Pulmonary Neoplasms Flashcards
List the common risk factors for lung cancer
1) Smoking history: 20 PYH or less than 15 years since quitting
2) Age
3) Chronic lung disease
4) BMI < 25 Kg/m2
5) Family history of lung cancer?
6) Environmental: air/environmental pollution, radon, asbestos
Who should get screened for lung cancer?
Anyone aged 50 to 80 with a 20 pack year smoking history and currently smoke or have quit within the past 15 years
Differentiate between pulmonary nodules and lesions. Which is often noted on lung cancer screening or incidental finding on CXR?
1) 30 mmor less = anodule (coin lesion)
2) > 30 mm cmthe lesion = amass
-PN often noted on lung cancer screening or incidental finding on CXR
What patient characteristics favor malignancy?
1) Increasing age and smoking history increases risk of lung cancer:
-Age > 50
-Smoking > 20 PYH and currently smoking or quit less than 15 years
2) + family history lung cancer
3) Exposure to air/environmental pollution, asbestos, uranium, radium (solid), or radon (gas)
What 2 pulmonary nodule characteristics indicate increased risk of for lung cancer?
1) Solid nodules that are large, have irregular boarders, asymmetric calcification, volume doubling time of 1-12 months, or are in the upper lobes
2) Subsolid (ground glass) nodules more likely to be cancer than solid nodules
-Combination: subsolid with solid component
Which are more likely to be cancer, ground glass/ subsolid nodules or solid nodules?
Ground glass/ subsolid
Are lung cancers single nodules or multiple?
May not be a single PN or multimodule; address evaluation with largest most concerning nodule
Describe what each of the following would look like to suggest malignant etiology of a pulmonary neoplasm:
1) Appearance
2) Boarder
3) Density
4) Location
5) Multiple nodules
6) Size
7) Doubling time
1) Eccentric calcifications, noncalcified or ground glass (subsolid)
2) Spiculated or irregular
3) Subsolid (ground glass)
4) Upper lobes
5) No dominant nodule present
6) 6 or more mm
7) Between 30-400 days
What are usually benign lesions?
Healed granulomas
1) What are 3 characteristics of malignant pulmonary nodules?
2) What are 2 common pt characteristics?
1) ->/= 10 mm
-Irregular boarder
-Malignant calcifications: stippled or eccentric/asymmetric
2) Older age + h/o smoking
Benign pulmonary nodules:
1) What are the common characteristics?
2) What are 2 common pt characteristics?
1) < 10 mm
Regular boarder
Benign calcifications – central, laminated, diffuse, or popcorn
2) Younger age
No history of smoking
Describe what each of the following would look like to suggest benign etiology:
1) Appearance
2) Boarder
3) Density
4) Location
5) Multiple nodules
6) Size
7) Doubling time
1) Concentric, central, diffuse, or popcorn like calcifications
2) Smooth
3) Solid
4) Perifissural, subpleural
5) Dominant nodule present
6) <6mm
7) Less than 30 days (infection) or more than 400 days (granuloma)
What are 4 patterns of appearance that suggest benign pulmonary nodules noted on hrct?
1) Diffuse
2) Central
3) Popcorn
4) Concentric (NOT eccentric)
1) What are the symptoms and signs of pulmonary nodules?
2) What abt specifically benign pulmonary nodules?
3) What does evidence of malignancy include?
1) Asymptomatic
2) Asymptomatic
3) Weight loss, fever, diminished BS, ddventitious BS
“Incidental” Pulmonary Nodules:
1) Are found how?
2) What is the goal of initial imaging?
1) Often incidental finding on CXR/CT or found on lung cancer screening
2) Estimate the malignant potential of the nodule
PN found on CXR or lung cancer screening
1) What CXR do you order to look for pulmonary nodules (PNs)?
2) What do you do for benign or probably benign nodules? What does screening interval depend on?
1) CXR PN - Chest CT w/o contrast
2) Repeat low dose chest CT
-Morphology and size
Define morphology and size of a benign pulmonary nodule
1) Morphology = solid or subsolid, calcification pattern, boarders
2) Size:
Small < 6 mm
Medium 6-8 mm
Large > 8 mm
1) What additional imaging is needed for concerning nodules?
2) What are the 2 groups of nodules that are considered concerning?
1) HRCT or PET/CT or referral for biopsy
2) For very suspicious large solid PN: 15 mm + or 8mm + that are new or growing
Subsolid PN with large solid component: 8 mm + or 4 mm + if new or growing
American academy of chest physicians
1) Patient risk based on what?
