Neoplastic Lung Diseases

Question 1

patient history suggesting lung cancer

Answer 1

*most common symptoms: cough, dyspnea, chest pain, hemoptysis
*less common symptoms: clubbing, hoarseness, dysphagia, wheeze
*only 5-15% are asymptomatic
*15% have extra-pulmonary symptoms
*5% may present with a paraneoplastic syndrome

Question 2

paraneoplastic syndromes associated with lung cancer

Answer 2

*HPO and clubbing
*hypercalcemia (more common with NSCLC, squamous cell)
*more common with SCLC:
-SIADH
-Cushing syndrome
-myasthenia gravis
-Lambert-Eaton syndrome

Question 3

which cancer is associated with hypercalcemia paraneoplastic syndrome

Answer 3

squamous cell carcinoma (non-small cell lung cancer)

Question 4

which lung cancer is associated with most paraneoplastic syndromes

Answer 4

small cell lung cancer

Question 5

epidemiology of lung cancer

Answer 5

*3rd most common cause of new cancer cases
*1st most common cause of cancer DEATHS

Question 6

etiologic factors that increase the chance of developing lung cancer

Answer 6

*SMOKING
*environmental tobacco smoke
*cooking fumes
*hormonal factors (estrogen receptors)
*radon exposure
*asbestos, polycyclic hydrocarbons, cadmium, chromium, nickel, and arsenic

Question 7

most common demographic for lung cancer in an individual who has never smoked

Answer 7

female of East Asian descent

Question 8

pathologic types of lung cancer: non-small cell lung cancer (NSCLC)

Answer 8

1. adenocarcinoma
2. squamous cell carcinoma
3. large cell carcinoma
   *surgical cure if localized; if not, chemo and/or XRT
   *TNM stage at presentation has the greatest impact on prognosis

Question 9

pathologic types of lung cancer: small cell lung cancer (SCLC)

Answer 9

*usually metastatic at time of presentation
*treatment: chemo and/or radiation
*most important prognostic factor is the stage of disease at presentation

Question 10

diagnostic methods for lung cancer

Answer 10

*sputum cytology
*flexible bronchoscopy
*transthoracic needle biopsy
*VATS

Question 11

TNM staging of non-small lung cancer

Answer 11

*T for the extent of the primary tumor (size)
*N for lymph node involvement
*M for metastatic disease

note - ANY metastatic disease means that it is stage IV

Question 12

staging for small cell lung cancer

Answer 12

*limited vs. extensive
*limited - in one hemithorax
*extensive - outside one hemithorax

Question 13

treating stage 1A & 1B NSCLC

Answer 13

*surgery
*stereotactic body radiation therapy (SBRT)

Question 14

treating stage 2A & 2B NSCLC

Answer 14

*surgery (adjuvant chemo is usually considered)
*stereotactic body radiation therapy (SBRT)

Question 15

treating stage 3A NSCLC

Answer 15

*combination of radiation, chemo, and/or surgery
*chemo and radiation can come before surgery (neoadjuvant) or after surgery (adjuvant)
*if not healthy enough for surgery, radiation is often used, with or without chemo

Question 16

treating stage 3B NSCLC

Answer 16

*NOT a surgically curable disease
*acceptable patients receive chemo & radiation
*patients that respond to treatment are often continued on immunotherapy for cancer (Durvaiumab)

Question 17

treating stage 4 NSCLC

Answer 17

*NOT a surgically curable disease
*treatment with chemotherapy, targeted therapy, immunotherapy, and radiation therapy may be part of tx plan (targeted therapy is used depending on mutation status)

Question 18

common driver mutations associated with lung cancer

Answer 18

*EGFR
*ALK
*ROS

Question 19

treating SCLC

Answer 19

*NOT a surgically treated type of cancer
*limited stage: chemo is often given in combination with radiation
*extensive stage: chemo with or without immunotherapy (radiation is less commonly used)

Question 20

complications of lung cancer

Answer 20

1. local complications:
   -superior vena cava syndrome
   -intractable hemoptysis
2. distant complications:
   -metastases

