pulmonary neoplasms Flashcards
define solitary pulmonary nodule (SPN) “coin lesion”
well-circumscribed isolated round opacity completely surrounded by normal lung not associated with infiltrate, atelectasis or adenopathy 3 cm or less
what are the most common etiologies of SPN?
bronchogenic carcinoma
metastatic lesion
infectious granuloma
calcification
what is the clinical presentation of SPN?
asymptomatic
found incidentally on CXR
what are important history components to obtain for SPN?
age of pt smoking recent travel recreational activities occupation
what are CXR features of SPN
size 1% malignancy in 2-5 mm
well circumscribed
cavitary with thick walls > 16 mm (higher malignancy)
calcification (less = more malignant; dense calcification = less malignant)
what CT features for SPN = malignancy?
spiculated margins
peripheral halo
density on CT scan
who is a low risk for SPN malignancy (<5%)?
age <30
stable lesion x 2 or more years
characteristic benign calcification pattern
how to manage low vs intermediate vs high risk SPN pts?
low: watchful waiting/serial imaging (CXR or CT)
intermediate: diagnostic biopsy (transthoracic needle aspiration or bronchoscopy) and PET
high risk: resection
what are the steps to take when evaluating a SPN?
obtain chest CT
if benign - no F/U
if not benign - consider biopsy or resection if nodule is growing
define lung cancer
malignant neoplasm of the lung arising from respiratory epithelium (bronchi, bronchioles/alveoli)
what are the two most common lung cancers?
adenocarcinoma
squamous cell carcinoma
what are the two groupings of lung cancer?
non-small cell lung cancer (NSCLC) - most common
small cell lung cancer (SCLC)
what is the average age of a lung cancer pt?
65+ y/o
what is the most common risk factor of lung cancer?
tobacco smoke radon exposure (second most common)
what are the NSCLCs?
adenocarcinoma
adenosquamous carcinoma
squamous cell carcinoma
large cell carcioma
list characteristics of adenocarcinoma
40% of lung cancers most common type in non-smokers from mucus glands usually peripheral nodules or masses slow growing
what is the characteristic of adenosquamous carcinoma?
composed of >10% malignant glandular and squamous components
list characteristics of squamous cell carcinoma?
20% of lung cancers centrally located associated with hypercalcemia mets out of the chest later central necrosis
list characteristics of large cell carcinoma
epithelial neoplasm lacking both glandular and squamous differentiation
10-15% of lung CA
aggressive, rapid doubling times
large, peripheral mass but can be central
list characteristics of small cell lung cancer
bronchial origin
begin centrally, infiltrate submucosally to cause narrowing of the bronchus
aggressive poor prognosis
regional or distant mets at diagnosis
list characteristics of bronchial carcinoid tumors
pedunculated or sessile growths in central bronchi
derived from neuroendocrine cells
M=F
< 60 y/o
what is the clinical presentation of bronchial carcinoid tumors?
hemoptysis, cough, focal wheezing, recurrent PNA
peripherally located
grow slow
mets rarely
list symptoms of carcinoid syndrome
rare
flushing, diarrhea, wheezing, and hypotension
what can you see on CXR of bronchial carcinoid tumors, centrally vs peripherally?
central: pneumonitis, atelectasis, bronchiectasis, collapse
peripheral (rare): SPN that is 4 cm or less and slightly lobulated
what is the purpose of CT of bronchial carcinoid tumors?
to evaluate for endobronchial lesions and mets
what is the purpose of octeotide scitigraphy of bronchial carcinoid tumors?
localization of tumor
how to definitely diagnose bronchial carcinoid tumors?
biopsy
how to treat bronchial carcinoid tumors?
surgical excision with mediastinal lymph node sampling or dissection
*most resistant to radiation and chemo
what are the complications of bronchial carcinoid tumors?
bleeding and airway obstruction
what is the prognosis of bronchial carcinoid tumors?
