PULMO- CA Flashcards
d/t bronchial epithelium local expansion, and subsequent infiltration of adjacent tissue resulting in lymphatic, hematogenous metasases.
leading cause of cancer related deaths WW for MW
cause 80-90%smoking
Rule of 20. 90 % - smokers_pack per day 20 years = 20x risk of nonsmoker
Bronchogenic carcinoma
Loss of cilia- 2wks to recover
Increase in number of cell rows
Increased atypical cells
*metaplastic squamous epithelium” replaces columnar epithelial lining l/t atypical proliferation>dysplasia>carcinoma.
Physiologic changes in respiratory epithelium related to cigarette smoking:
Prognosis
Bronchogenic CA
aggressive with high mortality rate
Poor prognosis due in part to late diagnosis
Early diagnosis and resection offers some chance of cure
assooc/w 5 year survival rate of < 40 %.
90% respiratory symptoms at the time of diagnosis: Cough Dyspnea Chest pain Hemoptysis Postobstructive pneumonia
Clinical Presentation
Bronchogenic carcinoma
35% PERIPHERAL tumor from mucous secreting cells
MC females and nonsmokers
doubling time of 3-6 months.
Adenocarcinoma
invasion of tumor into GVEsympathetic chain/trunk-
Lesion in sympathetic chain head for head.
vessels to body wall (only SNS)
miosis constricted eye dialator pupillae
ptosis drooping eye (smooth ms) tarsal
enopthalmus- sunken eye
facial flushing-red inc. temp, vasodialtion
anhidrosis-dry
tumor invasion of trachea; vocal cord paralysis d/t entrapment of recurrent laryngeal nerve by mediastinal mass
tumor at apex; shoulder pain, ulnar paresthesia due to encroachment on brachial plexus.
Bronchogenic carcinoma Extrapulmonary/Mediastinum Symptoms Horner’s syndrome Hoarseness: Pancoast (APICAL) syndrome
Anorexia Cachexia Weight loss Fever Digital clubbing (hypertrophic osteoarthropathy -combining clubbing and periostitis of the small hand joints, (adenocarcinoma))
Common metastatic sites: pleura, bone, brain, liver, adrenal glands.
Extrathoracic Symptoms
disorders that are triggered by an altered immune system response to a neoplasm
Endocrine syndromes : 10-15%
Hypercalcemia (inc. squamous cell)
Inappropriate antidiuretic hormone release (SAIDH)
Syndrome of inappropriate antidiuretic hormone secretion
Ectopic adrenal corticotropic hormone secretion (sudden-hypertension, hyperglycemia, hypokalemia, m.alkalosis)
Neurologic: Eaton-Lambert syndrome: muscle weakness mimicking myasthenia gravis.
Thromboembolic disease- sudden, randon, idopathic. DVT, PE, Stroke
Paraneoplastic Syndromes
unrevealing
Occasionally local wheezing from bronchial obstruction
Pleural effusion
Evidence of metastasis or a paraneoplastic syndrome
*Supraclavicular adenopathy
Physical Exam
Cell type:
Squamous and Small
Sx
Atelectasis
Pneumonia
Dyspnea
Bronchogenic carcinoma
Centrally located tumors are more likely to
Chest X-ray-comparison with old films rate of progression
CT Scan-
- anatomical extent of the disease
- Guides diagnostic and therapeutic procedures
- additional lesions not seen on chest x-ray
- Characterizing size, shape, and composition of lesions.
Bronchogenic carcinoma
Diagnostics
Successful diagnosis depends on the cell type and location of the tumor.
80% Squamous cell produces positive
5% Peripheral adenocarcinoma sputums positive
Sputum Cytology
diagnosis and staging
Location determine what diagnostic procedure
Visualizes the proximal extent of the tumor
distance from the carina determines surgical resectability.
Multiple diagnostic procedures:
transbronchial biopsy
Bonchoscopy: brushing for cytology, less lilke squammous
Bronchoalveolar lavage
Transbronchial needle aspiration- ins collapse
Bronchoscopy
Useful if mass or nodule is located peripherally near the pleura or in the apex of the lung
metastatic lesions (difficult by bronchoscopy)
Risk of pneumothorax; especially in patients with emphysema
Needle Biopsy
when enlarged nodes cannot be adequately sampled by less invasive techniques.
Requires hospitalization
Complications: wound infection, injury to major vascular structures, recurrent laryngeal nerve paralysis.
