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leading cause of cancer death among both men and women accounting for about 1 out of 4 cancer deaths.

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Lung cancer

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The American Cancer Society estimates for lung cancer in 2016 that:

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About 224,390 new cases of lung cancer (117,920 in men and 106,470 in women) 2. About 158,080 deaths from lung cancer (85,920 in men and 72,160 in women)

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risk factors for lung cancer

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Smoking Radiation Therapy Environmental Toxins HIV Genetic Radon exposure Occupational-Asbestosis

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2 types of lung cancer

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Small cell Non small cell- accounts for 85% of all lung cancers.

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Lung cancer has been classified into 2 major categories as the result of

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of a difference in clinical features & treatment responsiveness.

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tends to have a faster growth rate, more central & mediastinal localization, earlier metastasis to extrathoracic sites.

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SCLC

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2 stages of SCLC

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Limited Stage Extensive Stage-tumors that extend beyond the ipsilateral hemithorax, such as those that reach the contralateral lymph nodes or that find their way to distant organs

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NSCLC-85-90% of cancer

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Adenocarcinoma Squamous Large cell

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Arising from the bronchial mucosol glands. Most common.

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adenocarcinoma

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It is the subtype observed in those who don't smoke. Peripheral in origin.

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adenocarcinoma

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Central portion of the lung Type associated with hypercalcemia

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squamous cell

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25-30% of all lung cancers Starts in the early versions of squamous cells which are flat cells that line the inside of the airway.

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squamous cell

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10-15% of lung cancer Any part of the lung Tends to grow and spread quickly.

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large cell

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At initial diagnosis:

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20% of patients have localized disease. 25% of patients have regional metastasis. 55% have distant spread.

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clinical manifestations of lung cancer

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Majority of patients have advanced disease at presentation Cough- 50-75% Hemoptysis- 20-50% Recurring infections Weight loss Anorexia Dyspnea Hoarseness Wheezing Chest pain Shoulder pain NEW COUGH IN A SMOKER!

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hoarseness indicates what???

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Malignancy involving the recurrent laryngeal nerve along its course under the arch of the aorta and back to the larynx.

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Obstruction causes symptoms that commonly include a sensation of fullness in the head & dyspnea.

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Superior Vena Cava Syndrome

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S&S of superior vena cava syndrome

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Facial edema Dilated neck veins Widening of mediastinum or a right hilar mass on x-ray. More common with SCLC.

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Pancoast Syndrome

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Superior Sulcus. Pain in the shoulder- C8, T1,T2 dermatomes. Horner's Syndrome. Bony destruction. Atrophy/weakness of the hand muscles. NSCLC (squamous cell).

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shoulder pain & lung cancer ???

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Invasion of the bronchial plexus Pain may radiate up to the head and neck or go down the medial aspect of the scapula, axilla, and anterior chest.

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horner's syndrome!!!!

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Ipsilateral ptosis-drooping of the upper eyelid. Miosis-excessive constriction of the pupil of the eye. Anhidrosis-lack of sweat in response to heat.

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Syndrome of Inappropriate Antidiuretic Hormone Secretion. (SIADH)

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Effects of the tumor are remote effects that are not related to the direct invasion, obstruction, & metastasis. Frequently caused by SCLC and result in HYPONATREMIA.

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Ectopic production of ADH by a tumor Disorder of impaired water excretion caused by the inability to suppress the secretion of ADH.

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SIADH

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IN SIADH, Severity of symptoms is related to the degree of ____;

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hyponatremia and the rapid fall of Na in the serum.

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S&S SIADH

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Anorexia, N/V, cerebral edema.

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Tx of SIADH

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treat the malignancy Will resolve within weeks of chemo Normal saline Fluid restriction

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labs for lung CA

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CBC CMP- abnormal liver enzymes Elevation in calcium should prompt the additional imaging for bone metastasis Increase Alk Phos - liver or bone mets.

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Imaging for lung CA

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Every patient with suspected lung cancer should undergo a CT scan with IV contrast. Image the liver and adrenals.

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Provides information on metabolic activity of the primary tumor, mediastinal involvement, and potential distant mets.

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PET scan

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The patient receives a short half life radioactive drug. The drug accumulates in certain tissues more than others. Diagnosis CAN NOT be made without definitive biopsy.

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Pet scan

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Can determine whether tumor tissue is actively growing and can aid in determining the type of cells within a particular tumor.

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pet scan

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distant mets of lung cancer

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Liver Adrenal glands Bones Brain

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5 steps to confirm the dx of lung ca

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Bronchoscopy Sputum Cytology Thoracentesis Thoracoscopy Transthoracic Needle Biopsy - CT Guided

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ipsilateral hemithorax and regional lymph nodes.

