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Clinical Medicine II > Pulmonary Neoplasms > Flashcards

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

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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

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3
Q

what can CXR detect evidence of?

A

Heart failure
-Pleural/pericardial effusions
-Pneumonia
<b>-Lung nodule/mass</b>

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4
Q

what thoracic imaging tool is utilized often?

A

CXR

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5
Q

what views are CXRs done in?

A

PA and lateral b/c trying to visualize 3D structure on 2D image

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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

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7
Q

what thoracic imaging tool is more sensitive than CXRs for detecting small nodules?

A

Chest CT +/- IV contrast

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8
Q

what do Chest CT scans help diagnose?

A

cause of clinical symptoms (cough, SOB, chest pain, fever)

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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

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10
Q

what thoracic imaging tool is not good for pts over 400 lbs?

A

Chest CT scan

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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

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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

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13
Q

what can you not differentiate on PET scans?

A

Cannot differentiate between inflammation and malignancy

Inflammation/infection has high uptake too

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14
Q

what can PET scans be used for?

A
  • Diagnosis (never rely solely on radiographic imaging for diagnosis)
  • Staging
  • Monitoring treatment
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15
Q

what size lesions are too small for PET to characterize?

A

lesions smaller than 8-10mm

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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

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17
Q

what are chest MRIs good to show?

A

good to show tissue planes/looks at soft tissue

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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>

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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

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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>

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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>

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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
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23
Q

what is common to see in adenocarcinoma in situ, but also seen with diffuse pneumonia?

A

ground-glass appearance

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24
Q

is there one radiographic finding that is pathognomonic for cancer dx?

A

NO!

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25
Q

what radiographic features do you look for, for lesions?

A

size, border, calcification, growth

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26
Q

what are benign causes of pulmonary nodules?

A 
Infectious granulomas (most common)
-histoplasmosis, coccidiomycosis, mycobacterium

Inflammatory nodules
-RA, Wegener granulomatosis, sarcoidosis

Harmatoma

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27
Q

what is histoplasmosis?

A

infectious granuloma; benign cause of pulmonary nodules

AKA Ohio Valley Fever

Inhale fungal spores -> embedded in lung -> immune system walls them off

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28
Q

what is harmatoma?

A

10% of benign tumors

Benign tumors of the lung that are comprised of cartilage, fat, muscle

Have popcorn calcifications -> within them are calcium deposits

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29
Q

when assessing a patients probability of pulmonary nodule malignancy what do you look at?

A

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
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30
Q

when do you follow-up for a low-risk pt with ≤ 4mm size nodule?

A

no follow-up needed

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31
Q

when do you follow-up for a high-risk pt with ≤ 4mm size nodule?

A

follow-up CT at 12 months - if unchanged, no further follow-up

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32
Q

when do you follow-up for a low-risk pt with >4-6mm size nodule?

A

follow-up CT at 12 months - if unchanged, no further follow-up

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33
Q

when do you follow-up for a high-risk pt with >4-6mm size nodule?

A

initial follow-up CT at 6-12 months then at 18-24 months if no change

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34
Q

when do you follow-up for a low-risk pt with >6-8mm size nodule?

A

initial follow-up CT at 6-12 months then at 18-24 months if no change

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35
Q

when do you follow-up for a high-risk pt with >6-8mm size nodule?

A

initial follow-up CT at 3-6 months then at 9-12 and 24 months if no change

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36
Q

when do you follow-up for a low-risk pt with >8mm size nodule?

A

follow-up CT at around 3, 9, and 24 months, dynamic contrast-enhanced CT, PET, and/or biopsy

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37
Q

when do you follow-up for a high-risk pt with >8mm size nodule?

A

follow-up CT at around 3, 9, and 24 months, dynamic contrast-enhanced CT, PET, and/or biopsy

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38
Q

for ground glass opacities <5mm, when do you follow up?

A

follow up CT scan in 6 months

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39
Q

for ground glass opacities 6-10mm, when do you follow up?

A

follow up CT scan in 3 months

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40
Q

for ground glass opacities >10mm, what do you recommend?

A

biopsy or resection if possible

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41
Q

if ground glass opacities are stable, when do you follow up?

A

every 3-6 months for a total of 36 months (after that, pretty sure its benign)

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42
Q

what is the main risk factor for pulmonary neoplasms?

A

smoking

-Risk is discussed in terms of pack-years

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43
Q

what benign lung diseases are risk factors for lung cancer?

A

Fibrosis, COPD, Alpha-1-antitrypsin deficiency, TB

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44
Q

what is second hand smoke associated with?

A
  • lung cancer in non-smokers
  • heart disease in adults
  • SIDS, ear infections, and asthma in children
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45
Q

what is used as a biomarker test for smoke exposure?

A

cotinine - an alkalod found in tobacco and is also a metabolite of nicotine

46
Q

what is third hand smoke?

A

lingering of tobacco smoke after a cig is extinguished

47
Q

who are especially at risk for third hand smoke?

A

young children b/c they put their hands in their mouths after touching contaminated surfaces

48
Q

what cancers does smoking increase the risk of?

