Thoracic Neoplasms Flashcards
Mediastinum
Anatomic space located between the lungs
Anterior mediastinum borders
Sternum to anterior aspect of the heart
Anterior mediastinum contents
Thymus
Internal mammary arteries
Lymph nodes
MC etiologies of anterior mediastinal masses
Thymoma
Teratoma
Thyroid/parathyroid
Middle mediastinal borders
Anterior aspect of the heart to the posterior aspect of the heart
Contents of middle mediastinum
Heart
Great vessels
Trachea
MC etiologies of middle mediastinal masses
Granulomatous or metastatic lymphadenopathy
Posterior mediastinum borders
Everything posterior to the heart
Contents of posterior mediastinum
Esophagus
Thoracic duct
Sympathetic chain
Spine
Descending thoracic aorta
MC etiologies of posterior mediastinal masses
Neurogenic tumors
Meningocele
Esophageal diverticula
Hiatal hernia
50% of mediastinal masses are found ___
Incidentally
Clinical presentation of mediastinal mass
Symptoms related to the structures that are compressed by the mass
Constitutional symptoms if malignant
Effects of compression of the lungs, esophagus, vascular, heart and sympathetic chain
Lungs: hoarseness
Esophagus: dysphagia
Vascular: facial or extremity swelling
Heart: hypotension
Sympathetic chain: Horner’s syndrome
Initial imaging of a mediastinal mass
CXR
If the CXR is inconclusive, what is the follow-up imaging for mediastinal mass?
Chest CT with IV contrast
If the patient complains of difficulty swallowing due to mediastinal mass, what test could be run?
Barium swallow
If there is a suspected malignancy of mediastinal mass, what test should be run first?
PET scan
PET scan
Shows metabolic activity
Anti-acetylcholine receptor antibodies are elevated in ___ tumors
Thymic
Alpha fetoprotein and beta HCG are elevated in ___ tumors
Germ cell
LDH is elevated in ___ tumors
Seminomas and lymphoma
Referral for mediastinal masses
Cardiothoracic or general surgery
Indications for percutaneous biopsy of mediastinal mass
If it is near the periphery of the chest
Percutaneous biopsy
Uses CT guidance for exact location of biopsy
Indications for endobronchial biopsy
If mediastinal mass is located immediately adjacent to an airway
Indications for mediastinoscopy biopsy
If they are also planning to resect the tumor at that time
Characteristics of a solitary pulmonary nodule (SPN)
Less than 3cm
Isolated and round opacity
Surrounded by normal lung
Not associated with infiltrate, atelectasis, or adenopathy
T/F most SPN are malignant
F - most are benign
Benign causes of SPN
Infectious granulomas
Hamartomas
Pulmonary AV malformation
MC organisms that cause infectious granuloma SPN
Endemic fungi
Mycobacteria
Appearance of infectious granuloma SPN
Well-demarcated, fully calcified, or centrally calcified
Presentation of hamartoma
Heterogenous
CXR: popcorn
CT: areas of fat
Pulmonary AV malformation
Tangle of connecting arteries and veins causing a hard time for blood to move through
Should you biopsy pulmonary AV malformations?
No - there is a bleeding risk
Malignant causes of an SPN
Primary lung cancer
Lung metastasis
Carcinoid tumors
Most pulmonary metastases present as ___
Multiple nodes
Risk factors for malignancy in SPN
Smoking
Age
Family History
Female sex
Emphysema
Previous malignancy
Asbestos exposure
You should repeat CXR prior to ordering CT if ___
Suspected nodule is likely a nipple shadow
Evidence of infection
Nodule characteristics are pathognomonic for benign lesion
Imaging modality of choice for SPN
CT chest w/o contrast
CT imaging helps to assess malignancy risk factors such as ___
Size
Location
Attenuation
Calcification
___ nodules have a higher malignancy rate
Larger
Nodules found in the ___ have an increased risk of being malignant
Upper lobe
(Solid/subsolid) nodules are more likely to be malignant
Subsolid
Types of subsolid nodules
Ground glass nodules
Part-solid nodules
Shape of nodules that are more likely to be malignant
Ill-defined, lobular, spiculated, and peripheral halo
Benign lesions have smooth, well-defined borders
Growth of SPN
More likely to see growth on malignant tumors
Benign tumors are likely stable
Calcification patterns of SPN
Benign: diffuse, central, popcorn, laminated
Malignant: stippled and eccentric
If the nodule is over 3cm, then it is already classified as ___ risk
High
If the nodule is under 3cm, how do you determine risk?
