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Lung CancerPresentation: fever, chest pain, weight loss, fatigue, weakness, decreased activity, worsening cough, dyspnea, decreased appetite, weight loss, and pain / malignant serosanguineous pleural effusions are common and are often large and recurrent. Diagnosis (also see SPN below) [NEJM] CXR (mass, effusion) bronchial narrowing and irregularity, parenchymal infiltration, or atelectasis. Cavitation may be visible in an obstructed area or within a peripheral tumor. Pleural effusions are often associated with infiltrating or peripheral tumors thoracentesis (60% yield in NSCLC; would be IIIB T4) / pH usu. > 7.3 (< 7.2 worse prognosis) / WBC < 4000 cells/mm3 (< 25% neutrophils; more suggests infection) CT (chest, head, liver) bronchoscopy MRI (its role is evolving) CT (still debated whether screening is beneficial or cost-effective 3/07) bone scan LFT bronchial biopsy, washings mediastinoscopy with lymph node biopsy exploratory thoracotomy required in < 10% of cases to establish the diagnosis (if any evidence of mets, probably no benefit; such as lymph nodes, skin, liver, pleura) Ddx: foreign bodies, nonsegmental pneumonia, endobronchial and focal pulmonary manifestations of TB, systemic mycoses, autoimmune disease, metastatic disease caused by an extrathoracic primary cancer. Solitary pulmonary nodules are difficult to differentiate. Metastases to the lungs are common from primary cancers of the breast, colon, prostate, kidney, thyroid, stomach, cervix, rectum, testis, bone and melanoma Treatment: radiation / chemotherapy (see other sources) Primary Lung Cancer Staging: T - location (3 cm cutoff) N - nodes involved M - metastases (brain, bone, liver)
squamous, small cell, adenocarcinoma, large cell Non-smokers (15%) ⅔ are adenocarcinoma (even most adenocarcinomas are from smoking), bronchoalveolar adenoma, other Central squamous, small cell, adenocarcinoma (↓) Peripheral large cell, adenocarcinoma (↑) Pattern of spread all types also commonly spread via the lymphatics / large cell also more through bloodstream Bronchogenic Carcinomas (SCLC vs. NSCLC) divided into small cell and non-small cell (adenocarcinoma, large cell, squamous cell) Note: treatment is chemotherapy and/or radiation for SLCL (rarely surgery) and resection (if possible) and/or chemo for NSCLC / 10% of NSCLC develop some form of HOA (Pierre-Marie-Bamberger syndrome) [pic] Small Cell Carcinoma (SCC) (20%) – central oat cell / metastases / smoking / often secrete ectopic hormones (SIADH, ACTH) causing symptoms of hypokalemia (ACTH) or hyponatremia (ADH) / hemoptysis uncommon Associations: Lambert-Eaton syndrome Treatment: chemotherapy (not resectable) / 20% can be cured if caught very early Squamous Cell Carcinoma (30%) – central metastasis uncommon / smoking / PTH-related (PTHrP) hypercalcemia / HOA with clubbing Adenocarcinoma (35%) – peripheral > central characteristic HOA w/ clubbing / makes up 70% of lung cancers in non-smokers Large Cell (10%) – peripheral smoking / usually spreading through the bloodstream Bronchoalveolar adenoma – peripheral not associated with smoking / multifocal origin but often does not extend beyond the lungs / watery, profuse, blood-streaked hemoptysis Bronchial carcinoid (5%) benign or malignant / male = female Complications: may obstruct lumen, frequent bleeding, recurrent pneumonia, pleural pain / carcinoid syndrome (3%) Course: prolonged / mets (uncommonly) to regional lymph nodes Pancoast tumorrefers to an apical carcinoma causing pancoast syndrome Other Lung Tumors Lymphoma – usually solitary, can be multifocal Sarcoma – malignant Carcinosarcoma
Adenoid cystic .5% Mucoepidermoid carcinoma .2% Malignant fibrous histiocytoma Melanoma Blastoma
Mucoepidermal Angiomas – may regress Squamous papillomatosis – often recur
“popcorn” or “bull’s eye” pattern of calcification / cartilage, connective tissue, epithelium Sclerosing hemangioma 80% female / calcification on X-ray / blood spaces Horner’s syndrome invasion of the cervical thoracic sympathetic nerves (paravertebral stellate ganglion) (often by lung cancer) Findings: enophthalmos, miosis, ptosis, ipsilateral facial anhidrosis, narrowing of palpedral fissure [pic][pic][pic] Ddx: brainstem or posterior circulation CVA, carotid artery dissection, cavernous sinus thrombosis, trauma, metastatic disease Pancoast syndrome infiltration of brachial plexus and neighboring ribs and vertebrae, may involve phrenic nerve / Findings: pain, numbness, and weakness of the affected arm and/or Horner’s syndrome (see above) Superior vena cava syndrome (SVC syndrome or SVCS) obstruction of venous drainage dilation of collateral veins in upper chest, neck edema and plethora of face, neck, upper part of the torso, including the