Pulmonary neoplasms

Question 1

Solitary Pulmonary Nodule

Answer 1

● Sometimes referred to a “coin lesions,” solitary pulmonary nodules are rounded, isolated opacities see on chest imaging.
○ Less than 3 cm in size
● They are surrounded by normal lung and are not associated with infiltrates, lymphadenopathy, atelectasis or symptoms of illness

Question 2

Solitary Pulmonary Nodule appearance on CT

Answer 2

They may be solid or subsolid, and may appear with ground glass or mixed consistency on CT

Question 3

Most benign nodules are _______

Answer 3

infectious granulomas

Question 4

Goal of evaluation for Solitary Pulmonary Nodule

Answer 4

Identify and resect malignant tumors while avoiding unnecessary invasive procedures in benign disease.

Question 5

How can we decide who is at high risk of malignancy?

Answer 5

A combination of clinical and imaging data are needed to assess the probable level of risk

Question 6

______ is an important marker for cancer

Answer 6

“Doubling time”

Question 7

If the nodule doubled in size in
_____ , there’s a higher probability of cancer

Answer 7

less than 30 days

Question 8

If the nodule appears _____, this is
characteristic of a benign process.

Answer 8

smooth with well-defined edges

Question 9

Lesions with ____ and/or a peripheral halo are highly suggestive of malignancy

Answer 9

spiculated margins

Question 10

In patients with a high probability of malignancy, proceed
directly to _____

Answer 10

resection following staging

Question 11

There are two main methods for Solitary Pulmonary Nodule biopsy:

Answer 11

○ Transthoracic Needle Aspiration
(TTNA)
○ Bronchoscopy needle aspiration

Question 12

Resection technique for Solitary Pulmonary Nodule

Answer 12

● Some recommend video-assisted thoracoscopic surgery (VATS)
for resection of all solitary pulmonary nodules with intermediate
probability of malignancy

Question 13

85-90% of cases of Bronchogenic Carcinoma are caused by _____

Answer 13

cigarette smoking

Question 14

Risk Factors of Bronchogenic Carcinoma

Answer 14

○ Smoke from tobacco or marijuana
○ Exposure to industrial carcinogens
○ Exposure to ionizing radiation
○ COPD, Sarcoidosis, or Pulm Fibrosis
○ Recurrent severe lung inflammation
○ A familial predisposition is recognized

Question 15

The median age at diagnosis of Bronchogenic Carcinoma is _____

Answer 15

71 years

Question 16

5 main histological categories of Lung cancer, split them into 2 main groups:

Answer 16

○ Small Cell Lung Cancer
○ Non-Small Cell Lung Cancers
■ Squamous Cell Carcinoma
■ Adenocarcinoma
■ Adenocarcinoma in situ (AKA Bronchioloalveolar Carcinoma)
■ Large Cell Carcinoma

Question 17

Small Cell Lung Cancer

Answer 17

● Unique and accounts for approximately 13% of lung cancer cases.
● Bronchial epithelial tumor that exhibits
neuroendocrine function- Associated with a
variety of paraneoplastic syndromes (later)
● Infiltrates the submucosa and can cause
narrowing of the bronchial lumen

Question 18

SCLC is prone to early ______

Answer 18

hematogenous spread,
often involving the hilar lymph nodes very early

Question 19

AKA “Oat Cell” Cancer

Answer 19

Small Cell Lung Cancer

Question 20

Squamous Cell Carcinoma

Answer 20

● Accounts for approximately 23% of lung cancer cases.
● Arises from the ciliated bronchial epithelium.
● More likely to present with hemoptysis as it
is often centrally located and involving the
bronchi lumen.
● Can often be diagnosed with sputum
cytology, which is unique to this type of lung
cancer.

