thoracic neoplasms Flashcards
what is the mediastinum
anatomic space located between the lungs that contains all principal tissues and organs of the chest except the lungs
what are the borders of the anterior mediastinum
posterior sternum and anterior aspect of the great vessels and pericardium
what are the contents of the anterior mediastinum
- thymus
- internal mammary arteries
- lymph nodes
- connective tissue
- fat
what are the MC etiologic masses in 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
what are the borders of the middle mediastinum
- ventral border: anterior aspect of the pericardium, great vessels and trachea
- dorsal border: posterior pericardium, anterior esophagus
What are the 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 )
what are the borders of the posterior mediastinum
- everything behind the posterior pericardium
what are the contents of the posterior mediastinum
- descending thoracic aorta
- esophagus
- thoracic duct
- azygos and hemiazygos veins
- sympathetic chains
- posterior group of mediastinal lymph nodes
- spine
what are the MC etiologic masses of the posterior mediastinum
- Neurogenic tumors, meningocele, meningomyelocele
- Gastroenteric cysts, esophageal diverticula/tumor
- Hiatal hernia, hernia through foramen of Bochdalek
- Extramedullary hematopoiesis
when are most mediastinal masses found?
incidentally 50% of the time
what is required when a mediastinal mass is suspected
a comprehensive H&P with a full ROS
what physical exam systems are particularly important to be observed in mediastinal masses
- head/neck
- upper extremity
- chest
- abdomen
- all lymph nodes
- scrotal/testicular exam in males
what is the mediastinal mass effect
direct involvement or compression of normal cardiothoracic structures
what are symptoms associated with the mediastinal mass effect?
- lungs - stridor, hoarseness, shortness of breath, dyspnea, cough, hemoptysis, retrosternal chest pain
- esophagus - dysphagia
- vascular compression - facial and/or extremity swelling
- heart - cardiac compression, hypotension
- sympathetic chain - horners syndrome
what is the mediastinal mass effect on the sympathetic chain
causes horners syndrome:
remember this is characterized by PAM Horner!!
P - Ptosis (drooping of the upper eyelid)
A - anhidrosis (absence of sweating of the face)
M - miosis (constriction of pupil)
what symptoms are more often related to malignant lesions such as lymphoma and paraneoplastic disorders
systemic (constitutional) effects
- fever
- night sweats
- weight loss
What is the imaging that is obtained with a mediastinal mass
initial - CXR - PA/lateral
CT chest w IV contrast - provides information on location, size, relationship to other structures, and tissue characters
(I feel like this is CXR to confrim that there is a nodule, then CT to learn more about the nodule)
what are some additional imaging options for mediastinal masses and when would you obtain these types of images
- barium swallow - suspected esophageal disease
- doppler US, CT/MRI - vascular etiology
- thyroid scan and uptake - intrathoracic goiter
- PET scan or PET-CT - suspected lymphoma or malignancy
- testicular/ovarian US - to assess for primary site of germ cell tumor
what are laboratory evaluations that should be done in evaluation of mediastinal masses
- tumor markers if thymoma or germ cell tumors are suspected
- anti-acetylcholine receptor antibodies (+ in thymic tumors)
- alpha fetoprotein and beta human chorionic gonadotropin (+ in germ cell tumors)
- lactate dehydrogenase (high in seminomas and lymphoma)
what labs are positive in thymic tumors
anti-acetylcholine receptor antibodies
what labs are elevated with germ cell tumors
alpha fetoprotein and beta human chorionic gonadotropin
what labs are elevated with seminomas and lymphoma
lactate dehydrogenase
what other laboratory studies could be done in evaluation of mediastinal masses
- lymphoma workup
- thyroid workup
- biopsy
what are the three types of biopsies for mediastinal masses
- percutaneous
- endobronchial
- surgical mediastinoscopy with biopsy
what is a percutaneous biopsy
uses CT guidance for exact location of biopsy
when is a encobronchial biopsy obtained
- appropriate if mediastinal mass is located immediately adjacent to an airway
- using endobronchial US can improve yield of diagnostic procedure
when are surgical mediastinoscopy biopsies obtained
- small tumors that can be resected at the time of biopsy
- large masses that are unresectable to obtain biopsy
what is the treatment for mediastinal masses
Treatment and prognosis depend on the underlying cause of the mediastinal mass
so I assume we dont gotta know! yayyyy
what are solitary pulmonary nodules also referred to as
coin lesion
what are the characteristics of a solitary pulmonary nodule
- less than/equal to 3 cm (30mm)
- isolated and round opacity
- surrounded by normal lung
- not associated with infiltrate, atelectasis, adenopathy
what is the etiology of solitary pulmonary nodules
they can be benign or malignant but MOST are benign
what are the non-malignant (Benign) causes of solitary pulmonary nodules
- infectious granulomas (80% of benign SPN)
- benign tumors (hamartomas)
- pulmonary AV malformation
what are the MC organisms causing infectious granulomas
- endemic fungi (histoplasmosis, coccidioidomycosis)
- mycobacteria (TB, non TB)
how do non-malignant (benign) SPN appear
well-demarcated and fully calcified or centrally calcified nodule
how do hamartomas typically present clinically and on imaging?
