Pulmonary Neoplastic Disease Flashcards
pulmonary nodule
-≤ 3 cm isolated, rounded opacity on cxr
-Outlined by normal lung
-Not associated with infiltrate, atelectasis, or adenopathy
-Most asymptomatic unexpected finding on cxr
-Most benign nodules are infectious granulomas
-Importance: carries a significant risk of malignancy
what do we do about a pulmonary nodule
-Identify and resect malignant tumors in pts who stand to benefit from resection
-Avoid invasive procedures in benign disease
-Identify nodules with high probability of malignancy to warrant bx or resection
-Identify those with low probability of malignancy to justify observation
-CT is indicated in any suspicious solitary pulmonary nodule!
lung cancer screening
-USPSTF recommends low-dose computed tomography (LDCT)*** in adults aged 50-80 years with 20 pack-year smoking hx and currently smoke or quit within past 15 years
-criteria expanded eligible population from 8-6 mil and is associated with increased overall proportion of women, racial and ethnic minority groups, and individuals with lower socioeconomic status who are eligible for screening
-Screening should be d/c if no smoking for 15 years or develop a health problem that substantially limits life expectancy or ability or willingness to have curative lung surgery
-Result- now detecting large numbers of lung nodules (majority benign)
-Estimated 237,000 people in the U.S. will be diagnosed with lung cancer this year.
-only 5.8% of eligible Americans have been screened
-many incidental nodules are found -> from other CT scans
lung cancer screening- requirements and benefits
-USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.
-Change in recent criteria expanded eligible population from 8 million to 16 million and is associated with an increased overall proportion of women, racial and ethnic minority groups, and individuals with lower socioeconomic status who are eligible for lung cancer screening.
-Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have a curative lung surgery.
-As a result, we are now detecting large numbers of lung nodules
-From a 2015 article there were 4.8 million CT scans performed in the US.
-1.57 million patients were found to have a lung nodule (125,000 from lung cancer screening)
-The overwhelming majority are benign nodules
-115,000 new cases of lung cancer each year
how to evaluate nodule: age, smoker, prior malignancy
-Age:
-Malignant nodules are rare < 30 yo
-Likelihood of malignancy increases with age
-Smokers- Likelihood increases with number of cigarettes/day
-Prior malignancy:
-Higher likelihood of having a malignant solitary nodule
doubling time
-important marker for malignancy
-Rapid progression (doubling time less than 30 days) suggests infection
-Long term stability (doubling time over 500 days) suggests benignity
radiographic features
-size
-calcifications
-borders
size of nodule
-Size is correlated with malignancy:
-A recent study of solitary nodules identified by CT scan:
-1% malignancy rate in those measuring 2–5 mm
-24% in 6–10 mm
-33% in 11–20 mm
-80% in 21–45 mm
borders of nodule
-Benign process:
-Smooth, well-defined edge
-Malignancy:
-Ill-defined margins or lobular appearance
-Spiculated (jagged) margins and a peripheral halo -> Highly associated with malignancy
nodule: calcifications
-Benign lesions: Dense calcification
-Malignant lesions: Sparser calcification
nodule: cavitary
-infection vs malignant
-usually more infection but can be malignant
diff dx of nodule
nodule tx: Low probability of malignancy (<5%)
-Watchful waiting:
-Age under 30
-Characteristic pattern of benign calcification
-Management:
-Serial CT scans at intervals that would identify growth that would suggest malignancy
nodule tx: high probability (>60%) of malignancy
-Directly to resection if no contraindications
-large and ugly looking nodules
-dont even need to bx sometimes
nodule tx: intermediate probability of malignancy (5-60%)
-remains controversial
-Bx: transthoracic needle aspiration (TTNA) or bronchoscopy
-Pet Scan- look at metabolic activity not necessarily cancer -> cancer, infection, inflammation can light up
-Sputum cytology: highly specific but useless unless central lesion (not really used)
-Video-assisted thoracoscopic surgery (VATS) offers a more aggressive approach to dx -> high risk pts
fleischner society risk scale: solid nodules
fleischner society risk scale: subsolid nodule
carcinoid tumors
-slow growing
-usually dont metastases
-doesnt act typical
-Low grade malignant neoplasms -> bronchial carcinoid tumors grow slowly and rarely metastasize
-Men=women
-Most patients usually < 60 yo
-Location:
-Central* bronchi -> Pedunculated or sessile growths
-usually in the larger airways
-Peripherally located:
-Present as asymptomatic solitary pulmonary nodules
-Rare
carcinoid tumors: S&S
-symptomatic bc in the airway
-Hemoptysis
-Cough
-Focal wheezing
-Recurrent pneumonia
-Carcinoid syndrome (flushing, diarrhea, wheezing, hypotension) is rare
carcinoid tumor dx
-Bronchoscopy: Pink or purple tumor in a central airway
-CT scanning: Localize the lesion and follow growth over time
-Octreotide scintigraphy, Dotatate PET/CT*: Localization of metastatic tumors (normal PET scan doesnt really show)
-neuroendocrine tumor
-Complications- Bleeding and airway obstruction
carcinoid tumor tx
-Surgical excision
-Bronchoscopic removal if entirely endoluminal and poor surgical candidate
-Prognosis is generally favorable
bronchogenic carcinoma
-this is the lung cancer you mostly think/worry about
-Leading cause of cancer deaths in men and women
-More Americans now die of lung cancer than of colorectal, breast, and prostate cancers combined
-Cigarette smoking causes > 85% of cases of lung ca
-Mean age at diagnosis 70: Unusual under the age 40
-decline in mortality- early detection!
paraneoplastic syndromes
-when tumor secretes something that causes other systemic findings
-almost all are small cell-> bc they are neuroendocrine tumors
-squamous cell- hypercalcemia (this is an exception to SCLC)*
lung cancer symptoms
-mostly asymptomatic
-symptoms usually only in advanced
-cough, wt loss, dyspnea- MC
lung cancer complications
-can be any cancer
pancoasts tumor
-tumor of the lung apex
-causes horners syndrome and shoulder pain
-affects brachial plexus and cervcial sympathetic nerve
-Horner’s syndrome:
-unilateral
-problem with sympathetic nerve supple to one side of face
-miosis- constriction
-ptosis- droopy eye
-anhidrosis- failure to sweat
staging NSCLC
-Stages are 1-4; with 4 being the worst
-Stage is determined by looking at 3 separate components
-T= Tumor size
-N= Lymph node involvement
-M= Absence or presence of metastasis
-recently anything stage 1a or more should get adjuvant chemo (bc resection isnt enough!)
-small cell- straight to chemo
NSCLC survival
-68% survival even with resection -> thats why they recomend adjunctive chemo with it :(
