PULM PART 3 Flashcards
Cystic Fibrosis
Patho
Most common cause of severe chronic lung disease in young adults and the most common fatal hereditary disorder of whites in the US
• __________ disorder affecting 1 in 3200 whites; 1 in 25 is a carrier
• Caused by abnormalities in membrane ______ channel (cystic fibrosis transmembrane conductance regulator or ____ protein resulting in altered chloride transport and water flux across the apical surface of epithelial cells
• ½ of nearly 20,000 DF patients in the US are adults
• Increased risk of malignancies of GI tract, osteopenia and arthropathies
S/S
Chronic or recurrent productive _____, dyspnea, and wheezing
• Recurrent airway infections or chronic colonization of the airways with _______, _______, S aureus or Burkholderia cepacian. ________ and scarring on chest radiographs
• Almost all exocrine glands produce an abnormal ______that obstructs glands and ducts leading to tissue damage
• Respiratory tract: inadequate _____ of the tracheobronchial epithelium impairs mucociliary function
• High concentration of extracellular DNA in airway secretions increases sputum _______
Clinical Findings:
• Suspected in young adult with hx of chronic lung disease (esp bronchiectasis), pancreatitis or infertility
• Cough
• Sputum production
• Decreased exercise tolerance
• Recurrent hemoptysis
• Chronic rhinosinusitis
• _______
• ________
• ________l pain
Also possible
• Malnourished with low body mass index
• Digital clubbing
• Lungs
o Increased _______ diameter
o ________ to percussion
o Apical crackles
• Sinus tenderness
• Purulent nasal secretion
• Nasal polyps
• Biliary cirrhosis and gallstones are possible
• Men: congenital bilateral absence of the vas deferens with _______
Diagnostics
Sweat chloride concentration greater than __ mEq/L on two occasions or gene mutations known to cause cystic fibrosis
• Arterial blood gas studies reveal hypoxemia and in advanced disease a chronic compensated respiratory acidosis
• PFTs show mixed obstructive/restrictive pattern
o Reduction in ___, airflow rates and TLC
o Air trapping (high ratio of __ to TLC)
o Reduction in pulmonary diffusing capacity
Imaging
• ______ in early disease
• Peribronchial cuffing, mucus plugging, bronchiectasis, increased interstitial markings, small rounded peripheral opacities and focal atelectasis are common
• Pneumothorax can also be seen
• __ can confirm bronchiectasis
Diagnosis
• Quantitative pilocarpine iontophoresis sweat test
o Elevated sodium and chloride levels (greater than 60mEq/L
o Two tests on different days performed in experienced labs
o Normal sweat chloride test does not exclude the diagnosis
o Pursue genotyping or other alternative diagnostic studies
o Nasal membrane potential difference, semen analysis or assessment of pancreatic function
Prevention
Treatment
Early recognition and comprehensive multidisciplinary therapy improve symptoms control and the chance of survival
• Referral to regional treatment center
• Conventional tx programs focus on
o Clearance and reduction of lower airway secretions
o Reversal of bronchoconstriction
o Treatment of respiratory tract infections a
o Pancreatic enzyme replacement a
o Nutritional and psychosocial support
• Clearance of lower airway secretions
• ________
• Chest percussion or vibration techniques
• Positive expiratory pressure or flutter valve breathing devise
• Directed cough and other breathing techniques
• Inhaled recombinant human _____
o Cleaves extracellular DNA in sputum
o Decreases sputum _____
o Long term at daily nebulized dose of 2.5 mg
Improves FEV1 and reduces the risk of DF related respiratory exacerbation and need for IV ABX
• Inhalation of hypertonic saline twice daily
o Small improvements in pulmonary function and fewer exacerbations
Short term ABX
• Treat _____ airway infections based on C and S of sputum
• S aureus including ____, mucoid variant of ______ are common
• H Flu and others are occasionally isolated
Long term ABX
• Helpful in slowing the disease progression and reducing exacerbations in patient with positive P aeruginosa cultures
• Include _______ (500mg three times a week; has immunomodulatory properties )
• Also ______ ABX two to three time a day.