- usually presents in middle age and grows slowly over years
- radiologically and histologically heterogenous
- CXR - popcorn calcifications
- CT - areas of fat or alternating fat/calcifications
what are pulmonary AV malformations
a tangle of connecting arteries and veins
AVOID BIOPSY IN THESE
what are the three categories of malignant causes for SPN
- primary lung cancer
- lung metastasis
- carcinoid tumors
what are the primary lung cancers
- Small Cell Carcinoma - presents centrally
- Adenocarcinoma - present peripherally
- Squamous Cell Carcinoma - presents centrally
- Large Cell Cancer - anywhere but often more peripheral
how do lung metastasis usually present ?
multiple nodules
what are the MC pulmonary metastises
- melanoma
- sarcoma
- carcinomas
of the: - bronchus
- colon
- breast
- kidney
- testicle
what type of carcinoid tumors are MC
endobronchial
20% are present peripherally
what are cancer risks that should be looked for in patient history
- Smoking (increases with the pk yr hx)
- Increasing age (risk increases beginning at age 35)
- Family history
- Female sex
- Emphysema
- Previous malignancy
- Environmental - asbestos
what does comparison of a previous CXR determine when assessing a SPN
- nodule stability
- chance of malignancy
when is a repeat CXR prior to ordering CT indicated
- suspected nodule that is likely a nipple shadow (repeat with nipple markers)
- evidence of infection (repeat in 6-8 weeks)
- nodule characteristics are pathognomonic for benign lesions
what does CT help to assess as far as malignancy risk factors
- Size
- Location
- Attenuation
- Calcification
what size nodules correlate to malignancy rates
- Nodules <5 mm: <1%
- Nodules 5 to 9 mm: 2-6 %
- Nodules 8 to 20 mm: 18%
- Nodules >20 mm: >50 %
- larger nodules often have higher malignancy rates
what nodule location has increased probability of being malignant
nodules found in the upper lobe
what are the possible attenuations of SPN on CT imaging
- solid - MC found and less likely to be cancer
- subsolid - higher likelihood of cancer (can be ground glass nodules which have no solid component, or part-solid nodules which is combo of ground glass and solid)
How does shape differ between benign and malignant lesions
- benign lesions are smooth, with well defined edge
- malignant are ill-defined, lobular or spiculated in appearance; may have a peripheral halo on CT
how does growth differ from malignant to benign SPN
- malignent - growth seen on serial imaging (3-12 mo)
- benign - solid nodule stable for 2 years, subsolid nodule stable for 5
how does lesion calcification differ from benign and malignant lesions
- benign lesions have dense calcifications
- malignant lesions are associated with sparser calcification (stippled or eccentric patterns)
what is the management for SPN
based on probability of malignancy!
what is the solitary pulmonary nodule malignancy risk calculator
estimates the probability that a lung nodule will be diagnosed as cancerous within a 2-4 year f/u period
what is considered high malignancy
- > 30mm nodule
- <30mm and >60% solitary pulm nodule malignancy risk (based off of the calculator)
what is considered low and intermediate risk for malignancy
- low - <30mm and <5% SPN malignancy risk
- intermediate - <30 mm and 5-60% SPN malignancy risk
what treatment is reccommended for SPN that have high malignancy risk
resection
what is the treatment reccomendation for SPN that is low probability of malignancy
“watchful waiting” with serial CT scans
frequency of scanning depends on size of nodule and risk for cancer
what is the management for intermediate probability malignancy risk SPN
controversial recommendations (yay)
options include:
- sputum cytology
- PET scan
- refer for biopsy/tissue sample
when is sputum cytology recommended in intermediate risk SPNs
recommended only for central lesions and those patients who are poor candidates for invasive diagnostic procedures
highly specific but not sensitive
why are PET scans suggested in intermediate risk SPNs
assesses glucose metabolism of lesions and detects metabolic activity of lesion
the higher the metabolism of the lesion, the higher the likelihood of malignancy
what is used to biopsy SPN
CT transthoracic FNA or bronchoscopy
when is VATS with frozen tissue sampling indicated
if (+) malignancy, lobectomy and lymph node sampling will follow
how should you approach a patient with multiple nodules?
