Pulm nodules/cancer Flashcards by Leslie Mancini

Pulmonary Nodules

general

Small, discrete lesions(< 3 cm (30 mm) in diameter) completely surrounded by pulmonary parenchyma
Often foundincidentally on imaging of the chest or during lung cancer screening
Single or multiple nodules
Multiple nodules are usually the result of metastasis

Nodules are often confused with non-pulmonary soft-tissue densities
Nipple shadows, cutaneous nodules, and bone abnormalities

Lesions > 30 mm are classified as a mass → increased likelihood of malignancy

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Evaluation of Pulmonary Nodules

Primary goal is to detect cancer and active infection
History – suggesting malignant and nonmalignant causes
Current or past smoking
History of cancer
History of an autoimmune disorder
Occupational exposure risk (asbestos, vinyl chloride, radon)
Travel to or living in areas with endemic mycosis or tuberculosis
Risk factors for opportunistic infections (HIV, immune deficiency)

Physical examination
Complete physical examination looking for an etiology

Example: breast lump or a skin lesion found on physical examination

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nodule

Benign/Malignant nodule etiology

Benign
Granulomatous infection (blastomycosis, histoplasmosis, tuberculosis)
Benign tumor (lipoma, fibroma, hamartoma)
Vascular lesion (pulmonary arteriovenous malformation)
Inflammatory lesion (rheumatoid nodules, sarcoidosis)
Infection (bacterial abscess, aspergillosis)

Malignant
Primary lung cancer (adenocarcinoma, squamous cell carcinoma)
Lung metastases (melanoma, sarcoma, carcinomas of the breast, colon, kidneys, testicles)
Carcinoid tumor

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Nodules

Cxr and CT
Calcification
Diameter
Border
Location

Estimate the malignant potential of the pulmonary nodule
Chest x-ray followed by CT scan
Radiographic characteristics of nodules
Growth rate
Comparison with previous imaging
Lesion that have not enlarged in ≥ 2 years → benign lesion
Attenuation (density)…more on the next slide

Calcification
Suggest a benign lesion
Pattern of calcification:
Central, diffuse, laminated, and popcorn – benign
Punctate, eccentric, amorphous – possibly malignant

Margins
Spiculated or irregular (scalloped) → malignant lesion
Regular, well-defined → benign lesion

Diameter
Risk of malignancy increases with increasing diameter
≤ 8 mm → benign lesions

Location
Upper lobe nodules carry a higher risk of malignancy

Cancerous nodules often double in size every 25 days to 4 months
Spiculation is due to growth of malignant cells along the pulmonary interstitium

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left has one nodule
(1 on bottom is lesslikely to be cancer)

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Nodule

Imaging Attenuation

Nodule density
Solid
More common

Sub-solid
Increasing incidence due to rising incidence of adenocarcinoma worldwide
Part-solid have a higher likelihood of being malignant
Pure ground glass can correspond to benign, very slow-evolving lesions or invasive adenocarcinoma

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nodules

Quantitative Predictive Models

Combine clinical and imaging features to estimate the probability of malignancy

Most useful for nodules measuring 8-30 mm
Help to guide management choices
Mayo Clinic Model
https://www.mdcalc.com/solitary-pulmonary-nodule-spn-malignancy-risk-score-mayo-clinic-model
Six independent predictors:
Older age, smoking history, history of cancer, nodule diameter, spiculation, and upper lobe location

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Quantitative Predictive Models

Six independent predictors

Six independent predictors:
1. Older age
2. smoking history
3. history of cancer
4. nodule diameter
5. spiculation
6. upper lobe location

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Management of Solid Pulmonary Nodules

Fleischner Society Guidelines for Incidental Pulmonary Nodules
https://www.mdcalc.com/fleischner-society-guidelines-incidental-pulmonary-nodules

> 6 mm
Assess likelihood of malignancy (clinically or quantitative predictive model)
Low – no further evaluation
Intermediate or high – chest CT scan at 12 months

6-8 mm
Chest CT scan at 6-12 months

> 8 mm
Assess likelihood of malignancy (clinically or quantitative predictive model)
Low – chest CT at 3 months
Intermediate or high-risk nodule → PET/CT, biopsy, or resection

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Lung carcinoma

General

Uncontrolled division of epithelial cells lining the respiratory tract (malignant transformation)
Leading cause of cancer-related death in the United States
230,000 new cases annually in the United States
90% of cases are fatal

Incidence increases with age:
Rare under 50 years old
Peak incidence: 75–79 years
85–90% of lung cancer cases are attributed to smoking

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luung carcinoma

Smoking (most common)
Increased risk related to the number of pack-years
Increased risk with low intensity smoking over a longer period

Environmental exposures:
Secondhand smoke
Exposure to carcinogens: Asbestos, Radon, Chromium, Nickel, Arsenic, Polycyclic aromatic hydrocarbons

Radiation treatment – the number CT scans matters!