• Incidence of atypical mycobacterial colonization is higher in CF patient
• Directed ABX recommended for frequent exacerbations, progressive decline in lung function or failure to thrive
• Yearly screening with sputum acid-fast bacilli cultures is advised
Inhaled bronchodilators
• ____2 puffs every 4 hours as needed
• Considered in patients who demonstrate an increase of at least 12% in FEV1 after inhaled bronchodilator
• Inhaled corticosteroid should be added to the tx regimen for patient with persistent asthma or allergic bronchopulmonary mycosis
______
• Oral medication available for the 5% of CF patients with G551D mutation
• Potentiator of the CFTR channel
• Works by increasing the time the channel remains open
• Found to improve lung function by 10% within 2 weeks of treatment
• Decreases pulmonary exacerbations by 55% and decrease sweat chloride into the indeterminate range
__________
• Only definitive treatment or advanced CF
• Double lung or heart-lung is required
• Afew transplant centers offer living lobar lung transplantation to selected patients
• 3 year survival rate is about 55%
Vaccination
• Pneumococcal infection and annual influenza vaccination
• Screening
• Family members and genetic counseling are suggested
autosomal recessive chloride CFTR cough H flu P aeruginosa bronchiectasis mucus hydration viscosity steatorrhea diarrhea abdominal ap chest hyperresonance azoospermia 60 FVC, TLC RV hyperinflation CT postural drainage DNA viscosity active MRSA P aeuginosa azithromycin inhaled Albuterol ivacaftor lung transplantation
Bronchiectasis
Patho
Congenital or acquired disorder of the large bronchi
• Characterized by permanent, abnormal _____ and _______ of bronchial walls
• May be caused by recurrent inflammation or _____ of the airways and may be localized or diffuse
• Most patients have pan hypergammaglobulinemia possibly reflecting an immune system response to chronic airway infection.
• ___ causes about ½ of all cases
• Other causes:
o Lung infection (__, fungal infections, lung abscess, pneumonia
o Abnormal lung defense mechanisms
o Deficiency with cigarette smoking
o Mucociliary clearance disorders
o Immunodeficiency states
o Localized airway obstruction
S/S • Chronic cough with production of copious amounts of _______ sputum
• _______
• Pleuritic chest pain
• ______ and wheezing in 75% of patients
• Weight loss, anemia and other systemic manifestations are common
• Physical findings are nonspecific
• Persistent crackles at lung bases are common
• Clubbing is infrequent in mild cases but common in severe cases
o Exact cause unknown; vasodilation/growth factors
• Copious, ________, purulent sputum is characteristic
• Obstructive pulmonary dysfunction with hypoxemia is seen in moderate or severe disease
Diagnostics
Radiographs
• Dilated and thickened bronchi that may appear as “_________” or as ______ like markings
• Scattered irregular _______, atelectasis and focal consolidation may be present
• High resolution ___ is the diagnostic study of choice
Microbiology
• _____ is the most common organism recovered from non CF patients
• ________ , S pneumonia and S Aureus are commonly identified
• Accelerated course with P Aeruginosa
o More frequent exacerbations and rapid decline in lung function
Prevention
Treatment
ABX
o Guided by sputum smears and cultures
o Screen for nontuberculous mycobacteria (may underlie lack of treatment response)
o Empiric oral antibiotic therapy for 10-14 days
o Amoxicillin or _________ ; ______ or tetracycline; ______ ; Cipro
• Chest physiotherapy with _________ and chest percussion
o Hand held flutter valve devices may be as effective as chest physiotherapy in clearing secretions
• Inhaled bronchodilators
• Preventive or suppressive treatment is sometimes given to stable outpatients with copious purulent sputum
o Prolonged macrolide therapy for 6-12 months decreases the frequency of exacerbations
o High dose Amoxicillin
o alternating cycles of _______ /______ for 2-4 weeks
• Underlying CF
o Inhaled aerosolized ________ reduce colonization by Pseudomonas species, improve FEV1 and reduce hospitalizations
• Surgical resection
o Reserved for the few patients with localized bronchiectasis and adequate pulmonary function in whom conservative treatment fails.
Misc.
dilation, destruction infection CF TB purulent hemoptysis dyspnea foul smelling tram tracks ring opacities CT H flu P areuginosa amoxicillin c lavulanate ampicillin TMP/SMX (bactrim) macrolide/amoxicillin aminoglycosides
Mallamparti scoring
• To perform a Mallampati evaluation, with the patient seated, have the patient extend his neck, open his mouth fully, protrude his tongue, and say “ah.”
• Visualize the airway, looking for the tongue, soft and hard palate, uvula, and tonsillar pillars.
