Crr Week 6: Lung Cancer (Jones)

Front 1

List some risk factors for developing lung cancer.

Back 1

1. Smoking
2. Second-hand smoke
3. COPD
4. Genetics
5. Others (asbestos, radiation, radon, chromium, nickel)

Front 2

List the 4 major types of lung cancer

Back 2

1. Squamous cell carcinoma
2. Adenocarcinoma
3. Large cell carcinoma
4. Small cell carcinoma

Front 3

Which lung cancers are considered surgically resectable?

Back 3

Non-small cell lung cancers
(squamous cell, adenocarcinoma, and large cell carcinoma)

Front 4

How is small cell carcinoma typically treated?

Back 4

Chemotherapy and radiation
(typically not operative)

Front 5

Which types of lung cancer are more common in women?

Back 5

1. Adenocarcinoma
2. Small cell carcinoma

Front 6

Which type of lung cancer is more prevalent in men?

Back 6

Squamous cell carcinoma

Front 7

List 3 types of clinical presentations that occur at the time of diagnosis.

Back 7

1. Intrathoracic disease
2. Distant metastasis
3. Paraneoplastic syndrome

Front 8

List some symptoms that typically arise at the time of diagnosis of lung cancer.

Back 8

1. Cough
2. Dyspnea
3. *Hemoptysis
4. Chest pain
5. Unilateral wheezing/stridor
6. Hoarseness
7. Dysphagia

Front 9

If a patient is experiencing hemoptysis, what should you ALWAYS ask about?

Back 9

TB exposure

Front 10

How can a tumor cause hoarseness?

Back 10

If it is impinging upon the L recurrent laryngeal N, it can cause hoarseness

Front 11

What are some clinical SIGNS that may indicate lung cancer?

Back 11

1. Weakness
2. Weightloss
3. Fever
4. SVC syndrome
5. Brachial plexus involvement
6. Bone pain
7. Neurological symptoms

Front 12

Which syndrome presents with facial swelling, engorged neck veins, and chest wall swelling?

Back 12

Superior Vena Cava syndrome

Front 13

What causes paraneoplastic syndromes?

Back 13

Production of biologically active substances

Front 14

Hypercalcemia is often seen with which type of lung cancer?

Back 14

Squamous cell carcinoma

Front 15

List 5 examples of Paraneoplastic syndromes

Back 15

1. Hypercalcemia (esp with SCC)
2. SIADH
3. Ectopic ACTH production
4. Gynecomastia
5. Hypertrophic pulmonary osteoarthropathy

Front 16

Which type of lung cancers will show centrally located lesions upon chest x-ray?

Back 16

1. Small cell carcinoma
2. Squamous cell carcinoma

Front 17

List 5 diagnostic tests used for lung cancer.

Back 17

1. Chest x-ray
2. CT scan
3. Sputum cytology
4. Fiberoptic bronchoscopy
5. Percutaneous needle aspiration

Front 18

Which diagnostic test is safe, easy, and good to use for diagnosing centralized lesions?

Back 18

Sputum cytology

Front 19

Spiculations seen on a lung CT scan are suggestive of what?

Back 19

Malignancy

*Get a tissue diagnosis!

Front 20

When is it appropriate to use PET scans for diagnosis?

Back 20

PET scans should be reserved for PREOPERATIVE patients to make sure they don't have metastatic disease. It could also be used for inoperable patients who may require radiation therapy.

Front 21

Thoracic surgeons will often require what sort of diagnostic test before surgery?

Back 21

PET scan

Front 22

Which type of bronchoscope should be used be used for checking central airway and tracheal lesions?

Back 22

Rigid bronchoscope

Front 23

Which type of bronchoscope can be used to check the lobes for lesions?

Back 23

Flexible bronchoscope

Front 24

If a lesion is located in the outer 1/3 of the lung periphery, what type of diagnostic procedure should be done?

Back 24

Fine needle aspiration

*However, don't be too hasty to do an FNA. It has a much higher risk of pneumothorax than bronchoscopy

Front 25

If a lesion is located in the inner 1/3 of the lung, what type of diagnostic procedure should be done?

Back 25

Flexible bronchoscopy

Front 26

What is the disadvantage of fine needle aspiration?

Back 26

Risk of pneumothorax

Front 27

What are the risks of transbronchial biopsies?

Back 27

Risk of lethal complication due to bleeding or pneumothorax
(small risk: 0.1 - 0.2%)

Front 28

List 3 conditions that transbronchial biopsies are used to diagnose.

Back 28

1. Malignancy
2. Lung transplant rejection
3. Sarcoidosis

Front 29

Transbronchial biopsies are specifically NOT recommended for diagnosing what lung disease?

Back 29

Idiopathic pulmonary fibrosis

Front 30

While performing transbronchial biopsies, how many passes can be made before the risk of pneumothorax outweighs the possibility of making diagnosis?

Back 30

5-6 passes

Front 31

What is Endobronchial Ultrasound (EBUS) used to diagnose?

Back 31

Mediastinal lymphadenopathy

Front 32

Which diagnostic modality is particularly useful in staging lung cancer?

Back 32

Endobronchial ultrasound (EBUS)

Front 33

Endobronchial ultrasound is best for sampling which anatomical areas?

