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MS2 Respiratory > 9/17- Clinical Presentations of Lung Cancer > Flashcards

9/17- Clinical Presentations of Lung Cancer Flashcards

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1
Q

What are some primary tumors of the lung?

Other lung malignancies (non-lung parenchyma cells)?

A
  • Squamous cell
  • Adenocarcinoma
  • Large cell
  • Small cell
  • Other

Other lung malignancies:

  • Mesothelioma
  • Sarcoma
  • Lymphoma
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2
Q
  • Lung cancer is the __ most diagnosed cancer in men and __ in women.
  • In terms of mortality, lung cancer is the __ most fatal cancer in men and __ in women
A
  • Lung cancer is the 2nd most diagnosed cancer in men and 2nd in women.
  • In terms of mortality, lung cancer is the #1 most fatal cancer in men and #1 in women
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3
Q

T/F: Lung cancer kills more people than breast, colorectal, and prostate cancer combined

A

True

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4
Q
  • Smokers are __x more likely to develop lung cancer
  • Passive exposure?
  • Over __% of lung cancer is related to smoking
A
  • Smokers are 13x more likely to develop lung cancer
  • Passive exposure: 1.5x greater
  • Over 90% of lung cancer is related to smoking
  • Risk is decreased when you stop smoking, but takes about 20 years to come near the same level as non-smoker
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5
Q

The risk of cancer is proportional to what smoking factors?

A
  • Number of pack years
  • Age at starting
  • Depth of inhalation
  • Amount of tar
  • Less risk with cigars/pipes
  • Quitting decreases your risk (20 years to come near non-smoker, but never equal)
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6
Q

T/F: Smoking rates have stabilized in the US (no more increases)

A

False

  • Smoking is decreasing in the US
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7
Q

T/F: There are more male smokers than female

A

False

  • About 24% of women and 23% of men (currently)
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8
Q

What population has the greatest percentage of smokers?

A

Adolescents

  • Minorities and youth
  • Increasing problem in 3rd world countries
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9
Q

What are non-smoking risk factors for cancer (occupational carcinogens)?

What proportion of lung cancers are due to these occupational exposures?

A

9-15% of lung cancers are due to occupational exposures

  • Asbestos
  • Arsenic
  • Bis(cholormethyl)ether
  • Chromium
  • Coke oven emissions
  • Iron and steel founding
  • Mustard gas
  • Nickel compounds
  • Radiation
  • Vinyl chloride

Suspected (not proven):

  • Be
  • Cd
  • Crystalline silica
  • Fibrous glass
  • Formaldehyde
  • Welding fumes
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10
Q

When is the peak incidence for asbestos-related cancer?

A

Peak 30-35 years after initial exposure

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11
Q

T/F: The risks of smoking and asbestos exposure is additive

A

False; multiplicative (not just independent)

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12
Q

What are other environmental risk factors for lung cancer?

A

Air pollution

  • Indoor air pollution (developing world with cooking fuels): as bad as smoking!
  • Atmospheric air pollution: urban effect (weak association)

Radiation

  • Radiation that is a risk for lung cancer is the high-dose stuff involved in atomic bomb… not really x-rays and whatnot
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13
Q

What diets may effect lung cancer development?

A

Diet high in antioxidant nutrients may protect against oxidative DNA damage and protect against cancer

  • Weak evidence showing protection with high fruit intake; better with increased veggies
  • Dietary retinol may reduce risk
  • Better evidence for carotenoids and vitamin C (Need to take them in naturally, not supplements)
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14
Q

Why do a minority of exposed persons with the mentioned environmental agents not get lung cancer?

A

Host factors

  • Familial aggregation seen in case-control studies after being controlled for smoking
  • Genetic factors may play a role in many stages of the multi-stage model of lung cancer development
  • Previous acquired lung diseases: COPD and fibrotic lung disease (asbestosis)
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15
Q

Explain how lung cancer is a “multi-hit” problem

A

Body has many natural protective factors; tumor development requires:

  • Persistence/miscoding
  • Activation of dominant oncogenes
  • Inactivation of tumor suppressors
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16
Q

What are the big (2) divisions of lung cancer types?

Subtypes? Percentages?

A

Non-small cell carcinomas ~ 70% (other lecture said 80%)

  • Squamous
  • Adenocarcinoma
  • Large cell

Small cell carcinoma ~25% (other lecture said 20%): aka “oat-cell”

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17
Q

When is lung cancer commonly discovered? Peak?

