Lung Cancer and Pulmonary Nodules

solitary pulmonary nodule

coin lesion

< 30mm, isolated rounded opacity on chest imaging outlined by normal lung

• does not touch hilum or mediastinum, lung border or pleura

• > 30mm considered a mass

not associated with infiltrate, atelectasis or adenopathy

benign descriptions

diffuse, central, popcorn, concentric

malignant description

ground glass, eccentric

size of nodules and malignancy percentages

< 5mm: 1%

6-10mm: 24%

11-20mm: 33%

>20mm: 80%

solid module < or equal to 8mm

less likely to be malignant

monitor with CT

solid nodule > 8mm

more likely to be cancerous

monitor with PET scan

lung cancer screening

annual low dose CT screening for those

• 50-80 years

• 20 pack year history of smoking and

• currently smoking or quit within last 15 years

stop lung cancer screening when

15 years have elapsed since quitting smoking

if comorbid disease renders benefits of screening null

if a nodule is identified during screening

utilize lung-RADS guidance

pulmonary nodule malignant lesion description

bigger

fast growth rate

upper lobes

spiculated margin

stippled or eccentric center

nodule enhancement with IV contrast

pulmonary nodule benign lesions

smaller

slower growing/slow doubling time (stable at 2 years)

smooth, well defined borders

calcified

pulmonary nodule infectious etiology

mostly mycobacterial or fungal

pulmonary nodule noninfectious etiology

sarcoidosis

wegener granulomatosis

hypersensitivity pneumonitis

aspiration pneumonia

talc granulomatosis

pulmonary nodule malignant etiology

primary lung cancer

metastatic cancer

carcinoid tumors

smokers

family hx

personal hx of cancer

exposure to chemicals

pulmonary nodule dx

CT chest without contrast with thin sections (preferred)

PET scan

VATS

• if biopsy positive - immediate lung resection

brock equation

fleischner society - utilizes size from CT scan for pts > 35 years

brock equation

low probability < 5% - serial imaging

intermediate probability 5-60% - likely diagnostic biopsy

high probability >60% - resection

when to refer for pulmonary nodule

managed by pulmonologists

any nodule in any category other than no further follow up

any nodule in a high risk patient

lung cancer #1 prevention

smoking cessation

lung cancer sx

cough

weight loss

anorexia

hemoptysis

nonspecific chest discomfort or pain

dyspnea

lung cancer dx

H&P with complete ROS

CXR: compare to old cxr if possible

CT

PET

biopsy: tissue biopsy or cytology

thoracentesis: malignant effusions

pleural biopsy: thoracoscopy

FNA (fine needle aspiration) of supraclavicular

CXR abnormal findings for lung cancer

new or enlarging focal lesion

pleural effusion

pleural nodularity

enlarged hilar or paratracheal nodes

endobronchial lesion

post obstructive pneumonia/lobar atelectasis

if abnormal → CT

CT findings suggestive of malignancy

solitary nodule >8mm

mass with irregular or spiculated borders

upper lobe location

thick walled cavitation

doubling time > 30 days <365 days

ground glass lesion, multiple nodules = metastatic disease

CT pros

provides greater degree of detecting tumor invasion, occult disease, lymph node involvement and metastasis

CT cons

high degree of false positive

no standardized criteria for what a positive PET scan is

small cell lung cancer general info

affects central airways of people who smoke

perihilar mass

aggressive:

• early hematogenous spread and metastasis

• median survival time 6-18 weeks

limited disease SCLC

confined to one hemithorax (ipsilateral hemithorax and regional lymph nodes)

treat with chemo and radiation

prophylactic brain irradiation

no surgery

extensive disease SCLC

disease outside one hemithorax

lymph nodes on both sides of chest

malignant cells in pleural space

pericardial effusions

distant metastasis

extensive disease SCLC treatment

palliative chemotherapy

SCLC common organ involvement

brain

liver

adrenals

bone

bone marrow

SCLC dx

CXR: large hilar mass with bulky mediastinal adenopathy

CT/PET-CT

cytology

bronchoscopy guided biopsy is most often used

SCLC complications

SVC syndrome

finger clubbing

thrombophlebitis

Cushing syndrome

paraneoplastic syndromes

myasthenia (lambert-eaton syndrome)

