Lecture 11: Thoracic Neoplasms Flashcards
1
Q
What is the superior mediastinum?
A
Anything above the heart.
2
Q
What are the common etiologic masses within the anterior mediastinum?
A
- Terrible T’s (Thymoma, Teratoma, Thyroid/Parathyroid)
- Foramen of Morgagni hernia
- Mesenchymal tumors (lipoma, fibroma)
- Giant lymph node hyperplasia, lymphoma
- Germ cell tumor (seminoma/teratoma)
3
Q
What are the MC etiologic masses within the middle mediastinum?
A
- Granulomatous or metastatic LAN
- Cysts (pleuropericardial, bronchogenic, enteric)
- Masses of vascular origin (pulmonary artery enlargement, aortic aneurysm)
Grainy Central Masses
4
Q
What are the MC etiologic masses within the posterior mediastinum?
A
- Neurogenic tumors, meningocele, meningomyelocele
- Gastroenteric cysts, esophageal diverticula/tumor
- Hiatal hernia, hernia through foramen of Bochdalek
- Extramedullary hematopoiesis
Neuro = posterior mediastinum
5
Q
How are mediastinal masses usually found?
A
Incidentally in half of all cases.
Do full H&P if found!!!!!!!!
6
Q
If a mediastinal mass sits upon the sympathetic chain within the chest, what is likely to occur?
A
Horner’s syndrome
Ptosis, Anhidrosis, Miosis
Miosis is smaller than mydriasis, so miosis is pupillary constriction, while mydriasis is dilation.
7
Q
If systemic/constitutional symptoms are occurring in relation to a medistinal mass, what does that tell us about the mass?
A
Most likely malignant.
8
Q
What is the initial imaging for a suspected mediastinal mass?
A
CXR PA/Lateral
CT w/ con for f/u
9
Q
If we suspect esophageal disease, what secondary imaging should we order?
A
Barium swallow
10
Q
What is a good option for imaging for vascular etiologies?
A
CT or MR angiography or Doppler US
11
Q
What imaging modality might be best for lymphoma/malignancy?
A
PET scan/PET-CT
12
Q
What imaging modality is best to locate the origin of a germ cell tumor?
A
Testicular/ovarian US
13
Q
What tumor markers are associated with thymic tumors, germ cell tumors, or seminomas/lymphomas?
A
- Thymic: Anti-acetylcholine receptor antibodies
- Germ cell tumors: alpha-fetoprotein and beta-hCG
- Seminomas/lymphomas: serum LDH
14
Q
When a mediastinal mass is to be biopsied, what is the main concern?
A
Malignant seeding
15
Q
For a tumor sitting very close to the bronchus, what might be the best approach to biopsy it?
A
Endobronchial approach with US guidance
16
Q
For a tumor located centrally within the mediastinum, what might be the best way to biopsy it?
A
Mediastinoscopy
17
Q
What size is a pulmonary nodule?
A
<= 3cm (30mm)
18
Q
What are the characteristics of a solitary pulmonary nodule?
A
- <= 3cm
- Isolated and round opacity
- Surrounded by normal lung
- Usually benign
19
Q
What is the MC non-malignant cause of solitary pulmonary nodules?
A
Infectious granulomas caused by fungi or mycobacteria
Well-demarcated and well-calcified
20
Q
Describe a hamartoma on CXR and CT.
A
- CXR: Popcorn calcification
- CT: Areas of fat or alternating fat/calcifications
21
Q
What benign cause of SPNs should we AVOID biopsy of?
A
Pulmonary AV formations (vascular)
22
Q
How does pulmonary metastases typically present?
A
Multiple nodules.
23
Q
What are the 4 primary lung cancers that can cause SPNs?
A
- Small cell carcinoma: SCLC (centrally)
- Adenocarcinoma (peripherally)
- Squamous cell carcinoma (centrally)
- Large cell cancer (anywhere but usually peripherally)
24
Q
Where is the MC malignant cause of SPNs that present as carcinoid tumors?
