Lung Neoplasms

lung cancer

proliferative malignant neoplasm arising from the primary respiratory epithelium resulting from genetic mutations affecting tumor suppressor genes and oncogenes.

- Non-small cell lung cancer (NSCLC)

- Small cell lung cancer (SCLC)

two major histologic groups of lung cancer

Non-small cell lung cancer (NSCLC)

majority of lung cancer (85%) is __________

40, 80

Lung cancer is rare below the age of _____ which increases up to age _____, and tappers off.

males

males: 8%

females: 6%

Is lung cancer more common in M/F?

black men

also Hispanic, Native, Asian Americans are at risk compared to whites

_____ are at more risk for lung cancer than other groups of people

- Cigarette smoking

- Environmental tobacco smoke

- occupational exposure (asbestos, arsenic, mustard gas, nickel)

- ionizing radiation

- certain lung disease (COPD, emphysema, tuberculosis)

- Inherited risk for lung cancer

- Having a first-degree relative with lung cancer

Risk factors for lung cancer

Cigarette smoking

largest risk factor for lung cancer that increases the risk 10-fold

- Adenocarcinoma

- Squamous cell carcinoma

- Large cell carcinoma

Types of Non-small cell lung cancer...

Squamous cell carcinoma

non-small cell carcinoma that is centrally located and associated with smoking

adenocacinomas

non-small carcinoma that is located peripherally

large cell

non-small carcinoma that is located throughout the lung field

bronchial carcinoid

neuroendocrine tumor that is located throughout the lung field

- Squamous cell carcinoma

- Adenocarcinoma

non-small cell lung cancers that tend to present as Pancoast tumors (Horner's syndrome)

Pancoast tumor

squamous cell carcinoma and adenocarcinoma in the upper lung present as __________ that can damage the thoracic inlet, brachial plexus, and cranial sympathetic nerve

Horner's syndrome

Pancoast tumors compress blood vessels and nerves, patients present with _______

- Ptosis

- Anhidrosis

- Miosis

Symptoms of Horner's syndrome seen in Pancoast tumors (SCC and adenocarcinoma)

Parathyroid hormone

depleting calcium in bones and leading to brittle bones

Squamous cell carcinoma can release ______

Large Cell Carcinoma

lung cancer that is typically undifferentiated and can secrete Beta-hCG. Patients can present with gynecomastia. Also, associated with smoking.

Beta-hCG

large cell carcinoma can secrete ______

serotonin

bronchial carcinoid tumors can release _______

Bronchial carcinoid

neuroendocrine tumor associated with hypercalcemia of malignancy and grow very slowly

small cell lung cancer

Makes up a small portion of lung cancers that is associated with smoking. Develops from a small immature neuroendocrine cells.

small cell lung cancer

cancer that develops near main bronchus

Small cell lung cancer

lung cancer that grows fast and rapidly metastasizes. 60% of patients have metastasis at diagnosis. Tumors are commonly large and in multiple sites

- ACTH

- ADH

- Autoantibodies

small cell lung cancers can cause paraneoplastic syndrome in which tumors release...

ACTH

release of ____ from SCLC tumors leads to Cushing Syndrome due to cortisol release from the Adrenal glands. Patients present with elevated glucose and blood pressure

Cushing syndrome

elevated glucose and blood pressure

ACTH release from SCLC tumor causes _______ in patients

ADH

release of _____ from SCLC leads to water retention, increased blood pressure, edema, concentrated urine, polyuria, and polydipsia.

SIADH

water retention, elevated blood pressure, edema, concentrated urine, polyuria, polydipsia

ADH release from SCLC tumor causes ____ in patients

autoantibodies

release of ______ from SCLC leads to neuron destruction resulting in Lambert-Eaton Myasthenic Syndrome (Type 2 Hypersensitivity Reaction)

Lambert-Eaton Myasthenic Syndrome

Type II hypersensitivity reaction

autoantibody release from SCLC tumor causes neuron destruction resulting in ___________

Adenocarcinoma

Hypertrophic osteoarthropathy is the paraneoplastic syndrome associated with _______

hypertrophic osteoarthropathy

paraneoplastic syndrome associated with adenocarcinoma that causes fingernail clubbing, joint pain, and bone pain

Bronchial carcinoid tumors

lung cancer that can cause serotonin release leading to carcinoid syndrome (can produce hormones such as calcitonin --> hypercalcemia) and fibrosis of mitral and aortic valves.