A
  • Majority between 35-75 years
  • Peak = 60 yo
  • 5-15% asymptomatic at diagnosis (detected through screening or incidentally by imaging done for other reasons)
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18
Q

T/F: Lung cancer normally presents like other diseases (non-specifically) with things like dyspnea, cough…

A

False; commonly asymptomatic

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19
Q

What is a solitary pulmonary nodule?

A
  • Solitary pulmonary nodule = “coin lesion”
  • Spherical mass surrounded by lung parenchyma
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20
Q

What is the differential for a solitary pulmonary nodule (SPN)?

  • Malignant
  • Benign
A

Large differential (benign -> malignant)

Malignant:

  • Bronchogenic cancer
  • Metastasis: breast, head/neck, colon, kidney, germ cell
  • Bronchial carcinoid
  • Other

Benign:

  • Infectious granuloma: TB, Histo, Cocci
  • Hamartoma
  • Wegener’s
  • Rheumatoid nodule
  • A-V malformation
  • Pulmonary infarction
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21
Q

What are certain features of solitary pulmonary nodules that help distinguish between benign and malignant?

A

More commonly malignant if:

  • Very large
  • Irregular margin
  • Intermediate doubling time (30-490 days)

Less commonly malignant if:

  • More calcified
  • Fat present (hamartoma)
  • Doubling time under 30 or > 490 days
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22
Q

What is seen here?

A

Benign nodule (probably… can’t depend only on appearance)

  • Smooth boundary
  • Calcification
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23
Q

What should be the next step for a mass found in a high risk patient?

A

Removal!

  • Get diagnosis at the same time… but don’t waste time getting biopsy
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24
Q

What should be the next step for mass in intermediately-risky patient?