2) What are the 3 groups of risk?
1) Clinical judgement of validated clinical risk calculator
2) High (>65%), intermediate (5-65%), or low (<5%)
Describe what to do for a solitary incidental PN <6mm based on risk
1) Low risk (nodule and patient – based on validated clinical tool) = no f/u
2) Moderate to high risk = repeat CT @ 12 months
Describe what to do for a solitary incidental PN 6-8mm based on risk
1) Low risk: repeat CT @ 6-12 months, then consider @ 18–24 months
2) Moderate to high risk: repeat CT @ 6 -12 months, then repeat CT @ 18–24 months
Describe what to do for a solitary incidental PN >8mm based on risk
1) Low risk: CT @ 3 months, then @ 9 & 24 months
2) Moderate to high risk: PET/CT, refer for biopsy or resection
Describe what to do for multiple incidental PNs based on the size and risk of the largest nodule
1) < 6 mm and low risk: no routine f/u
-Higher risk: Optional CT @ 12 months
2) 6 mm or bigger & low risk: CT @ 3-6 months, then consider CT @ 18-14
-Higher risk: CT @ 3-6 months, repeat CT @ 18-24 months
List what to do for low risk (< 5%) cancer nodules based on size and number
1) <6mm = No routine f/u
2) 6-8mm = CT @ 6-12 months, then consider CT @ 18-24 months
3) >8mm = CT @ 3, 9 & 24 months
4) Multiple, largest < 6 mm = No routine f/u
5) Multiple, largest >/= 6mm = CT @ 3-6 months, then consider CT @ 18-24 months
List what to do for moderate (5-65%) or high risk (>65%) cancer nodules based on size and number
1) <6mm = Optional CT @ 12 months
2) 6-8mm = CT @ 6-12 months, then CT @ 18-24 months
3) >8mm = PET-CT, biopsy or resection
4) Multiple, largest < 6 mm = Optional CT @ 12 months
5) Multiple, largest >/= 6mm = CT @ 3-6 months, then CT @ 18-24 months
True or false: The term pulmonary neoplasm does not equate to cancer, but your patient will think cancer when you use
True
Pulm. neoplasms:
1) Define tumor
2) What may develop into neoplasia?
3) What are the types of neoplasms?
1) Un-checked growth, mass
2) Metaplasia or dysplasia
3) Benign
-In-situ neoplasms
-Malignant neoplasms - cancer
-Neoplasms of uncertain behavior
1) Lung cancer is the _______ most common cause of cancer
2) Most common non-specific symptom of lung cancer is what?
3) What are 2 assoc. Sx?
4) What is a constitutional Sx?
1 cause of cancer deaths in WOMEN and MEN
1) 2nd
2) Cough
3) Hemoptysis and dyspnea
4) Weight loss/anorexia
1) What should you do if lung cancer is suspected based on HRCT?
2) How is confirmation gained?
3) What do Tx options vary based on if lung cancer is confirmed?
1) Referral to multidisciplinary lung cancer team, imaging
2) Via sputum cytology, thoracentesis, fine-needle aspiration, or mediastinoscopy
3) Staging, histology, immunotherapy biomarker testing, and patient health status
1) What are Tx options for confirmed lung cancer?
2) What should primary care focus on?
1) Surgical resection, immunotherapy, ChemoTx, and/or XRT
2) Primary prevention of lung cancer: encourage smoking cessation and early recognition via screening at risk patients and following guidelines for pulmonary nodules
Best prevention for lung cancer is what 2 things?
1) Smoking cessation and
2) Lung cancer screening with chest CT in appropriate patients
Majority of lung cancers divided into what 2 histologic types? Which is more common?
Non-small cell lung cancer (NSCLC): 85%
Vs.
Small cell lung cancer (SCLC): 15%
1) Smoking related to _____-______% of lung cancer deaths
2) _______ pollution and ________ exposure are leading causes of non-smoking related lung cancers
1) 80-90%
2) air; radon
Small cell lung cancer (SCLC) ~ 15%
1) Where does it start?
2) What is it associated with?
3) Describe how it is usually presents, the prognosis, and the Tx
1) “S”entrally
2) Smoking
3) Aggressive
-Early mets; at time of diagnosis
-Poorer prognosis
-Palliative chemo
Describe Non-small cell cancer (NSCLC) ~ 85%
Less aggressive
Primary Tx is surgical resection 1st2
List + describe 4 types of non-small cell cancer
1) Adenocarcinoma (most common NSCLC ~ 45%)
-Peripherally located
Accompany underlying lung disease - COPD
2 )Squamous cell carcinoma - ~35%
Starts “S”entrally
Associated with smoking
Hypercalcemia
3) Large cell cancer (rare) ~ 5%
Associated with smoking
Starts throughout lungs
4) Carcinoid tumor (rare) ~1-2%
Neuroendocrine cells
Lung cancer risk factors include what?