• In patients with a Mallampati score of _, the entire posterior pharynx is easily visualized; with a _, no posterior structures can be seen
1, 4
Obstructive Sleep Apnea Patho • Intermittent cessation of airflow at the \_\_\_ and \_\_\_\_ during sleep • Sleep apnea syndrome – clinical disorder that arises from recurrent apneas during sleep • Apneas must be at least \_\_ seconds Influencing factors: Sleep • Airway dilator and abductor muscle (loss of \_\_\_\_) • Protective airway reflex responses • \_\_\_\_\_ • Anatomic disturbances–“pharyngeal crowding” o \_\_\_\_\_ hypertrophy o \_\_\_\_\_\_\_\_ is a type of malocclusion which refers to a maxilla or mandible which is further posterior than would be expected. A retrognathic mandible is commonly referred to as an "\_\_\_\_\_ " • Obesity o MEN OF NORMAL WEIGHT: 11% INCIDENCE o OVERWEIGHT: 21% o \_\_\_\_\_ : 63% • Hormones • Macroglossia • Pregnancy • Smoking
S/S PE findings: • Neck Circumference o >\_\_ inches in men; > \_\_ inches in women o Not applicable to children • Mallampati Score History of: • Snoring • \_\_\_\_\_ sleepiness • Nocturnal choking/gasping • Witnessed apneas during sleep • Moderate obesity • Large neck circumference (>17 males;>16 women) • Mild-mod \_\_\_\_ Complications: • Cognitive & Behavioral disturbances o Loss of \_\_\_\_\_ sleep • Daytime sleepiness o Initially during passive conditions o Later active: 2-7x increased Motor vehicle accidents • Memory loss • Personality disturbances (\_\_\_\_\_\_\_) • Cardiorespiratory (increased ventricular afterload) o \_\_\_\_/\_\_\_\_\_arrhythmias o HTN (systemic/pulmonary)
Epidemiology •
Any age
• Men > Women
• Age 30-60; can occur ANY AGE
Diagnostics
_________
• Detailed overnight sleep study
• Electrographic variables (EEG, EOG)
• Ventilatory variables (central/obstructive)
• O2 sats
• HR, rhythm
• +/- PCO2
EEG
• The EEG (electroencephalogram) monitors ______ and can be used to determine the level of sleep or _______
• It is helpful for determining if an event (respiratory or limb movement) disrupts the level of sleep
EOG
• An EOG (electro-oculogram) measures ____ movements using sticker electrodes placed next to each eye.
• This measurement can help determine the duration of REM sleep.
EMG
• An EMG (electromyogram) measures _____ movements.
• Frequently, an additional monitor is placed on the chin to measure muscle relaxation (tone).
• During stage 1-4 sleep there is a baseline muscle tone; however, during REM sleep all muscles relax.
• The EMG also helps to determine the duration of REM sleep.
• An EMG of the legs can be used to detect “restless leg syndrome” or periodic leg movements during sleep
More tests:
• ______. is used to measure the decreases in oxygen in the blood during apneas and hypopneas
• The video monitor is most helpful for detecting movement disorders, parasomnias, or seizures during sleep
• Often a patient will not remember sleepwalking, sleep talking, or other parasomnias, so a video is helpful to review the events with the patient.)
Severity levels:
• SLEEP APNEA: AN AHI GREATER THAN _ EVENTS PER HOUR WITH AT LEAST ___ SYMPTOM OF DISTURBED SLEEP
• Obstructive sleep apnea can be categorized as mild, moderate, or severe
• This stratification helps to determine the direction of treatment
Treatment
• In people with nasal airway obstruction causing obstructive sleep apnea, nasal steroid sprays have been shown to be effective
• Topical nasal _______ , like oxymetalizone and ________, also can temporarily improve nasal swelling.
• ______ where appropriate!
• Avoid alcohol and other hypnotic medications.
