Pulmonology #4 (Lung Cancer & Pulm Circulation)

Question 1

A solitary pulmonary nodule is MC an incidental finding on a CXR. Most are benign.

It is only considered a nodule if ______ or less.

Answer 1

30 mm

Question 2

What are some characteristics of a high risk solitary pulmonary nodule.

Answer 2

-Large > 2cm, irregular borders, asymmetric calcification, upper lobe location, smoker, enlarging lesions, >40 years old

Question 3

What are some characteristics of a low risk solitary pulmonary nodule.

Answer 3

-Small < 1cm, Well-circumscribed, smooth borders, dense diffuse calcification, nonsmoker, <30 years old

Question 4

Diagnostic Workup for solitary pulmonary nodule

Answer 4

-CXR: Initial
-CT chest to determine if malignant

Question 5

Treatment for Low, Intermediate, and High risk solitary pulmonary nodules

Answer 5

-Low: Active surveillance and monitoring for changes
-Intermediate: bronchoscopy for central lesions. Transthoracic needle aspiration if peripheral
-High: resection with biopsy

Question 6

Bronchial carcinoid tumors are rare enterochromaffin cell tumors characterized by slow growth, low metastasis, and well-differentiated. They may secrete, ______, ______, ______ or ________

Answer 6

Serotonin, ACTH, ADH, or melanocyte stimulating hormone

Question 7

Symptoms of bronchial carcinoid tumors

Answer 7

-Wheezing, cough, SIADH, Cushing’s
-Carcinoid Syndrome: periodic episodes of diarrhea (serotonin release), flushing, tachycardia, and bronchoconstriction (histamine release) and hemodynamic instability (hypotension)

Question 8

What is seen on bronchoscopy for a carcinoid tumor and what is the definitive diagnostic?

Answer 8

Pink to purple well-vascularized centrally-located tumor

Biopsy

Question 9

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?

Answer 9

Mets: brain, bone, liver, lymph, adrenals

Smoking, Asbestos

Question 10

Explain the screening recommendation for lung cancer

Answer 10

-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

Question 11

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?

Answer 11

Small cell (Oat Cell) Carcinoma

Smoking

Chemotherapy

Question 12

True or False: Small Cell Carcinoma is the MC type that presents with paraneoplastic syndromes

Answer 12

True

Question 13

What is seen on CXR for small cell lung cancer?

Answer 13

Centrally located

Histology: sheets of small dark blue cells with rosette formation

Question 14

Treatment for small cell lung cancer

Answer 14

Chemotherapy

Question 15

The MC primary lung cancer in everyone (nonsmokers, women, men, smokers)

Strongest risk factor is….

This type of cancer typically is located….

Answer 15

Adenocarcinoma

Smoking

Peripherally

Question 16

Treatment for adenocarcinoma

Answer 16

Resection

Question 17

Squamous Cell Carcinoma, usually located ________, has an acronym of CCCP. What does this mean?

Answer 17

Centrally

Centrally located, Cavitary lesions, Hypercalcemia, Pancoast Syndrome

Question 18

What is seen on biopsy for squamous cell carcinoma?

Answer 18

Keratinization and/or intracellular desmosomes (bridges)

Question 19

Large cell lung cancer lacks differentiating features on microscopy and is usually a diagnosis of exclusion. Where are these normally located?

Answer 19

Peripherally (like adenocarcinoma)

Question 20

What is the MC type of lung cancer to present with paraneoplastic syndrome?

Answer 20

Small cell lung cancer

Question 21

Superior Vena Cava Syndrome has symptoms such as…..

What is the treatment for this condition?

Answer 21

Face/neck swelling, facial plethora, headache, dilated and prominent neck and chest veins

Supportive: elevate head, endovascular management

Question 22

On the other hand, Lambert-Eaton Myasthenic Syndrome has a pathology of….

The MC type of lung cancer to present with this is ….

