Thoracic Neoplasms - Exam 2 Flashcards
What is the mediatstinum?
the anatomically space between the lungs?
What are the MC masses in the anterior mediastinum?
Thymoma
Teratoma
Thyroid/Parathyroid tissue
What is a teratoma?
A teratoma is a rare type of germ cell tumor that may contain immature or fully formed tissue, including teeth, hair, bone and muscle. Most teratomas are benign but they can be malignant.
What are the MC middle mediastinum masses?
Granulomatous or metastatic lymphadenopathy
cysts
masses of vascular origin (pulmonary artery enlargement, aortic aneurysm)
What are the MC masses of the posterior mediastinum?
Neurogenic tumors, meningocele, meningomyelocele
Gastroenteric cysts, esophageal diverticula/tumor
Hiatal hernia, hernia through foramen of Bochdalek
Extramedullary hematopoiesis
1/2 of all mediastinal masses are _____ in nature. What do you do next? How do they normally present?
incidental
comprehensive PE
direct involvement or compression of normal cardiothoracic structures
What is Horner’s syndrome?
miosis (constriction of the pupil)
ptosis (drooping of the upper eyelid)
anhidrosis (absence of sweating of the face).
caused by damage to the sympathetic nerves of the face
If the mass is malignant in nature, what are you more likely to see?
constitutional symptoms (fever, night sweats, weight loss)
vs just s/s of the mass compressing on whatever underlying structure
What do you order if you suspect someone has a mediastinal mass?
initial- CXR
then CT WITH contrast
What are some additional tests you could consider when working up a mediastinal mass?
barium swallow (for esophageal)
doppler, CT/MRI angiography if thinking vascular
thyroid scan
PET scan
testicular/ovarian US
What are the 3 different options for biopsy? The option that you pick is based on the risk of ______
percutaneous- use CT guidance for exact location
endobronchial- if the mass is located immediately within the bronchial
surgical- either small enough that the mass can be resected at the time of biopsy or a larger mass
pick one based on the risk of malignant seeding
What is another name for a solitary pulmonary nodule? **What is the difference between a nodule and mass? What are some associated characteristics?
coin lesion
**nodule =less than or equal to 3cm (30mm) is a nodule
**mass= greater than 3cm (30mm)
isolated and round opacity, surrounded by normal lung tissue, not associated with infiltrate
most solitary pulmonary nodules are ______. What are the MC cause?
most are benign
infectious granulomas make up 80%
What are the two MC organisms for a infectious granuloma? What are the defining characteristics?
fungal: histoplasmosis or coccidioidomycosis
mycobacteria: TB or non-TB
Classically appear as a well-demarcated and fully-calcified or centrally calcified nodule
What is a hamartomas? How does it present?
noncancerous tumor made of an abnormal mixture of normal tissues and cells from the area in which it grows.
presents in middle age, grows slowly (over years)
How would a CXR define a hamartoma? CT?
both look histologically heterogenous
CXR - “popcorn” calcification
CT - areas of fat or alternating fat/calcifications
What is a pulmonary AV malformation? Is it benign or cancerous? What biopsy method is perferred?
a tangle of connecting arteries and veins
benign
AVOID bx of these lesions due to bleeding
What are the causes of malignant SPNs?
primary lung cancer
lung metastasis
carcinoid tumors
Which types of lung cancers present centrally? peripherally?
Small Cell Carcinoma - presents centrally
Squamous Cell Carcinoma- presents centrally
__________________
Adenocarcinoma - present peripherally
Large Cell Cancer - anywhere but often more peripheral
lung metastasis usually presents as ______ nodules. What are some common cancers?
multiple nodules
melanoma, sarcoma¹, and carcinomas of the bronchus, colon, breast, kidney, and testicle
What are the MC carcinoid tumors?
endobronchial, some (20%) present peripherally
What are the 3 types of non-small cell lung cancer?
squamous
adenocarcinoma
large cell cancer
**What are the risk factors for a SPN?
Smoking (increases with the pk yr hx)
Over the age of 35
Family history
Female sex
Emphysema
Previous malignancy
Asbestos
When would you want to repeat the CXR before ordering CT when evaluating SPN?
if suspected nodule is a nipple shadow
infection
nodule characteristics are pathognomonic for a benign lesion
After a CXR, what is the next step in imaging for SNP? What does the size of the nodule indicate?
chest CT w/o contrast
larger nodules have a higher rate of malignancy.
nodules greater than 2cm (20mm) have over a 50% chance of being malignant
What lung location have an increased probability of being malignant?
nodules found in the upper lobe have an increased probability of being malignant
What does the attenuation of the nodule indicate? What key phrase is a higher likelihood of malignancy
solid= less likely to be cancer
subsolid= higher likely of malignancy
“ground glass” equals bad news because no solid component so higher likelihood of cancer
What does the shape of nodule tell you about the likelihood of malignancy?
benign lesions: are smooth, with a well-defined edge
malignant lesions: are ill-defined, lobular or spiculated in appearance; may have peripheral halo on CT
What does the growth of the nodule tell you about the likelihood of it being malignant?
malignant: growth on serial imaging, q3-12 months
benign: solid nodule stable for 2 years
subsolid nodule that is stable for 5 years
What does the lesion calcification tell you about the likelihood of malignancy?
