Neoplasm Flashcards
new cases rank?
Death rank?
2 new cancer
Unfiltered cigs
More carcinogenic
Risk factors
FH cancer before 60 y/o
Women more
More non-smokers now (genetic)
HIV (even if non-smoker)
Women never smokers?
1/2 get cancer worldwide
Classifications
Small cell (SCLC)
*MC non-small cell (NSCLC) = adeno, squamous, large
- MC type
- non-smokers
- more distant/peripheral metastisis than squamous
Adenocarcinoma
NSCLC
- non-smokers female
- Bronchocorrhea
- MUCH sputum
- CXR = interstitial pattern
- slow growing, late metastises
- solitary nodule, lobar consilodation or mutliple nodule
- BEST PROGNOSIS
Bronchoalveloar subtype (adenocarcioma) NSCLC
“CCCP”
- Centrally located
- CAVITARY LESIONS
- hyperCa2+
- Pancoast syndrome
- plug bronchus
- presents as pneumonia, or obstruction
- polypoid /sessile mass
- smoking hx
- related to Paraneoplastic syndromes
Squamous Cell (SCC) NSCLC
- peripherally located
- high mitotic, necrosis
- difficult to dx
- less common
- AGRESSIVE
- smoker
Large cell cancer
NSCLC
- declining incidence
- smoking
- mitosis necrosis
- major bronchi
- infiltration of wall w/ extrinsic narrowing
- early metastasis to regional nodes (found on presentation)
SCLC
*Dry cough
*hemoptysis
*chest pain
*bronchial obstructin
*dysnpea
Infx
Fever
Primary tumor
*chest pain
*hoarsness
*SVC obstruction
*dysphagia
cardio
Intrathoracic extrapulm extension
Metastisis
Mostly to lymph nodes
Also CNS, bone/marrown, cutaneous/subcutaneous
Anorexia
Weight loss
Weakness
Paraneoplastic syndrome
systemic nonmetastatic symptoms
SCLC hormones
- ACTH –> cushing’s
- ADH –> hyponatremia
- Calcitonin –> hyperCa2+
Squamous hormones
Parathormone
Adenocarcinoma homrone
Growth hormone
CXR
Get 6 weeks after resolution also
- hilar prominence/mass
- parenchymal mass
- localized trapping
- bronchial obstruction w/ atelectasis/consolidation
- mediastinial mass widening
- pleural effusion
- Elevation of hemidiaphragm
- TRACHEA deviation towards (w/ lung collapse)?
Solitary pulmonary nodule
Consider:
Patient characteristics:
Age, smoker, hz other tumor
Nodule characteristics:
Diameter, spiculation, upper lobe location
Size?
Bigger = more chance of malignancy
Border type
Good –> worse
- smooth
- lobulated
- SPICULATED
- CORONA RADIATA
Benign
Vs
Nonspecific calcifiation
Benign
- central
- laminar
- diffuse
- popcorn
Nonspecific
- stippled
- eccentric
Staging work up
- Hz, goals, weight loss, PE
- blood, serum, UA
- CXR
- CT chest/ab/pelvic, PET
- Determine procedures
LEAST INVASIVE APPROACH
HIGHEST STAGING
CONSIDER CO-MORBIDITIES
DX
- Sputum (NO)
- FIBEROPTIC BRONCHOSCOPY/ TRANBRONCHIAL BIOPSY
- Endobrochial ultra
- thoracentesis
- trans-thoracic needle biopsy
Surgical
- mediastinoscopy
- VATS
Staging
Invasive vs. non-invasiv
Non-invasive
- CT
- PET
Invasive
- non surgical EUS, EBUS
- surgical
Bronchoscopy
DIRECT ENDOBROCHIAL BX
- endobronchial brush
- wash
FOR PERIPHERAL (smaller they are, less likely for positive)
CT guided FNA
Better specificity, better view
Pleural fluid cytology
Highest stage
Least invasive
