, women, Asians
  • fond in 10-15% of lung cancer patients
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9
Q

SCLC vs. NSCLC

  • association with smoking:
  • growth kinetics:
  • early metastasis:
  • sensitivity to DNA damaging chemo:
  • sensitivity to radiotherapy:
  • advances in therapy:
A

SCLC

  • association with smoking: universal
  • growth kinetics: rapid
  • early metastasis: universal
  • sensitivity to DNA damaging chemo: high
  • sensitivity to radiotherapy: high
  • advances in therapy: few advances

NSCLC

  • association with smoking: highly variable
  • growth kinetics: variable
  • early metastasis: variable
  • sensitivity to DNA damaging chemo: variable
  • sensitivity to radiotherapy: variable
  • advances in therapy: dramatic advances
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10
Q

Pleural disorders

-pathogenesis (5)

A
  1. altered pleural membrane permeability
  2. decrease intravascular oncotic pressure
  3. increase capillary hydrostatic pressure
  4. lymphatic obstruction
  5. abnormal sites of entry
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11
Q

Pleural disorders

  • symptoms
  • physical exam
A

-cough, dyspnea, pain

  • dullness to percussion, decreased breath sounds, asymmetric chest expansion
  • decreased or absent vocal resonance and tactile vocal fremitus
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12
Q

Pleural disorders

-radiology (4)

A
  • x-ray: PA and lateral decub –> blunting of either costophrenic angle
  • ultrasound
  • CT: super sensitive, helps to see underlying lung, distinguish between lung abscess and empyema
  • MRI: pleural effusion, pleural tumor, chest wall invasion
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13
Q

Pleural disorders

-3 main questions that should be made

A
  1. should thoracocentesis be performed?
  2. if yes, is the fluid transudate or exudate?
  3. if exudate, what’s the etiology?
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14
Q

Pleural disorders

  • Thoracocentesis
    1. indications (2)
    2. contraindications (4)
A
  1. diagnostics (>10mm depth on lateral decubitus), therapeutically for symptomatic relief
  2. absolute –> none, relative –> small volume of fluid, patient on anti-coagulant, mechanical vent., active skin infection at the point of entry
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15
Q

Pleural disorders

-the color of the fluid and suggested diagnosis

A
  1. pale yellow - transudate, some exudate
  2. red - bloody - malignancy or embolism or trauma
  3. turbid - infected effusion
  4. pus - empyema
  5. white - chylothorax or cholesterol infusion
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16
Q

Pleural disorders

-transudate vs. exudate fluid

A

TRANSUDATE

  • due to increased hydrostatic pressure or low oncotic pressure
  • low in protein and LDH
  • ex: congestive heart failure, pulmonary embolism, nephrotic syndrome, myxedema, urinothorax

EXUDATE

  • inflammation and increased capillary permeability
  • high in protein and LDH
  • ex: neoplastic disease, infection, drug-induced disease, pulmonary embolization, GI disease
17
Q

Pleural disorders

-Light’s criteria

A

TRANSUDATE

  • protein ≤0.5
  • LDH (lactate dehydrogenase) ≤ 0.6
  • pleural fluid LDH >2/3 the upper limit of normal serum LDH
  • pleural fluid cholesterol <45 mg/dL

EXUDATE

  • protein > 0.5
  • LDH >0.5
  • pleural fluid LDH >2/3 the upper limit of normal serum LDH –> LDH is very high
  • pleural fluid cholesterol >55 mg/dL

if positive then –> send for total and differential cell counts, smears and culture for organisms, glucose and lactate dehydrogenase levels, cytology analysis, pleural fluid marker for tuberculosis

18
Q

Pleural disorders

-total and differential cell counts in pleural fluid

A
  • neutrophils >50% –> acute process, ex: parapneumonic effusions
  • mononuclear cells >50% –> chronic process, ex: cancer
  • eosinophilia >10% –> unusual causes, ex: reaction to drugs
19
Q

Pleural disorders

  • fluid glucose level
  • fluid lactate dehydrogenase level
A

-low concentration = complicated parapneumonic or a malignant effusion

  • correlates to the degree of inflammation
  • if it increases with repeated thoracocentesis = degree of inflammation is increases –> diagnosis is urgent
  • if it decreases with repeated thoracocentesis - a less aggressive diagnosis approach
20
Q

Parapneumonic pleural effusion

  • definition
  • etiology
  • classification
A
  • Accumulation of exudative fluid in the pleural cavity
  • pneumonia
  • complicated –> exudative effusion (with bacterial invasion)
  • uncomplicated –> exudative effusion (without bacterial invasion)
21
Q

Parapneumonic pleural effusion

  • symptoms
  • diagnosis
  • treatment
A

-fever, cough, chills, chest discomfort

  • chest x-ray
  • uncomplicated: pH >7.2, glucose is normal or low, increased LDH
  • complicated: pH <7.2, glucose is low, increased LDH
  • systemic antibiotics
  • complicated: requires pleural space drainage for resolution of pleural sepsis
22
Q

Pleural empyema

  • definition
  • etiology
A
  • accumulation of pus in the pleural cavity
  • exudative effusion (bacterial colonization)

-pneumonia (most common), rupture of lung abscess, infected hemothorax, esophageal tear, thoracic trauma

23
Q

Pleural empyema

  • symptoms
  • diagnosis
A

-fever, chills, cough, chest discomfort

  • chest x-ray
  • chest CT: split pleura sign
24
Q

Pleural empyema

-pleural fluid analysis (4)

A
  • pH <7.2
  • glucose is low
  • LDH increased
  • appearance: purulent
25
Q

Pleural empyema

-treatment (2)

A
  • systemic antibiotics

- chest tube (thoracostomy)

26
Q

Pleural empyema

-stages (3)

A

I - exudative - sterile pleural fluid develops secondary to inflammation without fusion of the pleura

II - fibrinopurulent - fibrinous peel develops on both pleural surfaces liming lung expansion

III - organizing - growth of capillaries and fibroblasts into the fibrinous peel

Pulmonology and Thoracic surgery (8 decks)

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