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limited stage SCLC

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distant metastases, malignant pericardial or pleural effusions, contra lateral supra clavicular or contra lateral hilar involvement.

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extensive stage SCLC

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NSCLC-Staging plays a major role in determining Treatment

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Stage 1- confined to the lung Stage 2 & 3- cancer is confined to the chest Stage 4- cancer spread from the chest to other parts of the body

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NSCLC best for long survival and care tx?

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Surgical resection offers the best opportunity for long term survival and care.

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tx of different stages of NSCLC

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Stage 1 or 2-complete surgical resection. (1 or 2 - not candidates-radiation) Stage 3- chemo/radiation Stage 4- systemic therapy are symptoms based on a palliative approach.

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how is SCLC Distinguished clinically from NSCLC

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by its rapid doubling time and early development of metastases.

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SCLC limited stage prognosis

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Limited stage- chemotherapy & radiation. -median survival 15-20 months -5 year survival is 10-13%.

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SCLC extensive stage prognosis

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Extensive Stage 8-13 month survival 5 year- 1-2% Chemotherapy

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To be used for NSCLC descriptive purposes

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T - Tumor-describes size of primary tumor. N - Node-describes the spread of cancer to regional lymph nodes. M - Metastasis-indicates whether cancer has spread.

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T in TNM for NSCLC

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Tx - Primary tumor cannot be assessed. T0 - No evidence of tumor. Tis - Carcinoma in Situ T1,T2,T3,T4-size and / or extension of the primary tumor.

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regional nodes cannot be assessed.

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Nx

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no regional node metastasis

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N0

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metastasis in the ipsilateral peribronchial and/or ipsilateral hilar nodes and intrapulmonary nodes

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N1

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metastasis in ipsilateral medistinal and/or subcarinal node

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N2

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metastasis in contralateral mediastinal, contralateral hilar, supraclavicular node.

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N3

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N in TNM

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lymph Node (which ones are involved, metastasis)

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M/Metastatic

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M0 - none M1 - distant metastasis

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Treatment-Surgery of lung cancers

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Lobectomy - surgical resection of a single lobe. Pneumonectomy - removing entire lung. Wedge Resection - removing part of a lobe.

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radiation may be used for______; Uses high energy xrays and other types of ____ to kill ____; Curative or Palliative (lower dose for palliative)

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both NSCLC and SCLC; radiation; dividing cancer cells.;

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Treatment of choice for most SCLC since these tumors are generally widespread in the body when they are diagnosed. May be given as an IV or a pill or both.

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chemotherapy

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Lung Cancer screening guidelines have been issued by the following organizations:

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American Cancer Society American College of Chest Physicians National Comprehensive Cancer Network US Preventive Services Task Force

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screening for lung cancer

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Low dose ct scan. Age 55-74. No symptoms of Lung Cancer. 30 pack year smoking hx. If the patient has quit within the last 15 years.

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In addition, the NCCN guidelines recommend considering screening starting at age 50 in patients with a 20 pack year smoking history and one of more of the following risk factors:

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Radon exposure Occupational Exposure Cancer Hx Family hix lung cancer-1st degree relative COPD or Pulmonary Fibrosis

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It is a focal process involving a lobe, segment, or sub-segment of lung. Results in abnormal and permanent distortion of one or more of the conducting bronchi or airways.

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bronchiectasis

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Uncommon. Secondary to an infectious process. CF accounts for ½ cases.

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bronchiectasis

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In bronchiectasis, Abnormal dilation of the proximal and medium size bronchi >2mm diameter caused by

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weakening or destruction of the muscular and elastic components of the bronchial walls.

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in bronchiectasis, Impaired clearance of secretions causes

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colonization and infection with pathogenic organisms, contributing to the purulent expectoration commonly observed in these patients.

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In bronchiectasis, causes of primary infx

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klebsiella, staph aureus, mycobacterium.

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bronchiectasis - causes of bronchial obstruction

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tumors, stenosis, FB aspiration.

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other causes of bronchiectasis (not primary infx or bronchial obstruc)

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CF Immunodeficiencies Autoimmune AAT

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S&S of bronchiectasis

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Cough. Daily mucopurulent sputum often lasting years. Dyspnea. Wheezing. Pleuritic CP. Fever. Weight loss. Hemoptyisis. There can be exacerbations as well.

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physical exam with bronchiectasis

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Crackles, rhonchi, scattered wheeze. Digital clubbing. Cyanosis. Wasting and weight loss. Cor pulmonale in advanced disease.

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imaging of bronchiectasis

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Chest x-ray-dilated and thickened bronchi that may appear as "tram tracks" or as ring like markings. CT scan- study of choice. Rule out AAT deficiency.

