Thoracic Neoplasms Flashcards
What is the Mediastinum?
- The anatomic space located between the lungs
- Contains all the principal tissues and organs of the chest except the lungs
- “Arbitrary” compartments for classification and differentiation of diagnosis
what are the compartments of the mediastinum?
- Superior - anything above the heart
- some texts combined with the anterior compartment - Inferior
- Anterior
- Middle
- Posterior
borders of the anterior medistinum
posterior sternum and anterior aspect of the great vessels and pericardium
contents of the anterior mediastinum
Thymus, internal mammary arteries, lymph nodes, connective tissue, fat
MC Etiologic Masses of the anterior mediastinum
- “Terrible T’s”
- Thymoma, Teratoma, Thyroid/Parathyroid tissue - Foramen of Morgagni hernia
- Mesenchymal tumors (lipoma, fibroma)
- Giant lymph node hyperplasia, lymphoma
- Germ cell tumor - seminoma /teratoma
Middle Mediastinum borders
Ventral border: anterior aspect of the pericardium, great vessels and trachea
Dorsal border: posterior pericardium, anterior esophagus
contents of the middle mediastinum
Pericardium, heart, ascending aorta, pulmonary vessels, trachea, lymph nodes
MC Etiologic Masses of the middle mediastinum
- Granulomatous or metastatic lymphadenopathy
- Cysts
- pleuropericardial, bronchogenic, enteric - Masses of vascular origin
- pulmonary artery enlargement (in PH), aortic aneurysm
borders of Posterior Mediastinum
Everything behind the posterior pericardium
contents of Posterior Mediastinum
Descending thoracic aorta, esophagus, thoracic duct, azygos and hemiazygos veins, sympathetic chains, the posterior group of mediastinal lymph nodes and the spine
MC Etiologic Masses of Posterior Mediastinum
- Neurogenic tumors, meningocele, meningomyelocele
- Gastroenteric cysts, esophageal diverticula/tumor
- Hiatal hernia, hernia through foramen of Bochdalek
- Extramedullary hematopoiesis
presentation of mediastinal mass
- Incidental finding in ½ of all cases
- When suspected a comprehensive H&P is required with a full ROS
- PE - head/neck, upper extremity, chest, abdomen, all lymph nodes, scrotal/testicular exam in males
Mediastinal mass effect - direct involvement or compression of normal cardiothoracic structures
what are the presentation?
- Lungs: stridor, hoarseness, shortness of breath, dyspnea, cough, hemoptysis, retrosternal chest pain
- Esophagus: dysphagia
- Vascular compression: facial and/or upper extremity swelling
- Heart: cardiac compression, hypotension
- Sympathetic chain: Horner’s syndrome
Systemic (constitutional) effects are more often related to ? (e.g. lymphoma, paraneoplastic disorders)
what are those sx?
malignant lesions
fever
night sweats
weight loss
imaging (+additional) for mediastinal mass?
- Initial: CXR - PA/Lateral
- CT chest w/ IV contrast - provides information on location, size, relationship to other structures, and tissue characteristics
- Barium Swallow - suspected esophageal disease
- Doppler US, CT/MRI angiography - (CTA/MRA) - vascular etiology
- Thyroid scan and Uptake (Iodine-131 scan) - intrathoracic goiter
- PET scan or PET-CT - suspected lymphoma or malignancy
- Testicular/Ovarian US - to assess for primary site of germ cell tumor
Laboratory Evaluation - Based upon DDx of mediastinal masses
- Tumor markers if thymoma or germ cell tumors are suspected
- Anti-acetylcholine receptor antibodies - positive antibodies in thymic tumors
- Alpha-fetoprotein (AFP) and Beta-human chorionic gonadotropin (beta-hCG) - elevated with germ cell tumors
- Lactate dehydrogenase (LDH) - elevated with seminomas, lymphoma - Lymphoma workup
- Thyroid Workup - TSH, Free T4
- Referral = surgery - cardiothoracic or general
doing this would risk of malignant seeding
in mediastinal mass
biopsying
types of biopsies for mediastinal masses
- Percutaneous
- uses CT guidance for exact location of biopsy - Endobronchial
- appropriate if mediastinal mass is located immediately adjacent to an airway
- using endobronchial US can improve yield of diagnostic procedure - Surgical - Mediastinoscopy with biopsy
- small tumors that can be resected at the time of biopsy
- large masses that are unresectable to obtain biopsy
tx for mediastinal mass
Treatment and prognosis depend on the underlying cause of the mediastinal mass
referred to as a “coin lesion”
Often found incidentally with an asymptomatic clinical presentation
Solitary Pulmonary Nodule (SPN)
≤ 3 cm (30 mm)
isolated and round opacity
surrounded by normal lung
not associated with infiltrate, atelectasis, or adenopathy
these characteristics are associated with what dx?