breasts; suffusion and edema of the conjunctiva; breathlessness when supine; CNS symptoms (headache, visual distortion, ΔMS, dizziness, syncope); dysphagia, hoarseness Causes: lung cancer (small cell, squamous cell), other malignant neoplasms (lymphoma, Hodgkin’s disease, small cell carcinoma, squamous cell carcinoma, germ cell tumors, and breast cancer), TB, fungal infections, retrosternal thyroid, aortic aneurysms, fibrosing mediastinitis, benign tumors Treatment: if airway impaired, may need urgent bronchoscopy with stenting, surgical consultation / if lymphoma strongly suspected, may begin steroids even before tissue diagnosis Hematogenous metastatic spread to the liver, brain, adrenals, and bone Paraneoplastic syndromes hypertrophic pulmonary osteoarthropathy (the best known), clubbing of the fingers and toes and periosteal elevation of the distal parts of long bones occur. All levels of the nervous system may be affected--principally causing encephalopathy, subacute cerebellar degeneration, encephalomyelitis, the CNS paraneoplastic 60% become symptomatic (CNS-wise) wise before any symptoms from primary tumor occur can test for variety of antibodies [table]; no specific antibodies are found in 40% (that may change) may use PET scan or MRI to locate mets or primary [MRI] (note can have false positive on axilla of side of injection of tracer material) Eaton-Lambert syndrome (see other) and peripheral neuropathy Paraneoplastic cerebellar degeneration [NEJM] may present as progressive cerebellar ataxia [table] / 20% have mild memory and cognitive impairment (paraneoplastic limbic encephalitis), new onset seizures (complex partial) Associated malignancies: small cell lung cancer > breast, ovarian, testicular, Hodgkin’s MRI: patchy increased T2 without enhancement on T1 distinguishes from brain tumor, other / Purkinje cell dropout in cerebellum shows as atrophy EEG: focal temporal sharp waves
antineuronal nuclear antibody type 1 (ANNA-1, anti-Hu) usu. positive with SCLC anti-Yo seen with breast, ovarian tumors anti-Tr, anti-glutamate receptor antibodies Polymyositis and dermatomyositis metabolic syndromes due to production of substances with hormonal activity Small cell carcinomas may secrete ectopic ACTH, resulting in Cushing’s syndrome, or ADH, causing water retention and hyponatremia, and are also associated with the carcinoid syndrome (flushing, wheezing, diarrhea, and cardiac valvular lesions). Squamous cell carcinomas may secrete parathyroid hormone-like substances that produce hypercalcemia. Other endocrine syndromes associated with primary lung carcinomas include gynecomastia, hyperglycemia, thyrotoxicosis, and skin pigmentation. Hematologic disorders, including thrombocytopenic purpura, leukemoid reaction, myelophthisic anemia, polycythemia, and marantic thrombosis, may also occur. Findings: gynecomastia, skin pigmentation Other associations: thyrotoxicosis, TTP, leukemoid reaction, polycythemia, myelophthisic anemia Single Pulmonary Nodule (SPN) 50% (< 3 cm) prove malignant / coin lesion without surrounding atelectasis or adenopathy Benign: 80% infectious granulomas, 10% hamartomas, 10% other Malignant: > 3 cm is probably malignant; most are bronchogenic carcinoma Ddx: Coccidioides, Histoplasma, Tb, RA, Wegener’s Bayesian approach pre-test risk of malignancy vs. need for early removal / if patient < 35 yrs, non-smoker, can follow radiographically first Risk factors: age, smoking, hemoptysis, size, edge characteristics on CT, prior malignancy Other: carcinogens, travel, endemic mycoses, prior lung disease Guidelines for following: constantly changing; (~4-8 mm seems to be a size parameter below which the optimal frequency of repeat CT is debated) CXR: size / growth rate / margin: corona radiata (80-90% malignant) calcification: laminated or central granuloma popcorn hamartoma diffuse benign eccentric/stippled malignant less specific cavitations [CXR], satellite lesions
if thought to be benign ( < 35 yrs, stable for 2 yrs, classic calcification pattern) repeat CXR q 3 months for 1st yr, q 4-6 mo for 2nd year if thought to be malignant VATS frozen thoracotomy/lobectomy indeterminate (usually will prove malignant) PET (18FDG PET scanning): has 95% sensitivity, 75% specificity (also good for demonstrating positive nodes) / false negatives more likely with tumors < 1 cm, bronchoalveolar carcinomas, carcinoid tumors / false positives from inflammation Bronchoscopy (better for central): sensitivity 80% > 3 cm (50% peripheral) / 2-3 cm (40-60% yield) / < 1.5 cm (10% yield) Transthoracic needle biopsy (better for peripheral): 80-95% sensitivity, 50-85% specificity; better than bronchoscopy for peripheral lesions Download 3.95 Mb. Share with your friends:
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