Pulmonary neoplasms Flashcards
Solitary Pulmonary Nodule
● Sometimes referred to a “coin lesions,” solitary pulmonary nodules are rounded, isolated opacities see on chest imaging.
○ Less than 3 cm in size
● They are surrounded by normal lung and are not associated with infiltrates, lymphadenopathy, atelectasis or symptoms of illness
Solitary Pulmonary Nodule appearance on CT
They may be solid or subsolid, and may appear with ground glass or mixed consistency on CT
Most benign nodules are _______
infectious granulomas
Goal of evaluation for Solitary Pulmonary Nodule
Identify and resect malignant tumors while avoiding unnecessary invasive procedures in benign disease.
How can we decide who is at high risk of malignancy?
A combination of clinical and imaging data are needed to assess the probable level of risk
______ is an important marker for cancer
“Doubling time”
If the nodule doubled in size in
_____ , there’s a higher probability of cancer
less than 30 days
If the nodule appears _____, this is
characteristic of a benign process.
smooth with well-defined edges
Lesions with ____ and/or a peripheral halo are highly suggestive of malignancy
spiculated margins
In patients with a high probability of malignancy, proceed
directly to _____
resection following staging
There are two main methods for Solitary Pulmonary Nodule biopsy:
○ Transthoracic Needle Aspiration
(TTNA)
○ Bronchoscopy needle aspiration
Resection technique for Solitary Pulmonary Nodule
● Some recommend video-assisted thoracoscopic surgery (VATS)
for resection of all solitary pulmonary nodules with intermediate
probability of malignancy
85-90% of cases of Bronchogenic Carcinoma are caused by _____
cigarette smoking
Risk Factors of Bronchogenic Carcinoma
○ Smoke from tobacco or marijuana
○ Exposure to industrial carcinogens
○ Exposure to ionizing radiation
○ COPD, Sarcoidosis, or Pulm Fibrosis
○ Recurrent severe lung inflammation
○ A familial predisposition is recognized
The median age at diagnosis of Bronchogenic Carcinoma is _____
71 years
5 main histological categories of Lung cancer, split them into 2 main groups:
○ Small Cell Lung Cancer
○ Non-Small Cell Lung Cancers
■ Squamous Cell Carcinoma
■ Adenocarcinoma
■ Adenocarcinoma in situ (AKA Bronchioloalveolar Carcinoma)
■ Large Cell Carcinoma
Small Cell Lung Cancer
● Unique and accounts for approximately 13% of lung cancer cases.
● Bronchial epithelial tumor that exhibits
neuroendocrine function- Associated with a
variety of paraneoplastic syndromes (later)
● Infiltrates the submucosa and can cause
narrowing of the bronchial lumen
SCLC is prone to early ______
hematogenous spread,
often involving the hilar lymph nodes very early
AKA “Oat Cell” Cancer
Small Cell Lung Cancer
Squamous Cell Carcinoma
● Accounts for approximately 23% of lung cancer cases.
● Arises from the ciliated bronchial epithelium.
● More likely to present with hemoptysis as it
is often centrally located and involving the
bronchi lumen.
● Can often be diagnosed with sputum
cytology, which is unique to this type of lung
cancer.
Adenocarcinoma of the Lung
● Most common form of Lung Cancer,
accounting for approximately 50%.
● Arises from the bronchial glandular cells.
● Often appears in the periphery of the lung
and typically metastasizes to distant sites
Adenocarcinoma is the subtype of lung
cancer that is observed most commonly in
those that _____
do not smoke
Bronchioloalveolar Carcinoma
● Technically, a subtype of Adenocarcinoma that is uncommon, accounting for approximately 2% of lung cancer cases.
● Spreads along the alveolar structures
without significant evidence of invasion (slow growing).
● Arises from epithelial cells within or distal to terminal bronchioles, often involving the alveoli
“Adenocarcinoma in situ”
Bronchioloalveolar Carcinoma
Large Cell Carcinoma
● A heterogeneous group of undifferentiated cancer types that do not fit in other categories.
● Accounts for approximately 1.3%
of lung cancer cases
● Often appear as a large mass in
the periphery of the lung
● Characterized by lack of histologic
characteristics that would make it
SCC or Adenocarcinoma
Screening for Lung Cancer
○ Annual low-dose CT (LDCT) screening for those at high risk is recommended by multiple organizations.
○ High-risk criteria include age 50–80 years, at least a 20-pack-year smoking history, and either current smoking or quit date within the past 15 years
Clinical Presentation for Bronchogenic Carcinoma
○ The large majority of patients are symptomatic at diagnosis.
