PULM Week 4 PBL

Question 1

what is considered to be one of the primary causes of lung and oral cancer

Answer 1

smoking

Question 2

what percent of lung cancers worldwide are attributed to smoking

Answer 2

75%

Question 3

which two types of lung cancer are particularly rare in the absence of smoking

Answer 3

squamous cell carcinoma and small cell carcinoma

Question 4

what are the majority of non smoking related lung cancers?

Answer 4

adenocarcinomas (high in women)

Question 5

what aspect of a persons smoking history is considered most important when determining his or her risk for lung cancer

Answer 5

LENGTH of time smoking

20 years and over is associated with the highest risk

Question 6

what is the main toxic/carcinogenic chemical from cigarette smoking?

Answer 6

polycyclic aromatic hydrocarbons

Question 7

what are some other causes of lung and oral cancer?

Answer 7

1. environmental tobacco smoke
2. residential radon
3. cooking oil vapors
4. indoor coal and woodburning
5. genetic factors
6. HOV 16 and 18
7. EBV
8. HIV
9. pre-existing lung disease–COPD in particular
10. asbestos, arsenic, chromium compounds
11. infections like TB

Question 8

how many carcinogens are there in cigarette smoke?

Answer 8

60 at least

Question 9

what are the strongest carcinogens in cigarette smoke

Answer 9

polycyclic aromatic hydrocarbons and N-nitrosamines and aromatic amines

Question 10

what are the most abundant carcinogens in cigarette smoke

Answer 10

aldehydes, benzene and butadiene

Question 11

what are the most important carcinogens to lung cancer (from smoking)?

Answer 11

PAH, and tobacco specific, nicotine derived nitrosamine NNK

Question 12

how do carcinogens in cig smoke exert their effect?

Answer 12

carcinogens are enzymatically transformed into a series of metabolites

initial steps are carried out by CP450 enzymes, encoded by the CYP family of genes, which oxidize the substrate

nicotine addiction–>cigarette smoking–> PAH, NNK and other carcinogens (–>metabolic detox and excretion)–>metabolic activation–>DNA adducts (–>repair–>normal DNA)–> persistence and miscoding–> (1) apoptosis or (2) mutations and other changes: RAS, MYC, p53, RB, FHIT, and other critical genes–> lung cancer

humans metabolize carcinogens similarly to how they metabolize other foreign compounds–> some intermediates are “metabolically activated” by CYP450–reactive, electrophilic and binds DNA covalently

in smokers there is a chronic barrage or metabolically activated carcinogens which cause changes–> cancer

Question 13

what is hemoptysis

Answer 13

expectoration of blood or blood-stained sputum from bronchi, larynx, trachea or lungs

characterized by site of bleeding (airways, parenchyma, vasculature)

Question 14

what types of airway disease cause hemoptysis

Answer 14

1. inflammatory–bronchitis or brochiectasis
2. neoplasm–primary bronchi carcinoma, endobrachial metastatic carcinoma
3. foreign body (2nd most common cause in children after LRTI)

Question 15

how does an inflammatory airway disease cause hemoptysis

Answer 15

i.e bronchitis or bronchiectasis

inflammation of the mucosa–> vascular enlargement, desquamation, atrophy, erosion

Question 16

how does neoplasm in the airways cause hemoptysis

Answer 16

i.e primary bronchi carcinoma, endobrachial metastatic carcinoma

• lung CA (23%)–bronchigenic carcinoma most common lung cancer causing hemoptysis
• bleeding from malignant or benign tumor can be secondary to mucosal invasion, erosion into blood vessels
• tissue invasion–resulting angiogenesis

**metastatic lung cancer rarely results in bleeding

Question 17

what types of pulmonary parenchymal disease may cause hemoptysis

Answer 17

1. infection
2. inflammatory or immune disorders
3. coagulopathy
4. drug indiced
5. catamenial hemoptysis due to intrathoracic endometriosis
6. idiopathic

Question 18

what types of infections are most likely to cause hemoptysis? how do they do this?