Lung disease: (Chronic inflammation)
Idiopathic pulmonary fibrosis
Alpha-1 antitrypsin deficiency
Chronic obstructive pulmonary disease (COPD)

HIV infection
Family history
Alcohol consumption

Risk associated with electronic nicotine delivery systems remains to be determined

Cancer risk declines with smoking cessation, but never returns to the baseline risk in never-smokers; greatest benefit is seen in those who quit by 30-years-old

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pack year

pack-year = number of packs smoked/day x years of smoking

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lung carcinoma

classification

Majorhistologic typesof lung cancer:
Non-small cell lung carcinoma (NSCLC) - 85% of all lung cancers
40% have metastatic disease to the time of diagnosis
Subtypes:
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

Small cell lung carcinoma (SCLC) - 15% of all lung cancers
Highly aggressive
80% have metastatic disease at the time of diagnosis
Almost always occurs in smokers

Small cell lung cancer…small, but mighty!
Small in number, but highly aggressive

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lung carcinoma

Patho

Exposure to carcinogens → driver of acquired oncogenic mutations (mutations responsible for initiation and maintenance of the cancer)

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Adenocarcinoma
Location

Most common: 40–50% of lung cancers
Location: peripheral; arises from cells that line the alveoli and produce mucus

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Squamous cell carcinoma

~20% of lung cancers
Location:central; arises from squamous cell that line the proximal tracheobronchial tree

Large cell carcinoma
Location

2% of lung cancers
Location: peripheral or central

Small cell lung carcinoma
Location

About 15% of all lung cancers
Location: central; usually begins in themain bronchi

DEADLY

paraneoplastic syndrome

Set of signs and symptoms that can occur when there is an underlying cancer
Commonly occur in people withlung, ovarian, lymphatic, or breast cancer

Some lung cancer secrete hormones = paraneoplastic syndrome

paraneoplastic syndrome

Small cell carcinoma

Small cell carcinoma can secrete adrenocorticotropic hormone (ACTH)
Release of cortisol from the adrenal glands = Cushing syndrome (high blood glucose, high blood pressure, hyponatremia)

Small cell carcinoma can secrete antidiuretic hormone (ADH)
Water retention; patient will have edema, increase blood pressure, and concentrated urine

paraneoplastic syndrome

Large cell carcinoma secretes what hormone

Large cell carcinoma can secrete beta-human chorionic gonadotropin(HCG)

paraneoplastic syndrome

Squamous cell carcinoma releases what hormone?

Squamous cell carcinoma can secrete parathyroid hormone

Depletion of calcium from the bone causing them to be brittle; increased calcium in the blood

# Lung cancer Clin man

Asymptomatic ~25% of patients General symptoms Cough (most common): New-onset cough in a smoker or former smoker Frequent symptom in squamous and small cell cancers due to central location May have hemoptysis (more significant invasion) Dyspnea due to malignancy-related: Airway obstruction Atelectasis Pleural effusion Pneumothorax Chest pain: Vague Localized Pleuritic Fatigue Anemia Cancer cachexia: (typically seen in metastisis pts) Loss of muscle mass and fat Weight loss Anorexia

# Lung cancer Regional spread of laryngeal nerve, phrenic nerve, esophagus, blood vessels

Recurrent laryngeal nerve encroachment: Hoarseness Phrenic nerve encroachment: Diaphragmatic paralysis (elevated diaphragm) Dyspnea Hypoxia Esophageal compression: dysphagia Invasion of a blood vessel: hemoptysis