A
  • Nasopharyngeal
  • Laryngeal
  • Bladder
  • Esophageal
  • Pancreas
  • Breast, stomach, colorectal, uterine
49
Q

what makes up the majority of lung cancer?

A

non-small cell cancers

50
Q

what non-small cell cancers are the most common?

A

adenocarcinoma (most) and squamous cell carcinoma

51
Q

according to WHO, 90% of all epithelial lungs cancers are comprised of what?

A

adenocarcinoma, large cell carcinoma, and small cell carcinoma

52
Q

what lung has more lung function?

A

right lung

53
Q

what is large cell carcinoma?

A

Malignant epithelial neoplasm <b>lacking glandular or squamous differentiation</b>

When it is not adenocarcinoma or squamous, it is large cell, <b><i>diagnosis of exclusion (to include all poorly differentiated NSCLC that are not further classifiable)</i></b>

Usually presents as a large peripheral mass with prominent necrosis

54
Q

where do squamous cell carcinomas tend to occur on the lung?

A

centrally -> get embedded in the hilum

55
Q

what carcinoma is classically associated with a hx of smoking?

A

squamous cell carcinoma

56
Q

what may central & peripheral SCC show?

A

Central and peripheral SCC may show extensive central necrosis and cavitation (also present in TB)

57
Q

what is the most common type of lung cancer and esp in never smokers?

A

adenocarcinoma

58
Q

who is adenocarcinoma lung cancer especially common in?

A

never smokers

59
Q

where in the lung are adenocarcinomas most commonly found?

A

in the lung periphery (can can occur centrally)

60
Q

what rae the subtypes of adenocarcinoma?

A

<b>Bronchioloalveolar carcinoma (BAC)</b> -> grows within the alveoli without invasion
-can present as ground glass opacity (GGO)

<b>Mucinous adenocarcinomas</b>

<b>Papillary adenocarcinomas</b>

61
Q

why is lung cancer so deadly?

A

Aggressive biology of the disease (doesn’t grow fast, but is more <b>persistent</b>)

  • Lack of an effective screening test -> no blood test or breathing test that can make the dx
  • <b>***Absence of symptoms until locally advanced or metastatic disease is present</b>
62
Q

what is the clinical presentation of lung cancer?

A

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
Q

what are paraneoplastic syndromes?

A

Causes systemic/metabolic problems in your body

Lung cancer known to cause unprovoked DVT, hyponatremia (SIADH), and clubbing

64
Q

what is involved in lung cancer staging?

A
  • Diagnosis
  • Metastatic work-up
  • Mediastinoscopy <b>(lymph node biopsy)</b>
  • TNM staging
65
Q

what ways can you diagnose lung cancer?

A
  • CT guided needle biopsy
  • Bronchoscopy +/- lavage
  • Endobronchial US biopsy (EBUS)
  • Video-assisted thoracoscopic surgery biopsy (VATs)
  • Thoracentesis
66
Q

what must you get after doing CT guided needle biopsy?

A

CXR to ensure no pneumothorax

67
Q

what is video-assisted thoracoscopic surgery biopsy (VATs)?

A

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
Q

what is thoracentesis in terms of diagnosing lung cancer?

A

drain fluid and send for cytology

69
Q

what is lung cancer staging?

A

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
Q

if a patient has pleural involvement with their lung cancer, what stage are they?

A

stage 4 if pleural involvement is malignant

71
Q

when pts have lymph node involvement, what stage are they?

A

automatically stage 4

72
Q

what 3 main routes do lung cancers tend to spread by?

A

blood, lymphatics, direct invasion

73
Q

what areas do lung cancers commonly metastasize to?

A

-brain, bone, liver, adrenal glands

need to cover all of these areas when doing work-up

74
Q

for lung lesions >2.0cm, what work-up is recommended (assuming a CXR and chest CT have been obtained)?

A

<b>HMRI (head MRI) or head CT with contrast</b>
-Head CT w/out contrast doesn’t show metastatic disease to brain

<b>PET/CT scan</b>

<b>Bone scan (only if there is suspicion)</b>
-PET scans really take the place of bone scans b/c lytic lesions will light up on PET scan

<b><i>IF an extrathoracic lesions is detected, further work-up will be needed</i></b>

75
Q

what is mediastinoscopy?

A

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
Q

what 2 ways can you access lymph nodes?

A

anterior cervical approach

posterior esophageal approach

77
Q

prognosis of NSCLCa

A

<b>A=clinical stage</b>

  • pt has all the testing/lymph node biopsies
  • know pts stage based on all data from tests

<b>B=pathological stage</b>

  • after surgery
  • base prognosis on pathology report and what must be done next
78
Q

lung cancer treatment recommendations based on staging

A

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
Q

what are the 6 primary surgeries for txt of lung cancer?

A
  • VATs Resection (Wedge or Lobectomy)
  • Segmentectomy
  • Lobectomy
  • Pneumonectomy – take out entire lung
  • Robotic Lobectomy
  • Sleeve Lobectomy
80
Q

what are non-surgical treatments for lung cancer?

A
  • Radiofrequency Ablation (RFA)

- Photodynamic Therapy (PDT)

81
Q

when is VATs resection (wedge) txt done for lung cancer?