Answer 18

• especially TB, pneumonia, aspergillosis, lung abcess
• most COMMON cause of hemoptysis (60-70%)
• causes superficial mucosal inflammation and edema and thus rupture of superficial blood vessels
• most common agents are invasive bacteria–>

S. aureus
Pseudomonas aeruginosa
fungi (aspergillus)

• viruses may also cause hemoptysis–> influenza, HIV, predisposed Kaposi sarcoma
• most common cause in kids = LOWER RESP TRACT INFECTION

Question 19

what inflammatory/immune disorders of the pulmonary parenchyma cause hemoptysis

Answer 19

autoimmune–Goodpastures, systemic lupus

Question 20

what coagulopathies may cause hemoptysis

Answer 20

thrombocytopenia, use of anticoagulants

Question 21

what drug induced causes in the parenchyma may there be for hemoptysis

Answer 21

cocaine-induced diffuse alveolar damage

Question 22

how many patients have idiopathic hemoptysis

Answer 22

up to 30% of patients have no ID-ed cause after careful observation (good prognosis)

Question 23

how does vascular disease cause hemoptysis

Answer 23

• massive hemoptysis is usually related to involvement of systemic circulation
• vasculitis, pulmonary embolism (uncommon), pulmonary arteriovenous malformation, mitral stenosis, elevated pulmonary capillary pressure and significant LEFT VENTRICULAR FAILURE (most common CV condition causing hemoptysis)
• often difficult to distinguish parenchymal and vascular disease

Question 24

what conditions may cause elevated pulmonary capillary pressure? how might this elevated pressure result in hemoptysis?

Answer 24

mutral stenosis or significant left ventricular failure

higher pressure leads to rupture of pulmonary veins or capillaries

Question 25

what is the general clinical presentation of bronchial carcinoma

Answer 25

1. cough (75%) 2. weight loss (40%) 3. chest pain (40%) 4. dyspnea (20%)

Question 26

what causes the general symptoms on clinical presentation of bronchial carcinoma

Answer 26

symptoms arise due to local tumor growth, invasion/obstruction of adjacent structures, growth into regional lymph nodes, growth in distant metastatic sites after hematogenous dissemination, or remote effects of tumor products (paraneoplastic syndrome)

Question 27

how would a central/endobronchial growth present clinically

Answer 27

``` cough hemoptysis wheeze stridor dyspnea post-obstructive pneumonitis (fever, productive cough) ```

Question 28

how would peripheral growth of a primary broncial carcinoma tumor present clinically?

Answer 28

pain from pleural/chest wall spread, dyspnea on restrictive basis, symptoms of lung abscess

Question 29

how would a bronchial cancer's regional spread to thorax present clinically

Answer 29

1. tracheal obstruction 2. esophageal compression 3. recurrent laryngeal nerve paralysis with HOARSE VOICE 4. phrenic nerve paralysis with elevated hemi-diaphragm and dyspnea 5. malignant pleural effusion

Question 30

what is Horner's syndrome?

Answer 30

sympathetic nerve paralysis (i.e from bronchial cancer regional spread to thorax) 1. enophthalmos (recession of eyeball into orbit) 2. ptosis (drooping upper eyelid) 3. miosis (pupil constriction) 4. ipsilateral loss of sweating

Question 31

what is Pancoast syndrome?

Answer 31

local extension of tumor growing in apex of lung with involvement of C8 and T1 nerves shoulder pain--radiates in the ulnar distribution of the arm

Question 32

what is superior vena cava syndrome?

Answer 32

due to regional spread of tumor in the thorax tumor causes vascular obstruction (edema of the face and neck with dilated veins in the neck and upper torso; headache, dizziness, stupor, syncope, visual disturbances)

Question 33

what is extrathoracic metastatic disease

Answer 33

various symptoms caused by metastasis to brain, bone, bone marrow, liver, lymph node, spinal cord, adrenal glands

Question 34

what is paraneoplastic syndrome?

Answer 34

refers to the disorders that accompany benign or malignant tumors but are not directly related to mass effects or invasion neoplastic cells can produce a variety of peptides that can stimulate hormonal, hematologic, dermatologic, or neurologic responses especially common in SCLC and carcinoids anorexia, cachexia, weight loss, fever, suppressed immunity endocrine symptoms: electrolyte disturbances in calcium, phosphate, sodium, K+

Question 35

what are the three mechanisms/routes of lung cancer spread

Answer 35

1. local 2. lymphatic 3. hematogenous

Question 36

describe the process of local spread of lung cancer

Answer 36

-bronchial lumen obstruction causes PULMONARY COLLAPSE, accumulation of secretions, pneumonia, abscess formation and/or bronchiectasis distal to the obstruction - pleural involvement results in blood stained pleural effusion and can lead to chest wall invasion by tumor - superior vena cava compression (by lymph nodes) or invasion causes "superior vena cava syndrome" - invasion of nerves such as spread to the axilla with involvement of brachial plexus (pancoast tumor) or cervial sympathetic chain (horner's syndrome) - pericardial involvement resulting in hemorrhagic pericardial effusion - direct spread to bone such as ribs, sternum, and spine causes pain - esophageal involvement causes dysphagia or bronchoesophageal fistula

Question 37

describe lymphatic spread of lung cancer

Answer 37

- occurs early with invasion of regional intrapulmonary, hilar, and then extrapulmonary tracheobronchial and other mediastinal lymph nodes - further spread may occur to cervical, supraclavicular, axillary and more distant lymph node groups - nodal involvement can be MASSIVE and can be the presenting feature

Question 38

Describe hematogenous spread of lung cancer

Answer 38

- widespread systemic involvement is common--not uncommonly the first clinical manifestation of lung cancer - may occur in any organ but mainly ADRENALS (50%), LIVER (30-50%), brain (20%) and bone (20%)

Question 39

what does the right lymphatic duct drain? where does it drain into?

Answer 39

drains R side of the head and R side of the thorax drains into the right subclavian vein

Question 40

what does the thoracic duct drain? where does it drain into?

Answer 40

rest of body into L subclavian vein

Question 41

why do we use the TNM method to stage cancers?

Answer 41

for 1. communication 2. prognosis 3. to type of treatment

Question 42

what does the T indicate in TNM staging? the N? the M?

Answer 42

T = info on primary tumor--size and relationship to surrounding structures N = info on regional lymph nodes M = presence or absence of metastasis

Question 43

