Neoplasia Flashcards
ASA classifications
I: healthy
II: mild systemic disease (HTN, mild diabetes without end organ damange)
III: severe systemic disease (stable angina, mod-sev COPD)
Think twice about taking the following to bronchoscopy
IV: incapacitating disease that is a constant threat to life (advanced COPD, heart failure)
V: moribund pt not expected to live 24h with or without surgery (ruptured ao aneurysm, massive PE)
What comorbid condition makes TBBx (mostly) contraindicated
PH with mPAP >40
When should pre-bronch bronchodilators be given
in patients who have ASTHMA
not much benefit in COPD
When is it safe to do a bronch in pregnancy
Defer until 28wk GA
Avoid fluoroscopy
How long do you stop
clopidogrel
warfarin
UFH
LMWH
pre-bronch?
clopidogrel: 5-7 days
warfarin: 5 days –> resume 12-24h
UFH: 4-6h –> resume 24-72h after
LMWH: 24h therapeutic, 12h prophylactic –> resume in 24h, or 48-72h in high bleeding risk
True or False: There is no difference between complications in bronchoscopy with obesity, but there is a difference with morbid obesity
true
Max dose of topical lidocaine in bronch
7 mg/kg
Is it helpful to use atropine or glycopyrrolate to inhibit secretion during pre-bronch
no
Associated with arrhythmia
Main complication of bronch (2)
PTX 1-4%
hemorrhage 9%
Does Rapid Onsite Cytologic Evaluation improve accuracy of EBUS TBNA?
No
BUT it leads to decreased needle passes
What do you ALWAYS need to check in NSCLC
Driver mutations (EGFR, ALK, etc.)
Sensitivity for EBUS for lymphoma is ___
57%-67% only!
Non-Hodgkin is better sensitivity
Ok to do this first, then mediastinoscopy
Stage I survival
> 60% at 5 years
Most prevalent ca in men and women
Highest cause of death in women
Men: prostate
Women: breast
Lung ca = highest mortality in women
Does COPD increase rate of lung ca than smoking alone?
yes
Cavitary lung lesion, hypercalcemia and Hypertrophic pulmonary osteoarthropathy
squamous cell ca
Lambert eaton, SIADH, smoker, lung nodule
Small cell
How do you diagnose hypertrophic pulmonary osteoarthropathy?
Tc bone scan (most sensitive)
2 types of malignancy with low likelihood of PET avidity in the lungs
carcinoid
mucinous adenocarcinoma
Bronchorrhea, salt tasting sputum, lung nodule
mucinous adenocarcinoma (BAC)
Two trials in Lung cancer screening and what did they show
NLST:
27% mortality reduction in women
8% mortality reduction in men
7% survival improvement
NELSON:
26% mortality reduction in men
39% mortality reduction in women
Who should get LDCT
50-80
>20 py
quit within 15 years
Six independent predictors of malignant SPN
- Age
- Smoking status
- History of extrathoracic malignancy
- Diameter
- Spiculation
- Upper lobe location
Calcification pattern that is likely to be malignant
stippled
eccentric
Calcification pattern likely to be benign
central
laminate
diffuse
popcorn
What is the Lung-RADS follow up rec:
WHen are false negative PET more likely to occur
<8-10 mm nodule
well differentiated adeno
BAC (mucinous adeno)
Carcinoid tumor
What are the categories by size in TNM (just the T)
T1a: <1cm (including 1 cm)
T1b: 1.1-2
T1c: 2.1-3
T2a: 3.1-4 (or any size involving main bronchus, visceral pleura leading to atelectasis up to or beyond hilum)
T2b: 4.1-5
T3: 5.1-7 (or any size in parietal pleura, parietal pericardium, chest wall, T1-2 nerve roots, phrenic nerve, or satellite tumor in SAME lobe as primary tumor)
T4 >7.1 (or any size invading mediastinum, diaphragm, trachea, main carina, recurrent laryngeal nerve, esophagus, visceral pericardium, vertebral body, great vessels, heart, cervical nerve roots, satellite tumor in SEPARATE lobe of ipsilateral lung
What are the categories by NODE in TNM staging (node only)
N0 no regional lymph node involved
N1 Ipsilateral peribronchial hilar and intrapulmonary nodes (10,11)
N2 Ipsilateral mediastinal and subcarinal nodes (Ipsi 4, 7)
N3 Contralateral mediastinal, hilar, or any scalene or supraclavicular node
What are the METASTATIC categories by TNM (only M)
M1a separate tumor nodule in cotralateral lung, pleural or pericardial involvement
M1b SINGLE extrathoracic metastasis
M1c Multiple extrathoracic metastases (one or more sites)
What does Stage IA1, IA2, and IA3 involve
IA1: T1a
IA2: T1b
IA3: T1c
N0 M0
What does Stage IB include
T2a N0 M0
If T3 or less or N1 is involved, what stage are you AT LEAST at this point
Stage IIB
Stage IIB TNM?