Benign lesions have dense calcification
Malignant lesions are associated with sparser calcification: stippled or eccentric patterns
What are the 4 benign calcification patterns? 2 malignant?
benign:
diffuse
central
popcorn
laminated
malignant:
stippled
eccentric
What is the management of SPN based on? What does the size tell you?
the probability of malignancy
> 30 mm (mass) - high risk - resection is recommended
≤ 30 mm nodule - determine probability for malignancy
**What does the Solitary Pulmonary Nodule Malignancy Risk Calculator estimate? **What are the 3 categories?
the probability that a lung nodule will be diagnosed as cancerous within a 2-4 year f/u period
**Low probability = < 5 %
Intermediate probability = 5-60%
high probability = > 60%
What is the management for high probability pulmonary nodule? What is considered high?
surgical resection and staging
greater than 60% risk
What is the management for low probability SPN?
“watchful waiting” with serial CT scans
frequency of scanning depends on size of nodule and risk for cancer
**What is the scanning frequency for low probability SPNs?
What is the management for intermediate probability SPNs?
sputum cytology
PET scan
Refer to sx for further recommendation (bx or VATS with frozen tissue sampling)
When would you use a sputum cytology?
Sputum Cytology highly _____ but not ______
in the intermediate probability SPNs
for central lesions or those patients who are poor candidates for invasive dx procedures
specific NOT sensitive
What should you do if your patient is found to have multiple nodules?
each nodule should be assessed individually for the probability of malignancy and followed by CT surveillance or biopsy accordingly
What are the 6 hallmark capabilities of cancer?
- self-sufficiency in growth signals
- insensitivity to antigrowth signals
- evading apoptosis
- limitless replicative potential
- sustained angiogenesis
- tissue invasion and metastasis
What number is lung cancer in both men and women?
2nd MC cause of cancer and leading cause of cancer death
What are the risk factors for lung cancer?
smoking
older than 35, median age is 70
Occupational/Environmental Exposure
family hx
chronic lung dz
What is the annual low-dose CT lung cancer screening criteria?
- 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 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 some s/s of lung cancer?
often asymptomatic until advanced disease is present
cough, sputum streaked with blood, chest pain, increased SOB, voice changes, recurrent infections, malignant pleural effusions, superior vena cava syndrome, pan coast tumor
What is the tx for malignant pleural effusions? What is needed to confirm dx?
NOT curable and managed palliatively
cytology of pleural fluid is needed to identify the presence of malignant cells in the pleural fluid. Often multiple samples
What is superior vena cava syndrome? What cancer type is MC?
compression of the SVC by the pulmonary mass
MC in SCLC due to central pulmonary involvement
What is pemberton’s sign? What syndrome is it associated with?
when the pt raising both arms above their head for 1 minute their face started to turn red and swells due to problem with the venous system
SVCS
What will a pt with SVCS CXR show?
CXR shows mediastinal widening or right hilar mass
What is a pancoast tumor? What are some s/s?
tumor in the apex of the lung causing compression of surrounding structures
shoulder pain
horner’s syndrome
bone destruction
atrophy of hand muscles (because of nerve roots C8-T1)
What is the first imaging of choice for lung cancer? Then what do you move on to?
CXR- initial then CT WITH contrast
What are the parameters for a solid-appearing lesions to be considered stable and non-malignant? non-solid?
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
What can cause a PET scan to show metabolic activity everwhere? What is the main indication for PET scan?
uncontrolled DM
CT and PET are used for staging and biopsy planning.
What is the definitive way to dx lung cancer? What is the preferred bx for centrally located tumors? peripherally?
mass bx
central: Endobronchial Ultrasound Bronchoscopy
peripheral: Transthoracic percutaneous fine-needle aspiration (FNA) with CT guidance
How is lung cancer classified? What are the 4 options?
based upon histologic evaluation of biopsy specimen pulmonary neoplasms are categorized into one of 4 classifications
Small Cell Lung Cancer (SCLC)
Squamous Cell Carcinoma
Adenocarcinoma
Large cell carcinoma
How does small cell carcinoma grow and spread? Where does it start? Why is it usually detected? smokers or non-smokers?
