Pulmonology #4 (Lung Cancer & Pulm Circulation) Flashcards
A solitary pulmonary nodule is MC an incidental finding on a CXR. Most are benign.
It is only considered a nodule if ______ or less.
30 mm
What are some characteristics of a high risk solitary pulmonary nodule.
-Large > 2cm, irregular borders, asymmetric calcification, upper lobe location, smoker, enlarging lesions, >40 years old
What are some characteristics of a low risk solitary pulmonary nodule.
-Small < 1cm, Well-circumscribed, smooth borders, dense diffuse calcification, nonsmoker, <30 years old
Diagnostic Workup for solitary pulmonary nodule
-CXR: Initial
-CT chest to determine if malignant
Treatment for Low, Intermediate, and High risk solitary pulmonary nodules
-Low: Active surveillance and monitoring for changes
-Intermediate: bronchoscopy for central lesions. Transthoracic needle aspiration if peripheral
-High: resection with biopsy
Bronchial carcinoid tumors are rare enterochromaffin cell tumors characterized by slow growth, low metastasis, and well-differentiated. They may secrete, ______, ______, ______ or ________
Serotonin, ACTH, ADH, or melanocyte stimulating hormone
Symptoms of bronchial carcinoid tumors
-Wheezing, cough, SIADH, Cushing’s
-Carcinoid Syndrome: periodic episodes of diarrhea (serotonin release), flushing, tachycardia, and bronchoconstriction (histamine release) and hemodynamic instability (hypotension)
What is seen on bronchoscopy for a carcinoid tumor and what is the definitive diagnostic?
Pink to purple well-vascularized centrally-located tumor
Biopsy
Bronchogenic carcinoma (lung cancer) is the MCC of cancer-related death in the US. Where do the METS go to? What are the two MC risk factors?
Mets: brain, bone, liver, lymph, adrenals
Smoking, Asbestos
Explain the screening recommendation for lung cancer
-Annual low-dose CT scan for 55-80 with no symptoms of lung cancer + 30 PPY smoking history who currently smoke or who have quit in the last 15 years
What is the most aggressive type of lung cancer? It is associated with early metastasis and the biggest risk factor is ________.
it is VERY responsive to what treatment?
Small cell (Oat Cell) Carcinoma
Smoking
Chemotherapy
True or False: Small Cell Carcinoma is the MC type that presents with paraneoplastic syndromes
True
What is seen on CXR for small cell lung cancer?
Centrally located
Histology: sheets of small dark blue cells with rosette formation
Treatment for small cell lung cancer
Chemotherapy
The MC primary lung cancer in everyone (nonsmokers, women, men, smokers)
Strongest risk factor is….
This type of cancer typically is located….
Adenocarcinoma
Smoking
Peripherally
Treatment for adenocarcinoma
Resection
Squamous Cell Carcinoma, usually located ________, has an acronym of CCCP. What does this mean?
Centrally
Centrally located, Cavitary lesions, Hypercalcemia, Pancoast Syndrome
What is seen on biopsy for squamous cell carcinoma?
Keratinization and/or intracellular desmosomes (bridges)
Large cell lung cancer lacks differentiating features on microscopy and is usually a diagnosis of exclusion. Where are these normally located?
Peripherally (like adenocarcinoma)
What is the MC type of lung cancer to present with paraneoplastic syndrome?
Small cell lung cancer
Superior Vena Cava Syndrome has symptoms such as…..
What is the treatment for this condition?
Face/neck swelling, facial plethora, headache, dilated and prominent neck and chest veins
Supportive: elevate head, endovascular management
On the other hand, Lambert-Eaton Myasthenic Syndrome has a pathology of….
The MC type of lung cancer to present with this is ….
Antibodies against presynaptic voltage-gated calcium channels prevent acetylcholine release, leading to muscle weakness
Small Cell
Symptoms of Lambert-Eaton Myasthenic Syndrome
What is the diagnostic study that can be done for this?
-Proximal muscle weakness that improves with repeated muscle use
–Difficulty getting up stairs, from a chair, etc.
–Different from myasthenia gravis (which is worse with repeated use)
–Autonomic Symptoms: dry mouth, ED, postural hypotension
–Hyporeflexia, sluggish pupils
-Voltage gated Calcium chanel antibody assay
What is the first line medical management for LEMS?
Pyridostigmine (3-4,diaminopyridine)
Superior Sulcus (Pancoast) Tumors are tumors that are located in the sulcus (near apex) of the lungs.
