Pulmonary Neoplasms Flashcards
1
Q
what is a pulmonary nodule? what is it also called? what is the size?
A
-A lesion that is both within and surrounded by pulmonary parenchyma
Also called “Coin Lesion”
<3cm in size and not associated w/atelectasis or LAD
2
Q
what is the size of pulmonary nodule vs a pulmonary mass?
A
<b>pulmonary nodule</b> is <3cm and not associated with atelectasis or LAD
<b>pulmonary mass</b> is >3cm in diameter
3
Q
what can CXR detect evidence of?
A
Heart failure
-Pleural/pericardial effusions
-Pneumonia
<b>-Lung nodule/mass</b>
4
Q
what thoracic imaging tool is utilized often?
A
CXR
5
Q
what views are CXRs done in?
A
PA and lateral b/c trying to visualize 3D structure on 2D image
6
Q
what is the downfall of CXR being a 2D image?
A
a lot of overlap, especially on the left -> could result in missing a small nodule that is masked by cardiac silhouette
7
Q
what thoracic imaging tool is more sensitive than CXRs for detecting small nodules?
A
Chest CT +/- IV contrast
8
Q
what do Chest CT scans help diagnose?
A
cause of clinical symptoms (cough, SOB, chest pain, fever)
9
Q
what do soft tissue windows vs lung windows on a Chest CT scan look at?
A
<b>soft tissue window</b> - looking more at the lymphatics, not the lungs because they are black
<b>lung window</b> - looking at lung parenchyma
10
Q
what thoracic imaging tool is not good for pts over 400 lbs?
A
Chest CT scan
11
Q
what is the difference in the contrasts used for Chest CT scan vs PET/CT scan?
A
Chest CT scan - use iodine contrast
PET scan - use flurodeoxyglucose
12
Q
what is good about using flurodeoxyglucose contrast for PET scan vs. regular contrast?
A
Flurodeoxyglucose
is a radiolabeled sugar solution -> cancer cells feed on sugar to grow -> look for areas of increased uptake which can signal cancer
13
Q
what can you not differentiate on PET scans?
A
Cannot differentiate between inflammation and malignancy
Inflammation/infection has high uptake too
14
Q
what can PET scans be used for?
A
- Diagnosis (never rely solely on radiographic imaging for diagnosis)
- Staging
- Monitoring treatment
15
Q
what size lesions are too small for PET to characterize?
A
lesions smaller than 8-10mm
16
Q
what is the SUV for PET scan?
A
SUV = standardized uptake value
Anything >3 is higher than normal -> infection, inflammation or cancer until proven otherwise
17
Q
what are chest MRIs good to show?
A
good to show tissue planes/looks at soft tissue
18
Q
what are chest MRIs utilized for?
A
Utilized to assess tumor size, extent, and invasion into other adjacent structures
-Mesothelioma and pancoast tumors
<b>-For surgical purposes you want an MRI</b>
19
Q
in terms of size, what lesions are more likely to be malignant?
A
larger lesions are more likely to be maligant than smaller ones
> 20mm is 75% malignancy; 8-20mm is 15% malignancy; 4-7mm is 1% malignancy; <4mm is 0% malignancy
20
Q
what type of border will malignant lesions have?
A
- malignant lesions will have a more <b>irregular or spiculated border</b>
- benign lesions will have a <b>smooth and discrete border</b>
<b><i>***Metastatic lesions can also have smooth and discrete border - TAKE INTO ACCOUNT Cx HISTORY</i></b>
21
Q
tell me about types of calcification for lesions
A
diffuse, central, laminated, popcorn are types of calcification that are seen in granulomatous disease and harmartomas
<b><i>***beware, pts w/primary tumors (osteosarcoma or chondrosarcoma) may have pulmonary lesions with calcifications</i></b>
22
Q
tell me about growth of malignant lesions, benign lesins, and infectious lesions
A
- lesions that are malignant tend to have an interval increase in size between 4-6 months
- nodules that grow very rapidly are more likely benign
- lesions that grow from 1cm to 3cm in a month are more likely an infectious process
23
Q
what is common to see in adenocarcinoma in situ, but also seen with diffuse pneumonia?