○ Presentation varies depending on type and location of tumor
and the extent of spread, but may include:
■ Anorexia and weight loss (55-90%)
■ Asthenia (55-90%)
■ New cough or change in chronic cough (60%)
■ 6-31% have hemoptysis
■ 12-33% have a pleural effusion (exudative)
■ 25-40% experience chest or bone pain
■ Focal neurologic deficits if CNS metastasis
○ May see Superior Vena Cava syndrome
○ Pancoast tumors (tumors in the lung
apex) can cause Horner’s Syndrome.
Diagnostic Evaluation for Bronchogenic Carcinoma
○ Nearly all patients with lung cancer have abnormal findings on chest radiography or CT scan.
■ CXR should be followed by CT
○ PET scans are often utilized with CT
to evaluate for metastasis.
○ Biopsy technique depends on tumor location
Biopsy technique depends on tumor location:
■ Sputum Cytology (if lesion is in central airways)
■ Thoracentesis Cytology (if malignant pleural effusion)
■ Fine Needle Aspiration of involved nodes
■ Video-assisted thoracoscopic surgery (VATS)
■ Fiberoptic Bronchoscopy with needle biopsy
■ Transthoracic Needle Aspiration (TTNA)
Once tissue has confirmed malignancy, accurately staging the cancer is crucial for multiple reasons:
■ To provide information to guide treatment
■ To provide the patient with accurate information regarding prognosis
■ To standardize entry criteria for clinical trials to allow interpretation of results
Two principles of NSCLC staging:
● More extensive the disease, the worse the prognosis.
● Surgical resection offers the best hope for a cure (this is not the case with SCLC)
TNM Staging System:
● T- Size and location of primary tumor
● N- Presence and location of nodal involvement
● M- Presence or absence of distant metastasis
Referral Considerations and Treatment for Bronchogenic Carcinoma
○ If radiologic imaging is suggestive of a pulmonary malignancy, get a Pulmonologist involved quickly
○ Medical and Radiation Oncology should be consulted
○ For NSCLC, surgical resection is strongly considered as an initial priority if possible, then chemo/radiation
■ For SCLC, surgery is rarely helpful to prognosis due to aggressive micrometastasis, so chemo is the focus
Treatment priority by staging for Bronchogenic Carcinoma
● I-II: Surgical resection plus possible adjunct therapy
○ If inoperable, stereotactic body radiotherapy
● IIIa: Surgical resection plus chemo and/or radiation
● IIIb and inoperable IIIa: Concurrent chemo and radiation,
followed by immunotherapy (checkpoint inhibitors)
● IV: Chemo and/or immunotherapy, or symptom-based
palliative therapy, or a combination of both
Treatment for Small Cell Lung Cancer (SCLC)
■ Surgery plays no role in the treatment of most patients with
SCLC due to presumed metastasis.
■ Chemotherapy with or without chest radiation is mainstay.
■ Initial response rates can be strong, although remission is
generally short-lived (median of 6-8 months).
● After recurrence, survival is 2-4 months
■ Overall 2-year survival is 20–40% in limited-stage disease
and 5% in extensive-stage disease
Overall Prognosis for Bronchogenic Carcinoma
○ The overall lung cancer 5-year survival rate is about 22%.
○ Survival is best for those with early
stages of NSCLC
○ SCLC has the poorer prognosis,
especially extensive disease
Most common pulmonary mets:
Carcinoma of the kidney, breast,
rectum, colon, and cervix
Typically, extrapulmonary malignancy
that metastasizes to the lungs will
appear as _____
multiple dense nodules
If there are metastatic lesions in the lungs, you
need to get _____
a CT of the head, as well as Chest/Abdomen/Pelvis (both with contrast).
Symptoms of pulmonary mets could include:
○ Cough
○ Hemoptysis
○ Dyspnea
○ Hypoxemia
○ May be asymptomatic
Treatment/Management of Metastatic Tumors
○ Once the diagnosis has been established, treatment is
focused on the primary cancer.
○ If there is only a single pulmonary lesion, or a large mass
causing significant obstruction, surgery may be indicated
Mesothelioma
● Relatively rare primary cancer arising from
the mesothelial cells
○ Large majority are the pleural lining, but
small percentage are from peritoneum
● Confirmed association with a distant history
of exposure to asbestosis
Pathophysiology of Mesothelioma
○ Pleural mesotheliomas encase and
compress the lung, extending into the
fissures, yet largely sparing the
parenchyma of the lung
Mesothelioma Clinical Presentation
■ Insidious dyspnea
■ Unilateral, nonpleuritic chest pain
■ Weight loss
■ Dullness to percussion
■ Diminished breath sounds
■ Clubbing (occasionally)
Average age at diagnosis of Mesothelioma in US is ____ years of age
72-74
Mesothelioma Diagnostic Evaluation
○ Radiographic abnormalities:
Nodular, irregular, unilateral
pleural thickening and varying
degrees of Pleural Effusion
○ Evaluation of a Pleural
Effusion will reveal exudative
and often hemorrhagic fluid.