A
Endobronchial
25
What are the biggest cancer risks for SPN development?
* Smoking, increasing with pack year history.
* **Increasing age past 35**.
26
What would cause us to repeat a CXR prior to doing a CT?
* Suspected nodule is a nipple shadow
* Evidence of infection
* Nodule looks like a benign lesion.
27
What is the preferred advanced imaging modality for SPN?
CT Chest w/o contrast
28
What are the 4 things that a CT scan gives us to determine malignancy risk factors?
1. Size
2. Location
3. Attenuation
4. Calcification
29
What characteristics of a nodule on CT imaging make it more suspicious for malignancy?
* Size > 20mm = 50%
* **Upper lobes = malignant**
* **Subsolid** = higher likelihood of malignancy
* Ill-defined borders, **lobular or spiculated**, with peripheral halo.
* Rapidly growing
* Sparse calcification with **stippled or eccentric patterns.**
30
What are the two subsolid nodules?
* Ground-glass
* Part-solid
31
What is considered growth of a SPN for determining malignancy?
* Solid: stable for 2 years is fine.
* Part-solid: stable for 5 years at minimum.
32
What is considered low-risk and high-risk in the SPN calculator?
* Low < 5%
* High > 60%
| Only need to calculate if size is less than 30mm.
## Footnote
Estimates the probability that a lung nodule will be diagnosed as cancerous within a 2-4 year f/u period.
33
What do we do for low-risk SPN patients?
Serial CT scanning.
34
What are the risk factors for SPN malignancy?
* Size
* Age
* Tumor Hx
* Smoking Hx
* Hx of smoking cessation
* COPD
* Asbestos exposure
* Nodule characteristics
35
What is the pattern for 4-8mm SPN on a low-risk patient?
* Starts with no risk factors = selective.
* With risk factors = the same as nodule 2mm bigger without risk factors.
## Footnote
Essentially the initial f/u time for a scan gets halved, and then it becomes more frequent until 8mm.
36
What are the options for a intermediate risk SPN patient with a central lesion?
Sputum cytology
| Highly specific test, but not sensitive.
## Footnote
AKA it can tell you with good certainty that your SPN is not malignant.
High specificity = high true negative
37
What are the surgical procedures to help determine if a SPN needs full surgery?
* Biopsy
* VATS with frozen tissue sampling.
38
What should we do if a patient has multiple pulmonary nodules?
Test each nodule individually!!!!!!!!!!!!
39
What are the 6 hallmark characteristics of a cancer cell?
* Self-sufficient growth
* Insensitive to anti-growth signals
* Evades apoptosis
* Limitless replicative potential
* Sustained angiogenesis
* Tissue invasion and metastasis
40
What parts of the lungs falls under bronchogenic carcinoma?
* Bronchi
* Bronchioles
* Alveoli
| Respiratory epithelium
41
How much does smoking cessation decrease lung cancer risk?
* 90% of the risk attributable to tobacco if you stop by middle age.
* In general, decreases 50% risk of lung cancer
42
What are the 5 criteria for **annual** lung cancer screening via low-dose CT?
1. 50-80 in good health
2. Current smoker or in past 15 years.
3. 20-year pack history (advise cessation)
4. Inform/shared decision making about pros/cons of the screening.
5. Access to a lung center that can screen and treat.
| You need all of the first 3 to qualify for testing!!!!!!!!!!!!!!!!!!!!!!
43
What are the top 3 symptoms of lung cancer?
1. Cough
2. Weight loss
3. Dyspnea
44
What are the 3 intrathoracic complications common in lung cancer?
1. Malignant pleural effusions
2. SVC syndrome
3. Pan coast tumor
45
What is the prognosis of malignant pleural effusions?
Incurable and managed palliatively.
| Need cytology of pleural fluid!
46
What type of lung cancer is most likely to cause SVC syndrome?
Small cell lung cancer (SCLC)
47
Describe the S/S of SVC syndrome.
