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Lung Cancer Cheat Sheet by

ACNP CheatSheet
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Lung Cancer

Pathology
• Small cell lung cancer represents 25%. Non-­small cell represents 75%, and includes squamous cell carcinoma (30%), adenoc­arc­inoma (35%), large cell carcinoma (5-10%), and bronch­oal­veolar carcinoma. Tissue biopsy is needed to distin­guish the two.
Risk Factors
Ciga­rette smoking (>85% of patients) with a linear relati­onship between pack-years and risk. Adenoc­arc­inoma has the lowest associ­ation with lung cancer. Passive smoke, redone (high levels in baseme­nts), and COPD (indep­endent risk factor even after smoking is taken out). Asbestos (common in shipbu­ilding and constr­uction, car mechanics, and painting profes­sions) and smoking synerg­ist­ically increase risk of lung cancer.
Local Symptoms
• Most commonly associated with squamous cell. Airway involv­ement can lead to cough, hemopt­ysis, obstru­ction, wheezing, and dyspnea. Recurrent pneumonia (post obstru­ctive).
Consti­tut­ional Symptoms
• Anorexia, weight loss, and weakness. Usually associated with advanced disease.
Staging
• NSCLC uses the TNM system.
• SCLC is either limited (confined to chest plus suprac­lav­icular nodes--but not cervical or axillary nodes) or extensive (outside the chest and suprac­lav­icular nodes).
Prognosis
• In SCLC, 5-year survival is 10-13% for limited disease and 1-2% for extensive disease. 85% of SCLC have extensive disease at time of presen­tation. Overall 5-year survival for lung cancer is 14%.
Metastatic Disease
Most common sites are brain, bone, adrenal glands, and liver.
Malignant Pleural Effusion
Occurs in 10-15% of patients. Prognosis is very poor and equivalent to distant metast­ases.

Types

Features of NSCLC
• Squamous (20-25% of lung cancer) is usually central and can have necros­is/­cav­ita­tion. It is associated with hype­rCa and the leading cancer in nonsmo­kers.
• Adenoc­arc­inoma (40-50%) is often peri­phe­ral, involves pleura in 20% of cases, and can be associated with pulm­onary fibrosis, clubbing, and hypert­rophic osteoa­rth­rop­athy.
• Large cell (5-10%) is usually peripheral and associated with gyneco­mastia and galact­orrhea.
Features of SCLC
• Accounts for 10-15% of cases.
Cent­ral, tend to narrow bronchi by extrinsic compre­ssion, and widespread metastases are common (50-75% of patients at presen­tat­ion). • Associated with Cushing syndrome, SIADH, and Lamber­t-Eaton syndrome.

Solitary Pulmonary Nodule

Pathology
Single, well circum­scr­ibed nodule on CXR without associated medias­tinal or hilar lymph node involv­ement. Has a wide differ­ential diagnosis.
Diagnosis
Flexible bronch­oscopy for central lesions, transt­horacic needle biopsy, PET scan.
CXR
If stable for more than 2 years, likely benign. Malignant lesions grow relatively rapidly. Growth over days is usually infectious or inflam­matory (not malign­ant).
Indica­tions of Benign Nodule
Younger age (50% chance of malignancy if patient is >50), nonsmoker, smaller size (<1­cm), smoo­th/­dis­crete borders, dense, central calcif­ication (eccentric asymmetric calcif­ication indicates malign­ancy), no change in size.
Low Probab­ility Nodules
Get serial CTs.
Interm­ediate Probab­ility
<1cm: serial CTs.
Interm­ediate Probab­ility >1cm
PET scan. If positive, transt­horacic needle aspiration biopsy or fiberoptic bronch­oscopy, then excise the nodule.
High Probab­ility
Excision
 