Mediastinoscopy/Mediastinotomy
Lymph node biopsy
two goals:
determine the anatomic extent of the tumor;
determine the physiologic capacity of the patient to undergo therapy.
Tumor size
LN Nodes involved
Metastasis spread
Staging
TX: malignant cells, but tumor not visualized T1: < 3 cm diameter T2: > 3cm diameter T3 : Invasion of chest wall T4 : invasion of mediastinum
Tumor Extent ( primary tumor)
prognosis w/ lung ca is poor.
5-year survival rate for all stages <10%, dec. w/ stage
Size and extent determinants of survival.
TNM stage at presentation in patients with NSCLC is the factor that has the greatest impact on prognosis
Stage I : Surgical resection
Stage Ib-II : Surgical resection plus adjuvant chemotherapy
Stage IIIa: combined modality approach, investigational protocol: surgical resection after initial chemotherapy, with or without radiotherapy.
Stage IIIb: palliative therapy, combined modality therapy with radiotherapy and chemotherapy.
Stage IV: chemotherapy or a palliative, symptom-based approach.
Treatment
systemic chemotherapy combined w/ radiation,
based early metastatic disease.
solitary pulmonary nodule, surgical resection may be considered, in addition to systemic chemotherapy.
Treatment: Small Cell
- (SCLC) vs. (NSCLC), its rapid doubling time, early widespread metastases.
highly responsive to chemotherapy and radiotherapy, BUT relapses within two years -d/t rapid turn over
combination- prolong survival compared with chemotherapy therapy alone
Surgery - not recommended, except, in the rare patient who presents with a solitary pulmonary nodule without distant metastases or regional lymph node involvement
3 to 8 % of all patients with SCLC survive beyond five years.
Prognosis: Small Cell
Surgery = MOST EFFECTIVE therapy for bronchogenic carcinoma.
recommended for NSC stages I and II (some stage III resectable)
Inoperable if widespread mediastinal lymph node metastases, SVC obstruction, pleural involvement, distant metastases.
What is the MOST EFFECTIVE Bronchigenic CA?
Radiation
Pre-operative radiation does not increase survival rates
used for palliative therapy in patients with Inoperable reasons: SVC obstruction, pleural effusion, brachial plexus involvement, or hemoptysis.
What treatment is considered when surgical treatment contraindicated
Chemotherapy- drug therapy
also used w/ radiation therapy
Increases survival rates, but low potential for cure
Combination of several agents more effective than single drug
Chemotherapeutic agents changed whenever evidence of tumor progression
**Genetic mapping for most effective agents-helpful
What is the standard tx for patients with SCLC?
spherical density < 4 cm in diameter
malignancy is 40-50%
Surgical resection possible in 80%
5-year survival rate is 40%
Solitary Pulmonary Nodule
*percutaneous transthoracic needle aspiration
bronchoscopy
10% represent metastatic disease
Biopsy anyone with a hx of CA
How are SPN diagnosed?
Benign
Risks factors for malignancy:
age >35
tobacco or asbestos
hx of previous malignancy
Eccentric calcification- unusual looking
size > 3 cm; irregular shape / ill defined borders
Is a mass that has been present and unchanged or 3year benign or malignant?
What are the risk factors for malignancy?
NO FOLLW UP
symptomatic solid or subsolid (pure ground glass or part-solid) <6 MM
FOLLOW UP
repeat films every 3-4 months for 1 year
then every 6 months for 1 year, then yearly intervals
2 years of study adequate for patients with low suspicion.
5 years necessary for lesions with high suspicion of malignancy
solid SPNs stable on serial CT for 2 years, suggest no further diagnostic testing.
How should we monitor SNP?
NOT REALLY
Diagnosis usually made after metastases has occurred
Goal- detecting lung CA at an earlier, curable stage.
Study- annual low-dose CT screening in patients demonstrated a decrease in lung cancer and all-cause mortality.
Failure of the chest x-ray as a screening tool
1cm first detectable on chest film (30 cell doublings required to reach this size)
Smoke 20+ smoking hx, CC.Cough ins. will pay for CT/Chest Xray
Is Chest xray sufficent screening tool?
Never smoking or smoking cessation
beta carotene, retinoids,selenium, and multivitamins. None have been successful
beta carotene increase lung cancer risk.
Chemoprevention no benefit ,experimental.
Low dose CT screening may help identify patients with early disease
Genetic targeting for specific chemotherapy shows promise to slow progression BUT not cure.
Prevention
