Pulmonary Neoplasms Flashcards
Risk factors for lung cancer
- smoking & secondhand smoke
- asbestos (mesothelioma)
- Radon (uranium mining)
- FHX of smoking re-lated cancers
- air pollution
- prior lung diseases (COPD, TB)
WHat is the common age rage for the development of lung cancer?
40-80yrs
What cancer is the most common cause of cancer deaths?
lung cancer.
Smoking cessation is beneficial in individuals even with an established dx of lung cancer, True or False?
True
Smoking Cessation Tx
- Zyban (Buproprion/wellbutrin)
- chantix (varenicline)
- nicotine replacement therapy
- clonidine and nortriptyline are recommended as second-line txs
- hypnosis can work for some motivated smokers
Benign neoplasms aka?
Malignant neoplasms?
- tumors
- cancer
Benign Pulmonary Neoplasms
- describe cellular growth
- types
-cells grow in fairly orderly manner, stick together, dont migrate, seem to be encapsulated, smooth borders.
Types:
- Hamartomas: local tissues growing in disorganized manner
- Granulomas: chronic inflamm lesions with mfs.
Malignant Tumors
-cell growth?
- rapid, even continuous division, show de-differentiation (look less and less like parent cells/tissue; lose some or all of their normal cell functions)
- masses have irregular, invasive borders
- travel in search for new lands to conquer
Metastatic Lung Cancer
-routes of spread
Transcoelomic: along the surface of an organ (mesothelioma)
Lymphatic: most common route for carcinomas
Hematogenous: most common route for sarcoma.
Iatrogenic: transplantation or implantations
Most lethal of all cancers?
-Bronchogenic carcinoma
Bronchogenic carcinoma
-what are the two main families of this cancer and their subtypes
- Small cell lung cancer:
- primitive neuroendocrine cells - Non-small cell lung cancers
a. )adenocarcinoma
b. ) squamous cell carcinoma of the lung
c. ) large cell lung carcinoma
List some common types of lung cancer
- carcinoid
- Kaposi’s sarcoma
- melanoma
- lymphoma
- head and neck
- mesothelioma
Small Cell Lung Carcinoma
- aka
- where is this typically found?
- arises from which cells?
- rapid or slow growing?
- metastases?
- aka: “oat cell” lung cancer
- typically a central mass with endobronchial growth.
- arises from primitive small neuroendocrine cells
- very aggressive, rapidly fatal
- Yes, metastases. 90% of patients with SCLC develop brain metastases
Small Cell Lung Cancer
-what peptide hormones does this secrete?
Secretes:
- ACTH
- AVP (Arginine Vasopressin)
- ANF (Atrial natriuretic factor)
- Gastrin-releasing peptide (GRP)
Among women and young adults
- Adenocarcinoma
- Adenocarcinoma!!!
Non-small cell Lung Carcinoma (NSCLC)- ADENOCARCINOMA:
- where on the lung does this arise?
- greatest cause
- found on peripheral lung locations
- smoking
What is the most common type of lung cancer occurring in never somkers?
-Adenocarcinoma
NSCLC: BRONCHOALVEOLAR ADENOCARCINOMA
- subtype of which subtype?
- growth
- occurs when in life?
- commonly mistaken for?
- metastases?
- found where on the lungs?
- appearance on CXR and CT
- its a subtype of the Adenocarcinoma subtype of NSCLC.
- Growth: rapidly progressive, solitary or multicentric nodules
- occurs during 2nd decade of life
- commonly mistaken for non-resolving focal or bilateral “pneumonia”
- metastases? distant spread uncommon
- tends to be more peripheral and grows along the alveoli.
CXR: single mass, diffuse multinodular lesion, fluffy infiltrate.
CT: “groud-glass” opacity
NSCLC: Squamous Cell Carcinoma -found where on the lungs? -metastases? -CT findings -
- found in the proximal bronchi, occur centrally
- tend to remain localized and cavitate(nest of tumor cells with central necrosis resulting in cavitation)–metastasize late.
- CT: ground glass opacity
NSCLC: LARE CELL CARCINOMA: -dx -growth -found where on the lungs? -
- dx of exclusion
- growth: large poor differentiated cell, prominent necrosis.
- found peripherally, sheets of large malignant cells often associated with necrosis.
General Clinical Presentation of Lung Cancer
- asymptomatic
- Central lesions:
- -cough
- -hemoptysis
- -wheeze
- -stridor
- -SOB
- -collapse of lung
- -post obstructive pna (think bronchogenic CA when pna not responding to tx)
- Peripheral Lesions:
- -pain d/t plueral or chest wall invasion
- Metastases:
- -bone pain, back pain
- -diff breathing, chest wall pain
- -HA, sz, speech diff
- -weakness, weight loss, loss of appetite
Lung cancers kill their host by spreading throughout the body,
- ) local spread is via?
- ) distal spread is via?
- local spread in chest is through the lymphatics of simple invasion
- distal spread is via blood
Lung Cancer Metastases:
-most common sites?
- Adrenals 50%
- Liver 30-50%
- Brain 20%
- Bone 20%
Clinical findings suggestive of metastatic dz?
