pulmonary cancer

Question 1

Describe the epidemiology of Lung Cancer in the United States

Answer 1

Lung cancer is leading cause of cancer death in men and women in US and world.

Question 2

risk factors for disease development of lung cancer

Answer 2

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.

Question 3

Improvements in lung cancer survival are due to…

Answer 3

Staging, pre-operative/post operative care, combined modality therapy, targeted/personalized treatment

Question 4

Bach index

Answer 4

•Age, gender, asbestos exposure history, smoking history can be used to predict lung cancer risk

Question 5

Types of lung cancer

Answer 5

Non-small cell lung cancer which includes adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Small cell lung cancer

Question 6

Squamous cell carcinoma histology and pathology

Answer 6

Arises from the bronchial epithelium and typically more central in location. Histology shows irregular nests of cells, often with central keratin pearls (KP

Question 7

Adenocarcinoma and large cell carcinoma pathology

Answer 7

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.

Question 8

Small cell carcinoma histology and pathology

Answer 8

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.

Question 9

How is lung cancer staged

Answer 9

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

Question 10

stages of lung cancer

Answer 10

T0, Tis, T1a, T1b, T2a, T2b, T3, T4

Question 11

Describe T0, Tis, T1a, T1b, T2a, T2b stages

Answer 11

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

Question 12

Describe T3 and T4 stages

Answer 12

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.

Question 13

Nodal status of lung cancer

Answer 13

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

Question 14

Distant metastasis ratings of lung cancer

Answer 14

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

Question 15

Stages of lung cancer and T, N, M classifications

Answer 15

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

Question 16

4. Understand common genetic alterations in non-small cell lung cancer and how these form the basis of targeted therapy

Answer 16

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

Question 17

Targeted therapy for non small cell lung cancer- adenocarcinoma

Answer 17

EGFR treatments include erlotinib (Tarceva), gefitinib (Iressa), cetuximab (Erbitux), afatinib (Gilotrif). Her2 mutation treatments include trastuzumab (Herceptin). vEGF mutations are treated with Bevacizumab (Avastin)

Question 18

Treatment for squamous cell carcinoma

Answer 18

No targeted therapies exist

Question 19

Treatment of small cell lung cancer

Answer 19

Cisplatin and etoposide- prognosis is bad

Question 20

2. List the characteristics of solitary pulmonary nodules

Answer 20

•Lesion < 3 cm diameter, Round or oval with smooth contour, Surrounded by aerated lung, No satellite lesions, No associated atelectasis, pneumonitis or regional adenopathy

Question 21

2. List the goals of evaluation of solitary pulmonary nodules

Answer 21

Expedite resection of potentially curable lung cancer, Minimize resection of benign nodules, Morbidity and mortality of nodule evaluation (including VATS): 5-10%

Question 22

Correlate nodule size at detection and likelihood of malignancy

Answer 22

Likelihood of malignancy increases with nodule size

Question 23

Approach to solitary pulmonary nodules

Answer 23

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

Question 24

Lung cancer screening methods. Which methods have shown no reduction in lung cancer mortality

Answer 24

Chest X-ray (no reduction in mortality), Sputum cytology (no reduction in mortality), Spiral CT, Autofluorescence bronchoscopy

Question 25

USPSTF recommendations for lung cancer screening

Answer 25

•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.

Question 26

American cancer society’s recommendations for lung cancer screening

Answer 26

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

Question 27

Use of CT as screening method

Answer 27

CT screening should be offered to patients who meet the NSLT criteria and are in overall ‘fair health’

Question 28

Use of PET CT in lung cancer

Answer 28

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

Question 29

What is chemoprevention

Answer 29

The use of specific agents to reverse, suppress or prevent carcinogenesis. Current trials include PGI2 analogue, selenium, COX-2

Question 30

Functions of PGI2 and PGE2

Answer 30

PGI2 is antimetastatic and PGE2 suppresses anti-tumor immunity