Lung cancer, Pleural Disorders Flashcards
Lung cancer
- risk factors
- prevention
- 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
Lung cancer
-2 major types
- Non-small cell (87%)
- most cases tumor is only found when the disease has already progressed –> prognosis is bad - Small cell
- surgery is not possible
Lung cancer
- symptoms
- metastasis
- non-specific
- persistent cough, sputum with some blood, chest pain, voice change, recurrent pneumonia or bronchitis
-CNS, pleura, liver, bone, adrenals
Lung cancer
-diagnostics
- 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
Lung cancer
-treatment options
- 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
Lung cancer
-treatment strategies for NSCLC
- resectable –> stage I, II, and some III
- unresectable –> stage III
- surgery with or without chemo
Lung cancer
-Anaplastic lymphoma kinase
- 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
Lung cancer
-EGFT mutations
- more commonly in severe smokers, adenocarcinomas, women, Asians
- fond in 10-15% of lung cancer patients
SCLC vs. NSCLC
- association with smoking:
- growth kinetics:
- early metastasis:
- sensitivity to DNA damaging chemo:
- sensitivity to radiotherapy:
- advances in therapy:
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
Pleural disorders
-pathogenesis (5)
- altered pleural membrane permeability
- decrease intravascular oncotic pressure
- increase capillary hydrostatic pressure
- lymphatic obstruction
- abnormal sites of entry
Pleural disorders
- symptoms
- physical exam
-cough, dyspnea, pain
- dullness to percussion, decreased breath sounds, asymmetric chest expansion
- decreased or absent vocal resonance and tactile vocal fremitus
Pleural disorders
-radiology (4)
- 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
Pleural disorders
-3 main questions that should be made
- should thoracocentesis be performed?
- if yes, is the fluid transudate or exudate?
- if exudate, what’s the etiology?
Pleural disorders
- Thoracocentesis
1. indications (2)
2. contraindications (4)
- diagnostics (>10mm depth on lateral decubitus), therapeutically for symptomatic relief
- absolute –> none, relative –> small volume of fluid, patient on anti-coagulant, mechanical vent., active skin infection at the point of entry
Pleural disorders
-the color of the fluid and suggested diagnosis
- pale yellow - transudate, some exudate
- red - bloody - malignancy or embolism or trauma
- turbid - infected effusion
- pus - empyema
- white - chylothorax or cholesterol infusion
Pleural disorders
-transudate vs. exudate fluid
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
Pleural disorders
-Light’s criteria
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
Pleural disorders
-total and differential cell counts in pleural fluid
- neutrophils >50% –> acute process, ex: parapneumonic effusions
- mononuclear cells >50% –> chronic process, ex: cancer
- eosinophilia >10% –> unusual causes, ex: reaction to drugs
Pleural disorders
- fluid glucose level
- fluid lactate dehydrogenase level
-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
Parapneumonic pleural effusion
- definition
- etiology
- classification
- Accumulation of exudative fluid in the pleural cavity
- pneumonia
- complicated –> exudative effusion (with bacterial invasion)
- uncomplicated –> exudative effusion (without bacterial invasion)
Parapneumonic pleural effusion
- symptoms
- diagnosis
- treatment
-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
Pleural empyema
- definition
- etiology
- accumulation of pus in the pleural cavity
- exudative effusion (bacterial colonization)
-pneumonia (most common), rupture of lung abscess, infected hemothorax, esophageal tear, thoracic trauma
Pleural empyema
- symptoms
- diagnosis
-fever, chills, cough, chest discomfort
- chest x-ray
- chest CT: split pleura sign
Pleural empyema
-pleural fluid analysis (4)
- pH <7.2
- glucose is low
- LDH increased
- appearance: purulent
Pleural empyema
-treatment (2)
- systemic antibiotics
- chest tube (thoracostomy)
Pleural empyema
-stages (3)
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
