pulmonary neoplasms

4 major types of lung cancer

small cell lung carcinoma (SCLC)

non-small cell lung carcinoma (NSCLC)

-adenocarcinoma

-squamous cell carcinoma

-large cell carcinoma

lung cancer epidemiology

-most common cause of cancer death

-40-80 yo

-cigarette smoke= 10x more risk

lung cancer metastasis

-mediastinum and hilar lymph nodes

-lung pleura

-heart

-breast

-liver

lung cancer screening

-early detection is key before metastasis

-low dose CT screening for lung cancer for: 50-80 yo, >20 pack-year smoke hx, either current or within the last 15 years

presentation of lung cancer

ABCDE

-A: bronchial airway disruption > pneumonia

-B: blood

-C: cough

-D: distribution (metastasis)

-E: wheezing

lung cancer sx

-cough

-weight loss >10lbs

-dyspnea

-chest pain

-hemoptysis

-bone pain

-clubbing, wheezing, weakness, fever, SVC obstruction, striodor

-neurologic sx

lung cancer dx

-confirmatory= tissue biopsy

-sputum cytology: less invasive, not diagnostic

non-small cell lung cancer (NSCLC)

-squamous cell carcinoma: central, smoking

-adenocarcinoma: peripherally, NO link to smoking

-large-cell carcinoma: throughout lungs, dx of exclusion if SCC and adenocarcinoma not it

-bronchial carcinoid tumor: low grade malignancy of neuroendocrine cells

NSCLC dx/tx

-dx: fine needle aspiration of the lung

-tx: surgical resection

-5 year survival 40%

small cell lung cancer (SCLC)

-strongly associated with smoking

-develops centrally in the lugn near bain bronchus

-fast and rapid

-secrete hormones

-paraneoplastic syndromes

SCLC- paraneoplastic syndromes

-cushing syndrome: excrete cortisol, elevated BP and glucose

-SIADH: release ADH, water retention, high BP and edema

-eaton-lambert: tumor producing autoantibodies, destroy neurons

SCLC sx

-limited (one lung) or extensive (spread)

-dyspnea, wheezing, cough, hemoptysis

SCLC sx

-biopsy= large cells with limited cytoplasm and nuclear moulding

Staging:

-CT + contrast scan chest and PET scan

-neuro or adenocarcinoma >3cm: MRI of the head w/o and w contrast

-CT abdomen

SCLC tx

-supportive care: palliative care, smoking cessation,

-NSCLC give chemotherapy before resection

-EGFR mutation + in NSCLC: erlotinib, gefitinib, afatinib

-tyrosine kinase inhibitors: erlotinib, gefitinib

-monoclonal antibody: cetuximab, necitumumab

-surgery and radiation

SPHERE

-SVC syndrome

-Pancoast tumor

-Horners syndrome

-Endocrine: flushing, diarrhea, telangiectasias

-Recurrent laryngeal nerve: hoarseness

-Effusions: exudative

pancoast tumor

-pulmonary neoplasms located in lung apices

-most NSCLC

-cervical sympathetic nerves, brachial plexus, laryngeal nerves, SVC

pancoast tumor sx

-cough, angia, dyspnea, hemoptysis, wheezing, pnuemonias, weight loss, loss of appetite, weakness

-local inflammation , pain in upper extremities and weakness due to brachial plexus

-compression of cervical sympathetic nerves

-voice hoarsenss

-flushing, edema, dyspnea

pancoast tumor dx

-CT of chest: tumor in lung apex

-biopsy= confirm

pancoast tumor tx

-manage impingement first before resection

-chemotherapy

-surgical resection

-radiation

Superior vena cava syndrome

-obstruction of SVC

-increased venous pressure and dilation

-caused by: lung cancers, blood clots, tumor invasion

Superior vena cava syndrome sx

-edema of face and neck

-inspiratory stridor

-voice change

-flushed appearance

Superior vena cava syndrome dx

-CT of chest

-venous angiography= vessel dilation

-biopsy

Superior vena cava syndrome tx

-steroids to reduce inflammation

-surgery

-chemotherapy

-head above heart

tumor staging

TMN staging

-T: tumor size and extent

-N: regional lymph nodes: N0= none, N1= ipsilateral peribronchial, N2= ipsilateral mediastinal or subcarinal, N3= contralateral

-M: metastases: M0= none, M1= distant

solitary pulmonary nodule

-coin lesion

-asymptomatic

-adenocarcinoma- most common cause

-Infectious granulomas= 80% of benign lung nodules by histoplasmosis, coccidioidomycosis, tuberculous, or nontuberculous mycobacteria

solitary pulmonary nodule dx

-evaluation of old imaging

-rapid progression, larger= higher risk of malignancy

-high resolution CT: any suspicious solitary pulmonary nodule

solitary pulmonary nodule tx

-watchingful waiting: low probability of malignancy, <30yo, stable for >2yo

-surgery: high probability of malignancy

bronchial carcinoid

-malignant tumors from neuroendocrine cells

-favorable prognosis

-pedunculated or sessile growth in central bronchi

bronchial carcinoid sx

-hemopytsis, cough, focal wheezing, recurrent post obstructive pneumonia

bronchial carcinoid dx

-fiberoptic bronchoscopy: pink or purple tumor in central airway

-CT scan

-grow slowly

bronchial carcinoid tx

-surgical excision lymph node dissection and resection

mediastinal masses

-nonspecific depends on surrounding structures

-sx: insidious onset of retrosternal chest pain, dysphagia, dyspnea

-dx: CT scan, tissue biopsy=diagnostic

-tx: depends on underlying cause

mesothelioma

-cancer of the mediastinum

-found in lungs and chest wall pleural lining

-associated with asbestosis exposure

-dx: CXR or CT scan

-biopsy: calretinin helps distinguish, fried egg appearance

-tx: chemotherapy, radiation