solitary pulmonary nodule (SPN)
what size is considered a pulmonary mass?
> 3 cm (30mm)
SPN is MCC are benign or malignant?
benign
Non-Malignant (Benign) Causes
- Infectious granulomas (80% of benign SPN)
- Benign Tumors (e.g. Hamartomas)
- Pulmonary AV Malformation
- Usually present in middle age, grows slowly (over years)
- Radiologically and histologically heterogeneous
- CXR - “popcorn” calcification
- CT - areas of fat or alternating fat/calcifications
what type of Non-Malignant (Benign) Cause SPN?
Benign Tumors (e.g. Hamartomas)
Classically appear as a well-demarcated and fully-calcified or centrally calcified nodule
what type of non-malignant cause of SPN?
Infectious granulomas
MCC (pathogens) of infectious granulomas in SPN
MC organisms
Endemic fungi (eg, histoplasmosis, coccidioidomycosis)
Mycobacteria (tuberculous or nontuberculous)
a tangle of connecting arteries and veins
what is this benign cause of SPN
Pulmonary AV Malformation
why Avoid biopsy of Pulmonary AV Malformation?
bleed risk
Malignant Causes of SPN
- Primary lung cancer
- Lung metastasis
- Carcinoid tumors
which primary lung cancers presents more centrally?
Small Cell Carcinoma - presents centrally
Squamous Cell Carcinoma - presents centrally
Most pulmonary metastases presents as ?
multiple nodules
MC Carcinoid tumors?
endobronchial, some (20%) present peripherally
which primary lung cancers present more peripherally?
Adenocarcinoma - present peripherally
Large Cell Cancer - anywhere but often more peripheral
MC pulmonary metastasis
melanoma, sarcoma¹, and carcinomas of the bronchus, colon, breast, kidney, and testicle
cancer risks for SPN?
Smoking (increases with the pk yr hx)
Increasing age (risk increases beginning at age 35)
Family history
Female sex
Emphysema
Previous malignancy
Environmental - asbestos
imaging for SPN
CXR: Compare to previous CXR - Determines nodule stability and chance of malignancy
CT chest w/o contrast: preferred, looks at anatomical features of lesion
Repeat CXR prior to ordering CT is indicated if:
- suspected nodule is likely a nipple shadow - repeat with nipple markers
- evidence of infection - repeat in 6-8 wks
- nodule characteristics are pathognomonic for benign lesion
CT imaging helps to assess malignancy with these risk factors
Size
Location
Attenuation
Calcification
Larger nodules often have (high/low) malignancy rates
what are the measurements-malignancy rate?
Nodules <5 mm: <1%
Nodules 5 to 9 mm: 2-6 %
Nodules 8 to 20 mm: 18%
Nodules >20 mm: >50 %
Nodules found in the upper lobe have what probability of being malignant
increased
attenuation CT imaging assessment for SPN shows? what do they mean?
Solid vs. subsolid
1. Solid- more commonly found and less likely to be cancer
2. Subsolid - higher likelihood of malignancy
- ground-glass nodules ( no solid component)
- part-solid nodules (both ground-glass and solid components)
what does the Shape of nodule tell for SPN?
