Pulm nodules/cancer

Question 1

Pulmonary Nodules

general

Answer 1

Small, discrete lesions(< 3 cm (30 mm) in diameter) completely surrounded by pulmonary parenchyma
Often foundincidentally on imaging of the chest or during lung cancer screening
Single or multiple nodules
Multiple nodules are usually the result of metastasis

Nodules are often confused with non-pulmonary soft-tissue densities
Nipple shadows, cutaneous nodules, and bone abnormalities

Lesions > 30 mm are classified as a mass → increased likelihood of malignancy

Question 2

Evaluation of Pulmonary Nodules

Answer 2

Primary goal is to detect cancer and active infection
History – suggesting malignant and nonmalignant causes
Current or past smoking
History of cancer
History of an autoimmune disorder
Occupational exposure risk (asbestos, vinyl chloride, radon)
Travel to or living in areas with endemic mycosis or tuberculosis
Risk factors for opportunistic infections (HIV, immune deficiency)

Physical examination
Complete physical examination looking for an etiology

Example: breast lump or a skin lesion found on physical examination

Question 3

nodule

Benign/Malignant nodule etiology

Answer 3

Benign
Granulomatous infection (blastomycosis, histoplasmosis, tuberculosis)
Benign tumor (lipoma, fibroma, hamartoma)
Vascular lesion (pulmonary arteriovenous malformation)
Inflammatory lesion (rheumatoid nodules, sarcoidosis)
Infection (bacterial abscess, aspergillosis)

Malignant
Primary lung cancer (adenocarcinoma, squamous cell carcinoma)
Lung metastases (melanoma, sarcoma, carcinomas of the breast, colon, kidneys, testicles)
Carcinoid tumor

Question 4

Nodules

Cxr and CT
Calcification
Diameter
Border
Location

Answer 4

Estimate the malignant potential of the pulmonary nodule
Chest x-ray followed by CT scan
Radiographic characteristics of nodules
Growth rate
Comparison with previous imaging
Lesion that have not enlarged in ≥ 2 years → benign lesion
Attenuation (density)…more on the next slide

Calcification
Suggest a benign lesion
Pattern of calcification:
Central, diffuse, laminated, and popcorn – benign
Punctate, eccentric, amorphous – possibly malignant

Margins
Spiculated or irregular (scalloped) → malignant lesion
Regular, well-defined → benign lesion

Diameter
Risk of malignancy increases with increasing diameter
≤ 8 mm → benign lesions

Location
Upper lobe nodules carry a higher risk of malignancy

Cancerous nodules often double in size every 25 days to 4 months
Spiculation is due to growth of malignant cells along the pulmonary interstitium

Question 5

Answer 5

left has one nodule
(1 on bottom is lesslikely to be cancer)

Question 6

Nodule

Imaging Attenuation

Answer 6

Nodule density
Solid
More common

Sub-solid
Increasing incidence due to rising incidence of adenocarcinoma worldwide
Part-solid have a higher likelihood of being malignant
Pure ground glass can correspond to benign, very slow-evolving lesions or invasive adenocarcinoma

Question 7

Question 8

nodules

Quantitative Predictive Models

Answer 8

Combine clinical and imaging features to estimate the probability of malignancy

Most useful for nodules measuring 8-30 mm
Help to guide management choices
Mayo Clinic Model
https://www.mdcalc.com/solitary-pulmonary-nodule-spn-malignancy-risk-score-mayo-clinic-model
Six independent predictors:
Older age, smoking history, history of cancer, nodule diameter, spiculation, and upper lobe location

Question 9

Quantitative Predictive Models

Six independent predictors

Answer 9

Six independent predictors:
1. Older age
2. smoking history
3. history of cancer
4. nodule diameter
5. spiculation
6. upper lobe location

Question 10

Question 11

Management of Solid Pulmonary Nodules

Answer 11

Fleischner Society Guidelines for Incidental Pulmonary Nodules
https://www.mdcalc.com/fleischner-society-guidelines-incidental-pulmonary-nodules

> 6 mm
Assess likelihood of malignancy (clinically or quantitative predictive model)
Low – no further evaluation
Intermediate or high – chest CT scan at 12 months

6-8 mm
Chest CT scan at 6-12 months

> 8 mm
Assess likelihood of malignancy (clinically or quantitative predictive model)
Low – chest CT at 3 months
Intermediate or high-risk nodule → PET/CT, biopsy, or resection

Question 12

Lung carcinoma

General

Answer 12

Uncontrolled division of epithelial cells lining the respiratory tract (malignant transformation)
Leading cause of cancer-related death in the United States
230,000 new cases annually in the United States
90% of cases are fatal

Incidence increases with age:
Rare under 50 years old
Peak incidence: 75–79 years
85–90% of lung cancer cases are attributed to smoking

Question 13

luung carcinoma

RF

Answer 13

Smoking (most common)
Increased risk related to the number of pack-years
Increased risk with low intensity smoking over a longer period

Environmental exposures:
Secondhand smoke
Exposure to carcinogens: Asbestos, Radon, Chromium, Nickel, Arsenic, Polycyclic aromatic hydrocarbons

Radiation treatment – the number CT scans matters!