Question 21

Adenocarcinoma of the Lung

Answer 21

● Most common form of Lung Cancer,
accounting for approximately 50%.
● Arises from the bronchial glandular cells.
● Often appears in the periphery of the lung
and typically metastasizes to distant sites

Question 22

Adenocarcinoma is the subtype of lung
cancer that is observed most commonly in
those that _____

Answer 22

do not smoke

Question 23

Bronchioloalveolar Carcinoma

Answer 23

● Technically, a subtype of Adenocarcinoma that is uncommon, accounting for approximately 2% of lung cancer cases.
● Spreads along the alveolar structures
without significant evidence of invasion (slow growing).
● Arises from epithelial cells within or distal to terminal bronchioles, often involving the alveoli

Question 24

“Adenocarcinoma in situ”

Answer 24

Bronchioloalveolar Carcinoma

Question 25

Large Cell Carcinoma

Answer 25

● A heterogeneous group of undifferentiated cancer types that do not fit in other categories. ● Accounts for approximately 1.3% of lung cancer cases ● Often appear as a large mass in the periphery of the lung ● Characterized by lack of histologic characteristics that would make it SCC or Adenocarcinoma

Question 26

Screening for Lung Cancer

Answer 26

○ Annual low-dose CT (LDCT) screening for those at high risk is recommended by multiple organizations. ○ High-risk criteria include age 50–80 years, at least a 20-pack-year smoking history, and either current smoking or quit date within the past 15 years

Question 27

Clinical Presentation for Bronchogenic Carcinoma

Answer 27

○ The large majority of patients are symptomatic at diagnosis. ○ Presentation varies depending on type and location of tumor and the extent of spread, but may include: ■ Anorexia and weight loss (55-90%) ■ Asthenia (55-90%) ■ New cough or change in chronic cough (60%) ■ 6-31% have hemoptysis ■ 12-33% have a pleural effusion (exudative) ■ 25-40% experience chest or bone pain ■ Focal neurologic deficits if CNS metastasis ○ May see Superior Vena Cava syndrome ○ Pancoast tumors (tumors in the lung apex) can cause Horner’s Syndrome.

Question 28

Diagnostic Evaluation for Bronchogenic Carcinoma

Answer 28

○ Nearly all patients with lung cancer have abnormal findings on chest radiography or CT scan. ■ CXR should be followed by CT ○ PET scans are often utilized with CT to evaluate for metastasis. ○ Biopsy technique depends on tumor location

Question 29

Biopsy technique depends on tumor location:

Answer 29

■ Sputum Cytology (if lesion is in central airways) ■ Thoracentesis Cytology (if malignant pleural effusion) ■ Fine Needle Aspiration of involved nodes ■ Video-assisted thoracoscopic surgery (VATS) ■ Fiberoptic Bronchoscopy with needle biopsy ■ Transthoracic Needle Aspiration (TTNA)

Question 30

Once tissue has confirmed malignancy, accurately staging the cancer is crucial for multiple reasons:

Answer 30

■ To provide information to guide treatment ■ To provide the patient with accurate information regarding prognosis ■ To standardize entry criteria for clinical trials to allow interpretation of results

Question 31

Two principles of NSCLC staging:

Answer 31

● More extensive the disease, the worse the prognosis. ● Surgical resection offers the best hope for a cure (this is not the case with SCLC)

Question 32

TNM Staging System:

Answer 32

● T- Size and location of primary tumor ● N- Presence and location of nodal involvement ● M- Presence or absence of distant metastasis

Question 33

Referral Considerations and Treatment for Bronchogenic Carcinoma

Answer 33

○ If radiologic imaging is suggestive of a pulmonary malignancy, get a Pulmonologist involved quickly ○ Medical and Radiation Oncology should be consulted ○ For NSCLC, surgical resection is strongly considered as an initial priority if possible, then chemo/radiation ■ For SCLC, surgery is rarely helpful to prognosis due to aggressive micrometastasis, so chemo is the focus

Question 34

Treatment priority by staging for Bronchogenic Carcinoma

Answer 34

● I-II: Surgical resection plus possible adjunct therapy ○ If inoperable, stereotactic body radiotherapy ● IIIa: Surgical resection plus chemo and/or radiation ● IIIb and inoperable IIIa: Concurrent chemo and radiation, followed by immunotherapy (checkpoint inhibitors) ● IV: Chemo and/or immunotherapy, or symptom-based palliative therapy, or a combination of both