- benign lesions are smooth, with a well-defined edge
- malignant is ill-defined, lobular or spiculated in appearance; may have peripheral halo on CT
what does the growth show in SPB CT imaging?
- malignant: growth seen on serial imaging
- imaging can be anywhere from every 3-12 months - benign
- solid nodule stable for 2 years
- subsolid nodule that is stable for 5 years
what does the lesion calcification in CT imaging assessment show in SPN?
- Benign lesions have dense calcification
- Malignant lesions are associated with sparser calcification
- stippled or eccentric patterns
management for SPN
- Based upon the probability of malignancy
- If there is no previous imaging look at nodule size
- > 30 mm (mass) - high risk - resection is recommended
- ≤ 30 mm nodule - determine probability for malignancy = Solitary Pulmonary Nodule Malignancy Risk Calculator
SPN malignancy risk calc estimates the probability that a lung nodule will be diagnosed as cancerous within what timing?
a 2-4 year f/u period
SPN malignancy risk calc results
Low probability = < 5 %
Intermediate probability = 5-60%
high probability = > 60%
Management for High Probability (> 60 % risk) for Malignancy Probability in Patients with Pulmonary Nodules
refer for surgical resection and staging
Management for Low Probability (<5% risk) for Malignancy Probability in Patients with Pulmonary Nodules
- “watchful waiting” with serial CT scans
- frequency of scanning depends on size of nodule and risk for cancer
CT scanning frequency of subcentimeter nodules (<8mm) guidelines
Management for Intermediate Probability (5-60%) for Malignancy Probability in Patients with Pulmonary Nodules
- Sputum Cytology
- highly specific but not sensitive
- only for central lesions and those pts who are poor candidates for invasive diagnostic procedures - PET scan detects metabolic activity of lesion
- assesses the glucose metabolism of the lesions - the more metabolic the lesion the higher the likelihood of malignancy - Refer to surgery for further recommendations
- Biopsy - CT transthoracic FNA or bronchoscopy
- VATS with frozen tissue sampling
- if (+) malignancy, lobectomy and LN sampling will follow
Exact recommendations remain controversial
how should pts with multiple nodules be assessed?
In patients who are found to have multiple nodules, each nodule should be assessed individually for the probability of malignancy and followed by CT surveillance or biopsy accordingly
Cancer cells have 6 hallmark capabilities
self-sufficiency in growth signals
insensitivity to antigrowth signals
evading apoptosis
limitless replicative potential
sustained angiogenesis
tissue invasion and metastasis
malignant tumors arising from the respiratory epithelium, which includes the bronchi, bronchioles, and alveoli
Bronchogenic Carcinoma
The exact cell of origin has not been clearly defined
It is not known if one cell of origin leads to all histologic forms or if there are different cell precursors for each form
Second most common cancer in both men and women
lung cancer
Leading cause of cancer death in both men and women
lung cancer
Lung cancer death rates have declined due to?