T1-2b N1 M0
T3 N0M0
Stage IIIA TNM staging
T4 N0 M0
T3-4 N1 M0
T1-2 N2 M0
Stage IIIB TNM?
T3-4 N2 M0
T1-2 N3 M0
Stage IIIC TNM?
T3-4 N3 M0
Difference between Stage IVA and IVB
IVA: M1a-b
IVB: M1c (multiple mets outside the thorax)
What Lung-RADS is this:
nodule with benign features (central, popcorn, concentric ring calcification or fat containing
When do you follow up imaging
Lung-RADS 1 (negative)
Follow up 12 mo LDCT
What Lung-RADS is this:
Solid nodule <6 mm at baseline or NEW <4mm
When do you follow up imaging
Lung-RADS 2 (benign)
f/u 12 mo LDCT
What Lung-RADS is this and when do you follow up?
Non-solid slowly growing >30 mm nodule
Lung-RADS 2 (benign)
f/u 12 mo LDCT
What Lung-RADS is this and when do you follow up?
Part solid <6 mm in diameter at baseline
Lung-RADS 2 (benign)
f/u 12 mo LDCT
What Lung-RADS is this and when do you follow up?
Airway nodule SUBSEGMENTAL, at baseline, new, or stable
Lung-RADS 2 (benign)
f/u 12 mo LDCT
What Lung-RADS is this and when do you follow up?
Part solid 7 mm nodule with solid component that has been stable or decreasing in size since 6 mo ago
Lung-RADS 3
f/u 6 mo LDCT
What Lung-RADS is this and when do you follow up?
15mm nodule proven to be benign in etiology
Lung-RADS 2 (benign)
f/u 12 mo LDCT
What Lung-RADS is this and when do you follow up?
Solid nodule >6 to <8mm at baseline
Lung-RADS 3 (probably benign)
f/u 6 mo LDCT
What Lung-RADS is this and when do you follow up?
New 4-6 mm solid nodule from prior imaging
Lung-RADS 3 (probably benign)
f/u 6 mo LDCT
What Lung-RADS is this and when do you follow up?
Part solid >6 mm nodule with solid component <6mm or new <6 mm total mean diameter
Lung-RADS 3 (probably benign)
f/u 6 mo LDCT
What Lung-RADS is this and when do you follow up?
Non-solid nodule >30 mm at baseline or new
Lung-RADS 3 (probably benign)
f/u 6 mo LDCT
What Lung-RADS is this and when do you follow up?
Atypical pulmonary cyst (with growing component of thick-walled cyst)
Lung-RADS 3 probably benign
f/u 6 mo LDCT
What Lung-RADS is this and when do you follow up?
Category 4A lesion that is stable or decreased in size at 3 mo follow up (excluding airway nodules)
Lung-RADS 3 (probably benign)
f/u 6 mo LDCT
What Lung-RADS is this and when do you follow up?
Solid nodule 14 mm
Lung-RADS 4A (suspicious)
f/u 3 mo LDCT, Consider PET/CT if there is a >8 mm solid component/nodule
What Lung-RADS is this and when do you follow up?
Growing <8 mm nodule
Lung-RADS 4A (suspicious)
f/u 3 mo LDCT, consider PET/CT if there is a >8mm solid component
What Lung-RADS is this and when do you follow up?
New 6-8 mm solid nodule after not being there before
Lung-RADS 4A (suspicious)
f/u 3 mo LDCT, consider PET/CT if there is a >8 mm solid component
What Lung-RADS is this and when do you follow up?