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
maybe look at this. im not sure
youre actually gonna want to memorize this one im sorryyy
what is cancer?
A disease in which abnormal cells rapidly divide resulting in an overcrowding of normal cells leading to tissue damage
what are the 6 hallmark capabilities of cancer cells
- self-sufficiency in growth signals
- insensitivity to antigrowth signals
- evading apoptosis
- limitless replicative potential
- sustained angiogenesis
- tissue invasion and metastasis
what is lung cancer?
aka bronchogenic carcinoma
“malignant tumors arising from the respiratory epithelium which includes the bronchi, bronchioles and alveoli
How common is lung cancer
second MC cancer diagnosed in both men and women
what is the leading cause of cancer death in both men and women
lung cancer
why have lung cancer death rates declined from 1990 to 2002
reduction in smoking and advancements in medicine
1990 - death rate 43%
2002 - death rate 17%
what percent of lung cancer deaths in the US are still caused by smoking
80%
what are risk factors for lung cancer
- tobacco smoking (10x increase in risk)
- second hand smoke (1st degree relatives of smokers have 2-3x risk compared to people who dont have 1st degree relatives who smoke)
- age (increased beginning at 30, peaks at 80)
- occupational/environmental exposure
- fam hx or personal hx
- chronic lung disease (COPD, pulm fibrosis, sarcoidosis, TB)
how much can smoking cessation affect lung cancer risk
- Smoking cessation decreases a patient’s risk of lung cancer by > 50% compared to those who continue to smoke
- Smoking cessation before middle age avoids more than 90% of the lung cancer risk attributable to tobacco
what is the median age for lung cancer developement
70
what is the screening criteria for obtaining an annual low-dose CT scan to look for lung cancer
- Must be 50 to 80 years and in fairly good health
- Must currently smoke or have quit within the past 15 years
- Must have at least a 20-pack-year smoking history (Should receive smoking cessation counseling if they are current smokers)
- Should be provided informed/shared decision making about the benefits, limitations, and harms¹ of screening with LDCT scans
- Should have access to a high-volume, high quality lung cancer screening and treatment center
what are the intrathoracic symptoms that present in lung cancer?
- often asymptomatic until advanced disease
- dry or productive cough
- sputum streaked with blood
- chest pain (pleuritic/dull on affected side)
- increased SOB
- voice changes
- recurrent infections: pneumonia or bronchitis
what are the intrathoracic complications that present in lung cancer
- malignant pleural effusions
- superior vena cava syndrome
- pan coast tumor
what is malignant pleural effusion and how is it diagnosed/treated
- malignancy spreading to the pleural space (this definition is googled! the slide didn’t have one)
- not all pleural effusions associated with cancer are malignant effusions
- must obtain a cytology of pleural fluid to identify presence of malignant cells in pleural fluid
- considered incurable and managed palliatively
what is superior vena cava syndrome in lung cancer? what is the MC lung cancer that presents with this?
- compression of the SVC by the pulmonary mass
- MC in small cell lung cancer d/t central pulm involvement
what are the signs and symptoms of superior vena cava syndrome in lung cancer
symptoms
- fullness in head/neck
- facial edema
PE:
- dilated neck veins
- prominent veins on the chest
- facial plethora with arm extension (pembertons sign)
what does CXR show in superior vena cava syndrome in lung cancer
mediastinal widening or right hilar mass
what is pancoast tumor in lung cancer
tumor in the apex of the lung causing compression of surrounding structures
what are the symptoms of pancoast tumor in lung cancer
- shoulder pain (brachial plexus)
- horners syndrome
- bone destruction
- atrophy of hand muscles
what is the purpose of a CXR in evaluation of lung cancer?
- initial imaging modality!