``` in NSCLC staging, what does: T1 T2 T3 T4 indicate? ```

Answer 43

T1 = tumor less than 3 cm without pleural or main stem bronchus involvement T2 = tumor 3-7 cm OR involvement of main bronchus 2 cm from carina, visceral pleura involvement or lobar atelectasis T3 = tumor larger than 7 cm OR one with involvement of chest wall, diaphragm, mediastinal pleura, pericardium, or entire lung atelectasis or separate tumor nodule in the same lobe T4 = tumor with invasion of mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina or separate tumor nodules in different ipsilateral lobe

Question 44

``` in NSCLC TNM staging, what does: N0 N1 N2 N3 indicate? ```

Answer 44

N0 = no demonstrable metastasis to regional lymph nodes N1 = ipsilateral hilar or peribronchial nodal involvement N2 = metastasis to ipsilateral mediastinal or subcarinal lymph nodes N3 = metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene or supraclavicular nodes

Question 45

``` in NSCLC TNM staging, what does: M0 M1 M1a M1b indicate? ```

Answer 45

M0 = no distant metastasis M1 = distant metastasis M1a = separate tumor nodule in contralateral lobe or pleural nodules or malignant pleural effusion M1b = distant metastasis

Question 46

stage Ia

Answer 46

T1N0M0

Question 47

stage Ib

Answer 47

T2N0M0

Question 48

stage IIa

Answer 48

T1N1M0

Question 49

stage IIb

Answer 49

T2N1M0

Question 50

stage IIIa

Answer 50

T1-3N2M0 T3N1M0

Question 51

stage IIIb

Answer 51

any T N3 M0

Question 52

stage IV

Answer 52

any T any N M1

Question 53

what is oral leukoplakia?

Answer 53

white lesion of oral mucosa that cannot be characterized as any other defined lesion, not readily removed Dx of exclusion--confirmatory biopsy some are benign lesions, many should be regarded as premalignancy lesions chief concern is malignant transformation to oral squamous carcinoma (esp in floor of mouth)

Question 54

causes of oral leukoplakia

Answer 54

TOBACCO use--most important smokeless/chewing tobacco excess alcohol chronic irritation due to ill-fitting dentures infection with candida albicans rarely tertiary syphilis, sanguinaria products (herbal toothpastes)