Risk calculator
Risk calculator for determining malignancy probability
Low: less than 5%
Intermediate: 5-60%
High: over 60%
Management of low probability SPN
Watchful waiting with serial CT scans
Management of high probability SPN
Surgical resection and staging
Management for intermediate probability SPN
If a central lesion: sputum cytology
If you suspect malignancy: PET scan
Biopsy for further malignancy testing
Management of patients with multiple nodules
Each nodule should be assessed individually for the probability of malignancy
Bronchogenic carcinoma
Malignant tumors arising from the respiratory epithelium, which excludes the bronchi, bronchioles and alveoli (lung cancer)
T/F second hand smoke exposure is still a significant risk factor for the development of lung cancer
True
Median age of lung cancer diagnosis
70
Risk factors for lung cancer
Smoking
Age
Occupational exposure
Family history
COPD
Screening criteria for lung cancer
Must be between 50-80
In good health
Currently smokers or has quit within the last 15 years
Has a 20 pack year history
Modality of lung cancer screening
Annual low-dose CT
Clinical presentation of lung cancer
Intrathoracic symptoms: cough, sputum streaked with blood, chest pain, SOB, recurrent infections
Intrathoracic complications
Malignant pleural effusions
Superior vena cava syndrome
Pan coast tumor
How is malignant pleural effusion managed?
Palliatively
How to identify the presence of malignancy cells in the pleural fluid?
Cytology
Superior vena cava syndrome
Compression of the SVC by pulmonary mass leading to facial and neck edema
CXR of superior vena cava syndrome
Mediastinal widening or high hilar mass
Pancoast tumor
Tumor in the apex of the lung causing compression of surrounding structures
Symptoms of pancoast tumor
Shoulder pain
Horners syndrome
Bone destruction around the tumor
Initial imaging modality for lung cancer
CXR
Indications for chest CT for lung cancer
New or enlarging lesion
Pleural effusion
What type of CT is used for lung cancer?
With contrast
T/F: the whole body PET scans are recommended for lung cancer
False - targeted PET scans are utilized for organs suspected of having malignancy based upon symptoms and CT imaging
PET false negatives
Diabetics
Small lesions
Slow-growing tumors
PET false positives
Certain infections and granulomatous disease
When are labs indicated for suspected lung cancer?
If radiologic evidence shows likely malignancy
MC sites for distant metastatic lung cancer
Liver
Adrenal glands
Bones
Brain
Liver mets in lung cancer
Often asymptomatic
Elevated LFTs
Imaging of choice for liver mets in lung cancer
CT w/o contrast
Bone mets in lung cancer
Pain in the back, chest, or extremities
Elevated serum alk phos and serum Ca
Imaging of choice for bone mets in lung cancer
PET scan
Adrenal mets in lung cancer
Often asymptomatic and found incidentally on staging CT
Imaging of choice in adrenal mets in lung cancer
PET scan
Brain mets in lung cancer
N/V, vision changes, papilledema, cranial nerve deficit
Imaging modality for brain mets of lung cancer
MRI with contrast
Only definitive way to make the diagnosis of malignancy in lung cancer
Biopsy
Modality options for primary neoplasm of lung biopsy
Endobronchial ultrasound bronchoscopy: preferred for centrally located tumors
Transthoracic percutaneous fine-needle aspiration with CT guidance: preferred for peripherally located tumors
Biopsy modalities for lung cancer
Video-assisted thoracic surgery
Mediastinoscopy for tumors that are going to be resected anyways
Classification of WHO lung cancer
Small cell lung cancer
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Small cell carcinoma patient population
Almost always a smoker
Where does small cell carcinoma generally start?