Very small cells that are very fast growing/doubling and result in an early development of widespread metastasis
starts in the bronchi: central
Usually detected as a large hilar mass with bulky mediastinal adenopathy
pt is USUALLY a SMOKER
What is the MC form of lung cancer? What are the 3 categories?
non-small cell lung cancer
adenocarcinoma
squamous cell
large cell
What kind of NSCLC is slow growing and usually involves the periphery of the lung?
adenocarcinoma
**_____ is the MC form of lung cancer in nonsmokers?
NSCLC- adenocarcinoma
Which form of cancer generally occurs in the center of the lung and develops in smoker?
squamous cell carcinoma
What type of lung cancer is rapidly growing mass occurring anywhere in the lung (more commonly found along the periphery)?
large cell carcinoma
What is the TNM staging? What kind of lung cancer is it associated with?
Tumor Node Metastasis
non-small cell
How do you determine what N stage a pt is in?
How do you determine what metastasis stage a pt is in?
**What is the tx for non-small cell LC stage 0?
sx alone is curative for these pts
**What is the tx for non-small cell LC stage 1?
sx +/- radiation (positive surgical margins or the pt isnt a sx candidate)
**What is the tx for stage II and III non-small cell lung cancer?
sx
chemo (especially if lymph node involvement)
+/- post-op radiation: positive surgical margins or candidate refuses sx
** What is the tx for non-small cell stage IV cancer?
chemo
molecularly targeted therapy
+/- immunotherapy
+/- palliative radiation and sx to improve the pt’s quality of life
What is the tx for limited stage small cell lung cancer with no distant metastasis or dz in the mediastinum?
Resection is indicated followed by chemotherapy
What is the tx for limited stage small cell lung cancer WITH distant metastasis or dz in the mediastinum?
Chemoradiotherapy is indicated as initial treatment
What is the tx for extensive stage small cell LC?
Systemic chemotherapy
Prophylactic cranial and thoracic irradiation decreases risks of mets in patients who respond to systemic chemotherapy
What are the MC sites for distant metastatic lung cancer?
Liver
Adrenal glands
Bones
Brain
What do you do if your pt has elevated LFTs and confirmed lung cancer? Are they going to show s/s?
imaging of choice: non-contrasted CT or CT-PET
often asymptomatic
What are some lab, PE and s/s findings that indicate the lung cancer has spread to the bone? More commonly seen with small- cell or non- small cell? What imaging do you order next?
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
PET scan (bone scan if not available)
-MRI is also acceptable
_______ most often asymptomatic and found incidentally on staging CT scan
adrenal cancer
What calcium level is a red flag for malignancy? What does it indicate?
calcium 14-15 is bad
tumor secretion of parathyroid hormone-related protein¹ (PTHrP) and vitamin D 1,25 inciting osteoclastic activity
usually associated with stage III and IV cancer
SIADH most often associated with _______. What are the s/s related to ?
small cell lung cancer
hyponatremia: anorexia, nausea and vomiting. always running the risk the risk of cerebral edema if onset is rapid
lung cancer is the most common cancer associated with ________. What kind of lung cancer is it associated with?
paraneoplastic neurologic syndromes
most often associated with small cell lung cancer
What is the MC multiple neurological paraneoplastic syndrome?
Lambert-Eaton myasthenic syndrome (LEMS)
What is Lambert-Eaton myasthenic syndrome (LEMS)? How does it present? What type of lung cancer is it associated with?
autoantibody formation results in impaired release of acetylcholine
muscle fatigue very easily, reduced reflexes, speech impairment, swallowing problems
small cell lung cancer-> need to order chest CT and PET to look for SCLC
What is hypertrophic osetoarthropathy? What will the x-ray of long bones show?
a symmetrical, painful arthropathy that usually involves the ankles, knees, wrists, and elbows. sometimes clubbing of the digits
x-ray of long bones will show periosteal new bone formation
What is Dermatomyositis/Polymyositis? What lab values will be elevated?
inflammatory myopathies manifested by muscle weakness. s/s usually present prior to dx of lung cancer
elevated CK and ANA
_____ and _____ are also usually present in cushing syndrome due to tumor production of ACTH
Hypokalemia and hyperglycemia
What are bronchial carcinoid tumors? What age do they present before? What is the major problem
a rare type of lung cancer that develops in the CENTRAL bronchi and rarely metastasizes
most often present before the age of 60
bleeding because these tumors are very vascular
hemoptysis, cough, focal wheezing and recurrent pneumonia
What am I?
flushing, diarrhea, wheezing, hypotension
What am I?
Bronchial Carcinoid Tumors
carcinoid syndrome
What is the management of bronchial carcinoid tumor? What will they look like on bronchoscopy?
observation with serial CT scans to follow growth, if symptomatic -> sx
bronchoscopy shows a pink/purple tumor (due to high vascularity) in the central air way
What are the 2 MC complications from a Bronchial Carcinoid Tumors?
bleeding and airway obstruction
