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pulmonology > Pulmonary Neoplasms > Flashcards

Pulmonary Neoplasms Flashcards

1
Q

What is the main contributor to lung cancer?

A
  • smoking (80-90%)
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2
Q

What percent of people in the US dx with lung cancer survive 5 years after dx?

A
  • only 15%
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3
Q

What racial group has highest incidence rates of lung cancer?

A
  • African Americans
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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
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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
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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
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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
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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
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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
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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
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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
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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

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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
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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)
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15
Q

What 4 histologies account fo 90% of all epithelial lung cancers?

A
  • SCLC
  • adenocarcinoma
  • squamous cell carcinoma
  • large cell carcinoma
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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
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17
Q

What peptide hormones may be produced by SCLC cells?

A
  • ACTH
  • AVP
  • ANF
  • GRP
  • hormones may be assoc with distinctive paraneoplastic syndromes
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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
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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)
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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
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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
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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
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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

pulmonology (20 decks)

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