Dental appliances:
• A dental appliance holds the jaw and tongue forward and holds the palate up thus preventing closure of the airway
• This small increase in airway size often is enough to control the apneas
• excellent treatment for ____. to _____ obstructive sleep apnea
____
• probably the best, non-surgical treatment for any level of obstructive sleep apnea
• In finding a treatment for obstructive sleep apnea, the primary goal is to hold the airway open so it does not collapse during sleep
• The dental appliances and surgeries focus on moving the tissues of the airway
• CPAP uses air pressure to hold the tissues open during sleep
Surgeries:
• UPPP: In simple terms, the _____ are removed, the _____ is removed, and the palate is trimmed higher
• A UPPP is successful 50-60% of the time in preventing or decreasing obstructive sleep apnea
Misc.
nose, mouth 10 tone tone ETOH adenotonsillar retrognathia overbite OBESE 17, 16 daytime hypertension slow-wave depression tachy/brady polysomnography brainwaves wakefulness eye muscle oximetry 5 one decongestants neosynephrine weight loss mild to moderate CPAP tonsils, uvula
Central sleep apnea
Patho
• Abolition of Central drive to the ______ muscles
• Occurs because your ____ doesn’t send proper signals to the muscles that control your breathing
Conditions causing CSA
• _____ and degenerative changes in the cervical spine or the base of the skull
• Bulbar poliomyelitis
• Complications of cervical spine surgery
• _____ affecting the brainstem
• Neurodegenerative illnesses such as Parkinson’s disease
• Obesity
• Radiation of the cervical spine
• ____ affecting the brainstem
• Primary hypoventilation syndrome
• Use of certain medications such as narcotic-containing painkillers
S/S Defects
• Metabolic respiratory _____ defect
• Respiratory neuromuscular apparatus defect
• Chronic ________ during wakefulness
• ____ high alt or due to cardiopulm dz)
• RECURRENT APNEAS ARE NOT ACCOMPANIED BY RESPIRATORY EFFORT
ventilatory brain arthritis encephalitis stroke control hyperventilation hypoxia
Pickwickian syndrome Patho Also called \_\_\_\_\_\_\_\_\_ syndrome S/S • Awake hypoventilation (PaCO2 > \_\_ mmHg) in an obese person (BMI> 30) • Coexisting \_\_\_\_\_\_\_ with desaturation Epidemiology Diagnostics Prevention Treatment Treatment: \_\_\_ and lifestyle modification for weight loss • Other tmts: \_\_\_\_\_\_ for sleep disordered breathing or \_\_\_\_\_\_\_. surgery Misc.
hypoventilation 45 OSA 45 PAP tracheostomy bariatric
. Staging and treatment of small cell lung cancer
• Traditionally divided into two categories
• _____ disease (30%) – tumor is limited to the unilateral hemithorax
• _______ disease (70%) – tumor extends beyond the hemithorax
• It is also recommended to stage according to the TNM guidelines
• Staging in NSCLC:
o T – describes the ____ and location of the primary ____
o N – describes the presence and location of _____ metastess
o M – refers to the presence or absence of _____metastases
o The TNM stages are grouped into summary stages I-IV
• Generalized staging guidelines:
o Thorough history and physical examination
o Identify performance status
o ____ scan can identify mediastinal spread and distant metastases
o _____I brain to evaluate for metastatic disease
o When PET not available, ____ abdomen/pelvis and bone scan are used
limited extensive size, tumor nodal distal PET MRI CT
Pulmonary metastasis
Patho
• Results from spread of an _______ malignancy to the lung parenchyma through vascular or lymphatic channels or by direct extension
• Typically present as _____ nodules or masses on imaging
• Most common primary cancers are ____ , ____t, colon and rectum, cervix, and malignant melanoma
• Also seen in head and neck cancers and soft tissue sarcoma
• Metastatic cancer can also present as a malignant _________
• Lymphangitic carcinomatosis is diffuse involvement of the pulmonary lymphatic network
S/S
Epidemiology
Diagnostics
• Investigate for primary location using imaging and tumor markers
• ____ is useful for diagnosis and staging, _________ staining is used to identify primary
Prevention
Treatment
• Treat _____ malignancy
• Treat any pulmonary complications
• ________of solitary pulmonary nodule is possible, only if primary cancer is otherwise under control
• Stereotactic radiosurgery may be an option
• Unfavorable prognosis for large number of pulmonary nodules and short disease-free interval
Misc.