Syndromes

SVC Syndrome
• Occurs in 5% of patients and is cause by obst­ruction of the SVC by a medias­tinal tumor (most commonly SCLC). Associated with facial fullness, dyspnea, venous conges­tion, facial and arm edema, dilated veins over the anterior chest, arms, and face, and JVD.
Phrenic Nerve Palsy
• Occurs in 1% of patients: destru­ction of phrenic nerve by tumor, as the phrenic nerve courses through the medias­tinum to innervate the diaphragm. Results in hemi­dia­phr­agmatic paraly­sis.
Recurrent Laryngeal Nerve Palsy
• Occurs in 3% of patients. Causes hoarse­ness.
Horner's Syndrome
• Due to invasion of cervical sympat­hetic chain by an apical tumor.
• Symptoms include unil­ateral facial anhidr­osis, ptosis, and miosis.
Pancoast's Tumor
• Superior sulcus tumor.
• Apical tumor involving C8 and T1-T2 nerve roots, causing shoulder pain radiating down the arm.
• Usually squamous cell cancers.
• Symptoms include pain, UE weakness due to brachial plexus invasion, suprac­lav­icular lymph node enlarg­ement, and weight loss.
• Associated with Horner's Syndrome (ipsil­ateral ptosis, mitosis, enopth­almos, and anhidr­osis) 60% of the time. Usually NSCLC.
Parane­opl­astic Syndromes
SIADH in SCLC (10%).
• Ectopic ACTH secretion in small cell carcinoma. PTH-like hormone secretion is squamous cell carcinoma (const­ipa­tion, thirst, anorexia).
• Hypert­rophic pulmonary osteoa­rth­ropathy in adenoc­arc­inoma and squamous cell carcinoma, associated with severe long bone pain.
• Eaton-­Lambert Syndrome most common in SCLC and looks like myasthenia gravis (proximal muscle weakne­ss/­fat­iga­blity, diminished deep tendon reflexes, parest­hes­ias), digital clubbing.

Treatment

Treatment of NSCLC
Surgery is the best option, but patients with metastatic disease outside the chest are not candid­ates. Recurrence can occur even after complete resection. Radiation is important. Chemot­herapy is of uncertain benefit.
Treatment of SCLC
For limited disease, combo chemor­adi­ation therapy used initially. For extensive disease, chemot­herapy alone as the initial treatment. If the patient responds, prophy­lactic radiation decreases incidence of brain metastases and prolongs survival. Usually unrese­ctable.
 

Testing

CXR
Most important study for diagno­sis. Demons­trates abnormal findings in nearly all patients.
• Stability of an abnorm­ality over a 2 year period is almost always associated with a benign lesion.
• May show pleural effusion, which should be tapped and examined for malignant cells.
CT Scan
With IV contra­st. Very useful for standing and accurate in revealing LAD in medias­tinum. Can demons­trate extent of local and distant metast­asis.
Cytology of Sputum
Diagnoses central tumors in 80% of cases but not peripheral lesions. Provides highly variable results. If negative and clinical suspicion is high, further tests are indicated.
Bronch­oscopy
Can only be inserted as far as secondary branches of bronchial tree. Useful for diagnosing central visualized tumors but not peripheral lesions. The larger and more central a lesion, the higher the diagnostic yield. For visible tumors, bronch­oscopy is diagnostic in >90% of cases.
PET Scan
Provides additional inform­ation that primary tumor is malignant, detect lymph node and intrat­horacic and distant metast­ases.
Transt­horacic Needle Biopsy
Highly accurate and useful for diag­nosing peripheral lesions as well. Under fluoro­scopic or CT guidance. Invasive procedure only used in selected patients.
Medias­tin­oscopy
Allows direct visual­ization of superior medias­tinum. Identifies patients with advanced disease who would not benefit from surgical resection.

Medias­tinal Mass

Causes
Meta­static cancer is the most common cause in older patients. If anterior, thyroid, terato­genic tumors, thymoma, or lymphoma. If middle, lung cancer, lymphoma, aneurysms, cysts, or Morgagni hernia. If posterior, neurogenic tumors, esophageal masses, enteric cysts, aneurysms, or Bochda­lek's hernia.
Clinical Presen­tation
Usually asympt­omatic. If symptoms are present, usually due to compre­ssion or invasion. Cough from compre­ssion of trachea or bronchi, sometimes with hemopt­ysis. Chest pain, dyspnea, post obstru­ctive pneumonia, dysphasia (esoph­ageal compre­ssion), SVC syndrome, hoarseness (compr­ession of recurrent laryng­eal), Horner's (compr­ession of sympat­hetic ganglia), diaphragm paralysis (compr­ession of phrenic).
Germ Cell Tumors
Anterior medias­tinal mass with elevated levels of BhCG and AFP. Occur primarily in young male patients and are locally invasive. BhCG occurs in both semino­matous and nonsem­ino­matous germ cell tumors, but only the latter makes AFP. Diagnosis confirmed with biopsy. Usually primary tumors and not metastatic from the testicles.
Diagnosis
CT is test of choice. Usually discovered incide­ntally on CXR.

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