Answer 22

Antibodies against presynaptic voltage-gated calcium channels prevent acetylcholine release, leading to muscle weakness

Small Cell

Question 23

Symptoms of Lambert-Eaton Myasthenic Syndrome

What is the diagnostic study that can be done for this?

Answer 23

-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

Question 24

What is the first line medical management for LEMS?

Answer 24

Pyridostigmine (3-4,diaminopyridine)

Question 25

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…

Answer 25

Small cell lung cancer

Question 26

Pancoast tumors compress ________, _______ and ________ and, therefore, symptoms include………

Answer 26

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

Question 27

What is the definitive diagnostic for a pancoast tumor?

Treatment?

Answer 27

Needle biopsy

Chemo/Radiation and then resection

Question 28

70% of PE’s arise from….

Risk Factors for a PE (There is a Triad). Name the three things and then some examples.

Answer 28

-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)

Question 29

Symptoms of a PE

Answer 29

-Sudden onset of dyspnea, pleuritic chest pain, hemoptysis
-Tachypnea, tachycardia, fever
-Positive Homan Sign

Question 30

What are three common findings on CXR for a PE?

Answer 30

-Atelectasis (MC abnormal finding)
-Westermark’s sign: avascular markings distal to the PE
-Hampton’s Hump: wedge-shaped infiltrate due to infarction

Question 31

What does an ECG for a PE show?

Answer 31

S1Q3T3
-wide deep S in lead 1, isolated Q and T wave inversion in lead 3

Question 32

What ABG is expected in a PE?

Answer 32

Respiratory alkalosis (from tachypnea) and hypoxia

Question 33

Diagnostics done for a PE

What’s the GOLD STANDARD?

Answer 33

-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

Question 34

Treatment for a patient who is hemodynamically stable with a PE

Answer 34

-Anticoagulation: Heparin bridge + Warfarin or novel (Dabigatran, Rivaroxaban)

Question 35

When should you use an IVC Filter?

Answer 35

-If anticoagulation contraindicated (recent bleed, bleeding disorder), anticoagulation unsuccessful, or RV dysfunction on echocardiogram

Question 36

What is the treatment for a patient with a PE if hemodynamically unstable (SBP < 90, RV dysfunction)

Answer 36

-Thrombolysis
-Thrombectomy or embolectomy if massive PE

Question 37

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

Answer 37

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

Question 38

Regarding the Wells Criteria, what are the points that are needed for a D-dimer, CTA or D-dimer, and CTA.

Answer 38

Low probability: < 2 points (D-Dimer)

Moderate probability: 2-6 points (CTA or D-dimer)

High probability: > 6 points (CTA)

Question 39

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: ___________

Answer 39

Early ambulation

Elastic stockings/compression devices

LMWH

Question 40

Pulmonary hypertension is defined as ……..

Explain what the pathology of this is

Answer 40

Elevated mean pulmonary arterial pressure > 20mmHg

Increased pulmonary vascular resistance –> RVH –> increased RV pressure –> RHF

Question 41

There are two types of pulmonary hypertension, primary and secondary. Name the causes of both.

Answer 41

Primary: Idiopathic, BMPR2 gene defect

Secondary: pulmonary disease, sleep apnea, PE, cardiac disease

Question 42

Diagnostics for pulmonary hypertension

Answer 42

-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)

Question 43

Treatment for pulmonary hypertension

Answer 43

-Vasoreactivity trial with inhaled nitric oxide, IV Adenosine, or CCB
–If vasoreactive = CCB (first line)
–Iloprost, Sildenafil, Tadalafil, Oxygen therapy if COPD related

Question 44

Cor Pulmonale is defined as _________

What are some causes of this condition?

Answer 44

Right heart failure secondary to severe pulmonary disease

Sarcoidosis, ARDS, PE, COPD, Asthma, Lung trauma (surgery)

Question 45

Treatment for cor pulmonale

Answer 45

-Oxygen, treat underlying disease (COPD, Asthma, PE, etc.)