Pulmonary Neoplasms Flashcards
1
Q
What is the main contributor to lung cancer?
A
- smoking (80-90%)
2
Q
What percent of people in the US dx with lung cancer survive 5 years after dx?
A
- only 15%
3
Q
What racial group has highest incidence rates of lung cancer?
A
- African Americans
4
Q
RFs of lung cancer?
A
- cigarette smokers have tenfold or greater increase in risk
- one genetic mutation is induced for every 15 cigs smokes
- cigarette smoking increases the risk of all the major lung cancer cell types
- ETS or second hand smoke is also an established cause of lung cancer
- asbestos - mesothelioma
- radon - uranium mining
- you can develop lung cancer even after stopping smoking years ago
- other family members who have had smoking-related cancers is a RF also
- prior lung diseases: Chronic bronchitis, emphysema, and TB
- air pollution
- risk related to age at onset of smoking, amt smoked, gender (women), product smoked, and depth of inhalation
5
Q
At what age are rates of lung cancer the highest?
A
- most common cause of cancer death among American men and women
- rare below age of 40, and rates increase until 80, after which the rate tapers off
6
Q
How is smoking cessation helpful?
A
- stopping tobacco use before middle age avoids more than 90% of lung cancer risk attributable to tobacco
- smoking cessation is beneficial iin individuals even with an est, dx of lung cancer
7
Q
smoking cessation tx?
A
- zyban (buproprion), chantix (varenicline)
- nicotine replacement therapy
- clonidine and nortriptyline 2nd line tx
- hypnosis can work for some motivated smokers
8
Q
What is a neoplasm?
A
- neoplasia is uncontrolled cell growth (not needed for normal development or replacement of dead or damaged tissues
- can be benign or malignant
- benign neoplasms: tumors
- malignant: cancers
metastatic (from lung): breast, colon, prostate, and bladder - primary: bronchogenic carcinomas and other small cell and non small cell
9
Q
Characteristics of benign pulmonary neoplasms? What are hamartomas and granulomas?
A
- cells grow in fairly orderly manner, stick together, and don’t migrate (encapsulated and have smooth borders)
- hamartomas: local tissues growing in disorganized manner: often have bronchial tissue and calcifications
- granulomas: chronic inflammatory lesions with macrophages: TB, sarcoidosis, histoplasmosis, cryptococcosis
10
Q
Characteristics of malignant cells/tumors?
A
- rapid, even continuous division (occasionally in hours)
- cells are geared up for dividing
- show de-differentiation: look less and less like parent cells or tissues
- lose some or all of their normal cell functions: have no useful function for the body, parasitize the host’s body: steal nutrients, energy, blood supply: space occupying masses
- masses have irregular, invasive borders
- will metastasize
11
Q
How do malignant tumors spread?
A
- transcoelomic: along surface of an organ - mesothelioma
- lymphatic: most common route for carcinomas
- hematogenous: most common route for sarcomas
- iatrogenic: transplantation or implantation
12
Q
Characteristics of metastatic lung cancer? Most common places of mets?
A
- can have single or multiple nodules
- most common: breast, colon, prostate, bladder
13
Q
What is the most lethal of all cancers? different types?
A
- bronchogenic carcinoma: two main families
small cell lung cancer: primitive neuroendocrine cells
and
non-small cell lung cancer: types
adenocarcinoma, squamous cell carcinoma and large cell carcinoma
14
Q
What are the other types of lung cancers?
A
- carcinoid, Kaposi’s sarcoma (AIDS), melanoma, lymphoma, head and neck
- mesothelioma (assoc with asbestos)
15
Q
What 4 histologies account fo 90% of all epithelial lung cancers?
A
- SCLC
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
16
Q
Characteristics of SCLC?
A
- known as oat cell lung cancer
- arises from primitive, small neuroendocrine cells
- 14% of pts with lung cancer
- bad disease, early metastases
- very aggressive cancer, rapidly fatal
- only small % curable: even with limited stage disease
- 90% of pts with SCLS develop brain metastases
- poorly diff neuroendocrine tumor, high prevalence in smokers
- incidence rates higher among men than women
- central mass with endobronchial growth
- incidence is on the decline
17
Q
What peptide hormones may be produced by SCLC cells?