- helps to determine the age and growth pattern of identified abnormalities
what are indications for a CT chest in 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
why would contrast be used in evaluation of lung cancer
Contrast is used to distinguish mediastinal invasion of the primary tumor or metastatic lymph nodes from vascular structures
( in notes, slide 70)
what would a CT chest WITH contrast look like in lung cancer patients
- 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
when are PET scans used
PET scans are utilized for organs suspected of having malignancy based upon symptoms and CT imaging
what could cause false negatives in PET scans
diabetic, in lesions <8 mm, and in slow-growing tumors
what could cause false positives in PET
certain infections and granulomatous disease (e.g. TB)
integrated PET/CT is more accurate for what type of staging
lymph node stagng
when is lab evaluation indicated in lung cancer? what does it look for?
- indicated if (+) radiographic evidence of malignancy
- utilized to look for signs of metastasis/paraneoplastic syndrome
what are the lab studies used to evaluate lung cancer
- 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
what is the MC sites for distant metastatic lung cancer
- Liver
- Adrenal glands
- Bones
- Brain
what is the presentation of metastatic lung cancer that is affecting the liver? what is the diagnostics for this?
- often asymptomatic
- suspect if elevated LFTs
- imaging of choice: non-contrasted CT or CT-PET
what is the presentation of metastatic lung cancer that is affecting the bones? what is the diagnostics for this?
- 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
- can do: PET scan preferred, MRI acceptable, Bone scan is alternative to PET scan
what is the presentation of metastatic lung cancer that is affecting the adrenal glands? what is the diagnostics for this?
- most often asymptomatic 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
what is the presentation of metastatic lung cancer that is affecting the brian, spine, nerves? what is the diagnostics for this?
- headache, vomiting, seizures
- papilledema, visual field loss, hemiparesis, cranial/focal nerve deficit
- MRI with contrast
what is the only definitive way to make the diagnosis of malignancy in lung cancer
biopsy of suspected lesions
what are the modality options for primary neoplasm biopsy in lung cancer
- Endobronchial Ultrasound Bronchoscopy (used for CENTRALLY located tumors)
- Transthoracic percutaneous fine-needle aspiration (FNA) with CT guidance (used for PERIPHERALLY located tumors)
- Video assisted thoracic surgery (invasive)
- mediastinoscopy (invasive)
what are the two indications for invasive biopsies
- resection is recommended prior to biopsy results
- inadequate specimen or tumor remains undiagnosed after less invasive options
what are the four WHO lung cancer classifications and how are they categorized?
categorized based on histologic evaluation of biopsy specimen
classifications:
- small cell lung cancer (SCLC)
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
How common is small cell carcinoma and who is it MC in?
- less common: accounts for appx 15% of lung cancers
- Very rare in non-smokers….patient is almost always a smoker
what is small cell carcinoma? what part of the lungs does it affect?
- 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 is the MC lung cancer type
non small cell lung cancer
(adenocarcinoma, squamous cell carcinoma, large cell carcinoma)
what is adenocarcinoma and who is it MC in
- 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
where is squamous cell carcinoma usually found and who is it MC in?
Generally occurs in center of lung and develops in smokers
what is large cell carcinoma, where is it typically found?
Rapidly growing mass occurring anywhere in the lung (more commonly found along the periphery)
what is TNM staging parameters for “T”
what is TNM staging for “N”
what is TNM staging for “M”
what is the treatment for non small cell lung cancer (NSCLC) stage 0
- stage 0 = 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
what is the treatment for non small cell lung cancer (NSCLC) stage 1
- stage 1 = no nodal involvement or metastasis
- surgery may be only treatment needed
- radiation indicated if there are positive surgical margins or if patient isnt a candidiate/refuses surgery
what is the treatment for non small cell lung cancer (NSCLC) stage 2 and 3
- surgical resection (with lymph node removal if malignant involvement)
- adjuvant chemo (strongly recommended in lymph node involvement)
- post op radiation (if (+) surgical margins on tumor resection, nodal involvement or not a candidate/refuses surgery)
what is the treatment for non small cell lung cancer (NSCLC) stage 4
- stage 4 = widespread distant metastises
- systemic therapy (chemo, molecularly targeted therapy, and/or immunotherapy
- palliative radiation therapy and surgery may be needed
- if isolated metastases - surgical excision of metastatic tumor may be beneficial
what are molecularly targeted therapies
Targeted cancer therapies are drugs or other substances that block the proteins that are involved in the growth, progression, and spread of cancer.
