pulmonary cancer Flashcards
Describe the epidemiology of Lung Cancer in the United States
Lung cancer is leading cause of cancer death in men and women in US and world.
risk factors for disease development of lung cancer
Environmental factors: Smoking, radon gas, asbestos, metals, polycyclic aromatic hydrocarbons. Suspected: air pollution, vinyl chloride, silica, history of TB. Diseases: COPD secondary to smoking, sputum cytologic atypia, genetics, females > men, sarcoidosis, pulmonary fibrosis/ILD, previous lung, head or neck cancer.
Improvements in lung cancer survival are due to…
Staging, pre-operative/post operative care, combined modality therapy, targeted/personalized treatment
Bach index
•Age, gender, asbestos exposure history, smoking history can be used to predict lung cancer risk
Types of lung cancer
Non-small cell lung cancer which includes adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Small cell lung cancer
Squamous cell carcinoma histology and pathology
Arises from the bronchial epithelium and typically more central in location. Histology shows irregular nests of cells, often with central keratin pearls (KP
Adenocarcinoma and large cell carcinoma pathology
adenocarcinoma arises from mucous glands and typically more peripheral in location. Large cell carcinoma is a heterogeneous group of poorly differentiated tumors that do not have features of adenocarcinoma, squamous cell, or SCLC.
Small cell carcinoma histology and pathology
bronchial origin and typically begins as central lesions that can often narrow or obstruct bronchi. Histology shows closely packed cells with scant cytoplasm and streaming nuclei.
How is lung cancer staged
History/Physical—weight loss, bone pain, neuro symptoms/signs, lymphadenopathy. Screening blood tests - high Alk Phos, Ca++, anemia, cytopenias suggest metastases.
CT scans to assess N2 nodes/upper abdomen. Fiberoptic bronchoscopy or needle biopsy – to establish histology (SCLC vs. NSCLC) – proximity to carina, mediastinal staging. Mediastinal biopsy (CME, EBUS, EUS, TBNA) – to confirm status of mediastinal nodesHistory/Physical—weight loss, bone pain, neuro symptoms/signs, lymphadenopathy. Screening blood tests - high Alk Phos, Ca++, anemia, cytopenias suggest metastases.
CT scans to assess N2 nodes/upper abdomen. Fiberoptic bronchoscopy or needle biopsy – to establish histology (SCLC vs. NSCLC) – proximity to carina, mediastinal staging. Mediastinal biopsy (CME, EBUS, EUS, TBNA) – to confirm status of mediastinal nodes
stages of lung cancer
T0, Tis, T1a, T1b, T2a, T2b, T3, T4
Describe T0, Tis, T1a, T1b, T2a, T2b stages
T0- No evidence of primary tumor; Tis- Carcinoma in situ; T1a- tumor < 2cm (not in mainstem bronchus); T1b- tumor > 2-3 cm (not in mainstem bronchus); T2a- tumor < 5cm or present in mainstem bronchus but not within 2 cm of carina, invasion of visceral pleura, associated atelectasis or pneumonitis extending to hilar region; T2b – tumor 5-7 cm
Describe T3 and T4 stages
T3- tumor > 7cm, tumor of any size that invades: chest wall, diaphragm, mediastinal pleura, parietal pericardium. Tumor < 2 cm from carina, associated atelectasis or pneumonitis of entire lung; 2 or more malignant nodules in the same lobe.
T4- tumor of any size with invasion of: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina; malignant nodules in ipsilateral lung.T3- tumor > 7cm, tumor of any size that invades: chest wall, diaphragm, mediastinal pleura, parietal pericardium. Tumor < 2 cm from carina, associated atelectasis or pneumonitis of entire lung; 2 or more malignant nodules in the same lobe.
T4- tumor of any size with invasion of: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina; malignant nodules in ipsilateral lung.
Nodal status of lung cancer
N0- no nodal involvement; N1- metastases to ipsilateral peribronchial or ipsilateral hilar region (including direct extension); N2- metastases to ipsilateral mediastinal and/or subcarinal lymph nodes; N3- metastases to supraclavicular or contralateral mediastinal, hilar, or scalene nodes
Distant metastasis ratings of lung cancer
M0 - no distant metastasis; M1a - separate tumor nodules in a contralateral lobe; tumor with pleural nodules; or malignant pleural or pericardial effusion; M1b - distant metastasis
Stages of lung cancer and T, N, M classifications
Stage0: Tis N0. Stage 1a: T1a N0 or T1b N0. Stage 1b: T2a N0. Stage 2a: T2b N0, T1a N1, T1b N1, or T2a N1. Stage 4: M1 N0, N1, N2 or N3
- Understand common genetic alterations in non-small cell lung cancer and how these form the basis of targeted therapy
50-80% of NSCLC have mutation in epidermal growth factor (ERB-1 or EGFR)which turns the gene on and leads to cell proliferation . 10% have Her2/neu (ERB-2) mutation. Vascular endothelial growth factor (vEGF) is overexpressed in some. Ras mutations occur in 2-30% and are associated with resistance to tyrosine kinase inhibitors
Targeted therapy for non small cell lung cancer- adenocarcinoma
EGFR treatments include erlotinib (Tarceva), gefitinib (Iressa), cetuximab (Erbitux), afatinib (Gilotrif). Her2 mutation treatments include trastuzumab (Herceptin). vEGF mutations are treated with Bevacizumab (Avastin)
Treatment for squamous cell carcinoma
No targeted therapies exist
Treatment of small cell lung cancer
Cisplatin and etoposide- prognosis is bad
- List the characteristics of solitary pulmonary nodules
•Lesion < 3 cm diameter, Round or oval with smooth contour, Surrounded by aerated lung, No satellite lesions, No associated atelectasis, pneumonitis or regional adenopathy
- List the goals of evaluation of solitary pulmonary nodules
Expedite resection of potentially curable lung cancer, Minimize resection of benign nodules, Morbidity and mortality of nodule evaluation (including VATS): 5-10%
Correlate nodule size at detection and likelihood of malignancy
Likelihood of malignancy increases with nodule size
Approach to solitary pulmonary nodules
review previous CXR, no further eval needed if stable for >2 yrs or benign central calcification. Spiral chest CT with contrast, PET, biopsy/resection + lymph node dissection, lobectomy
Lung cancer screening methods. Which methods have shown no reduction in lung cancer mortality
Chest X-ray (no reduction in mortality), Sputum cytology (no reduction in mortality), Spiral CT, Autofluorescence bronchoscopy
USPSTF recommendations for lung cancer screening
•Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative surgery.
American cancer society’s recommendations for lung cancer screening
Asymptomatic subjects at increased risk (as defined in the NLST) should be offered screening at experienced centers with teams of specialists that can provide appropriate care and follow-up. However, at this time screening is not recommended routinely
Use of CT as screening method
CT screening should be offered to patients who meet the NSLT criteria and are in overall ‘fair health’
Use of PET CT in lung cancer
Where available,PET to evaluate for mediastinal and extrathoracic metastases should be performed in nearly all patients with NSCLC being treated with curative intent. PET not required for ground glass opacities of <2cm or patients with peripheral stage T1a tumors
What is chemoprevention
The use of specific agents to reverse, suppress or prevent carcinogenesis. Current trials include PGI2 analogue, selenium, COX-2
Functions of PGI2 and PGE2
PGI2 is antimetastatic and PGE2 suppresses anti-tumor immunity