A
- ACTH
- AVP
- ANF
- GRP
- hormones may be assoc with distinctive paraneoplastic syndromes
18
Q
DDx of SCLC?
A
- poorly differentiated non-small cell carcinomas
- neuroendocrine carcinomas, poorly differentiated squamous cell carcinoma
- nonepithelial tumors: lymphoma, small round blue cell tumors or sarcomas
19
Q
Prognosis and signs and sxs of non-small cell lung carcinoma?
A
- 80% of cancers, rare before 35, peaks at 65-80
- adenocarcinoma is the most common
- all have similar prognosis and are tx the same but have different locations and patterns of spread
- signs/sxs are related to location of tumors, may have associated paraneoplastic syndromes
- bronchoalveoloar carcinoma is different, and more aggressive (subcategory of adenocarcinoma found more peripherally)
20
Q
Characteristics of NSCLC: adenocarcinoma
A
- associated with smoking
peripheral: arise from surface epithelium, peripheral scars (peripheral lung locations) - gland formation, papillary structures or mucin production
- may see metatstic disease before primary sxs
- most common type of lung cancer occuring in never smokers
21
Q
What is a bronchoalveoloar adenocarcinoma?
A
- subtype of adenocarcinoma
- can present as solitary or multicentric nodules, rapidly progressive
- can occur in 20s: multiple pulmonary nodules
- non-resolving focal or bilateral pneumonia
- nodal enlargement uncommon
- Distant spread uncommon
- tends to be more peripheral
- also seen in non-smokers
- grows along alveoli without invasion
- present radiographically as a single mass, as a diffuse multinodular lesion, as a fluffy infiltrate
- **on CT scans: GGO
22
Q
Describe squamous cell carcinomas?
A
- squamous cell or epidermoid carcinoma
- most frequently see in proximal bronchi
- tend to obstruct bronchi (atelectasis or pneumonia)
- tend to remain localized and cavitate - metastasize late
- CT: GGO
- identical to extrapulmonary (head and neck) squamous cell carcinomas
- occur centrally
- classically assoc with hx of smoking
- pattern is that of an infiltrating nest of tumor cells with central necrosis, resulting in cavitation
23
Q
- Describe large cell carcinomas
A
- least common subtype of NSCLC
- large poorly differentiated cells
- dx of exclusion
- large peripheral mass with prominent necrosis
- sheets of large malignant cells, often associated with necrosis
- cytologically, the tumore is arranged in synctial groups and single cells
24
Q
Clinical presentation of lung cancer?
A
- may be asx with normal PE
- centrally located lesions:
cough, hemoptysis, wheezing, stridor, SOB
collapse of lung due to tumor within or against bronchus
post obstructive pneumonia: think bronchogenic CA when pneumonia not responding to tx - peripheral lesions: pain due to pleural or chest wall invasion
- with mets: bone and back pain, difficulty breathing, chest wall pain, HA, seizures, and speech difficulties (mets to brain), weakness, wt loss, and loss ot appetite
25
Q
Mets from lung cancer?
A
- adrenals
- liver
- brain
- bone
26
Q
Clinical findings that suggest metastatic disease?
A
- sxs from hx:
wt loss more than 10 lbs, musculoskeletal pain, HA, syncope, seizures, weakness - signs from PE: lymphadenopathy, hoarseness, SVC syndrome, bone tenderness, hepatomegaly, papilledema
- routine lab tests:
hematocrit less than 40% in men, less than 35% in women, elev Alk phosph., GGT, SGOT, and Ca+ levels
27
Q
regional metastases affect on the body?