Lung disease: (Chronic inflammation)
Idiopathic pulmonary fibrosis
Alpha-1 antitrypsin deficiency
Chronic obstructive pulmonary disease (COPD)

HIV infection
Family history
Alcohol consumption

Risk associated with electronic nicotine delivery systems remains to be determined

Cancer risk declines with smoking cessation, but never returns to the baseline risk in never-smokers; greatest benefit is seen in those who quit by 30-years-old

Question 14

pack year

Answer 14

pack-year = number of packs smoked/day x years of smoking

Question 15

lung carcinoma

classification

Answer 15

Majorhistologic typesof lung cancer:
Non-small cell lung carcinoma (NSCLC) - 85% of all lung cancers
40% have metastatic disease to the time of diagnosis
Subtypes:
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

Small cell lung carcinoma (SCLC) - 15% of all lung cancers
Highly aggressive
80% have metastatic disease at the time of diagnosis
Almost always occurs in smokers

Small cell lung cancer…small, but mighty!
Small in number, but highly aggressive

Question 16

lung carcinoma

Patho

Answer 16

Exposure to carcinogens → driver of acquired oncogenic mutations (mutations responsible for initiation and maintenance of the cancer)

Question 17

Adenocarcinoma
Location

Answer 17

Most common: 40–50% of lung cancers
Location: peripheral; arises from cells that line the alveoli and produce mucus

Question 18

Squamous cell carcinoma

Answer 18

~20% of lung cancers
Location:central; arises from squamous cell that line the proximal tracheobronchial tree

Question 19

Large cell carcinoma
Location

Answer 19

2% of lung cancers
Location: peripheral or central

Question 20

Small cell lung carcinoma
Location

Answer 20

About 15% of all lung cancers
Location: central; usually begins in themain bronchi

DEADLY

Question 21

paraneoplastic syndrome

Answer 21

Set of signs and symptoms that can occur when there is an underlying cancer
Commonly occur in people withlung, ovarian, lymphatic, or breast cancer

Some lung cancer secrete hormones = paraneoplastic syndrome

Question 22

paraneoplastic syndrome

Small cell carcinoma

Answer 22

Small cell carcinoma can secrete adrenocorticotropic hormone (ACTH)
Release of cortisol from the adrenal glands = Cushing syndrome (high blood glucose, high blood pressure, hyponatremia)

Small cell carcinoma can secrete antidiuretic hormone (ADH)
Water retention; patient will have edema, increase blood pressure, and concentrated urine

Question 23

paraneoplastic syndrome

Large cell carcinoma secretes what hormone

Answer 23

Large cell carcinoma can secrete beta-human chorionic gonadotropin(HCG)

Question 24

paraneoplastic syndrome

Squamous cell carcinoma releases what hormone?

Answer 24

Squamous cell carcinoma can secrete parathyroid hormone

Depletion of calcium from the bone causing them to be brittle; increased calcium in the blood

Question 25

Lung cancer

Clin man

Answer 25

Asymptomatic ~25% of patients
General symptoms

Cough (most common):
New-onset cough in a smoker or former smoker
Frequent symptom in squamous and small cell cancers due to central location
May have hemoptysis (more significant invasion)

Dyspnea due to malignancy-related:
Airway obstruction
Atelectasis
Pleural effusion
Pneumothorax

Chest pain:
Vague
Localized
Pleuritic

Fatigue
Anemia

Cancer cachexia: (typically seen in metastisis pts)
Loss of muscle mass and fat
Weight loss
Anorexia

Question 26

Lung cancer

Regional spread of laryngeal nerve, phrenic nerve, esophagus, blood vessels

Answer 26

Recurrent laryngeal nerve encroachment:
Hoarseness

Phrenic nerve encroachment:
Diaphragmatic paralysis (elevated diaphragm)
Dyspnea
Hypoxia

Esophageal compression: dysphagia

Invasion of a blood vessel: hemoptysis

Question 27

Lung cancer

Regional spread to
Superior vena cava (SVC)

Answer 27

Regional spread
Superior vena cava (SVC) syndrome:
SCLC > NSCLC
Compression or invasion of the SVC leading to:
Headache
Head fullness
Facial & upper extremity swelling
Orthopnea
Dilated neck, face, and trunk veins
Facial and truncal flushing

