Lung Cancer (Respiratory Block)

Question 1

Lung cancer is the second most common cancer diagnosis but the ________ most common cause of cancer mortality

Answer 1

First/ number one

Question 2

Smoking is estimated to cause _____% of lung cancer causes

Answer 2

85-90%

Question 3

Currently about ___% of Americans still smoke

Answer 3

20%

Question 4

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

Answer 4

10; 20

Question 5

Why is smoking cessation beneficial even after a lung cancer diagnosis?

Answer 5

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)

Question 6

What is the relationship between second hand smoke and lung cancer

Answer 6

50% increased relative risk compared to non-smokers

3-5% of all lung cancers caused by second hand smoke

Question 7

Asbestos is associated with a ___x increased risk of lung cancer, and strongly associated with risk of _________

Answer 7

5x increased risk of lung cancer

mesothelioma

Question 8

______ is the second leading cause of lung cancer behind smoking and increases lifetime risk by 0.3%

Answer 8

Radon 222

Question 9

Describe the relative percentages of different types of lung cancers

Answer 9

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%

Question 10

Describe features of squamous cell carcinoma

Answer 10

• 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

Question 11

Describe features of large cell carcinoma

Answer 11

• large cells with pleomorphic nuclei, no glandular differentiation
• peripherally located
• common giant cells or clear cells

Question 12

Describe features of adenocarcinoma

Answer 12

• 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

Question 13

Describe features of carcinoid tumors

Answer 13

• 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

Question 14

Describe features of small cell carcinoma

Answer 14

• 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

Question 15

List mutations associated with adenocarcinoma

Answer 15

• KRAS

- EGFR

Question 16

What screening technique has been shown to lower lung cancer mortality in heavy smoking populations?

Answer 16

Serial CT, low dose

Question 17

List presentation/ features of Pancoast tumors

Answer 17

• 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

Question 18

List presentation for a patient with SVC syndrome

Answer 18

• large central mediastinal mass causes obstruction of SVC

- swollen purple face, headache, dyspnea, vascular distension and formation of collateral blood vessels

Question 19

Describe hypercalcemia as a paraneoplastic syndrome

Answer 19

bony invasion or secretion of PTH-RP (squamous cell carcinoma)

Question 20

Describe endocrine abnormalities associated with paraneoplastic syndromes

Answer 20

Ectopic ACTH production- Cushing’s
SIADH (hyponatremia)
Associated with small cell lung cancer

Question 21

Describe bronchoscopy and its limitations

Answer 21

Inserting fiber optic bronchoscope to detect intrabronchial pathology
Limitation if lesion is peripheral or if upper lobe

Question 22

Describe percutaneous image guided biopsy and its limitations

Answer 22

Using imaging to guide needle insertion to get biopsy

Limitation if central lesion

Question 23

List common sites of metastasis for lung cancer

Answer 23

** adrenal glands

liver, bone, brain

Question 24

True or false: CT is the best imaging modality to assess for CNS metastasis

Answer 24

FALSE, need brain MRI with contrast

Question 25

Describe treatment for non-small cell lung cancer

Answer 25

- 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)

Question 26

What is the rough median survival time for lung cancers

Answer 26

about 12 months

Question 27

What targeted agents are appropriate for patients with EGFR mutation positive primary tumors?

Answer 27

EGFR mutation common in non-smokers, women, Asians Erlotinib, gefitinib (no longer FDA approved), afatinib Dramatic improvement in progression free survival

Question 28

Erlotinib targets tumors with what mutation?

Answer 28

EGFR exon 19 mutation

Question 29

Why is the T790 mutation concerning?

Answer 29

EGFR mutation, confers resistance to erlotinib

Question 30

What is the targeted agent for primary tumors with ALK rearrangements?

Answer 30

Crizotinib

Question 31

Describe how small cell lung cancer is staged

Answer 31

limited- confined to one hemithorax | extensive: not confined to one hemithorax

Question 32

Describe how small cell lung cancer is treated

Answer 32

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.

Question 33

Describe prognosis for small cell lung cancer

Answer 33

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

Question 34

Describe double effect and its role in palliative care decisions

Answer 34

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).

Question 35

Describe features of bronchioloalveolar carcinoma

Answer 35

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)

Question 36

Describe features of atypical adenomatous hyperplasia

Answer 36

AAH: precursor lesion for BAC and ultimately ADCA | - Mild nuclear atypica, no nuclear crowding, few mitosis