ANKIT BHANDARI

Lung Cancer 1

Background information

More people die from lung cancer than from any other cancer

5-Year survival Rate is 49 Percent when confined to one part 16 percent spread within chest 2 Percent if it has spread outside of the chest

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Risk Factors

Cigarette smoking AsbestosRadon

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Who should be Screened?

U.S. Preventive services task force Recommends low Dose computer Tomography.

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Two Sub Groups of Lung cancer

Small cell lung cancer Non-small cell Lung cancer

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Clinical Features

Fever, weight loss and Hemoptysis

Chest X-ray

Lung Mass

CT Scan w/ IV contrast

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Symptoms

Local Invasion Recurrent laryngeal nerve palsy Horner’s syndrome SVC syndrome Phrenic nerve palsy

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SVC syndrome8

Phrenic Nerve Palsy 9

Paraneoplastic syndrome associated with lung cancers.

Syndrome Causes Likely Subtype

Cushing syndrome ACTH

Small cell carcinoma Lambert-Eaton Syndrome

Ab to voltage gated calcium channel

Hyponatermia SIADH

Hypercalcemia PTHrp Squamous cell carcinoma

Hypertrophic pulmonary osteoarthropathy

Painful periosteal growth and clubbing

Adenocarcinoma

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Pulmonary Nodule

No symptoms, X-ray

Pulmonary Nodule

New Nodule Nodule

changed in size > 2 yr?

Stop Workup Follow Yearly

CT with thin sections through nodule

Biopsy Resect

Follow every 3 mo

Film not available

Suspicious Benign

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Benign Versus Malignant Solitary Pulmonary nodules

Factors favor Benign diagnosis Factors that favor Malignancy

Age Less than 50 years Age more than 50 years

Non smoker Smoker or previous smoker

Size of nodule <2.0 cm Size of nodule > 3.0 cm

No Growth over 2 year period Steady growth on serial radiographs

Nodule circular and regular shaped

Nodule grossly irregular or speculated margins

Central laminated calcification Stippled or eccentric pattern

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Pathologic Confirmation

Bronchoscopy- central CT guided percutaneous biopsy- peripheral Video Assisted thoracoscopy- inside lung

parenchymaPleural effusion is present get cytology

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Therapy

Prognosis and management is based on tumor staging Non-small cell lung cancer

Staging Evaluation CT abdomen and a combined PET and CT scan Bone pain: bone scan and calcium and ALP levels

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Staging and Prognosis for non-small cell Lung cancer

Stage Definition Prognosis

I Tumor surrounded by lung or pleura and 2 cm from carina

60% to 70 long term disease-free survival

II Locally advanced disease without mediastinal involvement

40% to 50% long term disease-free survival

III Mediastinal involvement, or two separate tumor nodules in same lobe without mediastinal involvement

5% to 20% long term disease-free survival

IV Metastatic Median survival 7 months

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Treatment

NSCLC Overall Surgery is best option

Stage Treatment

I Surgery and in few cases adjuvant chemotherapy

II Surgery and adjuvant chemotherapy

III Combinations

IV Chemotherapy only

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Therapy

SCLC Limited

Combination of Chemotherapy and Radiation therapy Widespread

Only Chemotherapy first and Radiation to decrease the incidence of brain metastases

Even if good response to Chemotherapy, response is short lived.

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1) A 62-year-old man is evaluated for a persistent cough of 9 months' duration and a 4.5-kg (10-lb) unintentional weight loss over the past 6 weeks. The patient has a 30-pack-year history of smoking cigarettes and continues to smoke.

On physical examination, his vital signs are normal. His body mass index is 24. There are decreased breath sounds and dullness to percussion at the right base. The remainder of the physical examination is normal.

Chest radiography confirms a right pleural effusion. Chest computed tomography (CT) confirms a right pleural effusion and a 2.1-cm spiculated nodule in the right middle lobe.

Which of the following is the most appropriate next Diagnostic Test? A. CT-Guided biopsy of the lung nodule B. Integrated Whole body PET-CT scan C. Magnetic resonance imaging of the brain D. Radiographic bone survey E. Thoracentesis and pleural fluid cytology

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2) A 65-year-old woman seeks consultation in the office regarding lung cancer screening. She has a 40-pack-year history of cigarette smoking and continues to smoke. Her only active medical problem is chronic obstructive pulmonary disease treated with daily tiotropium inhaler and an albuterol inhaler as needed.

On physical examination, her vital signs are normal. Breath sounds are distant with occasional wheezing. The remainder of the physical examination is normal.

Which of the following screening tests can be recommended? A. Annual Chest radiography B. Annual Sputum for cytology C. Combination annual chest radiography and sputum for cytology D. Low-dose spiral chest computed tomography

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3) A 62-year-old man is evaluated following the incidental discovery of a 3-mm left lower lobe lung nodule on a recent computed tomography (CT) scan of the abdomen performed to evaluate for kidney stones. He has never smoked and has an otherwise unremarkable medical history. He takes no medications.

On physical examination, his vital signs are normal. The physical examination is unremarkable.

A dedicated CT of the chest shows only the 3-mm left lower lobe nodule and is otherwise normal. There are no other chest images available for comparison.

Which of the following is the most appropriate next step in management of this patient?

A. CT of the chest in 3 months B. CT of the chest in 6 months C. CT of the chest in 12 months D. No follow-up imaging

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4) A 55-year-old woman is evaluated for a cough, weakness, and fatigue of 4 weeks' duration. She has a 40-pack-year history of cigarette smoking.

On physical examination, her temperature is normal, blood pressure is 136/78 mm Hg, and pulse rate is 68 beats/min. No palpable lymphadenopathy is noted. The cardiopulmonary and neurologic examinations are normal.

A chest radiograph demonstrates a 5-cm left upper lobe pulmonary mass. A subsequent computed tomography (CT) scan shows the mass but no evident mediastinal lymphadenopathy. A positron emission tomography (PET) scan displays radiographic uptake in the mass but no disease elsewhere. A CT-guided biopsy demonstrates squamous cell carcinoma.

Which of the following is the most appropriate treatment? A. Combination chemotherapy and radiation B. Radiation C. Surgery and adjuvant chemotherapy D. Systemic chemotherapy

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