Pulm nodules/cancer Flashcards
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
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
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
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
left has one nodule
(1 on bottom is lesslikely to be cancer)
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
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
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
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
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
luung carcinoma
RF
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
pack year
pack-year = number of packs smoked/day x years of smoking
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
lung carcinoma
Patho
Exposure to carcinogens → driver of acquired oncogenic mutations (mutations responsible for initiation and maintenance of the cancer)
Adenocarcinoma
Location
Most common: 40–50% of lung cancers
Location: peripheral; arises from cells that line the alveoli and produce mucus
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 forlesion 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
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 betterprognosis
Several studies also show a favorable association withsmokingcessation
lung cancer
Risks of screening
High false-positive rate
Leads to unnecessarybiopsyor surgery
Increased radiation exposure
Overdiagnosis:
Detection of cancers that would not have affectedmorbidityormortalityfor the patient
Leads to unnecessary aggressive treatment
Mental distress
Most abnormalities detected arebenign nodules
LUNG CANCER
Screening Recommendations
The United States Preventive Services Task Force (USPSTF) 2021 recommendslung cancerscreeningfor (must meet all criteria):
Adults aged 50‒80 years
Those with a 20-pack yearsmokinghistory
Current smoker or has quit within the past 15 years
The American Cancer Society recommendsscreeningfor (must meet all criteria): -(not likely to be tested on)
Adults aged 55‒74 years
30-pack year smokinghistory
Current smoker or quit within the past 15 years
Allpatientsin ascreening program should receive smoking-cessation interventions
Discontinuing Lung cancer screening
Screeningcan be discontinued if the patient:
Has not smoked for ≥ 15 years
Develops a health condition that willlimitlife expectancy
Is unable or unwilling to have curative lung surgery
lung cancer
Strategies for screening
Low-dose computed tomography
Produces high-resolution images with lessradiation
Abnormal findings should be followed up with diagnostic computed tomography (CT)
Lung CTscreeningreporting 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