extrapulmonary multiple kidney, breast pleural effusion biopsy immunohistochemical primary surgical resection
Small cell Lung Cancer
Patho
Small cell (oat cell):
• About 10-15% of lung cancers
• Typically ______ located
• SCLC is more ______ and fast growing
• Usually responds more _____ to treatment
• Limited treatment options
S/S
• ______ and weight loss are common
• ___ cough or change in chronic cough
• ________
• Pain – nonspecific chest pain or pain due to bone metastases
• SOB – due to bronchial obstruction or pleural effusion
• ______
• Change in voice – due to compression of recurrent ______ nerve
• Superior vena cava syndrome
• ______ syndrome – ipsilateral ptosis, miosis, and anhidrosis
• ______ metastasis – weight loss and abdominal pain
• _____ metastasis – headache, N/V, seizure, dizziness, altered mental status
• Paraneoplastic syndromes – most common are ______, __________, hypercoagulability, and anemia
Biopsy methods:
• ____ guided lung biopsy
• _______ – allows for biopsy and brushing and lavage
• EBUS – endobronchial US with bronchoscopy can increase yield
• Navigational bronchoscopy allows biopsy of small peripheral nodules
• Risk of pneumothorax and bleeding varies
• Mediastinoscopy usually used for staging
• VATS and thoracotomy may be necessary
Epidemiology
Diagnostics
• Diagnosis is dependent on histology
• ________ gives best yield
• Sputum cytology is specific but not sensitive
• Fluid cytology also less sensitive
• Tumor markers are not sensitive or specific enough
• Diagnose and stage with single biopsy if possible
Prevention
Treatment General tx guidelines:
• Depends on type, stage, and molecular characteristics of the tumor
• SCLC – ________ and possibly _______
Surgical candidates:
• Preoperative assessment
o Labs
o Cardiac clearance
• Pulmonary function testing
o Many patients have chronic lung disease that increases risk of perioperative complications as well as long-term pulmonary insufficiency
o FEV1 determines risk for resection
SCLC tx:
• Response rate to _______ and _______ is 80-90% in limited-stage disease and 60-80% in extensive stage disease
• Remission tends to be ____ lived, median 6-8 months
• Median survival is 15-20 months in limited stage and 8-13 months in extensive stage
• Overall 2-year survival is 20-40% in limited stage and 5% in extensive stage
• Radiation therapy can improve survival in limited stage disease
• Consolidative RT may be indicated
• High rate of brain metastases, prophylactic whole brain RT is recommended
• Rarely, very early stage SCLC is found and patients are able to have surgery followed by adjuvant chemotherapy (due to high risk for micrometastases)
• _______ therapy:
o Can use radiation on central tumors to relieve obstruction or stop bleeding
o Radiation also used to palliate pain due to bone metastases
o Resection of a solitary brain metastasis improves quality of life and survival
o Pain syndromes are common in advanced disease and pain control is necessary
o Consult a Palliative Care team to help with symptom management
Misc. Risk factors:
• Cigarette smoking causes 80% of cases of lung cancer
o Risk increases with both quantity and duration of smoking
o Cigar and pipe smoking also increase risk
• Other environmental risk factors include radon gas, secondhand smoke exposure, asbestos, metals, industrial carcinogens
• Familial susceptibility plays a role in some cases
• Certain diseases increase risk: pulmonary fibrosis, COPD, sarcoidosis
centrally aggressive quickly anorexia new hemoptysis clubbing laryngeal horner liver brain SIADH, hypercalcemia CT. guided bronchoscopy tissue biopsy chemotherapy, radiation cisplatin, etoposide short palliative
Non-small cell Lung Cancer Patho Non-small cell: • NSCLC is the most \_\_\_\_\_type of lung cancer • Approximately 85% of lung cancers • \_\_\_\_\_\_\_ and \_\_\_\_\_\_\_ cell carcinoma subtypes are most common o Adenocarcinoma: Arises from \_\_\_\_\_ glands Most common (40% of cancers) Most common type in woman, non-smokers and younger patients Usually peripheral nodules \_\_\_\_ and \_\_\_\_\_ positive o Squamous cell carcinoma: Arise from \_\_\_\_\_ epithelium Linked with \_\_\_\_\_\_\_ Can be intraluminal mass or centrally located More likely to cause hemoptysis \_\_\_ and \_\_\_ positive
- Large cell carcinoma is more undifferentiated
- Sarcomatoid is another subtype – has features of both carcinoma and sarcoma
- Spreads more slowly
- May be cured by resection in early stage
