Lecture 10: Cancers of the Respiratory System

Question 1

Based on what concept why must the entire area be investigated when a malignancy is identified in the head or neck area?

Answer 1

“Field cancerization” - entire upper aerodigestive tract is exposed to carcinogens so multiple malignancies are common

Question 2

What is trismus and why must this be investigated?

Answer 2

Inability to open the jaw from compression of the trigeminal n. or muscle invasion by a tumor

Question 3

When does ear pain need further evaluation?

Answer 3

If not responding to conventional tx

Question 4

Which patient complain related to the upper GI tract needs prompt investigation?

Answer 4

ANY complaint of difficulty swallowing or intermittent choking

Question 5

What are the 3 tx’s commonly used for head and neck cancers that are locally or regionally advanced disease which make it multimodal?

Answer 5

• Radiotherapy + Systemic therapy (chemotherapy)
• Surgery

Question 6

What are 2 options for patients who have undergone a laryngectomy so that that they are able to speak?

Answer 6

• Electrolarynx –> placed in submandibular region; vibrates at constant pitch
• “Talking” tracheostomy –> provide a set of synthetic“vocal cords” to allow partial speech

Question 7

HPV-related tumors of the head/neck typically present with what as the first sign?

Answer 7

Neck lymphadenopathy

Question 8

Which imaging modalities are utilized to identify the extent of head/neck cancers; which modality is used to identify or exclude distant metastases?

Answer 8

• CT of the head and neck to identify extent of the disease
• PET scan can help identify or exlude distant metastases

Question 9

What is the definitive stage procedure for head/neck malignancies?

Answer 9

Endoscopic examination under anesthesia (i.e., laryngoscopy, esophagoscopy, and bronchoscopy); obtaining multiple biopsy samples

Question 10

Head and neck cancers are classified with what system?

Answer 10

TNM system

Question 11

In patients with lymph node involvement and no visible primary tumor of the head and neck, how should diagnosis be made?

Answer 11

Lymph node excision

Question 12

If results of a LN biopsy indicate SCC, what should be performed?

Answer 12

Panendoscopy, with biopsy of all suspicious-appearing areas and directed biopsies of common primary sites, such as nasopharynx, tonsil, tongue base, and pyriform sinus

Question 13

What is the preferred tx for laryngeal cancer as to preserve voice function?

Answer 13

Radiation therapy

Question 14

What is the preferred tx for small lesions/malignancies in the oral cavity?

Answer 14

Surgery, as to avoid long-term complications of radiation, such as xerostomia and dental-decay

Question 15

Most recurrences of head and neck cancer happen in what time frame and are often what?

Answer 15

Within the first 2 years following diagnosis and are usually local

Question 16

Pts with recurrent or metastatic disease are typically treated how?

Answer 16

With palliative intent; typically with chemotherapy for transient symptomatic benefit

Question 17

The addition of which drug to standard combination chemotherapy with cisplatin or carboplatin and 5-FU has shown to result in significant increase in median survival?

Answer 17

Cetuximab (EGFR-directed therapy)

Question 18

About 50% of patients who undergo tx for head/neck cancer develop decreased function of what organ?

Answer 18

HYPOthyroidism; thus, thyroid function should be monitored

Question 19

Distention of superficial veins and edema of the head and neck is characteristic of what paraneoplastic process of lung cancer?

Answer 19

SVC syndrome

Question 20

What is a good starting point for imaging of lung cancer?

Answer 20

CXR

Question 21

Following a CXR what is the most commonly performed test to further evaluate findings suspicious for bronchogenic carcinoma of the lung?

Answer 21

CT scan

Question 22

Which imaging modality when fused with CT gives higher predicatbility for cancer vs. benign disease?

Answer 22

PET scan

Question 23

Which imaging modality allows for visualization of the upper airway as well as mainstem, segmental, and some subsegmental bronchi?

Answer 23

Bronchoscopy

Question 24

Which diagnostic procedure is required for any patient in whom curative resection of lung cancer is considered?

Answer 24

Bronchoscopy

Question 25

What is the procedure of choice for peripheral lung lesions and has an accuracy of about 90%?

Answer 25

Fine needle aspiration (FNA) done w/ either plain radiographic or CT guidance

Question 26

What is a complication which may arise with fine needle aspiration?

Answer 26

Pneumothorax

Question 27

What is the recommended screening test for pt with high-risk of lung cancer?

Answer 27

Low-dose spiral CT

Question 28

Which patients should be considered for low-dose CT screening for lung cancer?

Answer 28

• 55-80 y/o who have a ≥30-pack-year smoking hx either as current smoker

or

• Former smokers who have quit within the past 15 years

Question 29

Hypercalcemia as a paraneoplastic process is most common with which lung cancers?

Answer 29

Adenocarcinoma or Squamous cell carcinoma

Question 30

Hypertrophic pulmonary osteoarthropathy is most common with what lung cancer?

Answer 30

Adenocarcinoma

Question 31

What is the best approach for histological confirmation in a pt with a lung mass in the setting of weight loss and unilateral supraclavicular LN enlargement?

Answer 31

Peripheral node biopsy; allows for diagnosis and staging

Question 32

Which diagnostic method for lung cancer is reserved for pt’s with poor pulmonary function who cannot tolerate invasive procedures?

Answer 32

Sputum cytology

Question 33

Which imaging modality may be indicated if pt has bone pain or an elevated serum Ca²⁺ or AlkPhos?

Answer 33

Bone scan

Question 34

What are 2 features which define benign pulmonary nodules?

Answer 34

1) No growth in 2 years

AND

2) Calcification in a diffuse, central, or laminar pattern

Question 35

What is the size, morphology, and location characteristic of malignant pulmonary nodules?

Answer 35

>2 cm w/ spiculated edges and located in the upper lobes

Question 36

What is the best strategy in patients with incidentally discovered pulmonary nodules?

Answer 36

Obtain prior CXR’s or imaging scans to determine stability over time

Question 37

What is the recommendation for incidentally discovered pulmonary nodules <4cm in pt who have never smoked and who have no other known risk factors for malignancy?

Answer 37

No follow-up recommended

Question 38

Which size pulmonary nodule requires follow-up at an interval determined by whether the patient is considered to be at high or low risk for malignany?

Answer 38

Nodules >4cm

Question 39

What is the recommendation for pt’s with solid pulmonary nodules ≥1.5 - 2 cm who are considered high-risk or low-risk?

Answer 39

Immediate biopsy; close interval CT scanning is option in low-risk pt’s

Question 40

What is the mainstay of tx for pt’s with stage I or II non-small cell lung cancer?

Answer 40

Surgery; adjuvant chemotherapy for pt’s with more advanced disesase

Question 41

What is the superior tx for pt’s with unresectable non-small cell lung cancer?

Answer 41

Chemo-radiation

Question 42

What is the tx of choice for small-cell lung cancer?

Answer 42

- Combination chemotherapy w/ platinum based agent (i.e., cisplatin) and etoposide is mainstay

- Radiation is given concurrently or sequentially

Question 43

Which tx should be used for airway obstruction or SVC syndrome?

Answer 43

Thoracic radiation

Question 44

What drug can be given to pt’s with brain metastases to decrease intracranial edema?

Answer 44

Glucocorticoids