* Head fullness
* Facial edema
* Dilated neck veins
* Prominent veins on the chest
* Pemberton's sign (Facial plethora with arm extension)
* Mediastinal widening/right hilar mass on CXR.
48
What is a pan coast tumor?
Tumor in the apex, resulting in compression of surrounding structures.
49
What are the symptoms of a pan coast tumor?
* Shoulder pain (brachial plexus)
* Horner's syndrome (sympathetic chain)
* Bone destruction (bones surrounding)
* Atrophy of hand muscles (C8, T1 nerve roots)
50
What would indicate us to do a CT chest w/ contrast for lung cancer after a CXR?
* New or enlarging lesion
* **Pleural effusion**
* **Pleural nodularity**
* **Enlarged hilar or paratracheal** nodes
* Endobronchial lesion
* Post-obstructive pneumonia
* Segmental or lobar atelectasis
51
What is the main purpose of CT and PET imaging for lung cancer?
Staging and biopsy planning.
| DOES NOT DEFINITIVELY DIAGNOSE
## Footnote
Integrated CT/PET is best for lymph node staging.
52
What cancer metastases usually elevate ALP?
Bone or liver mets.
53
What labs may be elevated in MSK paraneoplastic syndromes?
CK & ANA
54
What are the 4 MC organs that lung cancer tends to metastasize to?
* Liver
* Adrenal glands
* Bones
* Brain
55
What suggests that we have liver mets from lung cancer?
Elevated LFTs tends to be the only sign.
| Use CT w/o con or CT/PET.
56
What suggests we have bone mets from lung cancer?
* Pain in the back, chest, or extremity
* Elevated ALP
* Elevated Ca in severe cases
* Preferred imaging modality: PET
| MC in SCLC
57
If we need to check for bone mets, what is the alternative to PET and MRI?
Bone scintigraphy
58
How are most adrenal mets typically found?
Incidentally. Need a PET to differentiate if it is metastatic or not.
59
How does brain mets typically present?
* HA, vomiting, seizures
* Papilledema, visual field loss, hemiparesis, cranial/focal nerve deficit
| Need MRI w/ contrast.
60
What is the only definitive way to diagnose malignancy?
Biopsy of EVERY SINGLE NODULE YOU SUSPECT
61
How do we biopsy centrally and peripherally located lung tumors?
* Central: endobronchial US bronchoscopy
* Peripherally: Transthoracic percutaneous FNA with CT guidance.
62
What are the indications for alternative biopsy options for lung cancer?
## Footnote
Alternatives as in VATS or mediastinoscopy.
* Resection prior to biopsy results
* Inadequate specimen or undiagnosed with previous methods.
63
What are the NSCLCs?
* Adenocarcinoma
* Squamous cell carcinoma
* Large cell carcinoma
64
Describe SCLC.
* Almost exclusively in smokers.
* Small cells, rapidly growing, with early mets.
* Generally starts centrally in the bronchi.
* Often seen as a **large hilar mass with bulky mediastinal adenopathy**
| Only makes up 15% of lung cancers.
## Footnote
Smokers Catch Lung Cancer
65
Describe adenocarcinoma.
* Slow growing
* Periphery
* MC form of lung cancer in NONsmokers
## Footnote
Abstaining smokers get Adenocarcinoma
66
Describe squamous cell carcinoma.
* Center of lungs
* Smokers
| Both central lung cancers have SC in their abbreviation
67
Describe large cell carcinoma.
* Rapidly growing mass
* Anywhere, but usually periphery
68
How do I differentiate between limited and extensive SCLC?
* Limited: Ipsilateral hemithorax, with the entire thing being contained within a radiation field.
* Extensive: Overt metastatic disease. Often includes Cardiac tamponade, malignant pleural effusions, and bilateral involvement.
69
How should limited SCLC be treated vs extensive?
* Limited: Platinum based Chemo + Thoracic radiation treatment to try and **CURE** the cancer. Can also consider surgical resection per chest physicians guidelines in the text.