(in notes slide 94)
what is the prognosis for NSCLC
- Overall 5 year survival rate is between 10-15%
- Depends strongly on histology, tumor grade, comorbidity etc.
what is limited stage SCLC
tumor iis limited to the unilateral hemithorax
what is the treatment for limited stage SCLC
- Patients with no distant metastasis and no evidence of disease in the mediastinum - Resection is indicated followed by chemotherapy
- Patients with clinical or pathologic evidence of mediastinal disease or metastasis - Chemoradiotherapy is indicated as initial treatment
what is extensive stage disease SCLC
when the tumor extends beyond thehemithorax
what is treatment for extensive stage disease SCLC
- Systemic chemotherapy
- Prophylactic cranial and thoracic irradiation decreases risks of mets in patients who respond to systemic chemotherapy
what is the 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
what is paraneoplastic syndrome
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
what are organ systems that can be affected by paraneoplastic syndromes
what is the cause of hypercalcemia in paraneoplastic syndrome
- tumor secretion of parathyroid hormone-related protein¹ (PTHrP) and vitamin D 1,25 inciting osteoclastic activity
- calcium often rises quickly (weeks to months) compared to non-neoplastic etiologies
what are the s/s of hypercalcemia in paraneoplastic syndrome
- anorexia
- nausea
- vomiting
- constipation
- lethargy
- polyuria
- polydipsia
- dehydration
what stage is most assocaited with paraneoplastic syndrome and how does this impact survival rates
most often associated with advanced disease (stage III or IV) with a median survival time of a few months
what is SIADH in paraneoplastic syndrome? what type of cancer is it MC in?
- tumor releases ADH
- MC assocaited w/ SCLC
what are the symptoms of SIADH in paraneoplastic syndrome
- related to severity of hyponatremia
- anorexia, nausea, vomiting
- cerebral edema occurs if hyponatremia is rapid onset
- cerebral edema = irritability, restlessness, personality changes, confusion, soma, seizures, respiratory arrest
when are neurologic presentations of paraneoplastic syndromes MC
most often assocated with SCLC
lung cancer is the most common cancer associated with paraneoplastic neurologic syndromes
what is hte MC neurologic paraneoplastic syndrome
- MC is Lambert-Eaton myasthenic syndrome (LEMS)
- 3% of patients with SCLC will develop LEMS
what is lambert-eaton myasthenic syndrome
autoantibody formation results in impaired release of acetylcholine
Is LEMS or SCLC typically discovered first?
- symptoms of LEMS often precede dx of SCLC
- 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)
what are hematologic syndromes that could present with paraneoplastic syndromes
- Anemia, Leukocytosis,Thrombocytosis, Eosinophilia,
- Hypercoagulable disorders
what is hypertrophic osteoarthropathy in paraneoplastic syndromes
- 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 Dermatomyositis/Polymyositis in paraneoplastic syndrome nad how does it present?
- inflammatory myopathies manifested by muscle weakness
- may present with symptoms prior to dx of lung CA
- elevated CK and ANA
what is cushing syndrome as paraneoplastic syndrome and how does it present
- ectopic (tumor) production of ACTH
- S/S: muscle weakness, central weight gain, hypertension, hirsutism, and osteoporosis
- Hypokalemia and hyperglycemia are usually present
what are bronchial carcinoid tumors
a rare type of lung cancer that develops in the central bronchi and rarely metastasizes
when does bronchial carcinoid tumor typically present
before age 60
no links between smoking or other carcinogens
what is the clinical presentation of bronchial carcinoid tumors?
- hemoptysis, cough, focal wheezing and recurrent pneumonia
- 25% of patients are asymptomatic
- carcinoid syndrome¹ is rare - flushing, diarrhea, wheezing, hypotension
what would a bronchoscopy show in bronchial carcinoid tumors
Bronchoscopy shows a pink/purple tumor (due to high vascularity) in the central air way
what occurs when you biopsy a bronchial carcinoid tumor?
biopsy often results in significant bleeding
what is management for bronchial carcinoid tumors
- observation with serial CT scans to follow growth
- follow up evaluation for symptomatic progress (MC complication is tumor bleeding and airway obsruction)
- symptomatic lesions often require surgical excision
- prognosis is “favorable”
ugh so many cards…. but youre done! flip for doggo!