Bronchi (centrally located)
How is small cell carcinoma usually detected?
Large hilar mass with bulky mediastinal adenopathy
Most common type of lung cancer
Non-small cell lung cancer
Most common form of lung cancer in nonsmokers
Adenocarcinoma
Adenocarcinoma
Slow-growing and usually involves the periphery of the lung
Squamous cell carcinoma generally occurs in the ___ and develops in ___
Large cell carcinomas
Large cell carcinomas
Rapidly-growing mass occurring anywhere in the lung
Location of large cell carcinoma
Peripheral
TNM staging
Tumor: size of tumor
Node: lymph node involvement
Metastasis: mets to other organs
Stage 1 NSCLC
No nodal involvement or mets
Treatment of stage 0 NSCLC (in situ)
Surgery alone is usually curative for these patients
Treatment of stage 1 NSCLC
Surgery
Radiation if the surgical margins are positive and patient isn’t a candidate for surgery
Treatment of stage 2 and 3 NSCLC
Surgical resection
Followed by chemo
Post-op radiation if positive surgical margins and is not a candidate for surgery
Stage 4 NSCLC
Wide-spread with distant mets
Treatment of stage 4 NSCLC
Chemotherapy
Palliative radiation and surgery
Prognosis of NSCLC
5 year survival is 10-15%
Limited stage SCLC
Patients with no distant mets and no evidence of disease in the mediastinum
Patients with clinical or pathologic evidence of mediastinal disease or mets
Treatment for limited stage SCLC in patients with no distant mets and evidence of disease in the mediastinum
Resection followed by chemo
Treatment for limited stage SCLC in patients with evidence of mediastinal disease or mets
Chemoradiotherapy as initial therapy
Extensive stage SCLC
Tumor extends beyond the hemithorax
Treatment of extensive stage SCLC
Systemic chemo
Prognosis of SCLC
Rarely survive more than a few months without treatment
Paraneoplastic syndrome
Release of hormones by a tumor that affects other organ systems
Hypercalcemia in paraneoplastic syndrome
Tumor secretion of parathyroid hormone related protein and calcitriol inciting osteoclastic activity
S/S of hypercalcemia in paraneoplastic syndrome
Anorexia
N/V/C
Polyuria
Polydipsia
Dehydration
Hypercalcemia is most often associated with ___ paraneoplastic syndrome
Advanced stage
SIADH paraneoplastic syndrome
Tumor releases ADH
SIADH paraneoplastic syndrome is most commonly associated with ___
SCLC
S/S of SIADH paraneoplastic syndrome
Hyponatremia (neuro changes)
N/V
Anorexia
Lung cancer is the most common cancer associated with paraneoplastic ___ syndromes
Neurologic
Neurologic presentations are most often associated with ___
SCLC
MC neurologic paraneoplastic syndrome
Lambert-Eaton myasthenic syndromes
Lambert-Eaton myasthenic syndrome
Autoantibody formation results in impaired release of ACH which leads to poor muscle contraction
Hypertrophic osteoarthropathy paraneoplastic syndrome
Symmetrical painful arthropathy that usually involves the ankles, knees, wrists, and elbows
Digital clubbing
Periosteal new bone formation
Dermatomyositis/polymyositis paraneoplastic syndrome
Inflammatory myopathies manifested by muscle weakness
Cushing syndrome paraneoplastic syndrome
Ectopic production of ACTH
Bronchial carcinoid tumor
Rare type of lung cancer that develops in the central bronchi and rarely metastasizes
Bronchial carcinoid tumor commonly presents before ___
60
T/F - there are links to bronchial carcinoid tumor and smoking
False
Clinical presentation of bronchial carcinoid tumor
Hemoptysis
Cough
Wheezing
Recurrent pneumonia
Bronchoscopy of bronchial carcinoid tumor
Pink/purple tumor in the central airway
Why is the bronchial carcinoid tumor purple?
High vascularity
Management of bronchial carcinoid tumor
Observation with serial CT
Surgically remove if symptomatic
