Covid, Neoplasms

severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2)

What virus causes COVID-19?

14 days (most symptoms occur in 4-5)

What is the incubation period for COVID-19?

droplets

How is COVID-19 transmitted?

fever, loss of taste/smell, cough, SOB, N/V/D, abd pain, malaise fever

What are the classic features for COVID-19?

mild

How would you classify dyspnea that does not interfere with daily activities?

Moderate

How would you classify dyspnea that creates limitations to ADLs such as the ability to walk up the stairs without taking breaks?

Severe

How would you classify dyspnea that is characterized by SOB at rest, unable to speak in complete sentences, and interferes with basic ADLs?

full in-person eval

If a patient with COVID-19 has an O2 sat 94 or below?

ER time

If a patient with COVID-19 has an O2 sat 90 or below?

WBCs high or low, Elevated ALT/AST, Elevated LDH, Elevated CRP, ESR

What does our lab work look like for COVID-19?

ground glass opacities, pleural thickening, air bronchograms

What does a CXR or Chest X-ray show for COVID-19?

Cough suppressant, antipyretic, analgesic (Tylenol), hydration, self-prone

What is the standard treatment for COVID-19

Paxlovid (nirmatrelvir/ritonavir)

For COVID-19 patients 65 or older, those with multiple medical comorbidities, or those older 50 and unvaccinated what medication can we give if we are within 5 days of symptoms?

Remdesivir (7 days), Convalscent plasma (8 days)

For COVID-19 patients 65 or older, those with multiple medical comorbidities, or those older 50 and unvaccinated what medication can we give if we are within 6-8 days of symptoms?

supportive care

For COVID-19 patients 65 or older, those with multiple medical comorbidities, or those older 50 and unvaccinated what medication can we give if we are past day 9 of symptoms?

Patient is on any drugs metabolized by CYP3A4, liver disease, kidney disease

What are some of the contraindications of Paxlovid?

inhibits viral replication (peptidomimetic inhibitor)

What is the MOA for paxlovid?

inhibits viral replication (SARS-CoV-2 RNA polymerase inhibitor)

What is the MOA for remdesivir?

polyclonal antibodies for passive immunity

What is the MOA for convalescent plasma?

respiratory failure, cardiac failure, ischemia, shock, thromboembolism, encephalopathy, stroke, inflammatory crisis secondary infections

Complications of COVID-19

Pulmonary nodule

What is a solitary coin lesion that is less than 3 cm, isolated, and a rounded opacity that is outline by normal lung tissue - not associated with infiltrate, atelectasis or adenopathy?

resect malignant tumors, leave the benign ones alone (avoid invasive)

What is the goal of treating pulmonary nodules?

less than 30 y/o

Who is at a decreased risk of pulmonary nodules?

smokers (pack/year history), prior malignancy

Who is at an increased risk of pulmonary nodules?

review old imaging

What is the 1st step in treating pulmonary nodule

infection

If doubling time <30 days, this suggests

long term stability, benign status

If doubling time is >465, think

Evaluate nodule on CT imaging - size, shape, appearence

What is the second step in evaluating pulmonary nodules

Big risk for malignancy

Big nodule?

Smooth, well, define edge, dense calcification with central/laminated pattern

What shape/appearance has a lower risk for malignancy?

lobule shape, spiculated margins, peripheral halo, cavitary lesions with thick walls, stippled/eccentric calcification

What shape/appearance has a higher risk for malignancy?

probability of malignancy

In the case of biopsy vs. surgery this is decide on

watchful waiting, serial imaging

With pulmonary nodules with low probability of malignancy what is our game plan?

biopsy via TTNA (50-97% sensitive), bronchoscopy (10-80%), sputum cytology (specific), PET scan (PREFERRED sensitivity 85-97%, specificity 70-85%)

With pulmonary nodules with intermediate probability of malignancy how are we confirming our diagnosis?

VATs (removes the nodule and is staged while we are still in surgery)

With pulmonary nodules with intermediate probability of malignancy what is our game plan?

immediate resection, tumor stagings

With pulmonary nodules with high probability of malignancy what is our game plan?

Lung neuroendocrine tumor

Caused usually originate hormone producing cells that line small intestine/digestive tract but also occurs in bronchi and other organs - can be benign/malignant that affect people 40-60 y/o

flushing, diarrhea, wheezing, hypotension

Lung neuroendocrine tumors can release histamines and prostaglandins that cause carcinoid syndrome which is characterized by

cough, hemoptysis, focal wheezing, recurrent lung infections, carcinoid syndrome

What are respiratory symptoms of lung neuronendocrine tumors?

local bleeding, airway obstruction

Complications of lung neuroendocrine tumors

surgical excision, lymph node dissection, resection for localized disease

Treatment plan for lung neuroendocrine disease

lung cancer

What is the leading cause of cancer deaths in both men and women?

cigarette smoking, exposure to environmental tobacco smoke, radon gas, asbestos, industrial chemical carcinogens

What are the risk factors for lung cancer?

Squamous cell carcinomas (23%)

What type of lung cancer arises from a bronchial epithelium and often presents as an intraluminal mass

adenocarcinomas (50%)

What type of lung cancer arises from mucous glands or from any epithelial cell within or distal to the terminal bronchioles

adenocarcinoma in situ (13%)

What type of lung cancer spreads along pre-existing alveolar structures without evidence of invasion?

Small cell carcinoma (13%)

What type of lung cancer arises tumor of bronchial origin that typically begin centrally causing the narrowing of the bronchus without a discrete luminal mass and tends to be aggressive cancer that often involve regional/distant metastasis?

Large cell carcinoma (1.3%)

What type of lung cancer is a heterogeneous group of undifferentiated cancers that share large cells and do not fit into other categories, typically aggressive and rapid doubling times, and present as central or peripheral?

cough, anorexia, weight loss, fatigue, pain, hemoptysis, pleural effusion, obstructive pneumonia, digital clubbing, change in voice, superior vena cava syndrome, horner’s syndrome

What are the clinical findings associated with lung cancer?

ptosis, miosis, facial anhidrosis

What are some signs of Horner syndrome associated with a Pancoast tumor?

bone, liver, brain

What are some common metastases points for lung cancer?

syndrome of inappropriate antidiuretic hormone (SIADH)

What type of paraneoplastic syndromes are associated with small cell carcinoma?

hypercalcemia

What type of paraneoplastic syndromes are associated with squamous cell carcinoma?

Increase ACTH, anemia, hyper-coagulability, peripheral neuropathy, lambert-eaton myasthenic syndrome

What are some non-specific paranoplastic syndromes associated with lung cancer?

sputum cytology

What diagnostic test for lung cancer has high specificity, low sensitivity and is best for central airway lesions?

thoracentesis

What diagnostic test for lung cancer is diagnostic for malignant pleural effusions

fine needle aspiration (FNA

What diagnostic test for lung cancer is diagnostic for metastatic lymph nodes?

Bronchoscopy

What diagnostic test for lung cancer can visualize airways, brush visible lesions, lavage lung segments, direct biopsy, blind transbronchial biopsy, and FNA biopsy?

resection, chemo prior/following

For all non-small cell carcinoma (NSCLC) what is our treatment plant?

good response to chemo (if it reoccurs you have a 3-4 month survival)

For all small cell carcinoma what is our treatment plant?

adults 50-80 with more than 20 pack/year smoking hx (currently or quit within last 15 yrs)

When do we screen for lung cancer?

Person has not smoked for 15 years, develops a health problems that limits life expectancy

When do we stop screening for lung cancer?