- CD56

- neural cell adhesion molecule (NCAM)

- synaptophysin

- chromogranin

SCLC may be distinguished from NSCLC by the presence of _______

adenocarcinoma

the most common histologic type of lung cancer

- Squamous cell carcinoma

- small-cell carcinoma

the most commonly associated with heavy tobacco use

they are treated differently

Why is it important to differentiate SCLC and NSCLC?

Adults aged 50 to 80 years who have a 20-pack-year smoking history and currently smoke or have quit within the past 15 years

Who should be screened for lung cancer?

low-dose CT every year

stop screening once a person has not smoked in 15 years or has a health problem that limits life expectancy or the ability to have lung surgery

Patients that fit the criteria, should be screened for lung cancer with...

- new cough or change in chronic cough

- dyspnea

- hemoptysis

- anorexia

- weight loss

- night sweats

- clubbing of fingernails

- chest pain

symptoms depend on the type of cancer and location

presenting symptoms associated with lung cancer

new cough or change in chronic cough

most common presentation of lung cancer

- lung nodule/mass

- pleural effusion

lung cancer may be diagnosed after _____ is recognized incidentally on CXR

paraneoplastic syndromes

clinical manifestation of lung tumors that secrete hormones

Hypercalcemia

lab value that may hint at SCC of the lung due to its paraneoplastic effects.

- superior vena cava syndrome

- anemia

- hypercoagulability

- peripheral neuropathy

other clinical manifestations of lung cancer...

- Mediastinum and Hilar Lymph Nodes

- Lung pleura

- heart

- breasts

- liver

- adrenal glands

- brain

- bone

sites of secondary tumors seen in lung cancer

mediastinum and hilar lymph nodes

most common site of metastasis in Lung Cancer

brain

lung cancer metastasis to ____ is manifested by headaches and vomiting

bones

lung cancer metastasis to ____ is manifested by pain or fractures

liver

lung cancer metastasis to _____ is manifested by abdominal pain

adrenal gland

lung cancer metastasis to _____ is usually asymptomatic, but may present with adrenal insufficiency

Coin lesion, Non-calcified nodule

_____ on CXR or _______ on Chest CT scan can also be caused by infections so patients require tissue biopsy or fine-needle aspiration for histopathologic diagnosis.

- tissue biopsy from a Bronchoscopy

- CT guided fine needle aspiration

Coin lesions on CXR or Non-calcified nodule on Chest CT may also be due to infections so patients require _____________ for histopathologic diagnosis.

diagnostic thoracentesis

CXR revealing pleural effusion always need to be evaluated with _______.

Opacity in Right upper lung

Pancoast tumor

Coin like lesion, solitary lesion on CT

CT-guided biopsy

method used to diagnose peripheral nodules approaches 80-90%

Sputum cytology

method used to diagnose highly specific but insensitive

- CT guided biopsy

- Sputum cytology

- Thoracentesis

- Bronchoscopy

- Imaging (CT of chest with and without IV contrast)

diagnostic methods for lung cancer

bronchscopy

method of diagnosis of lung cancer that allows visualization of the major airways.

TNM international staging system

staging used for lung cancer that assists with treatment decisions and prognosis

Stage I and stage II

stages of lung cancer that are cured through surgery

Stage IIIB and IV

stages of lung cancer that do not benefit from surgery

Stage IIA

stage of lung cancer that is locally invasive disease that may benefit from surgery in selected cases as part of a multimodality therapy.

PET scan

imaging used to identify metastatic cancer.

- Tumor size

- Nodes

- Metastasis

What does TNM staging mean?

