Pulmonary- Lung Cancer – Flashcards
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A 68 y/o woman is brought to the ED after coughing up a cupful of red blood. For the previous 3-4 months, she has had a chronic non-productive cough but no fevers. More recently, she has noticed some blood-streaked sputum. On review of symptoms, she reports increased fatigue, decreased appetite, and a 25-lb weight loss in the past 3 months. She denies chest pain, fever, chills, or night sweats. The patient has smoked 1 PPD for past 35 years. PE Findings Thin woman who is mildly anxious, alert, and oriented. BP 150/90 mm Hg, HR 88 bpm, RR 16 breaths; T 99.2 F Neck examination reveals no lymphadenopathy, thyroidmegaly, or carotid bruit. Chest has scattered rhonchi bilaterally, but there are no wheezes or crackles. Cardiovascular exam reveals a regular rate & rhythm, without rubs, gallops, or murmurs. Abdomen is benign with no hepatosplenomegaly. Extremities reveals 1+ ankle edema and no cyanosis; there is finger clubbing. Neurological examination WNL Q1. What is the most likely diagnosis? A. TB B. Chronic Bronchitis C. Bronchogenic carcinoma D. COPD E. Bronchiectasis
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C. Bronchogenic carcinoma
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Q2. Which of the following is not a clinical characteristic of bronchogenic carcinoma ? A. Long term treatment is to prevent smoking B. Amendable to early detection due to hemoptysis C. Definitive diagnosis requires histological exam of tissue D. Small cell treated by chemotherapy
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B. Amendable to early detection due to hemoptysis
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Q 3. Regarding the TMN classification of lung cancer A. T4 is defined as a 3 cm tumor (and larger) with the invasion of the chest wall B. N3 is defined as an ipsilateral nodes involvement only C. M 0 is defined the absence of the distant metastases D. the stages IIIB and IV of the lung cancer is relatively easy to cure by surgery E. All of the above statements are true
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C. M 0 is defined the absence of the distant metastases
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Q4. Treatment strategies for lung cancer include A. surgical resection is the therapy of choice for small-cell carcinomas B. neoadjuvant chemotherapy is mostly indicated for stage IV cancers C. local forms of small-cell and non-small-cell carcinomas are treated similarly D. small-cell cancers are highly chemosensitive E. there are several cost-effective screening methods exist in management of the lung cancer
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D. small-cell cancers are highly chemosensitive
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A 50-year-old presents with a history of persistent cough, hemoptysis, and weight loss. He states he has had "several lung infections" over the past 3 to 4 months. The patient is a 30 pack per year smoker, and also complains of right shoulder and chest pain. The patient is afebrile, pale, and dyspneic with exertion. The CXR suggests mediastinal widening and perihilar adenopathy. Q1. Which of the following is the most likely diagnosis? A. Bronchiectasis B. COPD C. Chronic Bronchitis D. Asthma E. Bronchogenic carcinoma
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E. Bronchogenic carcinoma
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A 63-year-old male has a chronic cough, but recently has noted blood-tinged sputum. A chest x-ray reveals an ill-defined hilar mass in the right lung. He is found to have serum sodium of 120 mEq/L. Q1. Which of the following is MOST likely to be present? A. Low urine specific gravity (<1.005) B. Non-secretory (null cell) adenoma of pituitary C. Bitemporal hemianopsia D. Syndrome of inappropriate ADH secretion E. Decreased serum ACTH
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D. Syndrome of inappropriate ADH secretion
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A 33-year-old woman who is a not smoker had lost 30 lb of weight and had a cough. She is noted to have a peripheral lung mass on chest radiograph. Q1. Which of the following lung cancer's is most likely present in this patient ? A. Squamous Cell B. Adenocarcinoma C. Small cell D. Large cell E. None of the above
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B. Adenocarcinoma
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A 52-year-old man presents with dyspnea and chest x-ray shows a hilar mass with an ipsilateal pleural effusion. Which is the best next step? A. CT scan of the chest, head, and abdomen for cancer staging B. PFT to evaluate pulmonary reserve to evaluate for pneumonectomy C. Obtain a specific tissue diagnosis by biopsy of the hilar mass D. Initiate palliative radiation because the patient is not a candidate for curative resection
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C. Obtain a specific tissue diagnosis by biopsy of the hilar mass
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During a physical exam of a 55 y/o woman, who is a heavy smoker c/o of left eye swelling, dry eyes and left shoulder pain, you notice that the patient's left eyelid is drooping, the conjunctiva is dry, the left pupil is smaller than the right and she has left shoulder pain with certain movements Q1. Considering these findings you consider ? A. SVC Syndrome B. Pancoast's Syndrome C. Malingering D. Cushings Syndrome E. SIADH
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B. Pancoast's Syndrome
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A 60-year-old male has a pneumonia-like area of consolidation in the right lower lobe that does not respond to antibiotic therapy. A bronchoalveolar lavage yields atypical cells. The MOST likely diagnosis is? A. Bronchioloalveolar carcinoma B. Sarcoidosis C. Pulmonary infarction D. Silicosis E. Mycoplasma Pneumonia
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A. Bronchioloalveolar carcinoma
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A 68-year-old male with a 100 pack/year smoking history develops truncal obesity, easy bruisability, and osteoporosis. Q1. Which of the following is the MOST likely diagnosis? A. Large cell anaplastic B. Bronchial carcinoid C. Bronchioloalveolar carcinoma D. Small cell carcinoma E. Squamous cell carcinoma