A
  • Wait and watch
  • Can do a PET scan (lights up metabolically active cells)
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25
What are signs and symptoms of lung cancer (assuming pt isn't asymptomatic)- broadly?
**Constitutional symptoms**: important prognostic implications regardless of "stage" of disease - Weight loss (may be 1st seen) - Fatigue - Anorexia - Weakness
26
What are some symptoms/signs related to primary tumor?
- **Cough**: most common - **Dyspnea**: 60% of pts (so not too common; think, 2 cm tumor not affecting lung function too much) - **Hemoptysis**: rarely severe (esp if peripheral tumor- not gonna happen) - **Wheeze and stridor** (if obstructing airway) - **Post-obstructive pneumonia** symptoms (pneumonia distal to tumor and cant clear, so pneumonia symptoms that persist) - **Chest discomfort**: common, up to 50%, ill-defined
27
What are some signs/symptoms related to intrathoracic spread?
- **Tracheal obstruction** - **Dysphagia** due to esophageal compression - **Hoarseness** due to recurrent laryngeal nerve palsy; more on left side - **Phrenic nerve paralysis** (elevated hemi-diaphragm and dyspnea) - **Sympathetic nerve paralysis (Horner** syndrome) - **Pancoast syndrome** - **Superior vena cava syndrome**
28
What is Horner's syndrome? Symptoms/what causes it
- Involvement of **sympathetic chain** at the **thoracic inlet** at the **apex** of the lung _Syndrome:_ - Enophthalmos - **Ipsilateral anhydrosis** (no sympathetic innervation of sweat glands) - **Ptosis** (droopy eyelid b/c sympathetics innervate superior tarsal muscle that elevate eyelid?) - **Miosis** (constricted pupils; sympathetics normally work on dilator muscle to dilate eye)
29
What is Pancoast syndrome?
- From **local extension** of tumor at **apex** of lung. - Usual cause of Horner’s syndrome - Also **shoulder pain** that **radiates in ulnar distribution**
30
What is Superior Vena Cava Syndrome? - Common cause - Mechanism - Signs/symptoms
_Most common cause_: lung cancer _Mechanism_: compression of the thin walled vessel -\> obstructed drainage of the upper thorax, head, and neck _Signs and symptoms:_ - Swelling and plethora of the head and neck - Distended venous collaterals - Epistaxis - Headache - Confusion, and even coma
31
What are malignant pleural effusions? - Causes - Characteristics
_Either:_ - Secondary to tumor involvement of the pleura - Paramalignant (due to tumor involvement elsewhere) - Unrelated to lung cancer, i.e. coincident process _Characteristics of malignant effusion:_ - Typ **moderate - large** effusion - May be **bloody** - **Lymphocytes** predominate - **Low pH and glucose** predict **shorter survival**
32
What are symptoms related to extra-thoracic spread?
**- Bone:** Bone pain present in up to 25% at initial presentation **- Liver, Adrenals:** Usually normal LFTs until late; produce weakness and weight loss **- Brain and spine:** 10% of patients at presentation have intracranial mets, headache, nausea, vomiting
33
What are paraneoplastic syndromes (broadly)?
- Abnormalities due to production of substances by the tumor - Occur in ~ 10% of pts with lung cancer - Not related to extent of disease and can precede lung cancer diagnosis - Often relieved with successful treatment of the tumor
34
What are common specific paraneoplastic syndromes? **- Endocrine** - Neurologic-myopathic - Vascular - Skeletal - Dermatologic - Hematologic
_Endocrine (most common)_ - Ectopic ACTH - Hypercalcemia - SIADH - Acromegaly - Gynecomastia
35
What are common specific paraneoplastic syndromes? - Endocrine **- Neurologic-myopathic** - Vascular - Skeletal - Dermatologic - Hematologic
_Neurologic- myopathic (1%)_ - Eaton Lambert Syndrome - Retinal Blindness - Subacute Cerebellar Degeneration - Polymyositis Vascular - Trausseau's syndrome
36
What are common specific paraneoplastic syndromes? - Endocrine - Neurologic-myopathic **- Vascular** - Skeletal - Dermatologic - Hematologic
_Vascular_ - Trausseau's syndrome
37
What are common specific paraneoplastic syndromes? - Endocrine - Neurologic-myopathic - Vascular **- Skeletal** - Dermatologic - Hematologic
_Skeletal_ - Clubbing (30%) - Pulmonary Hypertrophic Osteoarthropathy
38
What are common specific paraneoplastic syndromes? - Endocrine - Neurologic-myopathic - Vascular - Skeletal **- Dermatologic** - Hematologic
_Dermatologic_ - Acanthoses Nigricans
39
What are common specific paraneoplastic syndromes? - Endocrine - Neurologic-myopathic - Vascular - Skeletal - Dermatologic - **Hematologic**
_Hematologic_ - Anemia - Leukemoid reaction (elevated WBCs without identifiable cause)
40
What are common specific paraneoplastic syndromes? ALL TOGETHER NOW - Endocrine - Neurologic-myopathic - Vascular - Skeletal - Dermatologic - Hematologic
_Endocrine (most common)_ - Ectopic ACTH - Hypercalcemia - SIADH - Acromegaly - Gynecomastia _Neurologic- myopathic (1%)_ - Eaton Lambert Syndrome - Retinal Blindness - Subacute Cerebellar Degeneration - Polymyositis Vascular - Trausseau's syndrome _Skeletal_ - Clubbing (30%) - Pulmonary Hypertrophic Osteoarthropathy _Dermatologic_ - Acanthoses Nigricans _Hematologic_ - Anemia - Leukemoid reaction (elevated WBCs without identifiable cause)
41
What causes ectopic ACTH paraneoplastic syndromes?
Typ **small** cell carcinoma - More electrolyte disturbances than frank Cushing's syndrome
42
What causes hypercalcemia paraneoplastic syndrome?