The MC type of lung cancer to present with this is…
Small cell lung cancer
Pancoast tumors compress ________, _______ and ________ and, therefore, symptoms include………
Lower brachial plexus, ulnar nerve, and cervical sympathetic nerve chain
-Shoulder and arm pain
-Horner Syndrome: ptosis, miosis, anhidrosis
-Weakness and atrophy of muscles of hand
-Ulnar neuropathy
What is the definitive diagnostic for a pancoast tumor?
Treatment?
Needle biopsy
Chemo/Radiation and then resection
70% of PE’s arise from….
Risk Factors for a PE (There is a Triad). Name the three things and then some examples.
-deep veins in the legs
-Virchow’s Triad: 1) intimal damage (trauma, infection, inflammation), 2) hyper coagulability (Protein C/S, Factor V Leiden, OCP, Pregnancy, Smoking), 3) Stasis (Immobilization, surgery, prolonged sitting > 4 hours)
Symptoms of a PE
-Sudden onset of dyspnea, pleuritic chest pain, hemoptysis
-Tachypnea, tachycardia, fever
-Positive Homan Sign
What are three common findings on CXR for a PE?
-Atelectasis (MC abnormal finding)
-Westermark’s sign: avascular markings distal to the PE
-Hampton’s Hump: wedge-shaped infiltrate due to infarction
What does an ECG for a PE show?
S1Q3T3
-wide deep S in lead 1, isolated Q and T wave inversion in lead 3
What ABG is expected in a PE?
Respiratory alkalosis (from tachypnea) and hypoxia
Diagnostics done for a PE
What’s the GOLD STANDARD?
-D-dimer: helpful if negative and low suspicion for PE
-Helical (Spiral) CT angiography: best initial test to confirm
-V/q Scan: used in pregnancy or kidney disease if CT can’t be done
-Pulmonary angiography: GOLD STANDARD
Treatment for a patient who is hemodynamically stable with a PE
-Anticoagulation: Heparin bridge + Warfarin or novel (Dabigatran, Rivaroxaban)
When should you use an IVC Filter?
-If anticoagulation contraindicated (recent bleed, bleeding disorder), anticoagulation unsuccessful, or RV dysfunction on echocardiogram
What is the treatment for a patient with a PE if hemodynamically unstable (SBP < 90, RV dysfunction)
-Thrombolysis
-Thrombectomy or embolectomy if massive PE
The Wells Criteria is the scoring system used to determine the probability of a PE. Explain what gets 3 points, what gets 1.5 points, and what gets 1 point
3 points: Clinical signs of a DVT, PE #1 diagnosis
1.5 points: HR > 100, Immobilization at least 3 days or surgery within last 4 weeks, previous DVT or PE
1 point: Hemoptysis, malignancy within last 6 months
Regarding the Wells Criteria, what are the points that are needed for a D-dimer, CTA or D-dimer, and CTA.
Low probability: < 2 points (D-Dimer)
Moderate probability: 2-6 points (CTA or D-dimer)
High probability: > 6 points (CTA)
What are the prophylaxis recommendations for a PE for the following things:
low risk, minor procedures, <40 years old: ___________
Moderate risk: _________
High risk, orthopedic surgery or neurosurgery, trauma: ___________
Early ambulation
Elastic stockings/compression devices
LMWH
Pulmonary hypertension is defined as ……..
Explain what the pathology of this is
Elevated mean pulmonary arterial pressure > 20mmHg
Increased pulmonary vascular resistance –> RVH –> increased RV pressure –> RHF
There are two types of pulmonary hypertension, primary and secondary. Name the causes of both.
Primary: Idiopathic, BMPR2 gene defect
Secondary: pulmonary disease, sleep apnea, PE, cardiac disease
Diagnostics for pulmonary hypertension
-CXR: enlarged pulmonary arteries, RHF signs
-ECG: Cor Pulmonale (RVH, RBBB)
-Echo: Large RV, RVH
-Right heart catheterization; GOLD STANDARD
-CBC: Polycythemia (lots of RBC’s)
Treatment for pulmonary hypertension
-Vasoreactivity trial with inhaled nitric oxide, IV Adenosine, or CCB
–If vasoreactive = CCB (first line)
–Iloprost, Sildenafil, Tadalafil, Oxygen therapy if COPD related
Cor Pulmonale is defined as _________
What are some causes of this condition?
Right heart failure secondary to severe pulmonary disease
Sarcoidosis, ARDS, PE, COPD, Asthma, Lung trauma (surgery)
Treatment for cor pulmonale
-Oxygen, treat underlying disease (COPD, Asthma, PE, etc.)