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D. Small cell carcinoma
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Q2. Paraneopastic syndromes are characterized by? A. pulmonary osteoarthropathy is generally seen in small cell cancer B. Hyponatremia is generally seen in Pancost's tumors C. Hyponatremia is never seen in local tumor and related to metastatic spreading D. Cushing's syndrome is related to ectopic ACTH production E. hypercalcemia occurs due to metastatic destruction of parathyroid glands
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D. Cushing's syndrome is related to ectopic ACTH production
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A 52- year-old woman with long-standing rheumatoid arthritis is hospitalized for total knee replacement. On her admission chest x-ray, a 2-cm nodule is noted near the right hilum. She has smoked one pack of cigarettes daily for the last 32 years. Q1. What would be the MOST appropriate management of this patient? A. Observation with chest x-rays every 4 months B. Therapy for 2 months with oral corticosteroids C. An upper gastrointestinal series D. Scalene node biopsy E. Exploratory thoracotomy
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E. Exploratory thoracotomy
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A 61-year-old women presents to the ER with dyspnea on exertion and facial swelling for nearly 2 weeks. She has smoked 3 packs of cigarettes per day for nearly 40 years. Her blood pressure is 120/88, pulse is 90/min, respirations are 16/minute, and she is afebrile. Heart and lung examination are normal. She has dilated veins in the neck and upper chest area Which of the following is the most likely diagnosis? A. Tumor lysis syndrome B. Superior vena cava syndrome C. Hypercalcemia D. Pericardial tamponade E. Cord compression
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B. Superior vena cava syndrome
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Histological Classification
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Histology (small cell versus non-small cell) is a major determinant of treatment approach Small cell usually widely disseminated at presentation while non-small cell may be localized Epidermoid & small cell typically present as central masses Adenocarcinoma & large cell usually present as peripheral nodules or masses Epidermoid & large cell cavitate in 20-30 % of patients
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Risk Factors for lung cancer
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Cigarette smoking-most important etiologic factor in USA (87 % males & 85 % females); Rare in non-smokers Other implicated factors: Air pollution Ionizing radiation Asbestosis Silicosis Arsenic Heavy metals & industrial carcinogens 10 or more acquired genetic lesions
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Superior Vena Cava (SVC) Syndrome -symptoms
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Obstruction of venous return of the superior vena cava SXS: Distention of thoracic and neck veins, edema of face and upper extremities, and cyanosis
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Horners syndrome sx
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Horner's Syndrome (Pancoast's Tumor) Ptosis, miosis, anhydrous Pancoast's Syndrome Horner's syndrome plus arm/shoulder pain
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Paraneoplastic Syndrome
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Endocrine: -Caused by hormonal substances produced by some lung tumors (12%) -Hypercalcemia (epidermoid) -SIADH (small cell) -Gynecomastia (Large cell) -Cushing's syndrome from excess ACTH -Carcinoid syndrome from biogenic amines Hematologic: -Anemia -Polycythemia -Disseminated intravascular coaggulation (DIC) -Eosinophilia -Granulocytosis -Thrombophlebitis
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Skeletal connective tissue syndromes associated with lung ca
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Clubbing in 30%(non-small cell) Hypertrophic pulmonary osteoarthropathy in 1-10% with clubbing, pain & swelling(adenocarcinoma) Acanthosis nigricans Dermatomyositis
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Neurologic lung ca symptoms
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Cancer-associated retinopathy Encephalomyelitis Myasthenic (Eaton-Lambert) syndrome unknown cause, appears to be related to lack of acetylcholine Neuropathies Cerebellar degeneration
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CXR Findings in Lung CA Types -adenocarcinoma -squamous cell carcinoma -mesothelioma -large cell tumors
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Adenocarcinoma: Commonly produces small peripheral masses. Squamous cell carcinoma (Epidermoid): Commonly produces a hilar mass, mediastinal widening, and cavitation Mesothelioma: presents with pleural thickening Large cell tumors: Produce large peripheral masses
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Epidermoid ca
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Tumor of large, segmental, more central bronchi within pulmonary parenchyma Most closely associated with cigarette smoking in men More frequently are diagnosed by sputum cytology. Local spreading, hilar adenopathy, mediastinal widening (CXR) Metastasis occurs via lymphatic & hematogenous routes Paraneoplastic syndrome may develop, usually manifested as hypercalcemia
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Adenocarcinoma
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Arises in first- & second-order bonrchi but tends to occur more peripherally Derived from mucosal glands. Occurs more often in non-smokers & in smokers who have quit. Said to occur in association with old trauma, scars, TB & infarctions Grows more slowly than SCC or undifferentiated carcinomas & tends to have a better prognosis
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Bronchioloalveoar Carcinoma
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Variant of adenocarcinoma, arising from epithelium of distal bronchioles. (Less common type of adenocarcinoma of lung) Clinical picture & imaging mimic pneumonia Intra-alveolar spreading, infiltrates large areas of lung parenchyma Better prognosis than most other primary lung cancers.