A
- esophageal compression: dysphagia
- laryngeal nerve paralysis: hoarseness
- lymphatic obstruction: pleural effusion
- pericardial/cardiac extension: effusion, tamponade
- sympathetic nerve paralysis: horners syndrome
- cervical/thoracic nerve invasion: pancoast syndrome
- vascular obstruction: SVC syndrome
28
Q
What is Horner’s syndrome?
A
- miosis (smaller pupil) and drooping of the eyelid with loss of sweating on that side of face
- lesion of superior cervical ganglion due to neoplastic or inflammatory involvement of cervical lymph nodes and proximal part of brachial plexus
29
Q
What is Pancoast’s syndrome?
A
- extension of tumor at apex of lung involving C8, T1, and T2 nerves and possible destruction of ribs
- shoulder pain radiating in ulnar distribution
30
Q
What is SVC syndrome?
A
- 90% of time due to bronchogenic cancer
- swelling of face, neck, and arms: venous dilation
- shortness of breath, cough and chest pain suggesting upper airway obstruction
- hoarseness, tongue swelling, and nasal congestion
- HA, syncope, lethargy due to cerebral edema
31
Q
What are paraneoplastic syndromes?
A
- disease or sx due to presence of cancer in the body
- mediated by humoral factors (peptides) excreted by cancer cells - may also be due to immune response against the tumor
- may be first manifestation of cancer
- seen in 10% of pts with lung cancer
- best tx is to tx cancer: may need to tx metabolic changes as well
SIADH: rx vasopressin, fluid restriction, saline infusion
Cushings
32
Q
Paraneoplastic syndrome: cachexia?
A
- wasting syndrome
only syndrome that is common in NSCLC - wt loss, weakness, impaired immune fxn
33
Q
Hypercalcemia?
A
- commonly seen with squamous cell cancer
- bone metastases
- ectopic production of PTH- like peptide
34
Q
Hypertrophic pulmonary osteoarthropathy?
A
- arthropathy and periostitis of long bones
- clubbing of fingers and toes
35
Q
Skeletal manifestations
A
clubbing, 30% usually NSCLCs
hypertrophic primary osteoarthropathy: 1-10% adenocarcinomas usually
- periostitis
36
Q
Cutaneous manifestations?
A
dermatomyositis and
acanthosis nigricans
(1% of time)
37
Q
Neuro manifestations?
A
- myopathic syndromes: 1%
- Myasthenic eaton syndrome and retinal blindness: SCLC
- peripheral neuropathies
- subacute cerebellar degeneration
- cortical degeneration
- polymyositis
38
Q
Hematologic manifestations?
A
1-8%
- migratory venous thrombophlebitis (Trousseau’s syndrome)
- nonbacterial thrombotic endocarditis with arterial emboli
- DIC
- thrombotic disease complicating cancer usually poor prognostic sign
39
Q
Renal manifestations?
A
- nephrotic syndrome and glomerulonephritis (1%)
40
Q
What is eaton-lambert syndrome?
A
- autoimmune response
- proximal muscle weakness, usually in lower extremities
- occasional autonomic dysfunction
- rarely: CN sxs
- frequently: depressed DTRs
- strength improves with serial effort (unlike myasthenia gravis)
- chemo is initial TOC
41
Q
Screening steps for lung cancer?
A
- for pts with hx of significant smoking: pts with 30+ pack years even if they quit within the last 15 years
- routine XRs are ineffective and not recommended: no decrease or incidence or mortality
- annual low dose helical CT screening may be recommended: slightly decreases mortality
- most common finding is a benign nodule: need to warn pt beforehand, may lead to invasive testing
- quiting smoking more positive health effect than screening
42
Q
CT screening for lung cancer?
A
- low dose, noncontrast, thin slice helical or spiral chest CT
- major challenge: high false positive rate
- it appears that nodules: less than 5 mm are unlikely to be cancerous and
5-10 mm are of uncertain sig
43
Q
What is the workup for a solitary pulmonary nodule?