Question 21

superior vena cava (SVC) syndrome - etiology

Answer 21

*a local complication that can occur with lung cancer (as well as other causes)
*symptoms result when the superior vena cava is obstructed, by extrinsic compression or tumor invasion
*lung cancer is the leading malignant cause of SVC syndrome

Question 22

superior vena cava (SVC) syndrome - clinical presentation

Answer 22

*swelling of the face, arms, or chest wall
*difficulty breathing (dyspnea)
*engorgement of neck and chest veins

Question 23

superior vena cava (SVC) syndrome - treatment

Answer 23

*emergency radiation
*emergency chemotherapy
*emergency surgery
*palliation alone

Question 24

intractable hemoptysis

Answer 24

*a local complication of lung cancer in which patient is continuously coughing up blood
*local control by bronchoscopy is effective in a minority of cases
*bronchial artery embolization is effective in most cases

Question 25

common sites of metastases of lung cancer

Answer 25

*small cell and adenocarcinoma are the most common lung cancers to metastasize
*sites: liver, lymph nodes, BRAIN, bones, or adrenal glands

Question 26

Pancoast Tumor - overview

Answer 26

*a tumor of the apex of the lung with no intervening lung tissue between the tumor and chest wall with involvement of structure of the apical chest wall above the level of the second rib
*often involves invasion into the lower part of the brachial plexus, first ribs, vertebrae, or subclavian veins

Question 27

Pancoast Tumor - clinical presentation

Answer 27

*Horner Syndrome on the affected side of the face:
-decreased pupil size (miosis)
-drooping eyelid (ptosis)
-decreased sweating (anhidrosis)

note - lung cancer, specifically NSCLC, is the leading cause of Horner Syndrome

note - Pancoast tumors can be of any of the lung cancer origins, it is just an indication of the location of the tumor

Question 27

“pearls” for squamous cell carcinoma

Answer 27

*centrally located
*almost exclusively in smokers
*paraneoplastic syndrome = HYPERCALCEMIA
*KERATIN PEARLS on histology
*histologic dx based on presence of keratin production by tumor cells and/or intercellular desmosomes
*may show extensive central necrosis with resulting cavitation

Question 28

“pearls” for small cell carcinoma

Answer 28

*centrally located
*almost exclusively in smokers
*characterized by small “blue” malignant cells about 2x the size of lymphocytes
*cytoplasm is sparse, and nuclear features include finely dispersed chromatin without distinct nucleoli
*NUEROENDOCRINE origin
*multiple associated paraneoplastic syndromes (Cushing’s, SIADH, Eaton-Lambert, etc)
*rapid doubling time, high growth fraction, early development of widespread metastases
*not treated surgically

Question 29

“pearls” for adenocarcinoma

Answer 29

*most common NSCLC
*more peripherally located
*tumor cells can have multiple mutations (EGFR, ROS1, p53, etc)
*most common cancer in non-smokers (esp. women of East Asian descent)
*paraneoplastic syndrome = hypertrophic pulmonary osteoarthropathy

Question 30

recommendation for lung cancer screening

Answer 30

*yearly chest CT scans
*recommended for adults aged 50-80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years

Question 31

what is a solitary pulmonary nodule?

Answer 31

*single, well-circumscribed opacity < 3cm in diameter
*surrounded completely by aerated lung:
-no involvement with the hilum or mediastinum
-not associated with lymph nodes, atelectasis, or pneumonia
*can be solid, semi-solid, or ground-glass nodules

Question 32

pre-test probability for cancer when a solitary pulmonary nodule is present

Answer 32

*clinical characteristics that favor malignancy: age, smoking status, personal cancer history, FHx of lung cancer in primary relative, chronic lung disease, lung carcinogen exposure
*radiographic characteristics of malignancy:
-diameter
-spiculation
-upper lobe location
-absence of calcification or indeterminant calcification (completely calcified nodule is almost certainly not malignant)

Question 33

approach for solitary pulmonary nodules

Answer 33

1. determine patient risk factors
2. determine nodule risk characteristics
3. decide pre-test probability of malignancy and share this with the patient
4. together, decide on one of:
   -no further imaging
   -continue observation with imaging
   -biopsy now
   -surgery now