7. Pulmonary Neoplasms

Screening recommendations for lung cancer

Annual low-dose CT for age 50-80 with 20+ pack year history, and current or quit within last 15 years

Issues with low-dose CT screen for lung cancer

Over-diagnosis, unnecessary invasive procedures

Solitary pulmonary nodule

<3 cm, round lesion surrounded by normal lung tissue NOT associated with infiltrate, atelectasis, adenopathy

Determining risk of solitary pulmonary nodule malignancy

- Age

- Risk proportional to smoking

- Prior malignancy

- Size/appearance

How to evaluate a suspicious solitary pulmonary nodule?

High-resolution chest CT

Rate of change for infectious nodule

Doubled in <30 days

Rate of change for likely benign nodule

Doubled in >465 days

Malignant appearance of nodule

- Spiculated/lobular

- Peripheral halo

- Sparse, stippled, eccentric calcification

- Cavitary lesion >16mm wall thickness

Management of low probability of malignancy of pulmonary nodule

Serial CT every 6-12 months

Management of intermediate probability of malignancy of pulmonary nodule

Biopsy, PET scans, sputum cytology for lesion in bronchi

Management of high probability of malignancy of pulmonary nodule

ASAP stage and resect, onc and thoracic surgery referral

Considerations for management of ALL pulmonary nodules

Discussion of risk/benefit/alternatives/patient preference

Scoring system of lung-nodule concern/recommended management

Lung-RADS

Bronchial carcinoid tumor (+ characteristics)

- Low-grade malignant neuroendocrine lung tumors

- Slow growing pedunculate/sessile growths in central bronchi

Risk factors for bronchial carcinoid tumor

Age <60

S/S of bronchial carcinoid tumor

Hemoptysis, cough, focal wheeze, recurrent pneumonia

Rare presentation of bronchial carcinoid tumor

Carcinoid syndrome - flushing, diarrhea, wheeze, hypotension

Diagnostic workup + findings of bronchial carcinoid tumors

Fiberoptic bronchoscopy

Complications with bronchial carcinoid tumors

Well vascularization → significant bleeding

Staging of aggressiveness of bronchial carcinoid tumor

Typical carcinoid: Low-grade

Atypical carcinoid: Intermediate-grade

Management of bronchial carcinoid tumor

Surgical excision with LN (usually resistant to radiation and chemo)

Prevalence/epidemiology of lung cancer

2nd MC cancer in US

Leading cause of cancer death worldwide

LOW 5 year survival-rate

MCC of lung cancer

SMOKING (any history)

5 main histologic categories of lung cancer

1. Squamous cell carcinoma **

2. Adenocarcinoma **

3. Adenocarcinoma in-situ **

4. Large cell carcinoma **

5. Small cell carcinoma

**Non-small cell

MC type of non-small cell lung cancer

Adenocarcinoma

What is the most likely type of cancer to present with hemoptysis?

Squamous cell carcinoma

Squamous cell carcinoma (+ characteristics)

- From bronchial epithelium

- Central intraluminal mass

Lung adenocarcinoma (+ characteristics)

- From mucous glands/epithelial cells distal to terminal bronchioles

- Peripheral mass

Lung adenocarcinoma in-situ characteristics

Spread along alveolar structures WITHOUT invasion

Which lung cancer is known for rapid doubling time?

Large cell lung carcinoma

Large cell lung carcinoma (+ characteristics)

- Heterogenous group of undifferentiated CA

- Aggressive with rapid doubling times

- Central OR peripheral mass

Small cell lung cancer (+ characteristics)

- Begins centrally in bronchial

- Submucosal infiltration narrows bronchus without discrete mass

- VERY AGGRESSIVE, metastases common at time of presentation

Small cell lung cancer vs. squamous cell carcinoma

SCLC: Pushes on bronchiole causing narrowing

SCC: Grows within bronchial epithelium

Significance of small cell lung cancer

- VERY AGGRESSIVE with metastases common at time of presentation

- Refractory to surgical resection

Small cell lung cancer vs. non-small cell lung cancer

SCLC: Aggressive, rapid mortality

NSCLC: Slower growth, curative with resection, chemo tailored to histology/mutations

