L16 Lung Cancer (clinical)

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L16 Lung Cancer (clinical)
2013-02-23 18:14:39
Pulmonary II

Clinical aspects of lung cancer
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  1. Lung cancer
    natural history
    • Long sub-clinical growth period
    • >30 doublings before tumor reaches 1cm diameter (detectable limit)

    • Discovered by
    • 1. Symptoms
    • -local effect: coughing, SOB, hemoptysis
    • -distant mets
    • -paraneoplastic

    2. Incidental finding on CT/CXr
  2. Sx related to primary lung tumor
    • Most common presenting symptom: cough and hemoptysis
    • -not specific (also common in pneumonia/bronchitis)

    Symptoms often attributable to inflammation from smoking

    May exacerbate underlying obstructive lung disease

    • Tumors that arise in the large airways:
    • (Squamous cell CA and Small cell lung cancer)
    • -Proximal airway obstruction
    • -Post obstructive pneumonia
    • -SOB associated with collapse and VQ mismatch

    • Tumors of the peripheral:
    • (Adenocarcinoma and Large cell carcinoma)
    • -discovery is often late and incidental
  3. Common sx and complications of lung cancer
    Endobronchial tumor: cough, hemoptysis, post-obstruction pneumonia, collapse with dyspnea

    Pleural involvement: chest pain, pleural effusion, dyspnea

    Invasion of adjacent structures: heart, great vessels, esophagus, spine/cord local complications

    Mediastinal involvement: diaphragm dysfunction/dyspnea, hoarseness, facial swelling, venous plethora (caused by phrenic nerve paralysis, recurrent laryngeal nerve paralysis, superior vena cava obstruction, respectively)

    Distant mets: Brain, bone, bone marrow, liver, adrenals

    Paraneoplastic syndromes: Hormone production by transformed/tumor cells; antibody production

    Constitutional: anorexia, weight loss, fevers, night sweats
  4. Patterns of presentation/spread
    • Adenocarcinoma:
    • -Peripheral presentation
    • -moderate-high risk of presentation with distant metastasis

    • Large/undifferentiated Carcinoma:
    • -Peripheral presentation
    • -moderate-high risk of presentation with distant metastasis

    • Squamous cell carcinoma:
    • -Central presentation
    • -Least likely to present with metastasis

    • Small cell carcinoma:
    • -Central presentation
    • -Most likely to present with distant metastasis
  5. Adenocarcinoma
  6. Large/Undifferentiated Carcinoma
  7. Squamous Cell Carcinoma
  8. Small Cell Carcinoma
  9. Paraneoplastic syndromes
    • -Occurs in 7-14% of tumors
    • -may be sole presenting symptom
    • -clinical syndromes not attributable to space-occupation or tumor invasion

    • Hormones: Small cell carcinoma most likely to produce hormones (neuroendocrine cell derived)
    • -Hypercalcemia - Squamous carcinomas  (PTHrP production; Bony mets)
    • -Hypertrophic Pulmonary Osteoarthropathy (clubbing/periostitis) - Adenocarcinoma 
    • -Trousseau's syndrome (hypercoag state) - Adenocarcinomas (role for mucins)
    • -SIADH - Small cell carcinoma (ADH production)
    • -Ectopic ACTH (cushing's) - Small cell (ACTH production)
    • -Eaton-Labert - Small cell (Antibody mediated)

    • Hormone-free:
    • -Neurologic syndromes
    • 1. Autoimmune antibody production
    • 2. Hypertrophic osteoarthropathy (HOA) or clubbing of the digits)
    • -Anorexia, night sweats, fever and fatigue
    • -Malignant weight loss
  10. Superior Sulcus (Pancoast) Tumor

    • Apical tumors often cause Superior Sulcus Syndrome:
    • -Brachial plexus involvement
    • -cervical sympathetic chain --> Horner's syndrome

  11. Pleural involvement
    • Invade pleural surface by 
    • -Direct extension
    • -metastatic spread

    • Sx:
    • -Chest pain
    • -Dyspnea from substantial accumulation of pleural fluid (can cause collapse or restriction)
    • -Extension into the heart may cause dysrhythmia, pericardial effusion, intracardiac clot & tumor may embolize
    • -Compression of esophagus may lead to dysphasia
  12. Mediastinal metastasis
    Lymph nodes numbered based on location; implications for severity (aggressiveness and metastatic risk)

