Neoplastic Diseases Flashcards
pulmonary nodule info
Definition: ≤ 3 cm isolated, rounded opacity on chest xray
- Commonly: Incidental finding with no clinical symptom
- ⅓ of all nodule findings are noted on CT scans ordered for other things
-Not associated with infiltrate, atelectasis, or adenopathy
-Most benign nodules = infectious granulomas
-Importance: pulmonary nodles carries a significant risk of malignancy
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Most benign nodules =_______ granulomas
infectious granulomas
what do we do about a pulmonary nodule benign vs malignant
Malignant Tumors: Resection if indicated
- Nodules with a high index of suspicion for malignancy may warrant resection
-CT is indicated in any suspicious solitary pulmonary nodule!
Benign Tumors: Avoid invasive procedures
lung cancer screening: Fleischner Society guidlines
Annual screening = LOW DOSE computed tomography (LDCT):
- adults aged 50 to 80 years AND
- have a 20 pack-year smoking history or quit smoking within 15 years
-dont screen if they have have a health problem that lowers life expectancy
-Change in criteria expanded eligible population ->
detecting large numbers of lung nodules (majority benign)
2022 “State of Lung Cancer” report: only 5.8% of eligible Americans have been screened for lung cancer
Risk factors for nodule malignancy
Age:
- < 30, malignant tumors are rare
- Risk ↑ with age
Smokers:
- Likelihood of malignancy ↑↑↑ with pack-years (20+ yrs)
Hx of Malignancy:
- Hx ↑ likelihood of further malignancy
Evaluation of Malignant Tumors: size of nodule
Mild: 2-5 mm = 1% Malignancy
Moderate: 6-10 mm = 24% Malignancy
Significant: 11-20 mm = 33% Malignancy
Severe: 21-45 mm = 80% Malignancy
Evaluation of Malignant Tumors: what factors
Factors that make nodules more likely malignant:
-Doubling time: rapid progression
-Size: large size
-Borders: ill defined margins, lobular, spiculated margins, peripheral halo
-Calcification: NO calcifications or sparse -> dense calcifications indicate prior inflammation
- cavitation: can be infectious or malignant
Evaluation of Malignant Tumors: borders of nodule
Benign: Smooth, well-defined edge
Malignant:
- Ill-defined margins or lobular appearance
- Spiculated margins and peripheral halo
Lobulated: malignancy
Cavitary: could be infectious or malignancy
Spiculated BAC: hazy
Smooth Granuloma: Beningn
Evaluation of Malignant Tumors: Doubling Time
Rapid progression (< 30 days) is suggestive of infectious process
Long term stability (> 500 days) suggests benignity
Evaluation of Malignant Tumors: calcifications
Benign lesions: Dense calcification
- calcification suggests prior inflammation
Malignant lesions: Sparser calcification
nodule tx: Low probability of malignancy (<5%)
Features of low probability:
-Age under 30
-Characteristic pattern of benign calcification: small, not growing, dense, well defined borders, etc
Tx = Watchful waiting!!!! + serial CTs at routine intervals
-Serial CT scans: with growth would suggest malignancy
Is this calcified vs not
Calcified nodule! incidental finding on chest xray
nodule tx: high probability (>60%) of malignancy
Resect nodule if no contraindications
if its large, spiculated + peripheral halo = high probability
nodule tx: intermediate probability of malignancy (5-60%)
5-60% = intermediate
Bx:
- transthoracic needle aspiration (TTNA)
- bronchoscopy
PET/CT: shows metabolic activity - + test could be infection or inflammation
Sputum cytology:
- highly specific but useless unless central lesion
Video-assisted thoracoscopic surgery (VATS):
- aggressive approach to dx
carcinoid tumors: definition + location
Definition:
- Low grade malignant neoplasm with a slow growth rate and rare metastasis chance
- “Cancer-ish”: Does not behave like regular lung cancer
- Typically < 60 years old patients-> YOUNGER
Location:
- Central Bronchi (MC): Sessile or Pedunculated growths
- Peripherally Located: Asymptomatic solitary pulmonary nodule (rare)
“CARcinoid tumor = only people under 60 should drive a car -> younger age because they are the CENTRAL part of society
Cars = SPEed -> SEssile or PEdunculated”
carcinoid tumors: S&S
-Hemoptysis
-Cough
-Focal wheezing
-Recurrent pneumonia
CARCinoid Syndrome: rare
- Cutatneous Flushing
- Asthmatic Wheezing
- Rapid HR/Hypotension
- Cramping/Diarrhea
- Due to the substances that the carcinoid secretes
carcinoid tumor dx
Bronchoscopy:
-PINK or PURPLE tumor in a central airway
CT scanning:
- localizes the lesion
- use to follow growth over time
Octreotide Scintigraphy, Dotatate PET/CT Scan:
- Localize region of metastasis
carcinoid tumor tx + complications
Surgical excision*
Bronchoscopic removal if:
- entirely endoluminal
- poor surgical candidate
Prognosis is generally favorable
Complication:
- Bleeding and airway obstruction
bronchogenic carcinoma description
Lung cancer: #1 cause of cancer deaths in men and women!!!