> 6mm part solid nodule with solid component >6 mm to <8 mm at baseline
Lung-RADS 4A (suspicious)
f/u 3 mo LDCT, consider PET/CT if there is a >8 mm solid component
What Lung-RADS is this and when do you follow up?
New part solid nodule with a new <4 mm solid component
Lung-RADS 4A (suspicious)
3 mo LDCT f/u, consider PET/CT if there is a >8 mm solid component
What Lung-RADS is this and when do you follow up?
Airway nodule, SEGMENTAL or more proximal - at baseline
Lung-RADS 4A (suspicious)
f/u 3 mo LDCT, consider PET/CT if >8 mm solid component
What Lung-RADS is this and when do you follow up?
Thick walled cyst
OR
multilocular cyst at baseline
OR
Thin or thick-walled cyst that becomes multilocular
Lung-RADS 4A (suspicious)
f/u 3 mo LDCT, consider PET/CT if there is a >8 mm solid nodule component
What Lung-RADS is this and when do you follow up?
Slow growing solid or part solid nodule over multiple screening exams
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
Airway nodule, SEGMENTAL or more proximal, stable or growing (not baseline) - persisting
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
Solid nodule >15 mm
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
New or growing > 8 mm solid nodule
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
Part solid nodule with a >8mm solid component
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
New or growing part solid nodule with a new or growing >4 mm solid component
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
thick walled cyst with growing wall thickness/nodularity
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
Multilocular cyst with increased loculation or new/increased opacity (nodular ground glass or consolidation)
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
What Lung-RADS is this and when do you follow up?
Growing multilocular cyst (mean diameter)
Lung-RADS 4B (very suspicious)
f/u now with HRCT
Consider PET/CT if > 8mm solid nodule/component
Tissue sampling +/- referral for further eval
Staging of small cell lung cancer
limited:
confined to one hemithorax, the mediastinum, or supraclavicular nodes
“all tumor is encompassed in a single XRT port”
NO contralateral hilar or supraclavicular node
extensive:
clinically detectible distant metastases
+ pleural and pericardial effusions
Bone, liver CNS, adrenal involvement
Contraindication for pneumonectomy and lobectomy (FEV1)
Pre-op
Pneumonectomy: FEV1 < 2L
Lobectomy: FEV1 <1.5 L
Risk stratification for surgical mass resection:
“low risk”
ppo FEV1 and ppo DLCO >60%
ppo FEV1 OR ppo DOCL >60% AND both >30% –> must do STAIR CLIMB or SHUTTLE WALK
If >22m or >400 cm –> low risk
When to get a CPET for risk stratification pre-lobectomy or greater (3 possibilities)
If one of the following
1. ppo FEV1 or ppo DLCO <30%
2. Shuttle walk < 400 m OR Stair climb <22 m
3. Positive high risk cardiac evaluation
CPET VO2max thresholds for “low”, “moderate”, or “high” risk
low: VO2 max >20 ml/kg/min or >75%
moderate: VO2 max 10-20 ml/kg/min or 35-75%
High VO2 max <10 ml/kg/min or < 35%
Tumor makers for adenocarcinoma (4)
TTF1
CK7
Napsin A
MOC-31
Claudin-4
Tumor markers for SCC (2)
CK5/6
P63
p40
Tumor markers for SCLC (4)
TTF1 (but Napsin A neg)
Chromogranin A
Synaptophysin
CD 56
Neuroendocrine markers (3)
CD56
Synaptophysin
Chromogranin
Tumor markers associated with malignant mesothelioma (4)
BRCA associated germline BAP1 pathological mutation
Calretinin
Wilms tumor-1 gene product
Cytokeratin 5/6
(does not have to hav TTF-1 positive)
When does survival decrease in stage I lung ca if not resected
> 12 weeks after last CT
NSCLC IB-IIIA should get ___ as neoadjuvant if PDL1 status is >1% and if resectible
If unresectible, should get ___ as consolidation therapy
nivolumab (neoadjuvant)
durvalumab (consolidation)
Wedge and lobectomy has the same 5 year survival in nodes size _____
2 cm or smaller
Altorki et al NEJM 2023
Timing of checkpoint inhibitor pneumonitis
within 2 mo of treatment
Timing of taxane-induced pneumonitis
within days to weeks after treatment
can be associated with peripheral eosinophilia
Tumor markers in kaposi sarcoma
CD31, CD34, HHV 8
mantle whorl “onion skin” on path
Castleman Disease
Evidence behind IPC placement vs pleurodisis
IPC placement results in shorter hospital stays and fewer repeat pleural procedures
What can NF-1 transform into if it is increasing in size
malignant peripheral nerve sheath tumor
Surveillance for post NSCLC currative intent ca therapy (imaging)
CT Chest in 6 mo intervals for 2 years
Yearly until 5 years
If still eligible for LDCT, keep doing it (second primaries are common)
Stain for carcinoid tumor
somatostatin
MOC-31
Claudin-4
type of cancer?
