Neoplastic Lung Diseases Flashcards
patient history suggesting lung cancer
*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
paraneoplastic syndromes associated with lung cancer
*HPO and clubbing
*hypercalcemia (more common with NSCLC, squamous cell)
*more common with SCLC:
-SIADH
-Cushing syndrome
-myasthenia gravis
-Lambert-Eaton syndrome
which cancer is associated with hypercalcemia paraneoplastic syndrome
squamous cell carcinoma (non-small cell lung cancer)
which lung cancer is associated with most paraneoplastic syndromes
small cell lung cancer
epidemiology of lung cancer
*3rd most common cause of new cancer cases
*1st most common cause of cancer DEATHS
etiologic factors that increase the chance of developing lung cancer
*SMOKING
*environmental tobacco smoke
*cooking fumes
*hormonal factors (estrogen receptors)
*radon exposure
*asbestos, polycyclic hydrocarbons, cadmium, chromium, nickel, and arsenic
most common demographic for lung cancer in an individual who has never smoked
female of East Asian descent
pathologic types of lung cancer: non-small cell lung cancer (NSCLC)
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
*surgical cure if localized; if not, chemo and/or XRT
*TNM stage at presentation has the greatest impact on prognosis
pathologic types of lung cancer: small cell lung cancer (SCLC)
*usually metastatic at time of presentation
*treatment: chemo and/or radiation
*most important prognostic factor is the stage of disease at presentation
diagnostic methods for lung cancer
*sputum cytology
*flexible bronchoscopy
*transthoracic needle biopsy
*VATS
TNM staging of non-small lung cancer
*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
staging for small cell lung cancer
*limited vs. extensive
*limited - in one hemithorax
*extensive - outside one hemithorax
treating stage 1A & 1B NSCLC
*surgery
*stereotactic body radiation therapy (SBRT)
treating stage 2A & 2B NSCLC
*surgery (adjuvant chemo is usually considered)
*stereotactic body radiation therapy (SBRT)
treating stage 3A NSCLC
*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
treating stage 3B NSCLC
*NOT a surgically curable disease
*acceptable patients receive chemo & radiation
*patients that respond to treatment are often continued on immunotherapy for cancer (Durvaiumab)
treating stage 4 NSCLC
*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)
common driver mutations associated with lung cancer
*EGFR
*ALK
*ROS
treating SCLC
*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)
complications of lung cancer
- local complications:
-superior vena cava syndrome
-intractable hemoptysis - distant complications:
-metastases
superior vena cava (SVC) syndrome - etiology
*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
superior vena cava (SVC) syndrome - clinical presentation
*swelling of the face, arms, or chest wall
*difficulty breathing (dyspnea)
*engorgement of neck and chest veins
superior vena cava (SVC) syndrome - treatment
*emergency radiation
*emergency chemotherapy
*emergency surgery
*palliation alone
intractable hemoptysis
*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
common sites of metastases of lung cancer
*small cell and adenocarcinoma are the most common lung cancers to metastasize
*sites: liver, lymph nodes, BRAIN, bones, or adrenal glands
Pancoast Tumor - overview
*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
“pearls” for squamous cell carcinoma
*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
“pearls” for small cell carcinoma
*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
“pearls” for adenocarcinoma
*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
recommendation for lung cancer screening
*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
what is a solitary pulmonary nodule?
*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
pre-test probability for cancer when a solitary pulmonary nodule is present
*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)
approach for solitary pulmonary nodules
- determine patient risk factors
- determine nodule risk characteristics
- decide pre-test probability of malignancy and share this with the patient
- together, decide on one of:
-no further imaging
-continue observation with imaging
-biopsy now
-surgery now
Pancoast Tumor - clinical presentation
*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