Question 28

regional spread of esophagus, blood vessels

Answer 28

Esophageal compression: dysphagia

Invasion of a blood vessel: hemoptysis

Question 29

lung cancer

Pancoast syndrome:

Answer 29

Pancoast syndrome:
Mostly due to NSCLC
Adenocarcinoma & SCC

Apical tumors invade the brachial plexus, pleura, or ribs resulting in:
Shoulder and upper extremity pain
Upper extremity weakness
Atrophy of the ipsilateral hand
Horner’s syndrome:
Ptosis, miosis, anhidrosis(no sweat on one side)

Question 30

lung cancer

liver metastisis

Answer 30

Abdominal pain, nausea, early satiety → hepatic insufficiency

Question 31

lung cancer

brain

Answer 31

Brain:
Behavioral changes, confusion, aphasia, seizures, paralysis

Question 32

lung cancer

bone mets

Answer 32

Severe pain (back, chest, extremities), pathologic fractures

Question 33

lung cancer

adrenal gland metastisis

Answer 33

Usually asymptomatic
Adrenal insufficiency (if both glands are affected by metastatic cancer)

Question 34

lung cancer

CXray

Answer 34

Chest x-ray
Not diagnostic
Initial imaging modality when evaluating a patient with symptoms concerning for lung cancer
Review previous chest imaging to assess forlesion properties and changes

Findings that should raise suspicion of malignancy:
New or enlarging focal lesion (coin lesion)
Pleural effusion
Pleural thickening
Enlarged hilar and paratracheal lymph nodes
Tracheobronchial narrowing
Segmental or lobar atelectasis

Question 35

Lung cancer

Chest CT

Answer 35

Chest CT scan
Obtained to further evaluate concerning pulmonary abnormalities found on chest x-ray

Allows for assessment of:
Pulmonary lesion
Lymph node involvement
Metastases
Aids in biopsy planning

Can also be used as a screening tool
Low-dose CT produces high-resolution images with less radiation

Question 36

lung cancer

Biopsy

Answer 36

Definitive pathology is required for diagnosis (tissue biopsy is preferred over cytologic specimen)

Question 37

TNM staging system

and prognosis

Answer 37

Non-small cell lung cancer
4 stages: I-IV using the TNM system
T = tumor
N = lymph node (mediastinum & hilar)
M = metastases

Survival varies by stage
5-year survival
60-70% for patients with stage I disease
<1% for patients with stage IV disease

4 is more severe than 1.

Question 38

small cell lung cancer staging

Answer 38

Small cell lung cancer
2 stages: limited and extensive

Overall prognosis is poor
Median survival – 20 months

Question 39

Lung cancer

Tx

Answer 39

Varies by cell type and stage of disease
Surgery
Chemotherapy
Radiation therapy

Immunotherapy
Utilizes the body’s immune system to eliminate the cancer

Targeted therapies
Target specific gene mutations (affects cell growth and replication)
Associated with improved survival

Question 40

lung cancer

Benefits of screening

Answer 40

Goal is to detect early disease, which is:
More amenable to treatment
Associated with betterprognosis
Several studies also show a favorable association withsmokingcessation

Question 41

lung cancer

Risks of screening

Answer 41

High false-positive rate
Leads to unnecessarybiopsyor surgery
Increased radiation exposure

Overdiagnosis:
Detection of cancers that would not have affectedmorbidityormortalityfor the patient
Leads to unnecessary aggressive treatment

Mental distress

Most abnormalities detected arebenign nodules

Question 42

LUNG CANCER

Screening Recommendations

Answer 42

The United States Preventive Services Task Force (USPSTF) 2021 recommendslung cancerscreeningfor (must meet all criteria):
Adults aged 50‒80 years
Those with a 20-pack yearsmokinghistory
Current smoker or has quit within the past 15 years

The American Cancer Society recommendsscreeningfor (must meet all criteria): -(not likely to be tested on)
Adults aged 55‒74 years
30-pack year smokinghistory
Current smoker or quit within the past 15 years

Allpatientsin ascreening program should receive smoking-cessation interventions

Question 43

Discontinuing Lung cancer screening

Answer 43

Screeningcan be discontinued if the patient:
Has not smoked for ≥ 15 years
Develops a health condition that willlimitlife expectancy
Is unable or unwilling to have curative lung surgery

Question 44

lung cancer

Strategies for screening

Answer 44

Low-dose computed tomography
Produces high-resolution images with lessradiation

Abnormal findings should be followed up with diagnostic computed tomography (CT)

Lung CTscreeningreporting and data system (Lung-RADS®)
Tool designed to standardize lung cancer screening CT reporting and management recommendations
Introduced in 2012
Modeled after the mammography reporting system (BI-RADS®)
Lung-RADS® coding
Category: 0, 1,2,3,4A, 4B, 4X
Modifier S that can be added to category 0-4
0 = incomplete exam