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tx of bronchiectasis

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ABX - mainstay. Chest Physiotherapy - mainstay. Bronchodilators. Steroid Therapy. O2.

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Surgical resection of involved bronchiectatic sites is an important adjunct to therapy for patients with

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focal disease and is poorly controlled on antibiotics.

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is the most common organism recovered from non CF patients.

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Haemophilus influenzae

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A 67 yo man has bronchogenic carcinoma in the apex of the left lung. Tumor involvement of the recurrent laryngeal nerve would result in which of the following?

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Hoarseness

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Which of the following is most common at the time of lung cancer diagnosis?

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The patient has distant spread of disease

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Which of the following is more suggestive of small cell cancer than NSCLC?

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paraneoplastic syndromes

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The expectoration of blood that originates below the vocal cords.

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hemoptysis

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potentially life threatening >500ml over 24 hrs.

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massive bleeding in hemoptysis

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Bleeding is difficult to quantify. It may be hard for a patient to discern whether they are vomiting ____

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blood, coughing, or spitting out bloody material.

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etiology of hemoptysis Blood from the airways:

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COPD Bronchiectasis Bronchogenic Carcinoma-bleeding from a malignancy can be secondary to superficial mucosal invasion, erosion into blood vessels or highly vascular lesions.

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etiology of hemoptysis - blood from the Pulmonary Vasculature:

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Mitral Stenosis PE AV Malformations=abnormal connection between the veins and arteries. Left Ventricular Failure

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Narrowing that slows blood thru the left atrium to the left ventricle. High pressure can cause a vein or capillary to burst.

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mitral stenosis

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most common cause of hemoptysis

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Infection: Causes superficial mucosal inflammation and edema that can lead to the rupture of the superficial blood vessels. ex - TB

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Most hemoptysis presenting in the ____

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outpatient setting is due to infection!

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Children with hemoptysis

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Lower resp infection Foreign body aspiration

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Source of hemoptysis other than lower respiratory tract

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Upper airway GI bleeding

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causes of hemoptysis

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RTI, TB, lung ca, bronchiectasis, lung abscess, mitral stenosis, HF, PE, foreign body, trauma, Wegeners, good pastures, bleeding diathesis

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Hx involved in hemoptysis

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Tobacco HX Environmental exposures-asbestosis, nickel. History of chronic purulent sputum and frequent pneumonias. Travel HX-TB GERD HX Systemic Disease- hematuria, rash, joint pain. QUANTIFY IT- blood mixed with phlegm?

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Physical exam with hemoptysis

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Elevated Pulse Fever Hypotension Decrease Pulse O2 Heart Murmur. Evaluate for Heart Failure and Mitral Stenosis. Inspect Nares and Oropharynx.

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Skin and mucus membranes have to be inspected for cyanosis, pallor, bruising, gingivitis, or evidence of bleeding from the oral or nasal mucosa.

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hemoptysis phys exam

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Extremities- edema, joint effusions or warmth. Lymph nodes.

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hemoptysis phys exam

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Dx hemoptysis

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Chest X-Ray CBC Coagulation Profile - Exclude Thrombocytopenia UA / Renal Function LFT's Flex Bronchoscopy High resolution CT scan

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manage hemoptysis

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Bleeding cessation Aspiration prevention Tx underlying cause

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chronic cough

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Persists longer than 8 weeks.

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What is "Cough"

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A protective reflex serving a normal physiologic function of clearing excessive secretions and debris from the pulmonary tract. Pathology from the nose and nasopharynx to the distal bronchial tree

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causes of chronic cough

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PND Asthma GERD ACE Tobacco COPD Cancer Psychogenic

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post nasal drip

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Sensation of secretions from the nose or sinus that drain into the pharynx in addition to nasal dc and frequent throat clearing.

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should be considered in adolescents and adults with persistent or severe cough lasting more than 3 weeks.

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pertussis infection

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cough, fever, and weight loss.

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bronchogenic cancer

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persistent and chronic with excessive mucus.

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COPD

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2 mechanisms of GERD

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Distal esophageal acid exposure that stimulates an esophageal tracheobronchial cough reflex via the vagus nerve. Micro aspiration of esophageal contents into the laryngopharynx and tracheobronchial tree / (LPR).

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throat clearing, hoarseness, globus sensation

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GERD

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investigating chronic cough

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Chest x-ray: RO other diagnoses. Spirometry EGD

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tx of chronic cough

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Treat the cause. Antitussives- codeine & dextromethorphan.

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Empiric treatment with maximum strength regimen for ______for 4 weeks is recommended.

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pnd, asthma, or GERD

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A 61 year old woman has a nonproductive cough for the past 2 weeks. Which of the following medications is most likely the contributing factor?

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Captopril

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