* Extensive: Chemo only to **CONTROL** the cancer.
## Footnote
Limited Disease includes **contralateral** supraclavicular nodes, recurrent laryngeal nerves, and SVC obstruction.
70
What is physiologic staging?
* **An assessment of a patient's ability to withstand various antitumor treatments.**
* Using PFTs and ASCVD risk calculations, along with VO2max estimates.
| Mainly for NSCLC
71
What is anatomic staging?
**Determining the location of a tumor and possible metastatic sites.**
| Mainly for NSCLC
72
What does x mean in TNM?
Cannot be assessed
73
What size is T1 for a lung cancer?
< 3cm
| Every increase goes up by 2 cm, until T4 = 7cm.
74
When does N staging include contralateral lymph nodes for lung cancer?
N3.
| Prior to this is ipsilateral only.
75
At what M stage does lung cancer include extrathoracic mets?
M1b
76
Describe stage 0 for NSCLC.
* Only finding is **malignant cells on cytology.**
* Need bronchoscopy to identify.
* Surgery is usually curative.
77
Describe stage 1 for NSCLC.
* Still no nodal or mets
* Surgery is generally the only treatment needed
* Radiation only indicated for positive surgical margins or refuses/poor candidate for surgery.
## Footnote
Positive surgical margins = still cancerous at the edges.
78
Describe stages 2 and 3 for NSCLC.
* Surgery
* Adjuvant chemo, esp if lymph nodes are involved.
* Post-op radiation for positive surgical margins, nodal involvement, or poor/refuses surgery.
79
Describe stage 4 for NSCLC.
* Distant mets
* Systemic chemo + molecular therapy +/- immunotherapy
* Palliative radiation/surgery
* Isolated mets can be excised
80
Describe the limited stage of SCLC.
* No distant mets or mediastinal disease = resection + chemo
* Evidence of disease = chemoradiotherapy
81
Describe the extensive stage of SCLC.
* Systemic chemo
* Prophylactic irradiation of the cranial and thoracic areas.
| Extension past the hemithorax
82
What is the most common abnormality seen in paraneoplastic syndrome?
* Hypercalcemia due to secretion of PTHrP by proteins and Vit D-1,25.
* Often suggests advanced disease (stage 3-4)
83
What type of lung cancer is SIADH usually associated with and what symptoms does it present with?
* SCLC.
* Symptoms are correlated with the severity of hyponatremia.
84
What is the MC neurologic paraneoplastic syndrome due to SCLC?
Lambert-Eaton myasthenic syndrome (LEMS)
85
Describe LEMS.
* Autoantibody formation impairs release of ACh.
* Requires electrodiagnostic studies and antibody testing.
* Often can precede a Dx of SCLC.
| 50% of LEMS pts have SCLC.
86
What XRAY finding is indicative of hypertrophic osteoarthropathy due to paraneoplastic syndrome?
Periosteal new bone formation
## Footnote
Clubbing of digits can appear too.
87
What are the two MSK paraneoplastic syndromes associated with lung cancer?
* Dermatomyositis
* Polymyositis
| Elevated CK and ANA
88
What lyte abnormalities does Cushing's cause?
* HypoK
* Hyperglycemia
89
When do bronchial carcinoid tumors tend to appear?
Before age 60
| Not linked to smoking!!!!!!!!
90
How does bronchial carcinoid tumors present?
* Hemoptysis
* Cough
* Focal wheezing
* Recurrent pneumonia
* Carcinoid syndrome (rare)
91
What is carcinoid syndrome?
* Flushing
* Diarrhea
* Wheezing
* Hypotension
92
What does a bronchial carcinoid tumor look like on bronchoscopy?
Central airway will show a pink/purple tumor.
| Biopsy will cause severe bleeding ):
## Footnote
Highly vascularized
93
How do we manage a bronchial carcinoid tumor?
* Observe with serial CT scans
* F/u if symptomatic, could require excision
* MC complication: tumor bleeding and airway obstructions
| Generally a good prognosis.