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Small Cell Carcinoma
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Highly malignant form of neuroendocrine tumor Usually central with fast spreading in lung parenchyma & involvement of LN Very aggressive & often metastasize widely before primary tumor mass in lung reaches a large size. Occur almost exclusively in smokers Often associated with paraneoplastic syndromes from hormonal effects( Ectopic ACTH syndrome, SIADH) More amenable to chemotherapy than XRT
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Diagnosis
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Tissue needs to be obtained to confirm diagnosis of cancer. -Bronchoscopy w/ endobronchial needle aspiration, brushings & washings -CT Guided Biopsy -Open thoracotomy
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Physiologic staging of cancer
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-Assessment of pt's ability to withstand antitumor treatment -PFT's
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Staging Non-Small Cell Tumors
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T (Tumor) N (regional node involvement) M (presence or absence of distant metastasis) Above factors are taken together to define different stage groups which have different prognosis & treatment
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T1 tumor T1a T1b
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Tumor <3 cm diameter, surrounded by lung or visceral pleura without invasion more proximal than lobar bronchus T1a: Tumor 2 cm but < 3 cm in diameter
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T2 tumor T2a T2b
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Tumor > 3 cm but 2 cm distal to carina -Invades visceral pleura -Associated with atelectasis or obstructive pneumonitis extending to hilar region but not involving the entire lung T2a: Tumor > 3 cm but 5 cm but < 7 cm in diameter
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T3 tumor
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Tumor > 7 cm or directly invades any of the following chest wall(including superior sulcus tumors), phrenic nerve, mediastinal pleura, parietal pericardium -Tumor < 2 cm distal to carina but without environment of carina -Tumor with associated atelectasis or obstructive pneumonitis of entire lung -Separate tumor nodule(s) in same lobe
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T4 tumor
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Tumor of any size that invades any of the following: mediastinum, heart or great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina Separate tumor nodule(s) in a different ipsilateral lobe Tumor with malignant pleural or pericardial effusion
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Nodes : N0 and N1
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N0: No regional lymph node metastasis N1:Metastasis in ipsilateral peribronchial and/or hilar lymph node(s) and intrapulmonary node(s), including involvement by direct extensions
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N2 N3
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N2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s) N3: Metastasis in contralateral mediastinal, hilar, ipsilateral or contralateral scalene or supraclavicular lymph node(s)
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Metastasis: M0 M1 M1a M1b
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M0:No distant metastasis M1:Distant metastasis(includes tumor nodules in different lobe from primary) M1a:Separate tumor nodules in a contralateral lobe Tumor with pleural nodules or malignant pleural or pericardial effusion M1b:Distant metastasis
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Staging Small Cell Tumors
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Limited stage disease: Confined to one hemithorax & regional lymph lymph nodes Extensive disease: Involvement beyond this
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Treatment of lung cancer
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Cancer Type, Staging, & Performance status all guide treatment decisions & influence prognosis. Chemotherapy(CRx) with or without Radiation Therapy(RT) used to treat small cell lung cancer. Surgery is treatment of choice for early stage non-small cell lung cancer. Chemotherapy is the modality of choice for advanced non-small cell lung cancer.