A
ground-glass appearance
24
Q
is there one radiographic finding that is pathognomonic for cancer dx?
A
NO!
25
what radiographic features do you look for, for lesions?
size, border, calcification, growth
26
what are benign causes of pulmonary nodules?
```
Infectious granulomas (most common)
-histoplasmosis, coccidiomycosis, mycobacterium
```
Inflammatory nodules
-RA, Wegener granulomatosis, sarcoidosis
Harmatoma
27
what is histoplasmosis?
infectious granuloma; benign cause of pulmonary nodules
AKA Ohio Valley Fever
Inhale fungal spores -> embedded in lung -> immune system walls them off
28
what is harmatoma?
10% of benign tumors
Benign tumors of the lung that are comprised of cartilage, fat, muscle
Have popcorn calcifications -> within them are calcium deposits
29
when assessing a patients probability of pulmonary nodule malignancy what do you look at?
the pts age, risk factors, smoking history
- Low probability -> young, non-smoker -> follow it with serial scans
- High probability -> 50-60 years old with history of heavy smoking -> surgical excision
30
when do you follow-up for a low-risk pt with ≤ 4mm size nodule?
no follow-up needed
31
when do you follow-up for a high-risk pt with ≤ 4mm size nodule?
follow-up CT at 12 months - if unchanged, no further follow-up
32
when do you follow-up for a low-risk pt with >4-6mm size nodule?
follow-up CT at 12 months - if unchanged, no further follow-up
33
when do you follow-up for a high-risk pt with >4-6mm size nodule?
initial follow-up CT at 6-12 months then at 18-24 months if no change
34
when do you follow-up for a low-risk pt with >6-8mm size nodule?
initial follow-up CT at 6-12 months then at 18-24 months if no change
35
when do you follow-up for a high-risk pt with >6-8mm size nodule?
initial follow-up CT at 3-6 months then at 9-12 and 24 months if no change
36
when do you follow-up for a low-risk pt with >8mm size nodule?
follow-up CT at around 3, 9, and 24 months, dynamic contrast-enhanced CT, PET, and/or biopsy
37
when do you follow-up for a high-risk pt with >8mm size nodule?
follow-up CT at around 3, 9, and 24 months, dynamic contrast-enhanced CT, PET, and/or biopsy
38
for ground glass opacities <5mm, when do you follow up?
follow up CT scan in 6 months
39
for ground glass opacities 6-10mm, when do you follow up?
follow up CT scan in 3 months
40
for ground glass opacities >10mm, what do you recommend?
biopsy or resection if possible
41
if ground glass opacities are stable, when do you follow up?
every 3-6 months for a total of 36 months (after that, pretty sure its benign)
42
what is the main risk factor for pulmonary neoplasms?
smoking
-Risk is discussed in terms of pack-years
43
what benign lung diseases are risk factors for lung cancer?
Fibrosis, COPD, Alpha-1-antitrypsin deficiency, TB
44
what is second hand smoke associated with?
- lung cancer in non-smokers
- heart disease in adults
- SIDS, ear infections, and asthma in children
45
what is used as a biomarker test for smoke exposure?
cotinine - an alkalod found in tobacco and is also a metabolite of nicotine
46
what is third hand smoke?
lingering of tobacco smoke after a cig is extinguished
47
who are especially at risk for third hand smoke?
young children b/c they put their hands in their mouths after touching contaminated surfaces
48
what cancers does smoking increase the risk of?
- Nasopharyngeal
- Laryngeal
- Bladder
- Esophageal
- Pancreas
- Breast, stomach, colorectal, uterine
49
what makes up the majority of lung cancer?
non-small cell cancers
50
what non-small cell cancers are the most common?
adenocarcinoma (most) and squamous cell carcinoma
51
according to WHO, 90% of all epithelial lungs cancers are comprised of what?
adenocarcinoma, large cell carcinoma, and small cell carcinoma
52
what lung has more lung function?
right lung
53
what is large cell carcinoma?