excellent, 87-100% 5-year survival after resection
what is in the spectrum of clinical presentation of lung cancer?
asymptomatic
symptoms of local disease
symptoms of mets disease
symptoms of paraneoplastic syndrome
what symptom is usually associated with squamous and small cell cancers?
cough (most common presentation)
what are other common symptoms of lung cancer?
hemoptysis, dyspnea, and pain (more common in younger pts)
list details of superior vena cava syndrome
most common in small cell lung cancer
bulky upper lobe tumor
snesation of fullness in the head
dyspnea
what do you find on physical exam for super vena cava syndrome?
dilated neck veins
facial edema
plethoric appearance
what do you find on CXR of superior vena cava syndrome?
widening of mediastinum
R hilar mass
list details of pancoast syndrome
common in squamous NSCLC
shoulder pain
Horner’s syndrome (right pupil more mitotic and right upper lid is ptotic)
mets to the liver, bone, adrenal, and brain cause what?
liver: liver enzyme abnormalities
bone: pain (back, chest, and extremity), elevated alk phos and calcium, involves vertebral bodies
adrenal: asymptomatic
brain: h/a, vomiting, visual field loss, hemiparesis, CN deficit, seizure
list details of paraneoplastic syndromes/extrathoracic effects
effects of tumor not related to direct invasion, obstruction or mets
10-20% of lung cancer pts
common with SCLC and squamous cell cancer
what is a classic benign lesion distinct appearance on CXR?
hamartoma
if nodule <6mm, what is your next step?
assess likelihood of malignancy, F/U not required, but could get chest CT
if nodule 6-8 mm, what is your next step?
chest CT, and do another one in the next 6-12 months
if nodule >8mm, what is your next step?
chest CT or biopsy/resection
what labs for lung cancer?
CBC, electrolytes, calcium, creatinine, liver tests, LDH, and albumin
what imaging do you start with in lung cancer?
CXR
can you diagnose with imaging of lung cancer?
no
what is the gold standard diagnosis for lung cancer?
tissue biopsy (bronchoscopy, needle biopsy, thoracotomy)
what is the gold standard for mediastinal staging?
mediastinoscopy
what is the most common site of NSCLC distant mets?
brain
for advanced stages of lung cancer, what scan do you use?
bone scan, brain imaging
what is treatment in early stages of NSCLC?
resection
if nonsurgical candidate, what is the NSCLC treatment?
chemoradiation
sterotactic body radiation therapy
how to treat limited SCLC?
chemo and radiation
how to treat extensive SCLC?
chemo alone initial treatment
what are the SE of chemo?
N/V, fatigue, anorexia, weight loss anemia, neutropenia, risk for infection nephrotoxicity neurotoxicity dermatologic rash visual disturbances
what should you do for lung cancer post-treatment surveillance?
H&P & chest CT every 6 months x2 years and annually thereafter
what are complications of lung cancer post-treatment surveillance?
chronic pain, dyspnea, fatigue, impaired sleep, distressed mood, sexual dysfunction, QoL decrease neuropathy hearing loss neurocognitive changes skin changes radiation pneumonitis esophagitis CVD
list details of mesothelioma
primary tumor arising from the surface lining of the pleura
men > women
linked to asbestos exposure
what is the latent period of mesothelioma?
20-40 years
what are clinical findings of mesothelioma?
insidious onset SOB nonpleuritic CP weight loss dullness to percussion diminished breath sounds digital clubbing
how do you evaluate mesotheliomas?
look at pleural fluid (exudative and hemorrhagic)
cytology
VATS biopsy
Ct/PET-CT scan
how to treat mesothelioma?
chemotherapy
who should get an annual LDCT screening?
55-74 y/o that is a current smoker and former smoker (within 15 years) with a 30 or greater pack-year history
what groups of people do not need a CT screen?
<30 pack-years
<55 y/o or > 74 y/o or quit > 15 years ago or severe comorbidities that would preclude potentially curative and/or limit life expectancy
