pulmonology neoplastic disease Flashcards
leading cause of cancer related deaths in both men and women
The median age at diagnosis of lung cancer in the United States is 70; unusual under the age
of 40
Smoking remains the most major risk factor
- Estimated about 85% contribution
- Other causes: Asbestos, radon, tar, soot, arsenic, chromium, nickel
Bronchogenic carcinoma – cancer that arises from respiratory epithelium
Two major subgroups (95%):
- Non-small-cell lung cancer (NSCLC)
- Accounts for 80-85% of all lung cancer cases
- Small-cell lung cancer (SCLC)
- Accounts for 15-20% of all lung cancer cases
lung cancer
Adenocarcinoma (Bronchoalveolar, in situ, )
Squamous cell carcinoma
Large cell carcinoma
Staging: T,N,M classification
Non-small cell lung cancer (NSCLC):
Staging: T,N,M or limited/extensive
mall cell lung cancer (SCLC):
Arise from mucous glands or from any epithelial cell within or distal to the terminal bronchioles
Most common
Adenocarcinomas 48%
Arise from the bronchial epithelium and often present as intraluminal masses
Squamous cell carcinomas 23%
Aggressive and have rapid doubling times. They present as central or peripheral mass
Large cell carcinomas 10%
lung cancer risk factors
Cigarette smoking
Quantity of cigarettes, duration of smoking, starting age
Cigar, pipe smoking and secondhand smoke
Air pollution, alcohol and low fiber diet
Inheritance
Genetic markers (mutations)
EGFR mutation, EML4-ALK rearrangement, ROS1 rearrangement, PD-L1
Aggressive cancers that often involve regional or distant metastasis on presentation
Rarely amenable to surgical resection and has a more aggressive course with a median survival
(untreated) of 6–18 weeks
Most aggressive
Small cell carcinomas 13%
Anorexia, weight loss, or asthenia
occurs in 55–90%
New cough 65%
Hemoptysis 6-31%
Pain 25-40% chest or bone
Pneumonia
Pleural effusion
Change in voice (laryngeal nerve)
SVC syndrome
Horner syndrome (ipsilateral ptosis,
miosis, and anhidrosis)
Brain metastases (headache, nausea,
vomiting, seizures, dizziness, or AMS)
signs and symptoms of lung cancer
how to diagnose lung cancer
- chest xray –> if you see mass –>
- look at mass with non contrast CT
- definitive dx with biopsy
how to diagnose lung cancer
CT guided biopsy
Symptoms elicited in history:
* Constitutional: weight loss >10 lb
* Musculoskeletal: pain
* Neurologic: headaches, syncope, seizures, extremity
weakness, recent change in mental status
physical examination:
* Lymphadenopathy (>1 cm)
* Hoarseness, superior vena cava syndrome
* Bone tenderness
* Hepatomegaly (>13 cm span)
* Focal neurologic signs, papilledema
* Soft-tissue mass
Routine laboratory tests:
* Hematocrit, <40% in men; <35% in women
* Elevated alkaline phosphatase, GGT, SGOT, and calcium levels
metastatic disease
how to establish a diagnosis of
lung cancer in patients with malignant pleural effusions
thoracentesis
what do pts with lung cancer have on CXR
Nearly all patients with lung cancer have abnormal findings on chest radiography or CT scan
STAGING NSCLC
TNM international staging system
T - size and location of the primary tumor
N - presence and location of nodal metastases
M - presence or absence of distant metastases
- Cancer is confined
to lung tissue with
no involved lymph
nodes.
stage 1
- Cancer is confined
to lung tissue with
involved
surrounding lymph
nodes or lymph
nodes within the
chest cavity.
stage 2
- Cancer is confined
to lung tissue or
involves adjacent
resectable
structures and has
involved lymph
nodes within the
mediastinum
stage 3
- Any lung cancer
that has spread to
the opposite lung or
any other organ or
is disseminated
within the pleural
fluid
stage 4
NSCLC treatment
Surgical resection
-Is complete surgical resection feasabile?
-Can the pt tolerate surgery?
No surgery
-Extrathoracic metastases or a malignant pleural effusion; or tumor involving the heart,
pericardium, great vessels, esophagus, recurrent laryngeal or phrenic nerves, trachea, main carina,
or contralateral mediastinal lymph nodes
Chemotherapy
Stereotactic body radiotherapy
“coin lesion,”
is a less-than-3-cm isolated, rounded
opacity on chest imaging outlined by
normal lung and not associated with
infiltrate, atelectasis, or adenopathy
solitary pulmonary nodule
SCLC TREATMENT
chemotherapy (Cisplatin and Etoposide)
- Malignant nodules are rare in persons under age 30
- The likelihood of malignancy increases with age
- Smokers are at increased risk, and the likelihood of
malignancy increases with the number of cigarettes
smoked daily - The appearance of a smooth, well-defined edge is
characteristic of a benign process - Ill-defined margins or a lobular appearance suggest
malignancy - Chest CT is indicated for any suspicious solitary pulmonary
nodule
pulmonary nodule
diagnostic for pulmonary nodule
Start with transthoracic needle aspiration (TTNA) or bronchoscopy for biopsy
Positron emission tomography (PET) detects increased glucose metabolism within malignant lesions with high sensitivity (85–97%) and specificity (70–85%)
Sputum cytology is highly specific but lacks sensitivity. It is used in central lesions and in patients who are poor
candidates for invasive diagnostic procedures
Video-assisted thoracoscopic surgery (VATS) resection of all solitary pulmonary nodules with intermediate probability of malignancy
- Symptoms and signs of mediastinal
masses are nonspecific and are usually
caused by the effects of the mass on
surrounding structures. - Insidious onset of retrosternal chest pain,
dysphagia, or dyspnea is often an
important clue to the presence of a
mediastinal mass. - Physical findings vary depending on the
nature and location of the mass.
mediastinal masses
diagnostics for mediastinal mass
CT scanning is helpful in management
* Barium swallow if esophageal disease is suspected
* Doppler sonography or venography of brachiocephalic
veins and the superior vena cava, and angiography
* MRI is useful; its advantages include better delineation of
hilar structures and distinction between vessels and
masses.
* MRI also allows imaging in multiple planes, whereas CT
permits only axial imaging. Tissue diagnosis is necessary
if a neoplastic disorder is suspected
- Spread of an extrapulmonary
malignant tumor through vascular or
lymphatic channels or by direct
extension - Almost any cancer can metastasize to
the lung, including primary lung
carcinomas
pulmonary metastasis
pulmonary metastasis treatment
Treat primary neoplasm and any pulmonary complications
* About 15–25% of metastatic solid tumor patients have metastases limited to the
lungs and are surgical candidates
* Surgical resection