General S/S of lung cancer

Anorexia, fatigue, new/changing chronic cough, hemoptysis, bone pain with metastases, SOB

SVC syndrome (potential presentation of lung cancer)

Obstruction of mass → supraclavicular venous engorgement

Voice changes (potential presentation of lung cancer)

Affecting recurrent laryngeal nerve

Horner syndrome (potential presentation of lung cancer)

Involvement of inferior cervical ganglion and paravertebral sympathetic chain

Brain metastases symptoms (potential presentation of lung cancer)

HA, N/V, AMS

Liver metastases symptoms (potential presentation of lung cancer)

Weight loss, fatigue, ascites

Paraneoplastic syndromes

Organ dysfunction related to immune-mediated OR secretory effects of neoplasms

Management of paraneoplastic syndromes

Treating underlying tumor DESPITE incurable CA

Paraneoplastic syndrome of small cell carcinoma

SIADH

Presentation of SIADH is associated with...

Small cell carcinoma

Paraneoplastic syndrome of squamous cell carcinoma

Hypercalcemia

Presentation of hypercalcemia is associated with...

Squamous cell carcinoma

Common paraneoplastic syndromes of ALL lung cancers

- Digital clubbing

- Increased ACTH

Diagnosis of lung cancer

Tissue/cytology sample + visualization on scan (CXR/CT)

Staging of NSCLC + components

TNM with summary stages I-IV

Stage I-II: Most cured with surgery

Stage IIIA: May benefit from surgery

Stage IIIB-IV: NO benefit from surgery

Staging of SCLC

Limited: Confined to unilateral hemithorax

OR

Extensive: Beyond hemithorax OR malignant pleural effusion

Staging evaluation of lung cancer

- High-res CT (w/ and w/o contrast)

- Whole body PET - mediastinal/distant spread

- Brain MRI (with specific indications)

Indications for brain MRI for staging evaluation of lung cancer

SCLC

NSCLC II or high

Poor differentiated histology with biopsy

What is added to evaluation of lung cancer with a planned resection?

PFTs

What are circumstances where NSCLC is unresectable?

Extrathoracic metas, malignant effusion, tumor encases vital structures

Surgical treatment of NSCLC

Lobectomy preferred

Radiation therapy for NSCLC

Stereotactic body radiotherapy - targeted, small region

Treatment of stage IIIA/IIIB NSCLC

Chemo + radiation

Treatment of stage IV NSCLC

Chemo +/- palliative

Neoadjuvant chemotherapy for NSCLC

Chemo before surgery/radiation

Treatment of SCLC

Nonsurgical: Chemo

MC chemotherapy agents for SCLC

Cisplatin and etoposide

Function of prophylactic cranial radiation for treatment of SCLC

Decrease incidence of brain mets

Palliative therapy for lung cancer

- Photo-resection of endobrachial obstructing tumors

- Meticulous pain control

MC means of lung metastases

Pulmonary artery

MC cancers that cause lung mets

Breast, kidney, melanoma

Mesothelioma (+ characteristics)

- Primary tumor from surface lining of pleura (MC) or peritoneum

- Diffuse, malignant

- Can spread to pericardium, mediastinum, contralateral pleura

PE of mesothelioma

- Symptomatic 20-40 years post-exposure

- Pleural effusion: exudative and hemorrhagic

Risk factors for mesothelioma

M>F, exposure to asbestos , mining, milling, insulation

Diagnostic workup & findings of mesothelioma

VATS for adequate biopsy

Radiograph: Nodular, irregular, unilateral pleural thickening, unilateral effusion

MCC of death with mesothelioma

Respiratory failure and complications with extension

Treatment of mesothelioma

Chemotherapy