adeno
associated with insulin-like growth factor (hypoglycemia) and hypertrophic osteoarthropathy
solitary fibrous tumor of the pleura
“patternless pattern” on pathology
spindle cell – solitary fibrous tumor of the pleura
ppo DLCO is a predictor of ___
mortality
independent predictor of pulmonary complications, mortality, morbidity
How to calculate post operative product (best surgical mortality) and cut off (for lobectomy/pneumonectomy)
ppo FEV1 x ppo DLCO expressed as %pred
POP <1650 found in 75% of deaths and only 11% of those who survived surgery
V/Q scans should be done for ____
people being considered for pneumonectomy
risk of pneumonectomy
6-10%
If you suspect stage 1 disease what is the next intervention:
wedge/lobectomy and mediastinal node dissection
SBRT vs. Radiotherapy vs. Radiosurgery vs. Stereotactic
SBRT: stereotactic ablative radiotherapy
Radiotherapy: use of ionizing radiation to eradicate areas of cancer
Radiosurgery: Precision delivery of high dose radiation to target areas in the body, with intent of destroying malignant tissue while sparing adjacent normal tissue
Stereotactic: 3-D coordinate system to correlate virtual target on imaging with actual target in a patient
Alternative to surgery in stage I disease
SBRT (less number of fraction)
Adjuvant chemotherapy therapy is NOT indicated in which stage
Stage IA
Worse survival if received adjuvant chemotherapy (platinum based doublet)
Which stages of lung ca is surgery indicated
Stage IA
IB
IIA
IIB
Stage I disease management
Surgery (radiation if inoperable 1A)
1B
If EGFR or ALK negative, neoadjuvant chemoimmune followed by surgery
Post-op targeted therapy for 1B EGFR or ALK +
Forde NEJM 2022
Tsuboi NEJM 2023
Stage II disease management
Surgery with adjuvant chemo or
Targeted therapy for EGFR or ALK +
Neoadjuvant chemo immuno followed by surgery if EGFR or ALk are negative
(same with 1B)
Pancoast tumor symptoms
brachial plexus invasion - numbness and tingling
Horner’s syndrome
Need MRI
Horner’s syndrome
tumor involvement of sympathetic chain and stellate ganglion
ipsilateral enopthalmos, ptosis, meiosis, anhydrosis
Pancoast tumor management
Induction chemoradiotherapy
En bloc resection
If resectable, good results, better results with pre-op chemorad with 5yr survival 54%
If not completely resectible or have N2, involvement, concurrent chemo-rads
Stage 3 disease management
chemoradio + adjuvant immuno
Immuno for high PDL1
Adjuvant osimertinib for EGFR+, alectinib for ALK+
Neo adjuvant chemo immune followed by surgery if EGFR -
Targeted therapy for EGFR + NSCLC
osimertinib
erlotinib
CheckMate 816 trial outcome: platinum based therapy alone vs. nivolumab + platinum-based chemotherapy
Pathological complete response OR 13.94
Overall survival much improved in nivolumab
Included: IB through 3A disease
Consolidation of Durvalumab (anti-PDL1) is associated with what benefit in contrast to placebo?
progression-free survival much better at 27 mo
Included: Stage III unresectable NSCLC; already completed radiation
PACIFIC Trial, Antonia NEJM 2017
Treatment of Stage IV disease
platinum-based doublet chemo
Targeted therapy (immuno)
Supportive care
KRAS+ targeted therapy
sotorasib
adagrasib
G12C inhibitor
ALK+ targeted therapy
alectinib, brigatinib, and lorlatinib
(ALB!)