-Cigarette smoking causes > 85% of cases of lung ca
-Mean age at diagnosis 70
- Unusual under the age 40
bronchogenic carcinoma risk factors
-Tobacco smoke**
-Radon gas
-Asbestos
-Metals
-Industrial carcinogens
-Family Hx
-Medical conditions
-Previous primary lung cancer
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bronchogenic carcinoma: 4 histologic types
- Squamous cell carcinoma (20%)
- Adenocarcinoma (38% - MC) -> Bronchoalveolar cell carcinoma (2%)
- Large cell carcinoma (5%)
-Small cell carcinoma (13%)
For staging purposes, classifications are split into Small Cell Lung Cancer (SCLC) and Non-Small Cell Lung Cancer (NSCLC)
bronchogenic carcinoma: Small Cell Lung Cancer (SCLC) vs NSCLC
SCLC: small cell carcinoma
-Prone to early hematogenous spread
-Rarely amenable to surgical resection
-Very aggressive course with median survival (untreated) of 6–18 weeks
NSCLC:
-Spreads more slowly
-May be cured in early stages following resection
-Respond similarly to chemotherapy
-includes: SCC, Adenocarcinoma (Bronchoalveolar cell carcinoma), Large cell carcinoma
bronchogenic carcinoma: squamous cell carcinoma
Origin: BRONCHIAL epithelium
Starts off as centrally located, intraluminal sessile/polypoid mass
Descripton
-common sx: hemoptysis
-Spreads locally
-More frequently dx with sputum cytology-> DR VAFAIE DX with cytology BX
- hypercalcemia from paraneoplastic syndromes
bronchogenic carcinoma: adenocarcinoma (MC)
Origin: MUCUS glands
- Found in nonsmokers *
- Presents as peripheral nodules/masses *
Bronchoalveolar Cell Carcinoma:
- Spreads intra-alveolar
- May present as infiltrate or as single/multiple pulmonary nodules
- Radiographically looks like pneumonia
- Paraneoplastic: thromboplebitis
bronchogenic carcinoma: large cell carcinoma
-heterogeneous group of relatively undifferentiated tumors that share large cells and do not fit into other categories
-Typically have RAPID doubling times and an aggressive clinical course
-They present as central OR peripheral masses
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bronchogenic carcinoma: small cell carcinoma
Origin: Bronchial
- typically begins CENTRALLY*
- Infiltrating SUBMUCOSALLY -> narrowing or obstruction of the bronchus without a obvious luminal mass
- Since submucosal -> hard to biopsy
- Metastasizes early + is aggressive
-Very aggressive course with median survival of 6-18 weeks
- Prone to early hematogenous spread
Results in rarely amenable to surgical resection
“SMALL cell = SUBmucosal -> this is hard to bx -> hard to treat”
clinical picture
-Type and location of the primary tumor
-Extent of local spread
-Presence of distant metastases
-Paraneoplastic syndromes
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paraneoplastic syndromes
Carcinoid tumors may oftentimes secrete substances to cause Paraneoplastic Syndromes
Hypercalcemia = SCC
Endocrine issues = Small cell
Neuromuscular issues = small cell
Cardiovascular = adenocarcinoma
Hematological = all
Gynecomastia = large cell
lung cancer symptoms
Early stage lung cancers: asymptomatic
If symptoms present, malignancy has progressed to advanced stage = worse prognosis
Typical symptoms include:
- wt loss
- SOB
- hemoptysis
-cough
lung cancer complications
-SVC syndrome
- Pancoast’s tumor: tumor of the lung apex; horner’s syndrome*
-exudative pleural effusion
- hoarseness: recurrent laryngeal
- carcinoid syndrome
superior vena cava syndrome
-tumor obstructing SVC
-facial edema and plethora
-venous distension distal to obstruction
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horner’s syndrome
Problem with sympathetic nerve supple to one side of face:
- tumor invades sympathetic trunk -> unilateral sx
Sx:
-miosis- constriction
-ptosis- droopy eyelid
-anhidrosis- failure to sweat
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How to dx lung cancer
Dx = tissue or sputum/fluid cytology
-Thoracentesis*
-FNA*: palpable supraclavicular or cervical nodes
-Bronchoscopy: 10-90% yield
-Transthoracic needle bx with CT:
-Video assisted thoracoscopic surgery (VATS): only if above fails
-Mediastinoscopy
Tumor markers of lung cancer
-PDL1
-ALK gene
-EGFR gene
Tumor markers: complement bx; not definitive
Where can lung cancers metastize to?
