Lung Cancer (Respiratory Block) Flashcards
Lung cancer is the second most common cancer diagnosis but the ________ most common cause of cancer mortality
First/ number one
Smoking is estimated to cause _____% of lung cancer causes
85-90%
Currently about ___% of Americans still smoke
20%
Average smokers are defined as _____ pack-years and have a 10x increased risk of lung cancer whereas heavy smokers are defined as ___ pack- years and have a 20x increased risk of cancer
10; 20
Why is smoking cessation beneficial even after a lung cancer diagnosis?
Symptomatic relief from other problems
Anti-cancer therapies are more effective and have reduced side effects in non-smokers (oxidative damage from chemo is worse in smokers)
What is the relationship between second hand smoke and lung cancer
50% increased relative risk compared to non-smokers
3-5% of all lung cancers caused by second hand smoke
Asbestos is associated with a ___x increased risk of lung cancer, and strongly associated with risk of _________
5x increased risk of lung cancer
mesothelioma
______ is the second leading cause of lung cancer behind smoking and increases lifetime risk by 0.3%
Radon 222
Describe the relative percentages of different types of lung cancers
Small cell lung cancer (SCLC) ~15% of all lung ca Non small cell lung cancer (NSCLC) ~80% - Squamous cell 25-40% but decreasing - Adenocarcinoma 25-40% but increasing - Large cell carcinoma ~10%
Describe features of squamous cell carcinoma
- centrally located
- associated with smoking
- associated paraneoplastic syndrome= PTH-RP secretion, hypercalcemia
- precursor lesion: metaplasia–> dysplasia–> carcinoma in situ–> carcinoma
- keratinization and intracellular bridges
- can have central necrotic cavidation
- associated with p53 mutation
Describe features of large cell carcinoma
- large cells with pleomorphic nuclei, no glandular differentiation
- peripherally located
- common giant cells or clear cells
Describe features of adenocarcinoma
- common in women, non-smokers (75% occur in smokers)
- peripherally located, pleural puckering
- AAH is precursor lesion
- acinar appearance, clusters of glands with intracellular mucin
- TTF-1 positive
- associated with KRAS and EGFR mutations
Describe features of carcinoid tumors
- slow growing/ low grade neuroendocrine tumors derived from Kulchitsky cells; positive for chromogranin and synaptophysin
- nests or cords of uniform, bland cells
- post-obstructive pneumonia
- typical vs atypical
Describe features of small cell carcinoma
- small, blue staining cells with scant cytoplasm, fast growing soft masses with necrosis and metastasis to nodes
- blue tightly packed nuclei–> nuclear modeling, azzopardi phenomenon (encrusted DNA) and crushed cell appearance
- can quickly outgrow blood supply and show central necrosis
- associated with Eaton-Lambert paraneoplastic syndrome- antibody against voltage gated Ca channel, proximal symmetric muscle weakness
- associated with ectopic ACTH production and SIADH (hyponatremia)
- associated with p53 and RB1 mutations, positive neuroendocrine markers
List mutations associated with adenocarcinoma
- KRAS
- EGFR
What screening technique has been shown to lower lung cancer mortality in heavy smoking populations?
Serial CT, low dose
List presentation/ features of Pancoast tumors
- tumor of superior sulcus extending into chest wall/ pleura
- horner’s syndrome: ptosis, myosis, anhydrosis
- shoulder/ upper arm pain and wasting of intrinsic muscles of hand
List presentation for a patient with SVC syndrome
- large central mediastinal mass causes obstruction of SVC
- swollen purple face, headache, dyspnea, vascular distension and formation of collateral blood vessels
Describe hypercalcemia as a paraneoplastic syndrome
bony invasion or secretion of PTH-RP (squamous cell carcinoma)
Describe endocrine abnormalities associated with paraneoplastic syndromes
Ectopic ACTH production- Cushing’s
SIADH (hyponatremia)
Associated with small cell lung cancer
Describe bronchoscopy and its limitations
Inserting fiber optic bronchoscope to detect intrabronchial pathology
Limitation if lesion is peripheral or if upper lobe
Describe percutaneous image guided biopsy and its limitations
Using imaging to guide needle insertion to get biopsy
Limitation if central lesion
List common sites of metastasis for lung cancer
** adrenal glands
liver, bone, brain
True or false: CT is the best imaging modality to assess for CNS metastasis
FALSE, need brain MRI with contrast
Describe treatment for non-small cell lung cancer
- surgery if tumor is resectable and patient can tolerate (performance status matters)
- post- op chemo for larger primary tumors or those with positive ipsilateral nodal involvement
- Stage III disease- commonly chemo + radiation but no surgery- distant relapse before local so costs of surgery outweigh benefits
- metastatic disease treated primarily with chemotherapy with possible supportive tx with radiation/ surgery at metastatic sites to improve symptoms (CNS, bone)
What is the rough median survival time for lung cancers
about 12 months
What targeted agents are appropriate for patients with EGFR mutation positive primary tumors?
EGFR mutation common in non-smokers, women, Asians
Erlotinib, gefitinib (no longer FDA approved), afatinib
Dramatic improvement in progression free survival
Erlotinib targets tumors with what mutation?
EGFR exon 19 mutation
Why is the T790 mutation concerning?
EGFR mutation, confers resistance to erlotinib
What is the targeted agent for primary tumors with ALK rearrangements?
Crizotinib
Describe how small cell lung cancer is staged
limited- confined to one hemithorax
extensive: not confined to one hemithorax
Describe how small cell lung cancer is treated
limited: aggressive chemo + radiation- good overall response rate but high rates of distant relapse. Some evidence for prophylactic cranial irradiation but limited role for surgery
extensive: chemotherapy, possibly radiation (if few metastatic lesions), no role for surgery. Relapse is certainty.
Describe prognosis for small cell lung cancer
Limited: 14-20 months
Extensive: 8-13 months
5 year survival improving for limited stage disease with prophylactic cranial irradiation but near zero for extensive disease
Describe double effect and its role in palliative care decisions
Ethical principle, advocates for evaluating the permissibility of acting when one’s otherwise legitimate act (for example, relieving a terminally ill patient’s pain) may also cause an effect one would normally be obliged to avoid (sedation and a slightly shortened life).
Describe features of bronchioloalveolar carcinoma
BAC: subtype of adenocarcinoma
- cells grow along alveolar septa in lepidic pattern with no invasion or destruction of surrounding tissue
- low grade, well differentiated- good prognosis
- pneumonia like consolidation pattern
- derived from AAH and may be precursor to adenocarcinoma (AAH–> BAC–>ADCA)
Describe features of atypical adenomatous hyperplasia
AAH: precursor lesion for BAC and ultimately ADCA
- Mild nuclear atypica, no nuclear crowding, few mitosis