    • N1: hilar LN
    • N2: mediastinal or subcarinal LN
    • N3: Scalene or supraclavicular

    Larger N = worse tumor

    • Superior vena cava syndrome
    • edema of the face and upper extremities
    • Diaphragmatic paralysis, elevated hemidiaphragm on X-ray
    • often with sudden orthopnea
    • Vocal cord paralysis with hoarseness
    • recurrent laryngeal nerve invasion
  13. Diagnostic Approach
    • Macroscopic evaluation
    • Staging
    • Microscopic evaluation (Tissue is the issue! strongly dictates treatment)
    • Functional evaluation - may limit treatment
  14. Macroscopic Evaluation
    • CXR: peripheral (large-cell, AdenoCA) or central (SqCCA, SmCCA)
    • CT: extent of spread in chest and upper abdomen; enlarged lymph nodes?
    • PET scan: search for metastatic nodes and distant metastasis; "Hot" spots
    • Bronchoscopy: examine, sample lesions; cytologic and histologic evaluation of central lesions
    • Fine Needle Aspiration: with CT guidance (for peripheral lesions)
  15. Staging
    • Critical in defining therapy
    • "surgical stage" - extra stage for patient who get surgical resections

    • Non-small cell lung cancer: TMN
    • Tumor size, spread/location within thorax, local complications
    • Node status: hilar, mediastinal, extrathoracic node-involevement
    • Metastasis within thorax or outside thorax

    • Stage Ia (T1N0M0) ~60-70% cure rate
    • Stage IV (TxNxM1) <10% chance of cure

    • Small cell carcinoma:
    • -Limited stage (within confines of one hemithorax)
    • -Extensive stage (beyond hemithorax)
  16. Histology vs. Cytology
    • Cytology: less invasive, less specific
    • -FNA aspiration - cytological exam only
    • -Bronchoscopic lavage

    • Histology: bx allows for architecture
    • -Core biopsy needle specimen
    • -Endobronchial biopsy
    • -transbornchial approach
    • -Endobronchial ultra sound (EBUS) guided needle aspiration
  17. Functional assessment
    PFTs used to assess whether a patient can tolerate anatomic resection (lobe or lung)

    • Additional testing:
    • -Cardiac status
    • -Exercise capacity
    • -Performance status
  18. Lung cancer screening
    -CXR is NOT effective at screening for lung cancer

    • Low dose CT: shown to reduce mortality by 20% in...
    • -pts age 55-77
    • -30 packyear history (quit <15 years ago)
  19. Principles of therapy
    Tx based on Stage and cell type:

    • Non-small cell:
    • -Stage I and II: localized!! (surgery, chemo, radiation, targeted therapy...especially for adenocarcinoma)
    • -Stage III: combination chemotherapy and radiation therapy
    • -Stage IV: palliative chemo and palliative radiation

    • Small cell:
    • -chemotherapy followed by radiation if limited stage
    • -tumors tend to have good initial response but rule is recurrence for these
    • -almost never resect

    • Pts who's stage is amenable to surgery:
    • -overall 50% 5 year survival
    • -stage 1a disease have 80% 5 year survival
  20. Bronchial carcinoid dumors
    • 5% of primary lung tumors
    • smoking is not a risk factor
    • affects younger adults than that of NSCLC or Small Cell CA
    • excellent prognosis
    • Arise in airway
    • ectopic hormonal production - carcinoid syndrome rare
    • Most cured through surgical resection
  21. Malignant mesothelioma
    pleural based tumor

    • Risk factors: asbestos
    • -high exposure = highest risk, but low dose exposure is also associated

    • Presentation:
    • Chest pain, dyspnea
    • Imaging shows thick pleura +/- effusion

    • Prognosis:
    • poor <10% 3 year survival
  22. Solitary pulmonary nodule
    single lesion <3cm

    • Ddx:
    • -cancer vs granulma
    • -vs benign tumor
    • -vs solitary metastasis

    • Risk:
    • -Patient factors
    • -growth
    • -PET scan
    • -Calcification pattern
    • -Border appearance

    Bx is final determinant; depending on tolerability.