1) Cigarette smoking
2) Prior radiation
3) COPD
4) Environmental exposure: radon, asbestos
Describe lung cancer symptoms using OLDCARTS
1) Onset, Duration, Timing – usually insidious onset with progression, persistent cough
2) Location: primary lung, distant metastasis
3) Character: variably productive cough, +/- hemoptysis
4) Aggravating/alleviating: none
5) Radiation: may spread locally or metastasis
6) Associated Symptoms: constitutional: WL, anorexia, & fatigue, recurring visits for cough, paraneoplastic syndromes, symptoms related to extra thoracic mets (bone pain, headaches, seizures)
What are 5 things you may see on an exam of a pt with lung cancer?
1) Digital clubbing
2) Documented weight loss ~ 10%
3) Lymphadenopathy
4) Local invasion
Superior vena cava syndrome
Horner’s syndrome
Pancoast tumor
5) Paraneoplastic syndromes
Give 3 examples of local invasion of lung cancer
1) Superior vena cava syndrome
2) Horner’s syndrome
3) Pancoast tumor
SVC syndrome:
1) What does it cause?
2) What are the clinical Sx?
3) What are the clinical signs?
1) Compression, invasion, thrombosis
Decreased blood return to right heart
2) SOB, chest pain, headache
3) Facial or upper extremity edema
Facial plethora (excess blood … redness), distended neck and chest veins
Horner syndrome
1) What is it?
2) What does it look like?
1)Local invasion
2) Ipsilateral ptosis, miosis, anhydrosis
“Pancoast” tumor:
1) What is it?
2) What does it cause?
3) What are other Sx?
1) Local invasion; typically, squamous cell or adenocarcinoma in the upper lobes that compresses the nerves and vessels in the root of the neck
2) Shoulder and chest wall pain from tumor mass
3) Horner’s syndrome from compression sympathetic trunk
Boney destruction secondary to PTH excess resulting in osteoporosis and bony destruction
Give 4 examples of Paraneoplastic syndromes
1) Small cell carcinoma
2) Squamous cell carcinoma
3) Adenocarcinoma
4) Large cell carcinoma
List some paraneoplastic syndromes and local invasive complications that SCC can cause
1) Hyper PTH: hypercalcemia
2+3) Horner syndrome, Pancoast tumor
What paraneoplastic syndromes and local invasive complications can small cell carcinoma cause?
1) SIADH: hyponatremia
2) Cushing’s: elevated ACTH and cortisol
3) Carcinoid: flushing and diarrhea
4) SVC syndrome
5) Limbic encephalitis: acute onset of short-term memory, many other neuro symptoms
1) What 3 paraneoplastic syndromes and local invasive complications can Adenocarcinoma cause?
2) What 2 can large cell carcinoma cause?
1a) Hypertrophic osteoarthropathy – pain in hands and legs
b) Pancoast tumor
c) Marantic endocarditis: Libman-Sachs endocarditis, non-bacterial thrombotic endocarditis
2a) SVC syndrome
b) Gynecomastia
Initial evaluation for patients with a suspicion for lung cancer:
1) Includes what labs?
2) What imaging? Why/ why not?
3) What if there’s an abnormal or increased index of suspicion?
1) Labs: CBC, serum chemistries, calcium level, & LFT
2) a) CXR: normal does not rule out (low sensitivity); may be skipped based on index of suspicion for lung cancer
b) Chest CT + contrast (include liver and adrenals) for high index of suspicion.
c) PET-CT: biologic activity of tissue
3) Tissue to confirm
What should you do if a pt has suspected lung cancer?
Refer to multidisciplinary thoracic oncology team to help guide workup
Confirmation of lung cancer should be done by what methods? (additional methods if high index of suspicion and negative)
Tissue is the issue
1) Central lesion:
-Sputum cytology
-Bronchoscopy biopsy/FNA if seen
2) Peripheral lesion:
Transthoracic needle or excisional bx
Thoracentesis for pleural fluid analysis if pleural effusion present
Lung cancer staging:
What is TNM staging for NSCLC and SCLC for?