*often not positive, if not 2x send to surgery to biopsy (NO BLIND)
How to obtain tissue
Transbronchial Needle Aspiration (TBNA)
Endobronchial Ultrasound (EBUS)
Staging
Anatomic extent of cancer
- Size/location of primary
- growth directly outside lung
- metastases to regional lymph nodes in hilar area + Mediastinum
- distant metastases
Staging
TMN
T1abc23etc= each cm matters
T3 tumor
- Large = 5-7cm
- Invade something (not lung, not essential)
- Have 2nd tumor in same lobe
T4 tumor
- > 7cm
- invade something they can’t remove
- 2nd tumor = same side, diff lobe
N component
N0= no N1 = intrapulmonary/hilar N3 = opposite/supraclavicular
Small Cell Lung Cancer
Stages
VA study group system
- Extensive stage = distant metastases , + pleural/pericardial effusion
- limited stage = only in 1 hemothorax, medastinium, supraclavicular nodes
Resection
- NSCLC
- stage 1-2
- operable candidate= high risk, COPD, heart, old
Surgery
Bad PFTs
Probably no surgery
Short -term risk
- not age alone (fit or not?)
- hypoxemia/hypercapnea
- low FEV1
- EXERCISE TOLERANCE
Cardiac Eval
Could code if need to intubate w/ Rx
EKG
Planned lobectomy
Planned pneumonectomy
Post BD FEV1
> 1.5 lobectomy
> 2.0L Planned pneumonectomy
Lobectomny also segmental method
Pneumonectomy also V/Q
Extensive (mets) SCLC
Tx
CHEMO
(Cis-platin+ VP-16)
2 cycles then re-assess
NO SURGERY (already mets)
Extensive SLCL
Survival
6-12 months
Radiation?
No benefit to primary extensive SCLC
Limited SCLC
Tx
Chemo + Radiation
Concurrent > sequential
Survival 16-24 months
- NO SURGERY (probably already mets)
- prophylactic cranial irradiation (avoid mets)
Immunotherapy
Blocking PDL1 (causes evasion of T cells)
Pancoast Tumor
In apex, invades contiguous structurs
- brachial plexus
- pain
- HORNER’s SYNDROME (sympathetic chain/stellate ganglion) = Ptosis, meiosis, ipsilateral anydrosis
Lung cancer screening
- NO routine CxR
- Low Dose CT scan
TO PATIENT = must meet criteria, tell that if false positive, will need biopsy
Metastises
MC site
Lung
Breast
Colon
Kidney
- asbestos exposure
* 50-70 yrs old
Mesothelioma
*Poor survival
- NOT smokers
- Females
- <40yrs
Carcinoid tumor
Main risk lifestyle factors (3)
- 30+ pack year smoking history
- quit less than 15 years ago
- 55 year old
NSCLC
Stage 3a
No cycles of surgery b/f chemo
NSCLC Tx
Stage 1-4
SURGERY 1 = surgery 2 = surgery + chemo 3 = Radiation + chemo 4 = chemo, targeted therapy, immunotherapy
*Lobe w node sampling disection (VATS)
*follow up H+P plus CT every 6mos for 2 years THEN yearly for 5 yrs
+/- LowDoseCT
Dx
Biopsy
- supraclavicular nodes
- liver lesions
- adrenal enlargement
Methods of obtaining tissue
- transbronchial needle aspiration
- Endobronchial ultrasound EBUS (Stage mediastinum, better than TBNA)
- Esophageal Ultrasound EUS f
Bronchial carcinoid
Path
- rare
- neuroendocrine cells
- slow growth, low mets
- well differentiated, low grade
- asymptomatic
- diarrhea
- +/-SIADH, Cushings, Obstruction
- bronchoscopy: pink/purple, well-vascularized central tumor
Bronchial Carcinoid
Bronchial Carcinoid
Tx
Surgery