Liver or brain
Staging of Non Small Cell Lung Cancers
Stages are 1-4; with 4 being the worst
Stage is determined by looking at 3 separate components
T= Tumor size
N= Lymph Node involvement
M= Absence or presence of metastastis
new tx for NSCLC: immunotherapy
Definition: Use of medicines to help a Pt’s immune system recognize and destroy cancer cells
- Functions by blocking PD-1 or PDL-1 = T cells can now recognize tumor cells -> increases immune response = slows tumor progression
- Immunotherapy greatly helps recognize cancer as foreign
Specific blocking sites:
-PD-1 Blockers:
-PDL-1 Blockers:
Tumor marker: PDL1!!
immunotherapies: PD-1 and PDL-1
Target PD-1: “NP”
-Nivolumab (Opdivo)
-Pembrolizumab (Keytruda)
Target PDL-1: “MD - more letters (PDL), more schooling than NPs”
-Mezolizumab (Tecentriq)
-Durvalumab (Imfinzi)
——
Block receptor on tumor cells -> tumor is recognized as foreign -> body immune system works to destroy cancer
Targeted therapy tx for specific mutations in lung cancer
EGFR directed therapy
- immunotherapy helped prolong life in these pts
staging of SCLC
Limited Disease
Definition:
- Disease confined to ipsilateral hemithorax and within a single radiotherapy port
Extensive Disease
Definition:
- Evident metastatic disease OUTSIDE the ipsilateral hemithorax
SCLC: is usually disseminated in almost all pts
tx of SCLC: limited stage
- COMBO of chemotherapy and radiation therapy
- Surgery is NOT indicated unless there is a solitary pulmonary nodule without metastasis
- 12-15%: 5-Year Survival Rate
tx of SCLC: extensive stage
tx:
- Chemotherapy ONLY as initial therapy
- If responsive, then add radiation
- 2% 5-Year Survival Rate
metastatic lung cancer
Definition: Spread of any cancer to lungs through vascular or lymphatic channels or by direct extension
-Metastases usually through the pulmonary artery
-Typically present as MULTIPLE nodules or masses on chest radiography
- most are intraparenchymal (in alveoli/bronchioles; areas of gas exchange)
- less common is endobronchial
- MC: kidney, breast, colon cervix, and malignant melanomas.
“think of the pulm artery as a catapult that shoots the cannonballs into the lungs and then lands in the lower ung zones, intraparenchymal because the alveoli are also the balls (cannonball)”
Most likely primary tumor in metastatic lung ds
Most likely:
- kidney
- breast
- colon
-cervix
- malignant melanoma
metastatic lung cancer symptoms
MC = ASYMPTOMATIC
May present with:
-Cough, hemoptysis
-Dyspnea and hypoxemia (advanced)
-Symptoms are more often referable to the site of the PRIMARY tumor
metastatic lung cancer imaging
CT = most sensitive *
Chest radiographs:
- multiple spherical densities with sharp margins
-MC: lower lung zones
Image: endotracheal metastases (growth in trachea)
what type of cancer is this?
Metastatic lung cancer with MULTIPLE round lesions
- CANNONBALL LESIONS
- multiple spherical densities with sharp margins
- usually at the bases
- CT more sensitive than x-ray
this is very progressed ds -> pt would be symptomatic
“cannonballs need to land bc of gravity so they are in the bases/lower lung zones”
metastatic lung cancer dx
Usually established by identifying the primary tumor
If hx and PE fail to reveal the site of the primary tumor: TAKE LUNG TISSUE SAMPLE
- bronchoscopy
- percutaneous needle biopsy
- thoracotomy: incision into the chest; major surgery
metastatic lung cancer tx
1st: treat primary neoplasm and any pulmonary complications
2nd: Surgical resection of SOLITARY pulmonary nodule if:
- Primary tumor controlled
- Good surgical candidate
- All metastatic tumors can be resected
- No other metastasize
The overall 5-year survival rate in secondary lung cancer treated surgically is 20–35%
Contraindications to surgical resection in metastatic lung cancer
-Melanoma
-Pleural involvement
- Multiple metastasis
What is the first step in the treatment protocol for potentially resectable NSCLC?
Initial evaluation to determine the clinical stage of the cancer.
What approach is advised for patients with clinical stage III NSCLC?
multidisciplinary approach
- consultation with medical oncology, thoracic surgery,
- consideration of chemotherapy, surgery, or induction therapy followed by resection.
After resection of the NSCLC tumor, what determines the next steps in treatment? and what are the tx options?
Pathologic staging of the cancer
- pathologic stage 1a: Observation
- pathologic stage Ib, II, III: adjuvant chemotherapy
What is the preferred treatment for NSCLC patients who are not surgical candidates but have tumors less than 5 cm?
SBRT (stereotactic body radiation therapy).