with reduction in smoking and advancements in medicine
how is smoking a risk factor of lung cancer
- Risk increases with quantity and duration of exposure
- 10 fold risk of developing lung cancer compared to nonsmokers
- Smoking cessation decreases a patient’s risk of lung cancer by > 50% compared to those who continue to smoke
- Second hand smoke is now considered a risk for lung cancer
- first-degree relatives of smokers have a 2-3 fold excess risk of lung cancer - Smoking cessation before middle age avoids more than 90% of the lung cancer risk attributable to tobacco
risk factors for lung cancer
- smoking
- age - increasing beginning at age 35 peaking at age 80; median age 70 y/o
- occupational exposure
- tobacco smoke
- radon gas
- asbestos
- ionizing radiation
- metals (arsenic, chromium, nickel, iron oxide)
- industrial carcinogens - Fhx
- CLD - COPD, pulmonary fibrosis, sarcoidosis, TB
screening criteria for lung cancer screen
Annual low-dose CT scan (LDCT)
- 50-80 y/o and in fairly good health
- currently smoke or have quit within the past 15 years
- at least a 20-pk-yr hx
- provided informed/shared decision making about benefits, limitations, and harms of screening with LDCT scans
- have access to a high-volume, high quality lung cancer screening and treatment center
clinical presentation of lung cancer
- Often asx until advanced
- Intrathoracic sx
- Dry or productive cough, sputum streaked with blood, chest pain (pleuritic or dull on the affected side), increased SOB, voice changes
- Recurrent infections: pneumonia or bronchitis - Intrathoracic complications
- Malignant pleural effusions
- Superior vena cava syndrome
- Pan coast tumor - Malignant pleural effusion
- considered incurable and managed palliatively
- not all pleural effusions associated with lung cancer are “malignant effusions”
— cytology of pleural fluid is needed to identify the presence of malignant cells in the pleural fluid
— often times pleural fluid is assessed multiple times if initial assessment is negative for malignancy in persons with known pulmonary malignancy - SVC syndrome - compression of the SVC by the pulmonary mass
- MC in SCLC due to central pulmonary involvement
- sx: fullness in the head and neck, facial edema
- PE: dilated neck veins, prominent veins on the chest, facial plethora with arm extension (Pemberton’s sign)
- CXR shows mediastinal widening or right hilar mass - Pancoast Tumor - tumor in the apex of the lung causing compression of surrounding structures
- sx: Shoulder pain (brachial plexus), Horner’s syndrome (paravertebral sympathetic chain and inferior cervical ganglion), Bone destruction (bones surrounding the tumor), Atrophy of hand muscles (C8 and T1 nerve roots)
imaging for lung cancer? what would they show?
CXR
1. initial imaging modality
2. review old radiologic images if possible
- helps to determine the age and growth pattern of identified abnormalities
CT chest WITH contrast
1. Compare with previous CT chest imaging if available
- Solid-appearing lesions that are stable in size for at least two years are highly unlikely to represent lung carcinoma
- Malignant non-solid and part-solid nodules often grow more slowly, so a longer period of stability is needed to exclude malignancy
PET Scan
1. utilized for organs suspected of having malignancy based upon symptoms and CT imaging
2. Integrated PET/CT is more accurate for lymph node staging
Indications for CT chest for lung cancer
new or enlarging focal lesion
a pleural effusion
pleural nodularity
enlarged hilar or paratracheal nodes
endobronchial lesion
post-obstructive pneumonia
segmental or lobar atelectasis
PET false negatives in lung cancers
diabetic, in lesions <8 mm, and in slow-growing tumors
PET false positives in lung cancers
certain infections and granulomatous disease (e.g. TB)
are used for staging and biopsy planning. They can not definitively dx malignancy or metastasis
CT and PET
labs for lung cancer
- indicated if (+) radiographic evidence of malignancy
- utilized to look for signs of metastasis/paraneoplastic syndrome
- Lab studies
- CBC - abnormal in hematologic paraneoplastic syndrome
- Electrolytes - abnormal in various paraneoplastic syndromes
- Calcium - elevated in bone mets or paraneoplastic syndrome
- Alkaline phosphatase - elevated in bone or liver mets
- AST/ALT, total bilirubin - elevated in liver mets
- Creatine kinase (CK) - elevated in MSK paraneoplastic syndromes