Question 35

Treatment for Small Cell Lung Cancer (SCLC)

Answer 35

■ Surgery plays no role in the treatment of most patients with SCLC due to presumed metastasis. ■ Chemotherapy with or without chest radiation is mainstay. ■ Initial response rates can be strong, although remission is generally short-lived (median of 6-8 months). ● After recurrence, survival is 2-4 months ■ Overall 2-year survival is 20–40% in limited-stage disease and 5% in extensive-stage disease

Question 36

Overall Prognosis for Bronchogenic Carcinoma

Answer 36

○ The overall lung cancer 5-year survival rate is about 22%. ○ Survival is best for those with early stages of NSCLC ○ SCLC has the poorer prognosis, especially extensive disease

Question 37

Most common pulmonary mets:

Answer 37

Carcinoma of the kidney, breast, rectum, colon, and cervix

Question 38

Typically, extrapulmonary malignancy that metastasizes to the lungs will appear as _____

Answer 38

multiple dense nodules

Question 39

If there are metastatic lesions in the lungs, you need to get _____

Answer 39

a CT of the head, as well as Chest/Abdomen/Pelvis (both with contrast).

Question 40

Symptoms of pulmonary mets could include:

Answer 40

○ Cough ○ Hemoptysis ○ Dyspnea ○ Hypoxemia ○ May be asymptomatic

Question 41

Treatment/Management of Metastatic Tumors

Answer 41

○ Once the diagnosis has been established, treatment is focused on the primary cancer. ○ If there is only a single pulmonary lesion, or a large mass causing significant obstruction, surgery may be indicated

Question 42

Mesothelioma

Answer 42

● Relatively rare primary cancer arising from the mesothelial cells ○ Large majority are the pleural lining, but small percentage are from peritoneum ● Confirmed association with a distant history of exposure to asbestosis

Question 43

Pathophysiology of Mesothelioma

Answer 43

○ Pleural mesotheliomas encase and compress the lung, extending into the fissures, yet largely sparing the parenchyma of the lung

Question 44

Mesothelioma Clinical Presentation

Answer 44

■ Insidious dyspnea ■ Unilateral, nonpleuritic chest pain ■ Weight loss ■ Dullness to percussion ■ Diminished breath sounds ■ Clubbing (occasionally)

Question 45

Average age at diagnosis of Mesothelioma in US is ____ years of age

Answer 45

72-74

Question 46

Mesothelioma Diagnostic Evaluation

Answer 46

○ Radiographic abnormalities: Nodular, irregular, unilateral pleural thickening and varying degrees of Pleural Effusion ○ Evaluation of a Pleural Effusion will reveal exudative and often hemorrhagic fluid. ○ Biopsy required for diagnosis

Question 47

Clinical Course of Mesothelioma

Answer 47

○ The disease progresses rapidly and will eventually involve contralateral pleura, pericardium and mediastinum. ○ Patients develop progressive pain and dyspnea. ○ Often develop superior vena cava syndrome and Horner’s

Question 48

Treatment Options and Prognosis of Mesothelioma

Answer 48

○ A combination of chemotherapy, radiation, and surgery are usually attempted, but are generally unsuccessful. ○ Patients usually die of respiratory failure or complication of local extension (such as hemorrhage). ○ Median survival from diagnosis is 7-18 months; 5-year is 5-12%

Question 49

Anterior Mediastinal Mass DDx

Answer 49

○ Thymoma: Most common anterior mediastinal mass, associated with Myasthenia Gravis in 35% of cases ○ Lymphoma ○ Thyroid lesions

Question 50

Most common anterior mediastinal mass, associated with Myasthenia Gravis

Answer 50

Thymoma

Question 51

Middle Mediastinal Mass DDx

Answer 51

○ Lymphadenopathy ○ Pulmonary Artery enlargement ○ Aortic Aneurysm ○ Dilated azygos or hemiazygos vein ○ Pericardial Cyst: Most common mediastinal cyst