Goes through blood-brain barrier
BRAF V600E target therapy
dabrafenib + trametinib
Vemurafenib
HER-2 targeted therapy
trastuzumab
deruxtecan (Enhertu)
Extensive SCLC treatment
Doublet platinum based therapy
-platin + paclitaxel/pemetrexed/irinotecan
Contrast to standard: cis-platin and etoposide (V16)
Is XRT helpful in extensive SCLC?
No survival benefit for adding XRT to primary tumor
BUT can add XRT concurrently with some 5-7% survival benefit
Can give palliatively (for bone pain for example)
When to give prophylactic cranial irradiation
Small cell lung ca (limited or extensive)- usually for people with disease that is responsive to therapy
3 year survival improves from 15% to 21%
5% improvement in median survival
+ QOL benefit
Without PCI 60% chance of developing CNS mets within 2-3 years
With –> decreases chance of CNS mets by 50%
When to start corticosteroids for checkpoint-inhibitor pneumonitis
Grade 2 toxicity (symptomatic but with no limitation of usual activity) if not improving after holding therapy
OR
Grade 3-4 (symptomatic with O2 requirement or limitation of activity, severe or life-threatening
LN 6 and 5 are on which side? And how do you get to it for biopsy?
Left only
Chamberlain (Mediastinoscopy) or VATS
3As of Middle mediastinum tumors
Adenopathy
Malignant - lymphomas, metastases
Nonmalignant - sarcoid, drugs, silicosis
Anomalies developmental (bronchogenic/pericardial/forgut cysts)
Aneurysms or other vascular lesions
Others: lipomatosis, lymphangiomas
If you suspect germcell tumor in a young man, next diagnostic step is ___
scrotal US
Dotatate Ga-68 PET scan is useful to dx ___
neuroendocrine tumors
Tumor markers to test with anterior mediastinal mass (5)
anti-acetylcholine receptor Ab
AFP
B-HCG
LDH
Thyroid studies
M. gravis, hypogammaglobulinema, anterior mediastinal mass
Dx _____
thymoma
How long does it take for M. gravis sd to go away after thymectomyy?
1-10 years
Germ cell tumors are associated with what syndrome
Klinefelter (47, XXY) syndrome
(1/3 of men with mediastinal GCT)
Anterior mediastinal mass with elevated b-HCG level, nl AFP
seminoma
Management of seminomas
radiation +/- chemo (majority have metastatic disease)
80% cure rate
Anterior mediastinal heterogenous mass with elevated AFP, +/- elevated b-HCG
nonseminomatous tumor
Management of nonseminomatous tumor
cisplatin-based combination chemo
Tumor resection
Recurrence common
Multinodular anterior mediastinal mass, young woman, mass effect
intrathoracic thyroid
Fluid-filled mass in the middle mediastinum area, paratracheal or subcarinal. Dx ___
foregut malformation, duplicate cyst
Management of pericardial cyst
no intervention unless mass effect
Obesity, chronic steroids, Cushing’s or ectopic ACTH with anterior-mid mediastinal mass - smooth border
mediastinal lipomatosis
fluid filled cystic lesion, multiloculated or solitary, water attenuation usually not next to esophagus
mediastinal lymphangioma
resection if feasible, no medical therapy
If you suspect neurogenic tumor, possibly in spinal canal, next diagnostic step
MRI
If multiple posterior thoracic tumors, suspect ___
NF1
Most common type of neuroendocrine tumor
Peripheral Nerve Sheath Tumors
Benign (schwannoma - usually from intercostal nerve sheath)