Stage 0

stage of lung in which the cancer is only in the top layer of cell lining of the lungs, carcinoma in situ

Stage I

stage of lung cancer in which the cancer is small and only in one lobe of the lung

Stage IIA

lung cancer that is in one lung and the main tumor is less than 3-5 cm and is spread to nearly lymph nodes

OR

cancer is only in one lung and main tumor is 5-7 cm but has not spread to lymph nodes or elsewhere

Stage IIB

lung caner is only in one lung and tumor is 5-7 cm and is spread to nearby lymph nodes but not elsewhere

OR

main tumor is greater than 7 cm and has not spread to lymph nodes or elsewhere

Stage IIIA

lung cancer has spread to lymph nodes along the trachea on the same side as the main tumor

Stage IIIB

lung cancer has spread to lymph nodes along the trachea on the side opposite to the main tumor

Stage IV

stage of lung cancer that has spread to the other lung as well as lymph nodes outside the lungs. Small lumps or nodules in the lining of the lung fluid around the lung known as malignant pleural effusion. Fluid around the heart known as malignant pericardial effusion or other organs such as the liver, brain, and bones

- CBC (low hemoglobin, low platelets)

- CMP (low Na, high calcium)

- LFTs (elevated alk. phosphate)

lab evaluations for patients with lung cancer

SIADH

low sodium on CMP may be indicative of _____ (in suspected Lung Cancer patient)

paraneoplastic manifestation (SCC), bone metastasis

high calcium on CMP may be indicative of ____ (in suspected lung cancer patient)

liver metastasis

elevated Alk. phosphate on LFTs may be indicative of _____ (in lung cancer patients)

- pulmonary embolism

- tuberculosis

- pneumonia

- histoplasmosis

- sarcoidosis

- COPD

differential diagnosis for lung cancer

- surgery (remove as much as possible including nearby lymph nodes)

- chemotherapy

- immunotherapy

- radiation therapy

commonly used treatments in lung cancer

Pain management

- yoga and guided imagery

- pain medications

other than the mainstream treatments for lung cancer, we also have to consider other things in the patient's management such as...

surgical resection or lobectomy

treatment that offers the best chance for cure for stages I and II of NSCLC

radiation therapy, chemotherapy, clinical trials

patietns with Stage I and II NSCLC who either refuse or are not suitable candidates for surgery should be considered for ____________

stereotactic body radiation therapy (SBRT)

radiation therapy used for patients with Stage I and II NSCLC

cisplatin

chemotherapy used for patients with NSCLC that is used as an adjunct 6-12 weeks after surgical resection

every 6 months for the first 3 years, then annualy

All patients with resected NSCLC are at high risk of recurrence, most of which occur within the first 18-24 months of surgery. Follow up with CT scan without contrast should be performed...

chemotherapy and radiation

sometimes IIIA can be surgically removed

treatment for Stage III NSCLC

- systemic therapy (targeted therapy, chemotherapy, immunotherapy)

- radiation

- clinical trials

treatment for stage IV NSCLC

Monoclonal antibodies (ipilimumab)

_____ that activate antitumor immunity through the blockage of immune checkpoints show small but no statistically significant advantage in the treatment of Stage IV NSCLC

palliative care

pain and symptom control is important

patients with Stage IV NSCLC receive mostly...

chemotherapy and radiation

but if surgery is an option, it should be performed and followed up with chemo

first line treatment for SCLC

Cisplatin or carboplatin plus either etoposide or irinotecan

mainstay chemotherapy for SCLC

cyclophosphamide, doxorubicin, vincristine

may be alternative chemotherapy in SCLC patients who are unable to tolerate a platinum-based regimen

Thoracic radiation therapy (TRT)

standard component of induction therapy in SCLC patients

chemotherapy combined with chest irradiation

example: Cisplatin with etoposide with TRT

treatment plan for SCLC that improves 3-year survival by 5%

Reduce risk factors

- smoking cessation

- radon exposure

How do we prevent lung cancer?

cigarette smoking

cuases 85-90% of lung cancers

- bupropion (Wellbutrin)

- nicotine gum

- nicotine inhaler

- nicotine lozenge

- nicotine nasal spray

- nicotine patch

- varenicline (Chantix)

treatment options for smoking cessation

nausea, vivid dreams, anxiety, suicidal ideations

side effects of Varenicline (Chantix)