# Lung cancer Regional spread to Superior vena cava (SVC)

Regional spread Superior vena cava (SVC) syndrome: SCLC > NSCLC Compression or invasion of the SVC leading to: Headache Head fullness Facial & upper extremity swelling Orthopnea Dilated neck, face, and trunk veins Facial and truncal flushing

regional spread of esophagus, blood vessels

Esophageal compression: dysphagia Invasion of a blood vessel: hemoptysis

# lung cancer Pancoast syndrome:

Pancoast syndrome: **Mostly due to NSCLC** Adenocarcinoma & SCC **Apical tumors invade the brachial plexus, pleura, or ribs** resulting in: Shoulder and upper extremity pain Upper extremity weakness Atrophy of the ipsilateral hand Horner’s syndrome: Ptosis, miosis, anhidrosis(no sweat on one side)

# lung cancer liver metastisis

Abdominal pain, nausea, early satiety → hepatic insufficiency

# lung cancer brain

Brain: Behavioral changes, confusion, aphasia, seizures, paralysis

# lung cancer bone mets

Severe pain (back, chest, extremities), pathologic fractures

# lung cancer adrenal gland metastisis

Usually asymptomatic Adrenal insufficiency (if both glands are affected by metastatic cancer)

# lung cancer CXray

Chest x-ray **Not diagnostic** Initial imaging modality when evaluating a patient with symptoms concerning for lung cancer Review previous chest imaging to assess for lesion properties and changes Findings that should raise suspicion of malignancy: New or enlarging focal lesion (coin lesion) Pleural effusion Pleural thickening Enlarged hilar and paratracheal lymph nodes Tracheobronchial narrowing Segmental or lobar atelectasis

# Lung cancer Chest CT

Chest CT scan Obtained to further evaluate concerning pulmonary abnormalities found on chest x-ray Allows for assessment of: Pulmonary lesion Lymph node involvement Metastases Aids in biopsy planning Can also be used as a **screening tool** Low-dose CT produces high-resolution images with less radiation

# lung cancer Biopsy

Definitive pathology is **required for diagnosis** (tissue biopsy is preferred over cytologic specimen)

TNM staging system | and prognosis

Non-small cell lung cancer 4 stages: I-IV using the TNM system T = tumor N = lymph node (mediastinum & hilar) M = metastases Survival varies by stage 5-year survival 60-70% for patients with stage I disease <1% for patients with stage IV disease ## Footnote 4 is more severe than 1.

small cell lung cancer staging

Small cell lung cancer 2 stages: limited and extensive Overall prognosis is poor Median survival – 20 months

# Lung cancer Tx

Varies by cell type and stage of disease Surgery Chemotherapy Radiation therapy Immunotherapy Utilizes the body’s immune system to eliminate the cancer Targeted therapies Target specific gene mutations (affects cell growth and replication) Associated with improved survival

# lung cancer Benefits of screening

Goal is to detect early disease, which is: More amenable to treatment Associated with better prognosis Several studies also show a favorable association with smoking cessation

# lung cancer Risks of screening

High false-positive rate Leads to unnecessary biopsy or surgery Increased radiation exposure Overdiagnosis: Detection of cancers that would not have affected morbidity or mortality for the patient Leads to unnecessary aggressive treatment Mental distress | Most abnormalities detected are benign nodules

# LUNG CANCER Screening Recommendations

The **United States Preventive Services Task Force** (USPSTF) 2021 recommends lung cancer screening for (must meet **all** criteria): Adults aged 50‒80 years Those with a 20-pack year smoking history Current smoker or has quit **within** the past 15 years The American Cancer Society recommends screening for (must meet all criteria): -(not likely to be tested on) Adults aged 55‒74 years 30-pack year smoking history Current smoker or quit within the past 15 years All patients in a screening program should receive smoking-cessation interventions

Discontinuing Lung cancer screening

Screening can be discontinued if the patient: Has not smoked for ≥ 15 years Develops a health condition that will limit life expectancy Is unable or unwilling to have curative lung surgery

#lung cancer Strategies for screening

**Low-dose computed tomography** Produces high-resolution images with less radiation Abnormal findings should be followed up with diagnostic computed tomography (CT) Lung CT screening reporting and data system (Lung-RADS®) Tool designed to standardize lung cancer screening CT reporting and management recommendations Introduced in 2012 Modeled after the mammography reporting system (BI-RADS®) Lung-RADS® coding Category: 0, 1,2,3,4A, 4B, 4X Modifier S that can be added to category 0-4 0 = incomplete exam