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Treatment of non small cell tumors (1A, 1B, IIA, IIB, IIIA)
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Surgical Resection for stages 1A, 1B, IIA & IIIB Surgical Resection with complete-mediastinal LN dissection & consideration of neoadjuvant CRx for stage IIIA disease with "minimal N2 involvement" Consider postoperative RT for patients found to have N2 disease Stage IB: discussion of risk/benefits of Adjuvant CRx; not routinely given Stage IIA: Adjuvant CRx Curative potential for RT for "nonoperable patients"
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Tx for Stage IIIA with selected types of stage T3 tumors (CW invasion, Pancoast's tumor, proximal airway involvement)
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Tumors with chest wall invasion(T3):en block resection of tumor with involved chest wall and consideration of postoperative RT Superior sulcus (Pancoast's)(T3) :preoperative RT(30-45 Gy) & CRx followed by en bloc resection of involved lung & chest wall with postoperative RT Proximal airway involvement(< 2 cm from carina) without mediastinal nodes: sleeve resection if possible preserving distal normal lung or pneumonectomy
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Tx for Stage IIIB disease with carinal invasion (T4) but without N2 involvement
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Consider pneumonectomy with tracheal sleeve resection with direct reanastomosis to contralateral mainstem bronchus
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Stage IV & more advanced IIIB disease treatment
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RT to symptomatic local sites CRx for ambulatory pts Chest tube drainage of large malignant effusions Consider resections of primary tumor & mets for isolated brain or adrenal mets
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Bronchioloalveolar or Adenocarcinoma with epidermal growth factor(EGF) Receptor Mutations or ALK rearrangements treatment
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Gefitnib or erlotinib, inhibitors of RGF kinase activity Crizotinib, an alk inhibitor
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Major Contraindications to Curative Surgery
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Mets to contralateral lung Extrathoracic metastases SVC Syndrome VC & phrenic nerve paralysis Malignant pleural effusions Histological diagnosis of small cell cancer
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Carcinoid Tumors -sx -location -growth pattern -age -labs
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Symptoms are caused by action of serotonin, bradykinin, histamine produced by tumors arising from neuroendocrine cells. Carcinoid syndrome symptoms - flushing, diarrhea, bronchospasm, hypotension. Primarily found in the appendix, small bowel, rectum, bronchi, esophagus, stomach, colon, ovary, biliary tract, or pancreas Involves large bronchi & has an endobronchial growth pattern, which can fill bronchial lumina Age - most patients < 40 years Labs: Elevated 24 hour urine 5-HIAA in pts with diarrhea or malabsorption
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Imaging and tx of carcinoid lung tumors
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Imaging Studies CXR - may detect bronchial carcinoids CT scan Treatment -Surgical resection if the tumor is localized -Chemotherapy for pts with unresectable or recurrent carcinoid tumors Control of clinical manifestations -Lomotil for diarrhea -H1 and H2 receptor agonists (ie benadryl + ranitidine) for flushing -Bronchodilators (albuterol) for bronchospasm
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Metastatic Lung Cancer
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Both carcinomas & sarcomas can metastasize to lung (lymphatic, blood or direct contact) More common than primary lung neoplasms because so many primary tumors metastasize to lungs. Nodules are usually in periphery & do not cause major obstruction. Carcinomas often metastasize via lymphatics
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Malignant Mesotheliomas
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Identified today with occupational exposure to asbestos Rare, even in persons with asbestos exposure, & are virtually never seen in persons without a hx of asbestos exposure Spread diffusely over surfaces of both lungs, eventually completely encasing them in a thick rind of fibrous storm Biopsy of pleural tissue typically by thoracoscopic surgery is required for its diagnosis Poor prognosis
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Factors suggesting malignancy and need for resection of solitary nodules
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Cigarette smoking Age > 35 Relatively large(> 2 cm) lesion Lack of calcification Chest symptoms Growth of lesion compared to old CXR Prior malignancy history increases the risk
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Radiographic features suggesting malignancy of solitairy pulmonary nodules
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Absence of a benign pattern of calcification in the detected lesion A nodule or mass that is growing A nodule with a spiculated or lobulated border A larger lesion > 8mm is suspicious (>3 cm is considered malignant unless proven otherwise) A cavitary lesion that is thick walled
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Low, intermediate, and high probability pts
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Low probability patients: age under 30, lesions stable for more than 2 years, characteristic pattern of benign calcification -> watchful waiting with serial CT scans or CXR Intermediate probability patients: biopsy via bronchoscopy or CT guided biopsy High probability patients -> surgical resection (if surgical risk is acceptable).
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ddx of anterior mediastinal mass
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Thymoma Teratoma Thyroid Tumor Terrible Lymphoma mesenchymal Tumors (lipoma, fibroma).
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Middle mediastinal mass
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Structures in this location: trachea, esophagus, aortic arch & great vessels, PA, & LN. lymphadenopathy primary tumors of above structures vascular lesions duplication cysts.
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Posterior mediastinal mass
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Neurogenic masses (schwannomas or neurofibroma, neuroblastomas, ganglioneuroblastoma & ganglioneuroma)
