Lung Cancer - Clinical Aspects

Question 1

Lung cancer - how lethal is it? How common is it?

Answer 1

#1 cause of cancer death.
#2 most common cancer in both women and men (behind breast and prostate cancer)

Question 2

Does COPD increase the risk for lung cancer, independently of smoking?

Answer 2

Yes. Might be due to PMN-derived free radicals, decreased clearance of carcinogens.

Question 3

What are some risk factors for lung cancer other than smoking (and COPD)?

Answer 3

Asbestos exposure.
Radon.
Fine particulate air pollution.
2nd hand smoke.
Increased age...

Question 4

Is lung cancer more common in men than in women?

Answer 4

No. It’s very common in women.

Question 5

Can asymptomatic lung cancer be cured?

Answer 5

Yes, but it’s hard to screen for.

Question 6

What’s the prognosis for symptomatic lung cancer?

Answer 6

Poor.

Question 7

Sentinal lymph nodes for lung cancer?

Answer 7

Mediastinal and supraclavicular nodes

Question 8

What’s a place to which lung cancer commonly metastasizes that is uncommon in other cancers?

Answer 8

Adrenal glands.

Question 9

Is COPD associated with clubbing?

Answer 9

No. 20% of patients with lung cancer have clubbing, so if you see it in a patient, look into it. (and definitely don’t write it off as COPD)

Question 10

What’s the problem with screening for lung cancer?

Answer 10

You can pick up early lung cancer with HRCT - one recent study showed a 20% reduction in lung cancer mortality.
But… 39% of patients had positive findings, 96% of which were false positives. That’s a lot of money, testing, anxiety, radiation, etc. etc. etc.

Question 11

What’s the definition of a solitary pulmonary nodule (SPN)?

Significance?

Answer 11

A round lesion < 3cm, surrounded by lung.
(lesions < 1cm can be important, but only about 1% will be malignant)
The likelihood of a SPN being cancer depends on the patient population and size.

Question 12

Usefulness of looking at old chest films when you see a suspicious lesion?

Answer 12

Cancers usually grow.

Question 13

Which is a reliable sign that an SPN is benign?

a. No growth over 1 month.
b. Patient is a never-smoker.
c. Lesion is only 1cm.
d. None of the above

Answer 13

None of the above.

Question 14

Thoracic CT can detect mediastinal adenopathy of lung cancer with sensitivity and specificity around 70-80%. What’s an example of a false negative?
Of a false positive?

Answer 14

False negatives: small tumor-bearing nodes.

False positives: enlarged inflammatory nodes.

Question 15

When is sputum cytology most useful?

Answer 15

When the lesion is central, squamous cell, or something causing hemoptysis.
(stuff near the airways)
(seldom used these days for diagnosis)

Question 16

Utility of bronchoscopy?

Answer 16

Can directly visualize lesions.
Can sample with washing, brushings, and biopsy.
Can do a transbronchial needle aspiration of mediastinum (which is cool).

Question 17

When should a transthoracic needle biopsy be done?

or not done?

Answer 17

You don’t need to do it in good surgical candidates with a growing mass.
But in patients unfit for surgery, useful to confirm Dx before doing radiation therapy.

Question 18

How do you check the body for mets?

Answer 18

PET scan - including liver and adrenals.

MRI with gadolinium for brain.

Question 19

What does a PET scan light up?

Answer 19

Anything that’s metabolically active - so both tumors, and inflammatory lesions.

Question 20

At least whole lobe removed = generally better outcomes cancer-wise. What determines how much lung you can take out in surgery? Give 3 categories.

Answer 20

PFTs - specifically FEV1.
FEV1 > 2 liters: can take out whole lung.
FEV1 of 1-2 liters: lobectomy… refine risk with other studies.
FEV1 < 1 liter: segmentectomy… or just radiation therapy.

Question 21

When would you do invasive mediastinal sampling?

Answer 21

When a patient is a borderline surgical candidate, adenopathy is suggested with imaging, and proof of nodal involvement would change management.

Question 22

Current utility of chemotherapy in lung cancer?

Answer 22

Limited to use as adjuvant, but not very effective.
Except when the tumor’s driven by EGFR mutation, in which case chemo works better.
(and there are some specific therapies coming out)

Question 23

What are the characteristics that allow you to call a minimally invasive adenocarcinoma “in situ”?

Answer 23

Pure lepidic growth (along alveolar surface).

No invasion of basement membrane.

Question 24

What’s the first dichotomy in lung cancer types that an oncologist would care about?
Why?

Answer 24

Small cell vs. non-small cell lung cancer (NSCLC).

This guides treatment - small cell gets chemo, NSCLC gets surgery/radiation.

Question 25

3 main types of non-small cell lung cancer (NSCLC)?

Answer 25

Adenocarcinoma.
Squamous cell.
Large cell.

Question 26

Prognosis for small cell vs. NSCLC?

Answer 26

Small cell always has pretty poor prognosis, even if caught early-ish.
NSCLC has better prognosis if caught at Stage 1 or 2… but that’s hard to do.