MKSAP 7: Lung Tumors

Question 1

What are the risk factors for developing lung cancer?

Answer 1

Smoking
exposure to asbestos, ionizing radiation
radon and arsenic

Question 2

What lung cancers are found under the grouping of non-small cell lung cancer? What is the most common type?

Answer 2

Adenocarcinoma - most common
Squamous cell carcinoma
Large cell carcinoma 
Adenosquamous carcinoma
Sarcomatoid carcinoma

Question 3

What lung cancer are found under the grouping of neuroendocrine tumors?

Answer 3

Small cell lung cancer
Large cell lung cancer
Typical carcinoid tumor
Atypical carcinoid tumor

Question 4

How does adenocarcinoma usually present?

Answer 4

in the periphery of the lung

Most common type of NSCLC

Question 5

How does squamous cell carcinoma present?

Answer 5

Central portions of the lung and more common in patients with smoking history
2nd most common type of NSCLC

Question 6

How does small cell lung cancer present and what are the best initial treatment options?

Answer 6

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

Question 7

What is the first step in evaluating a patient for lung cancer?

Answer 7

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

Question 8

What is the rule in terms of obtaining tissue diagnosis in lung cancer?

Answer 8

Tissue diagnosis should be targeted at the lesion that would result in the highest potential staging

Question 9

What are the USPSTF guidelines for lung cancer screening?

Answer 9

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.

Question 10

What are the 3 types of preinvasive lung lesions that need to be under surveillance that used to be called bronchoalveolar cell carcinoma?

Answer 10

• atypical adenomatous hyperplasia
• adenocarcinoma in situ (AIS)
• minimally invasive adenocarcinoma

Question 11

How does AIS most commonly present on imaging?

How is it different from minimally invasive adenocarcinoma

Answer 11

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

Question 12

What is the treatment recommendation for preinvasive lung lesions?

Answer 12

5 year survival rate is 100% with surgical resection

Question 13

What are the presenting characteristics in patients with bronchial carcinoid tumors?

Answer 13

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

Question 14

What are the symptoms of carcinoid syndrome?

Answer 14

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.

Question 15

What are the 2 types of carcinoid tumors?

Answer 15

Typical and atypical

Question 16

Describe the definitions of and survival rates for typical vs atypical carcinoids

Answer 16

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

Question 17

What is the treatment recommendation for bronchial carcinoids?

Answer 17

Surgical resection for both types even if lymph node involvement is recommended

Question 18

What is the recommendation regarding chemo and radiation for carcinoids?

Answer 18

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

Question 19

When are somatostatin analogs used for carcinoids?

Answer 19

Reserved for patients who present with carcinoid syndrome and some patients with metastatic disease. Should be monitored for recurrence

Question 20

What is malignant pleural mesothelioma

Answer 20

Very aggressive tumor that arises from mesothelial cells of the pleura

Question 21

How do patients with mesothelioma present and what does CT imaging show?

Answer 21

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.

Question 22

How do pulmonary metastases most commonly present?

Answer 22

Present as multiple, peripheral or subpleural pulmonary nodules but can also present as solitary pulmonary nodules

Question 23

What are the most common primary malignancies to metastasize to the lung?

Answer 23

Colon, kidney, breast, testicle and thyroid, bone and melanoma

Question 24

What cancer is associated with endobronchial metastases?

Answer 24

Renal cell carcinoma

Question 25

What cancer are associated with lymphangitic spread of tumor?

Answer 25

lung, breast, GI tract, melanoma, lymphoma and leukemia

Question 26

What are the common lesions of the anterior mediastinum?

Answer 26

Thymomas, lymphoma and teratoma

Question 27

How do patients with thymomas present typically?

Answer 27

usually present as middle aged adults and may develop paraneoplastic syndromes such as myasthenia gravis

Question 28

How do patients with lymphoma present?

Answer 28

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

Question 29

What is the most common cause of middle medistinal masses?

Answer 29

Lymphoadenopathy.

Also several cysts including bronchogenic cysts can develop here. Also pericardial and esophagel duplication cysts

Question 30

What masses can develop in the posterior mediastinum? Think of based on children vs adults

Answer 30

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

Question 31

What do the 2017 Fleischner guidelines update in terms of screening?

Answer 31

They replace the recommendations for solid (2005) and subsolid pulmonary nodules (2013)

Question 32

How should pulmonary nodules be evaluated imaging modality wise?

Answer 32

Thin slice CT, images < 1.5mm

Question 33

How do you define low or high risk patients in the new Fleischner guidelines?

Answer 33

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

Question 34

What are the other “rules” for applying the Fleischner guidelines?

Answer 34

Separate patients to high and low risk, does not apply to subjects less than 35 yrs olf, immunocompromised or patients with hx of cancer

Question 35

What are the groupings for probability of malignancy in the Fleischner guidelines?

Answer 35

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

Question 36

What are the follow up recs according to Fleischner 2017 for <6mm solid nodule?

Answer 36

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

Question 37

What are the follow up recs according to Fleischner 2017 for 6-8mm solid nodule?

Answer 37

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

Question 38

What are the follow up recs according to Fleischner 2017 for >8mm solid nodule?

Answer 38

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

Question 39

What are the follow up recs according to Fleischner 2017 for < 6mm and > 6mm ground glass subsolid nodules?

Answer 39

< 6mm -> No FU indicated

> 6mm -> CT at 6-12 months to confirm persistence, then CT at 3 and 5 years

Question 40

What are the follow up recs according to Fleischner 2017 for < 6mm and > 6mm part solid nodules?

Answer 40

< 6mm -> No FU indicated

> 6mm -> CT at 3-6 months to confirm persistence then annual CT for 5 years

Question 41

What are the follow up recs according to Fleischner 2017 for < 6mm and > 6mm multiple subsolid nodules?

Answer 41

<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