Question 52

Posterior Mediastinal Masses

Answer 52

○ Neurogenic Tumors: Includes tumors such as neurofibroma, ganglioneuroma, meningocele. ○ Hiatal hernia ○ Esophageal tumor

Question 53

Clinical Presentation of Mediastinal Masses

Answer 53

○ Nonspecific and usually caused by pressure or mass effect on surrounding structures as the mass grows. ■ Superior vena cava syndrome ■ Retrosternal chest pain ■ Dysphagia ■ No symptoms at all (about 50% of cases)

Question 54

Mediastinal Masses diagnosis

Answer 54

● Often picked up as incidental findings on CXR. ● CT can help aid in diagnosis. ● MRI may be helpful in this situation because it can better delineate between hilar structures, vessels, and masses. ● Tissue biopsy is often required for definitive diagnosis when a neoplastic process is considered

Question 55

Carcinoid Tumors

Answer 55

● A type of neuroendocrine (glandular) tumor, these are low- or intermediate-grade malignancies that are slow-growing ● Carcinoid tumors most commonly occur in the GI tract or in the lungs. ● In the lungs, they start as small, pedunculated growths in the central bronchi

Question 56

Clinical Presentation of Bronchial Carcinoid Tumors

Answer 56

○ Hemoptysis ○ Cough ○ Focal wheezing ○ Recurrent postobstructive pneumonia ○ Carcinoid Syndrome (rare, but characteristic) ■ Flushing ■ Diarrhea ■ Wheezing ■ Hypotension

Question 57

Carcinoid Syndrome

Answer 57

■ Flushing ■ Diarrhea ■ Wheezing ■ Hypotension

Question 58

Diagnostic Evaluation of Carcinoid Tumors

Answer 58

○ If the lesion is located in the periphery, it may show up as a solitary pulmonary nodule that may grow slowly (seen on serial CT scans) ○ Bronchoscopy may reveal a pink or purple tumor in central airway

Question 59

Carcinoid Tumors treatment

Answer 59

○ Bronchial carcinoids grow slowly and rarely metastasize. ■ The concern is for bleeding or airway obstruction, rather than invasion and metastasis ○ Generally resistant to radiation and chemotherapy, treatment usually involves surgical excision. ■ Prognosis is generally favorable

Question 60

Paraneoplastic Syndromes

Answer 60

Remote effects of cancer that cannot be attributed to either the cancer’s direct invasion or metastatic spread, but occur secondary to ectopic hormone secretion or immune system attack on normal tissue.

Question 61

Paraneoplastic Syndromes are important because

Answer 61

○ They sometimes accompany relatively small amounts of cancer growth and can be an early clue of malignancy. ○ The metabolic effects can cause an urgent, life threatening situation (ex: hypercalcemia or hyponatremia). ○ The return of the syndrome can herald the return of cancer

Question 62

While these syndromes can occur with dozens of types of cancer, ____ is the one most likely to be associated with paraneoplastic processes

Answer 62

Small Cell Lung Cancer

Question 63

Common Paraneoplastic Syndromes seen with lung cancer:

Answer 63

○ ACTH production by SCLC and Carcinoid tumors leads to clinical picture of Cushing’s Syndrome. ○ ADH secretion by lung cancers (most commonly SCLC) can cause SIADH ○ In Squamous Cell Lung Carcinoma, PTH-related protein (PTHrP) can cause hypercalcemia (10% of cases). ○ SCLC commonly causes neurologic manifestations, such as cerebellar ataxia, peripheral neuropathy, and Lambert-Eaton Syndrome

Question 64

Lambert-Eaton Syndrome

Answer 64

○ Neuromuscular transmission condition that may be associated with SCLC, occasionally occurring before the tumor is diagnosed. ○ A voltage-gated calcium channel antibody produced by the tumor prevents normal synaptic transmission at the NMJ. ○ Opposite of Myasthenia Gravis, muscle strength is reduce in proximal muscle groups, rather than distal. ○ Steroids are often added to Tx plan