- Systemic therapy is specific to histology and molecular mutations
S/S
• Anorexia and weight loss are common
• New cough or change in chronic cough
• Hemoptysis
• Pain – nonspecific chest pain or pain due to bone metastases
• SOB – due to bronchial obstruction or pleural effusion
• Clubbing
• Change in voice – due to compression of recurrent laryngeal nerve
• Superior vena cava syndrome
• Horner syndrome – ipsilateral ptosis, miosis, and anhidrosis
• Liver metastasis – weight loss and abdominal pain
• Brain metastasis – headache, N/V, seizure, dizziness, altered mental status
• Paraneoplastic syndromes – most common are SIADH, hypercalcemia, hypercoagulability, and anemia
Biopsy methods:
• CT guided lung biopsy
• Bronchoscopy – allows for biopsy and brushing and lavage
• EBUS – endobronchial US with bronchoscopy can increase yield
• Navigational bronchoscopy allows biopsy of small peripheral nodules
• Risk of pneumothorax and bleeding varies
• Mediastinoscopy usually used for staging
• VATS and thoracotomy may be necessary
Epidemiology
Diagnostics
• Diagnosis is dependent on histology
• Tissue biopsy gives best yield
• Sputum cytology is specific but not sensitive
• Fluid cytology also less sensitive
• Tumor markers are not sensitive or specific enough
• Diagnose and stage with single biopsy if possible
Prevention
Treatment General tx guidelines:
• Depends on type, stage, and molecular characteristics of the tumor
• Early stage NSCLC – ______ is treatment of choice, with or without ______ or radiation
• Late stage NSCLC – _______, targeted therapy, and/or immunotherapy, possibly radiation
Surgical candidates: • Preoperative assessment o Labs o Cardiac clearance • Pulmonary function testing o Many patients have chronic lung disease that increases risk of perioperative complications as well as long-term pulmonary insufficiency o FEV1 determines risk for resection
NSCLC tx:
• Cure unlikely without resection
• Initial questions:
o Is surgical resection technically feasible?
o Is the patient able to tolerate the surgery?
• Surgery not possible in many instances
• Stage I and Stage II – ______
• Stage IIIA – undergo multimodality treatment that includes _____ when possible, and _____ or radiation, or both
• Stage IIIB – concurrent _______ and radiation
• Stage IV – _______ and/or symptom-based _______therapy
• Surgical resection:
o Wedge resection
o Sublobar resection
o Lobectomy
o Partial pneumonectomy
o Pneumonectomy
o VATS is a reasonable alternative to thoracotomy
• STEREOTACTIC RADIATION THERAPY
o Stage I patients who are not candidates for ______may have SBRT
o Large dose of radiation to a small, well defined target
o Usually given over 1-5 doses
o Takes 30-60 minutes each treatment
o Three-year local control exceeds 90%
• NEOADJUVANT CHEMOTHERAPY
o Giving ______ drugs in _____ of surgery or radiation therapy
o More widely used in Stage ___or Stage ___ disease to make patient a surgical candidate or make surgery more successful
• CONCURRENT CHEMOTHERAPY/RADIATION
o Chemotherapy and radiation are given together on a specific schedule
o Chemotherapy given on schedule depending on regimen
o Radiation given daily over 6-7 weeks
o More difficult to tolerate due to increased side effects
• ADJUVANT CHEMOTHERAPY
o Giving antineoplastic drugs ______ surgery or radiation
o Increases overall survival
o For patients with poor performance status, chemotherapy risks can outweigh the benefit
• CHEMOTHERAPY
o In Stage ___ or Stage ___ disease, chemotherapy is not curative, but provides an increase in survival when compared to supportive care alone
o Palliative chemotherapy can lead to increased symptom control and quality of life
o The choice of treatment is tailored to histologic type and NCCN guidelines
o Maintenance chemotherapy may be continued after the initial 4-6 induction cycles
• Immunotherapy
o Stimulates bodys own immune system to target and kill cancer cells
o Checkpoint inhibitors work by blocking a signaling protein that allows cancer cells to hide from the immune system
o Examples are: Opdivo (nivolumab), Keytruda (pembrolizumab), Tecentriq (atezolizumab), Imfinzi(durvalumab)
o Many can now be used first-line in combination with chemotherapy
common adenocarcinoma squamous cell mucous TTF-1, napsin-A positive bronchiol smoking P63, P40 surgery, chemotherapy chemotherapy resection surgery chemo chemo chemo palliatiive surgery antineoplastic advance IIIA, IIIB following IIIB, IV