Malignant epithelial neoplasm lacking glandular or squamous differentiation
When it is not adenocarcinoma or squamous, it is large cell, diagnosis of exclusion (to include all poorly differentiated NSCLC that are not further classifiable)
Usually presents as a large peripheral mass with prominent necrosis
54
where do squamous cell carcinomas tend to occur on the lung?
centrally -> get embedded in the hilum
55
what carcinoma is classically associated with a hx of smoking?
squamous cell carcinoma
56
what may central & peripheral SCC show?
Central and peripheral SCC may show extensive central necrosis and cavitation (also present in TB)
57
what is the most common type of lung cancer and esp in never smokers?
adenocarcinoma
58
who is adenocarcinoma lung cancer especially common in?
never smokers
59
where in the lung are adenocarcinomas most commonly found?
in the lung periphery (can can occur centrally)
60
what rae the subtypes of adenocarcinoma?
Bronchioloalveolar carcinoma (BAC) -> grows within the alveoli without invasion
-can present as ground glass opacity (GGO)
Mucinous adenocarcinomas
Papillary adenocarcinomas
61
why is lung cancer so deadly?
Aggressive biology of the disease (doesn't grow fast, but is more persistent)
- Lack of an effective screening test -> no blood test or breathing test that can make the dx
- ***Absence of symptoms until locally advanced or metastatic disease is present
62
what is the clinical presentation of lung cancer?
cough (dry or productive occurring for weeks)
- dyspnea
- hemoptysis
- recurrent pneumonias (get abx, but when off abx sx's return)
- weight loss (10lb weight loss over 2-3 months that is unintentional)
- chest pain (i.e. lung nodule pushing on other organs)
- bone pain
- dysphagia
- hoarseness (d/t possible impingement of recurrent laryngeal nerve by tumor)
- neurologic abnormalities (HA, syncope, cog impairment) - usually metastasis
- Horner's syndrome (ptosis, anhidrosis, miosis)
- superior vena cava syndrome (tumor compressing SVC ->prevents venous return from head and neck -> neck swells)
63
what are paraneoplastic syndromes?
Causes systemic/metabolic problems in your body
Lung cancer known to cause unprovoked DVT, hyponatremia (SIADH), and clubbing
64
what is involved in lung cancer staging?
- Diagnosis
- Metastatic work-up
- Mediastinoscopy (lymph node biopsy)
- TNM staging
65
what ways can you diagnose lung cancer?
- CT guided needle biopsy
- Bronchoscopy +/- lavage
- Endobronchial US biopsy (EBUS)
- Video-assisted thoracoscopic surgery biopsy (VATs)
- Thoracentesis
66
what must you get after doing CT guided needle biopsy?
CXR to ensure no pneumothorax
67
what is video-assisted thoracoscopic surgery biopsy (VATs)?
take biopsy of lung
if lesion is on periphery or outside of lung, do excisional biopsy (good b/c if it comes back cancerous it would be excised anyway)
68
what is thoracentesis in terms of diagnosing lung cancer?
drain fluid and send for cytology
69
what is lung cancer staging?
the assessment of the extent of tumor in a particular patient
- Local (T = tumor) -> size
- Regional (N = nodes) -> neighboring lymph nodes
- Distant (M = metastasis) -> distant involvement
70
if a patient has pleural involvement with their lung cancer, what stage are they?
stage 4 if pleural involvement is malignant
71
when pts have lymph node involvement, what stage are they?
automatically stage 4
72
what 3 main routes do lung cancers tend to spread by?
blood, lymphatics, direct invasion
73
what areas do lung cancers commonly metastasize to?
-brain, bone, liver, adrenal glands
need to cover all of these areas when doing work-up
74
for lung lesions >2.0cm, what work-up is recommended (assuming a CXR and chest CT have been obtained)?