Malignant: neuroblastoma, ganglioneuroblastoma
Syndromes associated with NET
von-Hippel-Lindau
NF1
MEN2
Carney triad
Posterior mediastinal mass in patient with thalassemia
extramedullary hematopoiesis
Lateral meningocele is associated with ___
NF1
Endobronchial lesion with hemoptysis
1. What is the likely to be the dx?
2. Could you use PET/CT for diagnosis?
3. Is it related to smoking?
Low-grade Carcinoid
Not related to smoking
Not PET/CT avid
Cannot be cured with resection
“nests of palisading cells” on path
carcinoid tumor
Management of lung carcinoid tumor
resection (or endobronchial laser if poor surgical candidate)
+/- chemo, everolimus, cytotoxic chemo, radiolabeled SSA (somatostatin analogues)
Salivary gland types of carcinomas (2)
- mucoepidermoid carcinoma
- adenoid cystic carcinoma
“ice berg” tumor
salivary gland types of carcinomas
cells with t(11;19)(q21;p13) chromosomal translocation, mucus-secreting, squamous and intermediate cells; can be children to elderly
mucoepidermoid carcinoma
Tx: resection
5th decade of life, mixed growth pattern, perineural invasion
adenoid cystic carcinoma
propensity to recur, worse prognosis than mucoepidermoid
Most common benign neoplasm in lung
hamartoma
malignant lung nodule associated with Sjogren’s
MALToma
Tx of MALToma
Rituximab
Where are plasmacytomas found and what can it develop into
bone
multiple myeloma
Pulmonary sarcoma etiology
usually metastatic
Originates from soft tissue
for example kaposi sarcoma
HU of blood
+30-+80
HU of water
0
HU of fat
-50 to -150
HU of air
-1000
Normal HU of lungs
-400 to -700
HU of bone
+700 to +1000
When do you follow up this incidental nodule:
solid <6 mm
low risk patient
no routine follow up
When do you follow up this incidental nodule:
Solid <6 mm
high risk patient
optional CT in 12 mo
When do you follow up this incidental nodule:
solid 6-8 mm
low risk patient
CT at 6-12 mo, then consider CT at 18-24 mo
When do you follow up this incidental nodule:
solid >8 mm
low risk patient
consider CT, PET/CT or tissue sampling at 3 mo
When do you follow up this incidental nodule:
solid 6-8 mm
high risk patient
CT at 6-12 mo
Then 18-24
When do you follow up this incidental nodule:
solid >8 mm
high risk patient
Consider CT/PET CT or tissue sampling at 3 mo
When do you follow up this incidental nodule:
multiple solid <6 mm
low risk patient
no routine follow up
When do you follow up this incidental nodule:
multiple solid 6-8 mm
low risk patient
CT at 3-6 mo
then consider CT at 18-24
When do you follow up this incidental nodule:
multiple solid >8 mm
low risk patient
CT at 3-6 mo,
then consider CT at 18-24
When do you follow up this incidental nodule:
multiple solid <6 mm
high risk patient
Optional CT at 12 mo
When do you follow up this incidental nodule:
multiple solid 6-8 mm OR >8mm
high risk patient
CT at 3-6 mo, then 18-24 mo
When do you follow up this incidental nodule:
subsolid ground glass <6 mm
no routine follow up
When do you follow up this incidental nodule:
subsolid ground glass >6 mm
CT at 6-12 mo to confirm persistence
then CT every 2 years until 5 years
When do you follow up this incidental nodule:
subsolid part solid <6 mm
No routine follow up
When do you follow up this incidental nodule:
subsolid part solid >6 mm
CT at 3-6 mo to confirm persistence
If unchanged and solid component remains <6 mm, annual CT for 5 years
When do you follow up this incidental nodule:
subsolid multiple <6 mm
CT at 3-6 mo, if stable, consider CT at 2 and 4 years
When do you follow up this incidental nodule:
subsolid multiple >6 mm
CT at 3-6 mo
subsequent management based on the most suspicious nodule(s)
Pt with APML starts treatment, 5 days later develops fever, peripheral edema, pulmonary opacities, hypoxemia, respiratory distress, hypotension, acute kidney injury, and elevation of transaminase levels.
Dx and cause?
Differentiation syndrome
all-trans retinoic acid
OR
arsenic trioxide
Tx of SCLC with limited disease
combination platinum-based chemotherapy, etoposide and concurrent radiation therapy
Prophylactic cranial irradiation should be added only if there is complete or partial response in both limited and extensive disease
Tx of SCLC with extensive disease
platinum-based chemotherapy alone, with radiation added later on a case-by-case basis
Prophylactic cranial irradiation should be added only if there is complete or partial response in both limited and extensive disease