A

for small lesions in periphery of lung

82
Q

when is VATs resection (lobectomy) txt done for lung cancer?

A

For bigger lesions

Isolate 3 regions – airway feeding lobe to take out, pulmonary artery, pulmonary vein

83
Q

what is the main problem with doing lobectomy txt for lung cancer?

A

thoractomy incision -> carries it’s own post-op problems

84
Q

when/how is pneumonectomy done for txt of lung cancer?

A
  • 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
Q

what determines the indication for doing a sleeve lobectomy?

A

location of the tumor

86
Q

what is radiofrequency ablation?

A

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 –<b>goal is to kill/burn off cancer cells</b> – area scars down but remains intact as a scar

Cryoablation isn’t as good as radiofrequency

87
Q

what is photodynamic therapy

A

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
Q

what is small cell carcinoma?

A

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
Q

what is so bad about small cell carcinoma?

A

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
Q

what carcinoma is almost exclusive found in smokers and is most common in heavy smokers?

A

small cell carcinoma

91
Q

does small cell carcinoma fit the classic staging of cancer?

A

NO!!! has 2 stage system (limited disease & extensive disease)

92
Q

2 stage system of small cell carcinoma

A

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)
<b><i>-this is when most pts present</i></b>

93
Q

when do most patients with small cell carcinoma present?

A

in <b>extensive disease stage</b>

94
Q

what is the prognosis of small cell carcinoma?

A

Limited Disease: 15-20 months
-5 year survival: 10-13%

Extensive Disease: 8-13 months
-5 year survival: 1-2%

95
Q

what is carcinoid tumor?

A

-Comprise 1-2% of all lung malignancies
<b>-Characterized by neuroendocrine differentiation and relatively indolent clinical behavior (slow growing)</b>
-made up of peptide and amine producing cells

-can arise at a number of sites throughout the body <b>(GI tract is most common)</b>

96
Q

what most common site do most carcinoid tumors arise in the body? what other sites can they arise in?

A

<b>***GI tract (intestines) = most common site</b>

Also: thumus, lung, and ovaries

97
Q

who do carcinoid tumors commonly affect?

A

Carcinoid tumors are the <b><i>most common primary lung neoplasm in <u>children</u></i></b>

98
Q

what 2 cell types are carcinoid tumors comprised of?

A

<b><u>-Typical carcinoid</u></b> have an excellent prognosis and are about 4x more common than atypical

<b><u>-Atypical carcinoid</u></b> have a greater tendency to metastasize (bad, don’t respond well to treatments)

99
Q

how do carcinoid tumors appear?

A

as round, ovoid opacities, and may be hilar or perihilar

100
Q

where do carcinoid tumors commonly arise in the airways?

A

Commonly arise in the proximal airways causing bronchial obstruction (if not the airway then more centrally located – hilar lesions)

101
Q

what is the most common sign/sx of carcinoid tumors?

A

Recurrent Pneumonias

102
Q

what is the treatment of choice for carcinoid tumors?

A

<b>En bloc surgical resection is the treatment of choice</b>
-Lobectomy or taking out segment of airway the tumor is involving
(Segmentectomy; sleeve lobectomy – b/c requires bigger resections)

<b>For metastatic carcinoid, the role of chemotherapy and radiation therapy is limited</b>
-Doesn’t respond well to chemo – so surgery is best

103
Q

what is pancoast tumor?

A

tumors in the apex of lungs

Also known as superior sulcus tumors as they are located in the <b>pulmonary apex, adjacent to the subclavian vessels
<i>-almost always involve the subclavian vessels</i></b>

104
Q

where do pancoast tumors typically spread?

A

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
Q

what is the pathology of pancoast tumors?

A

-A majority of these tumors are <b><u>squamous cell carcinomas</u></b>

However, studies have shown that adenocarcinomas, small cell carcinomas, mesothelioma, and lymphomas can all arise in this area
-Therefore, <b><u>a histologic dx is mandatory prior to definitive treatment</u></b>

106
Q

what is the clinical presentation for pancoast tumors?

A

<b>***Shoulder pain (44-96%) – most common</b>

<b><u>*Horner’s Syndrome 14-50%</u></b>
<b>All symptoms present on the side of the lesion:</b>
-Miosis (constriction of pupils)
-Enophthalmos (sunken eyes)
-Anhidrosis (lack of sweating)
<b>-*Ptosis (drooping of the eyelid)</b>
107
Q

what is the most common treatment of pancoast tumors?

A

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
Q

what cancers spread to the lungs?

A
  • 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
Q

who is lung cancer in non-smokers most common in?

A

young women

  • One hypothesis may be due to estrogen as a tumor promoter for lung cancer
  • Treatment seems to work better in women: <b>EGFR inhibitors (Tarceva, Irissa)</b>
110
Q

what is the most common pathology among non-smokers?

A

adenocarcinoma

111
Q

who is recommended to have an annual CT scan for lung cancer?

A

heavy smokers (>30 pack/years) b/w the ages of 55-80 are recommended to have an annual CT scan

Clinical Medicine II (10 decks)

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