HMRI (head MRI) or head CT with contrast
-Head CT w/out contrast doesn’t show metastatic disease to brain
PET/CT scan
Bone scan (only if there is suspicion)
-PET scans really take the place of bone scans b/c lytic lesions will light up on PET scan
***IF an extrathoracic lesions is detected, further work-up will be needed***
75
what is mediastinoscopy?
Helps with staging nodal status
Just b/c have lymph nodes lighting up, doesn’t mean cancer, b/c lymph nodes can light up when sick, etc.
76
what 2 ways can you access lymph nodes?
anterior cervical approach
posterior esophageal approach
77
prognosis of NSCLCa
A=clinical stage
- pt has all the testing/lymph node biopsies
- know pts stage based on all data from tests
B=pathological stage
- after surgery
- base prognosis on pathology report and what must be done next
78
lung cancer treatment recommendations based on staging
Stage 1 & 2 are surgical resection
Stage 3A – do chemo before surgery to shrink tumor (neoadjuvant therapy & then surgery)
Stage 3b – small window for surgery – do chemo/radiation (neoadjuvant therapy)
Stage 4 – palliative chemo and radiation therapy
79
what are the 6 primary surgeries for txt of lung cancer?
- VATs Resection (Wedge or Lobectomy)
- Segmentectomy
- Lobectomy
- Pneumonectomy – take out entire lung
- Robotic Lobectomy
- Sleeve Lobectomy
80
what are non-surgical treatments for lung cancer?
- Radiofrequency Ablation (RFA)
| - Photodynamic Therapy (PDT)
81
when is VATs resection (wedge) txt done for lung cancer?
for small lesions in periphery of lung
82
when is VATs resection (lobectomy) txt done for lung cancer?
For bigger lesions
Isolate 3 regions – airway feeding lobe to take out, pulmonary artery, pulmonary vein
83
what is the main problem with doing lobectomy txt for lung cancer?
thoractomy incision -> carries it's own post-op problems
84
when/how is pneumonectomy done for txt of lung cancer?
- For centrally located tumors
- For mesothelioma – cancer of the pleural surface (lining of the lung) -> as tumor evolves it gets thicker and prevents normal lung compliance
- Take out entire lung, diaphragm on that side, and pericardium
- Replace part of pericardium and diaphragm that’s removed with Gortex mesh
85
what determines the indication for doing a sleeve lobectomy?
location of the tumor
86
what is radiofrequency ablation?
non-surgical txt for lung cancer - for pts that aren't surgical candidates
-Insert a small bar into the lesion and metal wires go into lesion and heat the wires causing a caustic burn to the tumor –goal is to kill/burn off cancer cells – area scars down but remains intact as a scar
Cryoablation isn’t as good as radiofrequency
87
what is photodynamic therapy
non-surgical txt for lung cancer (also done in esophageal cancer)
-causing burn injury to cells of cancer via UV light, over 2-3 sessions after pt is infused with UV-sensitive chemical
pt must protect themselves from UV radiation (sun) after infused
88
what is small cell carcinoma?
Poorly differentiated neuroendocrine tumor that commonly occurs as a large hilar (central) mass with bulky mediastinal adenopathy (diffuse adenopathy)
- Has a rapid doubling time, high growth fraction, and early development of widespread metastases
- This carcinoma sheds off cells at any point in time
89
what is so bad about small cell carcinoma?
Has a rapid doubling time, high growth fraction, and early development of widespread metastases
- This carcinoma sheds off cells at any point in time
- Patients will present with diffuse evidence of disease (i.e. lung nodule with diffuse adenopathy or multiple nodules with adenopathy)
90
what carcinoma is almost exclusive found in smokers and is most common in heavy smokers?
small cell carcinoma
91
does small cell carcinoma fit the classic staging of cancer?