○ Biopsy required for diagnosis
Clinical Course of Mesothelioma
○ The disease progresses rapidly and will eventually involve contralateral pleura, pericardium and mediastinum.
○ Patients develop progressive pain and dyspnea.
○ Often develop superior vena cava syndrome and Horner’s
Treatment Options and Prognosis of Mesothelioma
○ A combination of chemotherapy, radiation, and surgery are
usually attempted, but are generally unsuccessful.
○ Patients usually die of respiratory failure or complication of local
extension (such as hemorrhage).
○ Median survival from diagnosis is 7-18 months; 5-year is 5-12%
Anterior Mediastinal Mass DDx
○ Thymoma: Most common anterior mediastinal mass, associated
with Myasthenia Gravis in 35% of cases
○ Lymphoma
○ Thyroid lesions
Most common anterior mediastinal mass, associated
with Myasthenia Gravis
Thymoma
Middle Mediastinal Mass DDx
○ Lymphadenopathy
○ Pulmonary Artery enlargement
○ Aortic Aneurysm
○ Dilated azygos or hemiazygos vein
○ Pericardial Cyst: Most common mediastinal cyst
Posterior Mediastinal Masses
○ Neurogenic Tumors: Includes tumors such as neurofibroma,
ganglioneuroma, meningocele.
○ Hiatal hernia
○ Esophageal tumor
Clinical Presentation of Mediastinal Masses
○ Nonspecific and usually caused by pressure or mass effect on
surrounding structures as the mass grows.
■ Superior vena cava syndrome
■ Retrosternal chest pain
■ Dysphagia
■ No symptoms at all (about 50% of cases)
Mediastinal Masses diagnosis
● Often picked up as incidental findings on CXR.
● CT can help aid in diagnosis.
● MRI may be helpful in this situation because it can better delineate between hilar structures, vessels, and masses.
● Tissue biopsy is often required for definitive
diagnosis when a neoplastic process is considered
Carcinoid Tumors
● A type of neuroendocrine (glandular) tumor, these are low- or intermediate-grade malignancies that are slow-growing
● Carcinoid tumors most commonly
occur in the GI tract or in the lungs.
● In the lungs, they start as small,
pedunculated growths in the central
bronchi
Clinical Presentation of Bronchial Carcinoid Tumors
○ Hemoptysis
○ Cough
○ Focal wheezing
○ Recurrent postobstructive pneumonia
○ Carcinoid Syndrome (rare, but characteristic)
■ Flushing
■ Diarrhea
■ Wheezing
■ Hypotension
Carcinoid Syndrome
■ Flushing
■ Diarrhea
■ Wheezing
■ Hypotension
Diagnostic Evaluation of Carcinoid Tumors
○ If the lesion is located in the periphery, it may show up as a solitary pulmonary nodule that may grow slowly (seen on serial CT scans)
○ Bronchoscopy may reveal a pink or purple tumor in central airway
Carcinoid Tumors treatment
○ Bronchial carcinoids grow slowly and rarely metastasize.
■ The concern is for bleeding or airway obstruction, rather than invasion and metastasis
○ Generally resistant to radiation and chemotherapy,
treatment usually involves surgical excision.
■ Prognosis is generally favorable
Paraneoplastic Syndromes
Remote effects of cancer that cannot be
attributed to either the cancer’s direct
invasion or metastatic spread, but occur
secondary to ectopic hormone secretion or
immune system attack on normal tissue.
Paraneoplastic Syndromes are important because
○ They sometimes accompany relatively small amounts of cancer growth
and can be an early clue of malignancy.
○ The metabolic effects can cause an urgent, life threatening situation
(ex: hypercalcemia or hyponatremia).
○ The return of the syndrome can herald the return of cancer
While these syndromes can occur with
dozens of types of cancer, ____ is the one most likely to be associated with paraneoplastic
processes
Small Cell
Lung Cancer
Common Paraneoplastic Syndromes seen with lung cancer:
○ ACTH production by SCLC and Carcinoid tumors leads to
clinical picture of Cushing’s Syndrome.
○ ADH secretion by lung cancers (most commonly SCLC) can cause SIADH
○ In Squamous Cell Lung Carcinoma, PTH-related protein (PTHrP) can cause hypercalcemia (10% of cases).
○ SCLC commonly causes neurologic manifestations, such as cerebellar ataxia, peripheral neuropathy, and Lambert-Eaton Syndrome
Lambert-Eaton Syndrome
○ Neuromuscular transmission condition that may be associated with SCLC, occasionally occurring before the tumor is diagnosed.
○ A voltage-gated calcium channel antibody
produced by the tumor prevents normal
synaptic transmission at the NMJ.
○ Opposite of Myasthenia Gravis, muscle
strength is reduce in proximal muscle groups, rather than distal.
○ Steroids are often added to Tx plan