Prognostic and tumor stratification purposes
T = primary tumor
N = regional lymph node involvement
M = distant metastasis
1) What imaging should NSCLC get?
2) What abt SCLC?
3) What should all get?
1) Brain imaging (MRI) considered for more advanced stages
2) All SCLC get brain imaging (metastasize early)
3) PET-CT to assess for LN involvement, metabolic activity of tumor
Lung cancer Tx:
1) Non-small cellcan be treated with what?
2) Historically what 5-yr survival rate for localized NSCLC? What abt with distant mets?
1) Surgery, then radiotherapy, CTX
2) ~ 59%; 5.8%
1) Why is prognosis poor for SCLC?
2) What has a 20-25% 5-year survival?
3) What has a < 10% 5-year survival?
1) Early metastasis at Dx, aggressive behavior
2) Limited stage SCLC – etoposide + cisplatin CTX AND concurrent thoracic radiotherapy with surgical resection offered to select patients – 20-25% 5-year survival
3) Extensive stage SCLC – palliative CTX and Immunotherapy
What are 2 common causes of the most common lung cancer in non-smokers?
Air pollution & radon
What are pancoast tumors and what do they do?
Pancoast tumors- masses in theupper region of the lung, compress the nervesandblood vessels, most likely squamous celloradenocarcinoma
Associated with shoulder pain + Horner’s syndrome + bony destruction
Carcinoid syndrome (rare): specific tocarcinoid tumors- release ofserotonin/vasoactiveresulting influshing, diarrhea, and bronchoconstriction (asthma type symptoms)
Erlotinib- epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor - treatment of non-small cell lung carcinoma after initial surgery
Lung cancer fun facts:
Lung cancer often found as incidental nodule on CXR or chest CT
Large cell and carcinoid tumors (non-small cell types) found throughout the lungs
Small cell and Squamous cell found “S”entrally – both associated with Smoking
Adenocarcinoma – found peripherally, not associated with smoking (Ain’t Smoking)
Lung cancer fun facts abt pancoast tumor and tissue being the issue
Pancoast tumor – adenocarcinoma or squamous cell carcinoma
“Tissue is the issue” – Biopsy/FNA for definitive dx - Bx via bronchoscope or CT guided percutaneous needle biopsy (interventional radiology)
Carcinoid syndrome – rare, ~ 1-2%:
1) Describe the classic S/Sx and why they happen
2) What do carcinoid tumors arise from?
1) *Cutaneous flushing, diarrhea, itching, bronchoconstriction (wheezing), and hypotension
-S/S manifested when vasoactive substance(serotonin, histamine, & bradykinin) secreted into systemic circulation from liver or lung mets
3)Neuroendocrine cells in GI (appendix most common), lungs, ovaries, and thymus.
1) _________ is the most common site of metastatic spread of carcinoid tumors
2) Describe what usually occurs
1) Liver
2) *GI tumor mets to liver then to lungs
GI tumor - vasoactive substances secreted into portal circulation to liver, inactivated = asymptomatic
Liver/lung mets vasoactive substances secreted into systemic circulation = symptomatic
Carcinoid tumors: List the hormones that are messed up and the effects of each
1) Serotonin – leads to fibrosis, heart valve disease, bronchoconstriction
2) Increased Serotonin synthesis leads to decreased tryptophan, decreased niacin/B3 = pellagra (see nutrition class)
3) Histamine and bradykinin – vasodilation and flushing
Carcinoid tumor diagnosis & treatment
“do not spend time on this”
UA – elevated 5-HIAA (5-hydroxyindoleacetic acid) - main metabolite of serotonin and is used to determine serotonin levels in body
Vit B3/Niacin def. (Pellagra)
CXR – Pulmonary Nodule throughout lung fields
Carcinoid tumordiagnosis&treatment
“do not spend time on this”
CT scan with octreotide (radiolabeled somatostatin analog binds to somatostatin receptors on the carcinoid tumors) to locate tumors
Tx:
Excision
Octreotide decreases secretion of serotonin
Niacin supplement
Describe smoking cessation and counseling
Smoking cessation reduces morbidity and mortality in patients with lung cancer
All actively smoking patients should be offered cessation support
Exercise training may improve exercise capacity and quality of life
Medical counseling may help with dyspnea and a range of psychological interventions may improve coping skills and QOL
Describe lung cancer screening for appropriate patients + cessation assistance as appropriate
Quitting smoking will reduce risk of all second cancers by 3.5 times
50-80 y/o, > 20 PYH smoking, either currently smoking or quit < 15 years