NO!!! has 2 stage system (limited disease & extensive disease)
92
2 stage system of small cell carcinoma
Limited Disease:
-Disease confined to the ipsilateral hemithorax and within a single radiotherapy field (confined to one side of the chest)
Extensive Disease:
-Metastatic disease outside the ipsilateral hemithorax (e.g. brain lesions)
-this is when most pts present
93
when do most patients with small cell carcinoma present?
in extensive disease stage
94
what is the prognosis of small cell carcinoma?
Limited Disease: 15-20 months
-5 year survival: 10-13%
Extensive Disease: 8-13 months
-5 year survival: 1-2%
95
what is carcinoid tumor?
-Comprise 1-2% of all lung malignancies
-Characterized by neuroendocrine differentiation and relatively indolent clinical behavior (slow growing)
-made up of peptide and amine producing cells
-can arise at a number of sites throughout the body (GI tract is most common)
96
what most common site do most carcinoid tumors arise in the body? what other sites can they arise in?
***GI tract (intestines) = most common site
Also: thumus, lung, and ovaries
97
who do carcinoid tumors commonly affect?
Carcinoid tumors are the most common primary lung neoplasm in children
98
what 2 cell types are carcinoid tumors comprised of?
-Typical carcinoid have an excellent prognosis and are about 4x more common than atypical
-Atypical carcinoid have a greater tendency to metastasize (bad, don’t respond well to treatments)
99
how do carcinoid tumors appear?
as round, ovoid opacities, and may be hilar or perihilar
100
where do carcinoid tumors commonly arise in the airways?
Commonly arise in the proximal airways causing bronchial obstruction (if not the airway then more centrally located – hilar lesions)
101
what is the most common sign/sx of carcinoid tumors?
Recurrent Pneumonias
102
what is the treatment of choice for carcinoid tumors?
***En bloc surgical resection is the treatment of choice***
-Lobectomy or taking out segment of airway the tumor is involving
(Segmentectomy; sleeve lobectomy – b/c requires bigger resections)
For metastatic carcinoid, the role of chemotherapy and radiation therapy is limited
-Doesn’t respond well to chemo – so surgery is best
103
what is pancoast tumor?
tumors in the apex of lungs
Also known as superior sulcus tumors as they are located in the pulmonary apex, adjacent to the subclavian vessels
-almost always involve the subclavian vessels
104
where do pancoast tumors typically spread?
given its location, they typically spread to the ribs, vertebrae, subclavian vessels, and brachial plexus
-can also involve the recurrent laryngeal nerve, cagus nerve, and sympathetic ganglion
105
what is the pathology of pancoast tumors?
-A majority of these tumors are squamous cell carcinomas
However, studies have shown that adenocarcinomas, small cell carcinomas, mesothelioma, and lymphomas can all arise in this area
-Therefore, a histologic dx is mandatory prior to definitive treatment
106
what is the clinical presentation for pancoast tumors?
***Shoulder pain (44-96%) – most common
```
*Horner’s Syndrome 14-50%
All symptoms present on the side of the lesion:
-Miosis (constriction of pupils)
-Enophthalmos (sunken eyes)
-Anhidrosis (lack of sweating)
-*Ptosis (drooping of the eyelid)
```
107
what is the most common treatment of pancoast tumors?
preoperative chemo/radiation therapy followed by surgical resection is the MOST COMMON TREATMENT
-Especially do chemo/radiation therapy if suspecting Horner’s syndrome where brachial plexus is involved
108
what cancers spread to the lungs?
- Malignant melanoma
- Sarcomas
Carcinomas of the:
-Breast, kidney, bladder, colon, prostate
***When diagnosed with these cancers – do full scan of chest to see if has spread to lungs***
109
who is lung cancer in non-smokers most common in?
young women
- One hypothesis may be due to estrogen as a tumor promoter for lung cancer
- Treatment seems to work better in women: EGFR inhibitors (Tarceva, Irissa)
110
what is the most common pathology among non-smokers?
adenocarcinoma
111
who is recommended to have an annual CT scan for lung cancer?
heavy smokers (>30 pack/years) b/w the ages of 55-80 are recommended to have an annual CT scan