**Squamous** cell carcinoma (only endocrine one that is not small cell!!) - Due to bony metastasis (osteolysis), production of PTH-like substances or PGE2
43
What causes SIADH paraneoplastic syndrome?
(Syndrome of inappropriate antidiuretic hormone) More in **small** cell carcinoma - Hyponatremia with inappropriately concentrated osmolality
44
Describe Eaton Lambert paraneoplastic syndrome?
- Presents with weakness, fatigability, and aching (similar to myasthenia gravis) - Differs from MG in that muscle strength gets better with repetitive exercise - Due to development of anti-voltage-gated calcium channel antibodies - More with SMALL CELL
45
What lung cancer is most commonly associated with retinal blindness?
Small cell carcinoma
46
What is Trousseau's Syndrome?
Vascular paraneoplastic syndrome - Migratory recurrent thrombophlebitis
47
What is Pulmonary Hypertrophic Osteoarthropathy (PHO)?
Skeletal paraneoplastic syndrome - Sub-periosteal new bone formation in distal joints/bones with edema and pain
48
What is acanthoses nigricans?
Dermatologic paraneoplastic syndrome - Hyperpigmented/hypertrophic skin - Usually in the axilla, intertriginous areas, neck
49
What is seen here?
Mass way up in apex; Pancoast
50
What is seen here?
Looks like pneumonia
51
In what ways can lung cancer look like pneumonia on CXR?
- **Obstructive pneumonia** (pneumonia distal to mass) - **Bronchoalveolar** subtype of **adenocarcinoma** (just looks like pneumonia on CXR)
52
What is seen here?
- Pleural effusion - Tumor encroaching into heart, mediastinum...
53
Use contrast or not to find met in brain?
Use contrast
54
Bone scan done to pick up what?
Bone metastases - PET scan used more commonly
55
What is seen here?
PET scan - Bright = high metabolic activity - PET scan looks at entire body
56
What are some diagnostic techniques for lung cancer?
- Sputum cytology (if pt coughing up blood) - Superficial lymph node or mass biopsy - Thoracentesis (if pt has pleural effusion) - Transthoracic needle aspiration (if tumor very close to chest wall) - Bronchoscopy - Endobronchial Ultrasound/Mediastinoscopy - Exploratory thoracotomy, VATS
57
What is the staging system for small cell tumors?
**Limited disease (30%)**- disease confined to one hemithorax and regional LNs (1 radiation portal) **Extensive disease (70%)**- disease beyond the hemithorax
58
What is the prognosis for small cell lung cancer?
Very **aggressive**; commonly diagnosed in extensive stage If untreated, median survival is: - **Limited** disease: **12 wks** - **Extensive** disease: **5-7 wks** This tumor is sensitive to CTX
59
What is the staging for non-small cell cancer?
**TNM Classification:** - T (primary tumor): T0-T4 - N (lymph node): N0-N3 - M (distant metastasis): M0-M1
60
On what does treatment of lung cancer depend?
- Cell-**type** (small vs. non-small; adeno vs. squamous) - **Stage** of tumor - **Resectability** of tumor - Patient's "**operability**" status: **FEV1**, other co-morbidities - Performance status
61
What is the treatment for **small** cell lung cancer?
**Chemo +/- radiation** _Stages:_ - **IA, IB**: surgical resection/curative radiation if nonoperable - **IIA, IIB**: surgical resection and adjuvant chemo - **some IIIA**: surgical resection and consideration fo neoadjuvant chemo and postop radiation - **IIIA, IIIB**: combined chemo/radiation - **IV**: symptomatic thearpy; palliative chemo if good performance status
62
What is the treatment for **non small** cell lung cancer?
- Defined by stage AND functional status, other medical problems - Surgery is mainstay - Radiation +/- chemo if surgery is not an option _STAGES:_ - **IA, IB**: surgical resection/curative XRT if non-operable - **IIA, IIB**: surgical resection + adjuvant chemo - **Some IIIA**: surgical resection and consideration of neoadjuvant chemo and postop radiation - **IIIA, IIIB**: combo chem/radiation - **IV**: symptomatic therapy; palliative chemo if good performance status
63
What are some contraindications to surgery?
- Advanced stage disease: extra-thoracic metastases, superior vena cava syndrome, malignant pleural effusion - Poor operability: recent MI, major arrhythmias ---- Poor FEV1 status
64
What does the prognosis of lung cancer depend on?
- Stage (most important!) - Cell type - Therapeutic options - Performance status
65
Screening guidelines for lung cancer?
New guidelines recommend screening with low dose CT scanning in high risk pts (20 pack years?)
66
What is mesothelioma? - Affects what tissue - Associated with what - Timeline - Prognosis
- Malignancy of pleura - Strong association with asbestos exposure - Latency of 35-40 yrs - Very poor prognosis with mortality within 12 mo
67
What tumors frequently metastasize to the lung?
- Breast - Thyroid - Germ-cell tumors - Renal cell carcinoma - Colon carcinoma - Melanoma
68
What are patterns of metastases in the lung?
- Solitary lung mass - Multiple lung masses (most common) - Lymphangitic spread
69
What are common benign lung masses?
Benign lung masses = under 5% of primary tumors _90% of benign lung tumors are either:_ - Hamartomas - Bronchial adenomas
70
What is a hamartoma?
- Contains normal pulmonary tissue elements in a disorganized fashion (muscle and collagen) - Peripheral, silent - Popcorn calcification
71
What is a bronchial adenoma?
- Mainly slow-growing endobronchial masses - Carcinoid is a type of neuroendocrine mass - Usually diagnosed with bronchoscopy - Bleed easily - Should be resected

MS2 Respiratory (26 decks)

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