Back 33

1. Mediastinal
2. Paratracheal
3. Subcarinal

Front 34

Lymphomas, sarcoidosis, and tumors metastatic to mediastinal lymph nodes can be diagnosed by which modality?

Back 34

Endobronchial US

Front 35

A lesion within ____cm of the carina is considered non-surgical.

Back 35

2 cm

Front 36

The information for staging is mainly obtained through what type of imaging?

Back 36

CT scan

Front 37

Describe limited and extensive small cell lung carcinoma in terms of radiation fields.

Back 37

Limited disease --> 1/3 of one radiation field
Extensive disease --> 2/3 of one radiation field

Front 38

How are non-small cell carcinomas staged?

Back 38

TNM system

T: primary tumor
N: lymph node involvement
M: distant metastasis

Front 39

If a patient is going in for surgery, is pathologic or radiographic staging preferred?

Back 39

Pathologic
(more accurate)

Front 40

List the various ways that lung cancer can be upraged on the T system.

Back 40

1. Size (T1 = < 3cm, T2 = 3- 7 cm, T3 = >7cm)
2. Structure
3. Location (T2 = > 2cm from carina, T3 = <2 cm from carina)

Front 41

List the T stages of lung cancer based on size.

Back 41

T1 = < 3 cm
T2 = 3 - 7 cm
T3 = > 7 cm

Front 42

If there is evidence of invasion what T stage would the lung cancer be defined as?

Back 42

T3

Front 43

If a patient is has two nodules within the same lobe of the lung, what stage would this patient be?

Can this patient be evaluated for resection?

Back 43

T3

Yes, this patient can be evaluated for resection. Any staging higher than T3 does NOT warrant evaluation for resection

Front 44

Can T3s be resected by surgeons? How about T4s?

Back 44

T3s can be resected, but T4s cannot

Front 45

In the TNM staging system, what do "a" and "b" stand for?

Back 45

"a" --> metastasis in chest
"b" --> more distant metastasis

Front 46

What is the main therapy for treatment of small cell carcinoma?

What treatment is used for limited disease?

Back 46

*Chemotherapy

For limited disease, chemotherapy + radiation therapy is used

Front 47

What procedure reduces the risk of brain metastasis in small cell lung cancer?

Back 47

Cranial irradiation

*Tumor spread to the brain is one of the main types of relapse after complete response from chemo and radiation therapy

Front 48

What are the estimated survival spans for limited and extensive small cell carcinomas?

Back 48

Limited disease --> 14 - 20 months
Extensive disease --> 8 - 13 months

Front 49

What type of treatment is done for Stage 1 Non-small cell carcinomas?

Back 49

1. Surgical resection
2. Radiation therapy for patients who are not surgical candidates

Front 50

Is post-op radiation recommended for Stage 1 or Stage 2 NSC carcinoma treatment?

Back 50

No; it is not recommended for either because it appears to be harmful

Front 51

What is the treatment for Stage II NSC?

Back 51

1. Surgery (most effective)
2. Radiation for patients who are not surgical candidates

Front 52

What type of treatment is best for Stage IIIa NSC?

Back 52

1. *Complete resection
2. Cisplatin based induction chemotherapy followed by surgery appears to improve survival

(Radiotherapy has no survival advantage)

Front 53

What is the standard of care for Stage IIIB NSC?

Back 53

1. Radiation therapy
(Addition of Platinum-based chemotherapy appears to have a modest survival benefit)

Front 54

What is the best treatment for Stage IV NSC?

Back 54

Chemotherapy
(platinum-based combination)

Front 55

List the 4 conditions in which a pneumonectomy is likely to be tolerated.

Back 55

1. FEV1 > 2L or >60% of predicted
2. MVV > 50% of predicted
3. RV/ TLC < 50%
4. DLCO > 60% of predicted

Front 56

List 2 relative contraindications for lung resections.

Back 56

1. Hypoxemia (<60 mmHg)
2. Hypercapnea (>45 mmHg)

Front 57

Before performing a pneumonectomy, how can post-op FEV1 be predicted?

What do you want the post-op FEV1 to be?

Back 57

A lung scan can be used to predict post-op FEV1
(pre-op FEV1 x %perfusion of the remaining lung)

*>40%

Front 58

When performing pre-op assessments prior to lung resections, which VO2 values are low risk and which are high risk?

Back 58

VO2 > 20 ml/kg/min --> low risk
VO2 < 10 ml/kg/min --> high risk

Front 59

List some therapies that are aimed at providing symptomatic relief.

Back 59

(bronchoscopic techniques)
1. Stents
2. Brachytherapy
3. Laser therapy (photodynamic therapy, cryotherapy)

Front 60

If a lesion is approaching an airway, what can be done to avoid airway collapse and provide symptomatic relief?

Back 60

Stent

Front 61

What type of therapy can be used to debride large bulky central airway tumors and provide symptomatic relief?

Back 61

Laser therapy

Front 62

How can you screen for lung cancers?

Back 62

Chest x-ray +/- sputum cytology

Front 63

What age group should be screened for lung cancer?

Back 63

55- 74 year olds

Front 64

Patients with what type of smoking history should be screened for lung cancer?

Back 64

Either current or former smokers
Smoking history of 30 pack years

Front 65

How often should high risk patients be screened for lung cancer?

Back 65

3 annual screens with either low dose CT or chest xray