- Antinuclear antibodies (ANA) - elevated in MSK paraneoplastic syndromes
MC sites for distant metastatic lung cancer
Liver
Adrenal glands
Bones
Brain
Metastatic Lung Cancer to the liver presentation and imaging choice
often asymptomatic
suspect if elevated LFTs
imaging of choice: non-contrasted CT or CT-PET
Bone Metastatic Lung Cancer presentation and imaging choice
- Pain in the back, chest, or extremity
- Elevated levels of serum alkaline phosphatase
- Elevated serum Ca in more severe mets
- More often seen with SCLC
- Imaging options
- PET scan - preferred modality
- MRI acceptable alternative
- Bone (scan) scintigraphy - alternative when PET isn’t readily available
what uses small amounts of radioactive materials (radiotracers) injected intravenously, inhaled or swallowed which travels through the area being examined and gives off energy in the form of gamma rays which can be seen via a gamma camera
bone (scan) scintigraphy
adrenal metastatic lung cancer presentation and imaging choice
- most often asx and found incidentally on staging CT scan
- not all adrenal masses found are metastatic
- PET scan can be used to differentiate a metastatic adrenal lesion from a non-metastatic lesion
Brain, spine, and nerve Metastatic Lung Cancer presentation and imaging choice
HA, V, seizures
papilledema, visual field loss, hemiparesis, cranial/focal nerve deficit
MRI with contrast
The only definitive way to make the diagnosis of malignancy
Both primary and metastatic suspected lesions require
biopsy
Modality options for primary neoplasm biopsy
- Endobronchial US Bronchoscopy - centrally located tumors
- Transthoracic percutaneous FNA w/ CT guidance - peripherally located tumors
- Alternative (invasive) options:
- Video-assisted thoracic surgery (VATS)
- Mediastinoscopy
- Indications:
— resection is recommended before bx results
— inadequate specimen or tumor remains undiagnosed after less invasive options
based upon histologic evaluation of biopsy specimen pulmonary neoplasms are categorized into one of 4 classifications
- Small Cell Lung Cancer (SCLC)
- Non-small Cell Lung Cancer (NSCLC)
- Adenocarcinoma
- Squamous Cell Carcinoma
- Large cell carcinoma
less common: accounts for appx 15% of lung cancers
Very rare in non-smokers….patient is almost always a smoker
Very small cells that are very fast growing/doubling and result in an early development of widespread metastasis
Generally starts in bronchi (centrally located)
Usually detected as a large hilar mass with bulky mediastinal adenopathy
what type of lung cancer is this describing?
Small Cell Carcinoma
Most common - accounts for appx 85% of all lung cancers
has 3 categories - what are they?
Non-Small Cell Lung Cancer
- Adenocarcinoma
- Squamous Cell Carcinoma
- Large cell carcinoma
Slow growing and usually involves the periphery of the lung
More common in smokers than non-smokers
The MC form of lung cancer in nonsmokers
what type of NSCLC?
Adenocarcinoma
Generally occurs in center of lung and develops in smokers
what type of NSCLC
SCC
Rapidly growing mass occurring anywhere in the lung (more commonly found along the periphery)
what type of NSCLC
Large Cell Carcinoma
Treatment: NSCLC Stage 0 (in situ)
malignant cells on cytology but normal imaging
- Requires meticulous examination of the bronchial tree with a fiberoptic bronchoscope
- Cancer limited to the lining of the bronchus and no deeper invasion
- Surgery alone is usually curative for these patients
Treatment: NSCLC Stage I - no nodal involvement or metastasis
- Surgery may be the only treatment needed
- Surgical Options: lobectomy, sleeve resection, wedge resection - Radiation indications
- positive surgical margins
- pt isn’t a candidate for surgery/refuses surgery
Treatment: NSCLC Stage II and III
- Surgical resection - as in Stage I
- Adjuvant chemotherapy
- Strongly recommended if (+) LN involvement - Post-op radiation if:
- (+) surgical margins on tumor resection, nodal involvement
- not a candidate or refuses surgery
Treatment NSCLC Stage IV
- Wide spread with distant metastasis when diagnosed
-
Systemic therapy
- Chemotherapy, molecularly targeted therapy, and/or immunotherapy - +/- Palliative radiation therapy & surgery
- If there is an isolated metastasis - surgical excision of the metastatic tumor may be beneficial
Prognosis NSCLC
Overall 5 year survival rate is between 10-15%
Depends strongly on histology, tumor grade, comorbidity etc.