neuropathies

horner syndrome

dermatomyositis

paraneoplastic syndromes

tumor production PTH related protein (hypercalcemia)

syndrome of inappropriate ADH secretion (SIADH)

hyponatremia

weakness, dysguesia (taste disorder)

non-small cell lung cancer general info

85% of all lung cancers are NSCLC

adenocarcinoma

squamous cell carcinoma

tumor staging

T0: no evidence of primary tumor

T1: < 3cm

T2: >3cm <5cm

T3: >5cm <7cm

T4: >7cm

nodal staging

NX: cannot be assessed

N0: no regional LN involvement

N1 and N2: ipsilateral

N3: contralateral nodes

metastasis staging

M0: no distant met

M1: distant

M1a: separate tumor nodule contralateral

M1b: single extra thoracic metastasis

M1c: multiple extra thoracic metastasis in one or more organ

NSCLC general sx

cough

hemoptysis

chest pain

dyspnea

hoarseness

NSCLC adenocarcinoma

peripheral lesions on CXR

NSCLC squamous cell carcinoma

central lesions on CXR

lesions cause obstruction, atelectasis, pneumonia

NSCLC pancoast tumor

invades brachial plexus/cervical symp ganglia, causes shoulder/arm pain, hand atrophy

horner syndrome

hypercalcemia

SIADH

Cushing gonadotropin secretion

dermatomyositis

appearance suggestive of NSCLC on CXR

mass >1cm

ill defined or spiculated margins

measurable growth

pleural nodules

upper lobe

ground glass appearance

adenopathy > 1cm

consolidation thought to be pneumonia not resolved with medical management

NSCLC dx

CXR

CT/PET-CT

biopsy

labs:

• CBC, BMP creatinine

• calcium, look for any bony metastasis

• LFT, if elevated get imaging

  • ALP, ALT, albumin

stage I and II NSCLC

localized, limited to one lung, no mediastinal involvement

surgical resection

• stage II add adjuvant chemo

radiation therapy for NSCLC if

non-surgical candidate

recurrent

surgical margins are positive

Stage IIIA tx NSCLC

surgery, chemo, full dose radiation therapy

Stage IIIB tx NSCLC

chemo, radiation

possible resection later

stage IV NSCLC tx

supportive care provides 16wks of survival:

• reduce pain, ease breathing, improve quality of life

systemic chemo; surgery, palliative

airway tumors general info

rare

primarily tracheobronchial tumors

often malignant and found at late stages

airway tumors sx

dyspnea, cough, wheezing, stridor

hemoptysis

airway tumors dx

bronchoscopy with biopsy

airway tumors tx

surgical

carcinoid tumors general info

well differentiated neuroendocrine tumor

mostly GI but 20-30% arise in lungs (endobronchial)

most pts < 60 yrs old

carcinoid tumors sx

low grade slow growing, rarely metastasize

can cause ectopic ACTH production

carcinoid syndrome due to hormone production:

• flushing

• diarrhea

• bronchospasm

vasoactive substance release: serotonin, histamines, bradykinin

carcinoid tumor dx

CXR: round mass or solitary nodule

5-hydroxyindolaceticacetate (24 hr urine colleciton)

CTA

biopsy

staged by TMN system

most common site for metastasis of carcinoid tumors

liver

carcinoid tumor complications

bleeding and airway obstruction due to central location

carcinoid tumors tx

surgical resection

chest wall tumor benign etiology

osteochondroma

chest wall tumor malignant etiology

chondrosarcoma

chest wall tumor sx

chest wall pain that doesn’t fit a msk origin

chest wall mass - pain soreness and swelling with palpable lump

exertional pain

radiation of pain

numbness

fever, chills, cough, SOB

chest wall tumors dx

labs, imaging, biopsy

CBC, BMP, LFTs

CXR

chest CT

chest wall tumor tx

surgery