- weight loss greater than 10lbs
- focal skeletal pain
- HA, syncope, sz
- Lymphadenopathy
- Hoarseness
- Hepatomegaly
- Papilledema
- Superior vena cava syndrome
- HCT less than 40% men and 35% women
Horners syndrome:
- what is this?
- sx
- a disrupted nerve pathway on one side from the brain to the face and eye.
- Miosis (smaller pupil), drooping of the eyelid with loss of sweating to that side of the face.
Pancoast Syndrome
- what is this?
- sx
- extension of a tumor at the apex of the lung involving C8, T1, T2 nerves and possible destruction of ribs
sx: shoulder pain radiating in the ulnar distribution
Superior vena cava syndrome
- cause
- signs
- sx
caused 90% of the time due to bronchogenic cancer.
signs:
- swelling of face, neck, arms - venous dilation
sx:
- SOB, cough, chest pain suggesting upper airway obstruction
- hoarseness, tongue swelling, nasal congestion
- HA, syncope, lethagry d/t cerbral edema.
What causes hoarseness secondary to Superior Vena Cava Syndrome?
-irritation to the left recurrent laryngeal nerve.
Paraneoplastic Syndromes:
- what are they?
- tx
- examples
- what are they: disease or sx d/t presence of cancer in the body.
- tx: treat the cancer
examples:
- Cachexia: only in NSCLC
- Hypercalcemia: squamous cell cancer
- Hypertrophic pulmonary osteoarthropathy(adenocarcinomas)
- skeletal manifestations: clubbing(NSCLC)
- Cutaneous manifestations: dermatomyositis and acanthosis nigricans
- Neurologic manifestations: Myasthenic Eaton-Lambert syndrome and retinal blindness (SCLC)
- -peripheral neuropathy
- -subacute cerebellar degenerations
- -cortical degenerations
- -polymyositis
- Hematologic manifestations:
- -migratory venous thrombophlebitis (Trousseaus’s)
- -nonbacterial thrombotic endocarditis with arterial emboli
- -DIC
- Renal Manifestations:
- -nephrotic syndrome
- -glomerulonephritis
Eaton-Lambert Syndrome
- what is this?
- tx
What: autoimmune response, proximal muscle weakness. Usually in lower extremities. Depressed deep tendon reflexes
- strength improves with serial effort.
tx: chemotheraphy is initial tx of choice!
screening of lung cancer
-what size nodule is cancerous?
low dose noncontrast thin slice helical or spiral chest CT
nodules less than 5mm are unlikely to be cancerous
noduels 5-10mm in diameter are of uncertain significance.
Characteristics of benign solitary pulmonary nodule?
Malignant?
Tx of solitary pulmonary nodule
Benign:
-younger patient, smooth edges, not growing, calcification, less than 5mm
Malignant:
-older pt, smoker, growing, rough edges, greater than 5mm
Tx:
-low probability of malignancy you should follow with serial CTs for at least 2 years
-high probability of malignancy you should get tissue/resect.
A lesion larger than ____cm is almost always malignant?
-3
Multiple Pulmonary Nodules
- what size is usually malignant? Benign?
- Nodule patterns
- greater than 1 cm usually malignant
- less than 5 mm usually benign, granulomas, lymph nodes, scars
Patterns:
- nodular: multiple round opacities, usually 1mm to 1cm
- reticular: overlapping, irregular linear opacities
- reticulonodular: combines nodular and reticular effects.
Dx and Work up of Lung Cancer
- History and Physical
- CXR
- Labs: CBC, CMP
- Possible tissue for histology
- stage of cancer (CT, PET, Bone scan, MRI)
- thoracentesis for plueral effusion
When would you do a fine needle biopsy? How does this work? May have what complications?
- peripheral lesions
- 22gauge needle, image guidance via flouroscopy, CT, or ultrasound.
Complications:
- pneumothorax
- hemoptysis
Staging Cancer
-TNM Classification
T (primary tumor, where and size)
N (regional lymph nodes metastasis)
M (distant metastasis)
Staging Cancer:
- Small cell lung cancer
- tx
- limited: confined to a single hemithorax; chemo & radiation
- extensive:intrathoracic malignant pleural effusion or metastatic disease; chemo only.
*cranial spread is frequently seen, prophylactic radiation recommended.
Non-small Cell lung cancer staging & tx for each stage
- confined to the lung; surgical resection, radiation or chemo
- lymph node involvement in lung; resection of tumor and lymph nodes, chemo and occasionally radiation.
- spread to mediastinal nodes.
a. ) same side as tumor: radiation + chemo + ?resection
b. ) wide spread in mediastinum; chemo + ? radiation
- spread to mediastinal nodes.
- other lobes or distal metastases; treated witch chemo
nearly half of lung cancers have ______ involvement on dx.
mediastinal
Mediastinoscopy is good at showing _____?
-may show spread into lymph nodes
Cancer Tx Options
- Surgery: resection of tumor and nearby lymph nodes. (Video Assisted thorascopic surgery)
- Chemo
- Radiation (high energy x-rays to destroy cancer cells)
- Targeted: stops action of abnormal proteins that promote growth (Avastin; prevents new blood vessel growth, Tarceva: helps in NSCLC)
- Adjuvnt: tx before/after surgery to decrease recurrence.
Types of lung cancer surgeries
- lobectomry or pneumonectomy
* used to be lateral thoracotomy now VATS!