Treatment SCLC Limited Stage
(tumor is limited to the unilateral hemithorax)
1. Patients with no distant metastasis and no evidence of disease in the mediastinum
- Resection + chemotherapy
2. Patients with clinical or pathologic evidence of mediastinal disease or metastasis
- Chemoradiotherapy is indicated as initial treatment
Treatment SCLC Extensive Stage Disease
(tumor extends beyond the hemithorax)
1. Systemic chemotherapy
2. Prophylactic cranial and thoracic irradiation decreases risks of mets in patients who respond to systemic chemotherapy
Prognosis for SCLC
- Patient with SCLC rarely survive more than a few months without treatment
- Median survival rate from time of original diagnosis is 8-13 months
- < 5 % will survive beyond 2 years
an altered immune system response to a neoplasm
a release of substances (hormones, hormone precursors, enzymes, or cytokines) produced by the tumor which affect other organ systems
Paraneoplastic Syndromes
what other organ systems are affected in Paraneoplastic Syndromes
endocrine
neuromuscular
musculoskeletal
cardiovascular
skin
hematologic
gastrointestinal
renal
tumor secretion of ? and ? inciting osteoclastic activity
Hypercalcemia, Paraneoplastic Syndromes
parathyroid hormone-related protein (PTHrP)
vitamin D 1,25
presentation of hypercalcemia in paraneoplastic syndromes
- calcium often rises quickly (weeks to months) compared to non-neoplastic etiologies
- sx - anorexia, nausea, vomiting, constipation, lethargy, polyuria, polydipsia, and dehydration
- most often associated with advanced disease (stage III or IV) with a median survival time of a few months
SIADH presentation in Paraneoplastic Syndromes
- tumor releases ADH
- most often associated with SCLC
- symptoms are related to severity of hyponatremia
- anorexia, nausea, and vomiting
- cerebral edema occurs if hyponatremia has rapid onset
— irritability, restlessness, personality changes, confusion, coma, seizures, respiratory arrest
Neurologic Presentations in paraneoplastic syndromes
- lung cancer is the most common cancer associated with paraneoplastic neurologic syndromes
- most often associated with SCLC
- there are multiple neurologic paraneoplastic syndromes
- MC is Lambert-Eaton myasthenic syndrome (LEMS) - 3% of pts with SCLC will develop LEMS
autoantibody formation results in impaired release of acetylcholine
symptoms often precede dx of SCLC
what is this dx? how do you confirm this?
Lambert-Eaton myasthenic syndrome (LEMS)
- 50% of patients dx with LEMS have SCLC
- CT chest and PET should be performed to look for SCLC
- Confirmed with electrodiagnostic studies and antibody testing (neurology referral)
Hematologic Syndromes of Paraneoplastic Syndromes
Anemia, Leukocytosis,Thrombocytosis, Eosinophilia,
Hypercoagulable disorders
a symmetrical, painful arthropathy that usually involves the ankles, knees, wrists, and elbows
clubbing of digits
x-ray of long bones will show periosteal new bone formation
what is this dx?
Hypertrophic osteoarthropathy
Dermatomyositis/Polymyositis presentation in Paraneoplastic Syndromes
inflammatory myopathies manifested by muscle weakness
may present with symptoms prior to dx of lung CA
elevated CK and ANA
Cushing Syndrome presentation in Paraneoplastic Syndromes
ectopic (tumor) production of ACTH
S/S: muscle weakness, central weight gain, hypertension, hirsutism, and osteoporosis
Hypokalemia and hyperglycemia are usually present
a rare type of lung cancer that develops in the central bronchi and rarely metastasizes
at what age does this present?
Bronchial Carcinoid Tumors
before age 60
no links between smoking or other carcinogens
presentation of Bronchial Carcinoid Tumors
- hemoptysis, cough, focal wheezing and recurrent pneumonia
- 25% of patients are asymptomatic
- carcinoid syndrome is rare - flushing, diarrhea, wheezing, hypotension
Bronchoscopy shows a pink/purple tumor (due to high vascularity) in the central air way
what is this showing?
Bronchial Carcinoid Tumors
biopsy often results in significant bleeding
management for Bronchial Carcinoid Tumors
- observation with serial CT scans to follow growth
- follow up evaluation for symptomatic progress
- MC complications from tumor is bleeding and airway obstruction - symptomatic lesions often require surgical excision
Prognosis is favorable
