MKSAP 7: Lung Tumors Flashcards
What are the risk factors for developing lung cancer?
Smoking
exposure to asbestos, ionizing radiation
radon and arsenic
What lung cancers are found under the grouping of non-small cell lung cancer? What is the most common type?
Adenocarcinoma - most common Squamous cell carcinoma Large cell carcinoma Adenosquamous carcinoma Sarcomatoid carcinoma
What lung cancer are found under the grouping of neuroendocrine tumors?
Small cell lung cancer
Large cell lung cancer
Typical carcinoid tumor
Atypical carcinoid tumor
How does adenocarcinoma usually present?
in the periphery of the lung
Most common type of NSCLC
How does squamous cell carcinoma present?
Central portions of the lung and more common in patients with smoking history
2nd most common type of NSCLC
How does small cell lung cancer present and what are the best initial treatment options?
Small cell lung cancer usually is more aggressive and usually already disseminated at presentation. Usually presents with large hilar mass and bulky mediastinal lymphadenopathy.
Initially more sensitive to chemotherapy and radiation
What is the first step in evaluating a patient for lung cancer?
CT imaging determines the size and location of the primary tumor, the presence and location of regional lymph node involvement and the presence of metastases which include not only extrathoracic organs but also nodules within the contralateral lobe of the lung and pleural disease
PET/CT can then help determine further lymph node involvement and if a biospy is necessary
What is the rule in terms of obtaining tissue diagnosis in lung cancer?
Tissue diagnosis should be targeted at the lesion that would result in the highest potential staging
What are the USPSTF guidelines for lung cancer screening?
Low dose CT in patients between the age of 55-79 years who have a 30 pack year or more smoking history who are currently smoking or quit within the last 15 years.
What are the 3 types of preinvasive lung lesions that need to be under surveillance that used to be called bronchoalveolar cell carcinoma?
- atypical adenomatous hyperplasia
- adenocarcinoma in situ (AIS)
- minimally invasive adenocarcinoma
How does AIS most commonly present on imaging?
How is it different from minimally invasive adenocarcinoma
AIS most commonly presents as an incidental finding of ground glass opacification on chest CT
Minimally invasive adenocarcinoma presents similarly but with a smaller area of invasion - <5mm
What is the treatment recommendation for preinvasive lung lesions?
5 year survival rate is 100% with surgical resection
What are the presenting characteristics in patients with bronchial carcinoid tumors?
Represent small percentage of lung cancers, but most common lung cancer to present in children and adolescents. Most involve the proximal airways so patients may present with symptoms related to endobronchial narrowing or obstruction including postobstructive pneumonia
What are the symptoms of carcinoid syndrome?
Only about 1-5% of patients with bronchial carcinoid tumors present with carcinoid syndrome characterized by release of vasoactive substances including serotonin causing flushing, bronchospasm and diarrhea. Also associated with large tumor size and liver metastases.
What are the 2 types of carcinoid tumors?
Typical and atypical
Describe the definitions of and survival rates for typical vs atypical carcinoids
Typical carcinoids are considered low grade tumors with excellent 5 year survival rate of 92-100%
Atypical carcinoids have higher mitoses or necrosis on pathology and considered intermediate grade malignancies with 61-88% survival
Invasion of lymph nodes by typical carcinoids is associated with worse prognosis
What is the treatment recommendation for bronchial carcinoids?
Surgical resection for both types even if lymph node involvement is recommended
What is the recommendation regarding chemo and radiation for carcinoids?
They tend to be resistant to chemo and radiation and routine use is controversial. but should be considered if residual disease is documented after attempted surgical resection
When are somatostatin analogs used for carcinoids?
Reserved for patients who present with carcinoid syndrome and some patients with metastatic disease. Should be monitored for recurrence
What is malignant pleural mesothelioma
Very aggressive tumor that arises from mesothelial cells of the pleura
How do patients with mesothelioma present and what does CT imaging show?
Patient present with symptoms of slowly enlarging effusion.
CT typically shows unilateral pleural effusion but can also show pleural thickening, nodules, masses, pleural plaques or calcifications.
How do pulmonary metastases most commonly present?