A
- common clinical finding: often incidental
- Lung Ca - met - granuloma (most common)
- more likely to be benign if:
younger pt, smooth edges, not growing, calcification (less than 5 mm) - low prob of malignancy: then follow with serial CTs for at least 2 years
- high prob of malignancy: get tissue/resect
44
Q
What are systematic questions to ask about a solitary pulmonary nodule?
A
- is it surrounded by normal lung tissue?
- assoc with adenopathy or atelectasis?
- lesions larger than 3 cm are almost always malignant
- solitary nodules must be 3 cm or less in diameter
- prompt dx and resection are usually advisable if nodule is concerning
45
Q
Workup of mult pulm nodules?
A
- may be malignant or benign
greater than 1 cm usually malignant
less than 5 mm usually benign, granulomas, lymph nodes,and scars - benign: infections - septic emboli, fungi, TB and parasites, Wegners, AV malformations, pneumoconioses
- malignant: usually met
- pattern: nodular, reticular or combined
nodular: multiple round opacities, usually from 1 mm to 1 cm
reticular: overlapping, irregular linear opacities
reticulonodular: combo of 2
46
Q
Describe the dx and workup of lung cancer?
A
- H&P
- dx test: CXR: may show nodules, widening of mediastinum, pneumonia
lab tests: CBC, CMP, could be primary or metastatic - need tissue to make histologic dx: bronchoscopy for fine needle bx: central v peripheral lesions
- bronchial washings, sputum cytology, or thoracentesis (if pleural effusion)
- eval bone pain or elevations in serum Ca or alk phosphatase with XRs or bone scans
- need to know the extent of the cancer: local invasion and distal spread, CT scans, PET scans, bone scans, MRIs
47
Q
What is a fine needle bx used for?
A
- peripheral lesions: dx yield - 90-97%
- out pt procedure: 22 gauge needle
- image guidance by fluoroscopy, CT, US
- pneumothorax (10-30%), hemoptysis: 30%
48
Q
Staging systems of tumors?
A
- T: primary tumor, where and size
- N: regional lymph nodes mets
- M: distant mets
- SCLC: 2 stages
limited - confined to single hemi thorax
extensive - malignant pleural effusion or met disease - NSCLC: 4 stages
- nearly half of lung cancers have mediastinal involvement on Dx
- no evidence of distant spread - must eval mediastinum
- may show spread to lymph nodes
if norm on CT, scope controversial - brain imaging in asx not cost effective
49
Q
Tx of lung cancer?
A
- refer to cancer center
- tx depends on stage and type
- surgery - limited, resectable lesion
- rad: mediastinum, node + limited
- chemo: 4-6 cycles recommended
- targeted therapy: chemo and rad
- lung cancer: usually tx with combo of therapies
- 90% of pts will develop brain mets
50
Q
When is surgery used?
A
- for NSCLC, lobectomy most effective (not really feasible in many pts)
- big surgery: lobectomy and pneumonectomy
- PFTs
- now video assisted thorascopic surgery
51
Q
Chemo used?
A
- may be used with surgery and rad
- may lessen sxs
52
Q
Radiation used?
A
- sig SEs. radiation pneumonitis in 15% of pts
- ## get PFTs to be sure pt has sufficient pulm function
53
Q
Targeted therapy?
A
- stops action of abnorm. proteins that promote growth
- avastin prevents formation of new blood vessels
- Tarceva helps in NSCLC
54
Q
Tx of SCLC?
A
- limited stage: one area of chest: 4-6 cycles of chemo with mediastinal radiotherapy
- extensive: intrathoracic and distal spread: chemo only, radiation for pain bone mets or SVC syndrome
- cranial spread: proph. radiation recommended for those responding to Rx
55
Q
Tx of NSCLC?
A
- stage 1: confined to lung - surgical resection, may supp with radiation or chemo
- stage 2: spread to lymph nodes in lung - resection of tumor and nearby lymph nodes, chemo and occasionally radiation
- stage 3: spread to mediastinal nodes
3A: same side as tumor: chemo+ rad+ resection?
3B: wider spread: chemo + rad? - stage 4: other lobes or distal mets:
tx with chemo