Present as multiple, peripheral or subpleural pulmonary nodules but can also present as solitary pulmonary nodules
What are the most common primary malignancies to metastasize to the lung?
Colon, kidney, breast, testicle and thyroid, bone and melanoma
What cancer is associated with endobronchial metastases?
Renal cell carcinoma
What cancer are associated with lymphangitic spread of tumor?
lung, breast, GI tract, melanoma, lymphoma and leukemia
What are the common lesions of the anterior mediastinum?
Thymomas, lymphoma and teratoma
How do patients with thymomas present typically?
usually present as middle aged adults and may develop paraneoplastic syndromes such as myasthenia gravis
How do patients with lymphoma present?
patients are typically younger. Hodgkin lymphoma is the most common lymphoma to involve the mediastinum followed by lymphoblastic lymphoma and primary mediastinal diffsue B cell lymphoma
What is the most common cause of middle medistinal masses?
Lymphoadenopathy.
Also several cysts including bronchogenic cysts can develop here. Also pericardial and esophagel duplication cysts
What masses can develop in the posterior mediastinum? Think of based on children vs adults
Children: posterior neurogenic tumors that arise from the sympathetic ganglia (neuroblastomas)
Adults: neurogenic tumors that arise from the nerve sheaths (schwannomas)
Paraspinal extramedullary hematopoiesis may also involve this mediastinal compartment
What do the 2017 Fleischner guidelines update in terms of screening?
They replace the recommendations for solid (2005) and subsolid pulmonary nodules (2013)
How should pulmonary nodules be evaluated imaging modality wise?
Thin slice CT, images < 1.5mm
How do you define low or high risk patients in the new Fleischner guidelines?
Risk factors include hx of heavy smoking, exposure to asbestos, radium or uranium, FamHx lung cancer, older age, sex F>M, race black and native hawaiian > white, marginal speculation, upper lobe location, mulitplicity <5 nodules increases risk of malignancy, emphysema dn pulmonary fibrosis particularly IPF
What are the other “rules” for applying the Fleischner guidelines?
Separate patients to high and low risk, does not apply to subjects less than 35 yrs olf, immunocompromised or patients with hx of cancer
What are the groupings for probability of malignancy in the Fleischner guidelines?
Low (<5%): young, less smoking, no prior cancer, small nodule size, regular margins and non-upper lobe
Intermediate risk (5-65%): mixture of low and high probability features
High (>65%): older, heavy smoking, prior cancer, larger size, irregular margin, upper lobe location
What are the follow up recs according to Fleischner 2017 for <6mm solid nodule?
Single -> Low risk -> No routine follow up
SIngle -> High risk -> Optional CT at 12 months
Multiple -> Low risk -> No routine follow up
Multiple -> High risk -> Optional CT at 12 months
What are the follow up recs according to Fleischner 2017 for 6-8mm solid nodule?
Single -> Low risk -> CT 6-12 mo, then consider CT at 18-24
SIngle -> High risk -> CT 6-12 mo, then CT at 18-24
Multiple -> Low risk -> CT at 3-6 mo then consider CT 18-24 mo
Multiple -> High risk -> CT at 3-6 mo then CT at 18-24
What are the follow up recs according to Fleischner 2017 for >8mm solid nodule?
Single -> ALL patients -> Consider CT at 3 mo, PET/CT or biopsy
Multiple -> Low risk -> CT at 3-6 mo then consider CT 18-24 mo
Multiple -> High risk -> CT at 3-6 mo then CT at 18-24
What are the follow up recs according to Fleischner 2017 for < 6mm and > 6mm ground glass subsolid nodules?
< 6mm -> No FU indicated
> 6mm -> CT at 6-12 months to confirm persistence, then CT at 3 and 5 years
What are the follow up recs according to Fleischner 2017 for < 6mm and > 6mm part solid nodules?
< 6mm -> No FU indicated
> 6mm -> CT at 3-6 months to confirm persistence then annual CT for 5 years
What are the follow up recs according to Fleischner 2017 for < 6mm and > 6mm multiple subsolid nodules?
<6mm -> CT at 3-6 months. If stable CT at 2 and 4 years
> 6mm -> CT at 3-6 months, subsequent management based on most suspicious nodule
