Updated: 7/2/2019

Lung Cancer

Topic
Review Topic
0
0
Questions
12
0
0
Evidence
9
0
0
Snapshot
  • A 65-year-old man with a 40 pack-year smoking history presents to his primary care physician for fatigue and cough. He reports that his symptoms began approximately 1 year ago and has progressively worsened. He has noticed a streak of blood when coughing into a napkin. He says that at times he wakes up from sleep drenched in sweat. Compared to his last visit 4 months ago he has lost 12 pounds which he states is unintentional. Physical examination is notable for finger clubbing. Radiography of the chest demonstrates a pulmonary nodule, and no prior imaging is available. A CT scan of the chest demonstrates an 11 mm pulmonary eccentric nodule located peripherally. 
Introduction
  • Clinical definition
    • malignancy that affects the lung parenchyma or airways
      • most lung cancers can be divided into
        • small cell lung cancer 
        • non-SCLC 
 
Small Cell Lung Cancer (SCLC)
Type
Location
Associated Findings Histology
SCLC (oat cell)
  • Central
  • MYC gene amplication
  • May produce
    • adrenocorticotropic hormone (ACTH)
      • leads to Cushing syndrome
    • excessive anti-diuretic hormone (ADH)
      • leads to syndrome of inappropriate ADH (SIADH)
    • presynaptic calcium channel antibodies
      • leads to Lambert Eaton syndrome 
  • Kulchitsky cells
  • Positive for
    • neuron-specific enolase
    • chromogranin A
 
Non-Small Cell Lung Cancer (NSCLC)
Type
Location
Associated Findings Histology
Adenocarcinoma
  • Peripheral
  • Most common  
    • cause of lung cancer in non-smokers
    • cause of lung cancer (excluding metastasis)
  • Adenocarcinoma in situ
    • tumor growth along alveolar structures
      • lepidic growth pattern
  • Patients may have hypertrophic osteoarthropathy
  • Common gene mutations include
    • KRAS
    • EGFR
    • ALK
  • Typically mucin positive and has a glandular appearance
Large cell carcinoma
  • Peripheral
  • Associated with a poor prognosis
  • Highly associated with smoking
  • Pleomorphic giant cells
Squamous cell carcinoma of the lung 
  • Central
  • Can arise from the bronchus
  • Keratin pearls
  • Intracellular bridges 
Bronchial carcinoid tumor -
  • Carcinoid syndrome
  • Better prognosis
  • Neuroendocrine cells
  • Chromogranin A positive
 
  • Epidemiology
    • incidence
      • second most common cancer
      • leading cause of cancer-related death
    • risk factors
      • cigarette smoking
        • most important risk factor
        • second-hand smoking
      • asbestos
      • radon
  • Etiology
    • tobacco smoke is the most common cause
  • Prognosis
    • depends on cancer type and severity
  • Screening
    • performed with a low-dose computerized tomography (CT) scan of the chest  
      • indicated in patients 55-80 years of age who have a 30 pack-year smoking history and
        • currently smoke or
        • has quit within the past 15 years
Presentation
  • Symptoms
    • cough
    • unintentional weight loss
    • hemoptysis
    • chest pain
    • dyspnea
    • hoarseness
      • suggests involvement in the recurrent laryngeal nerve
Imaging
  • Radiography
    • indication
      • initial imaging modality when evaluating a patient with symptoms concerning for lung cancer
        • it is highly important to review old chest imaging to assess for lesion properties and changes 
  • Computerized tomography (CT) scan
    • indication
      • perform with low-doses to screen for lung cancer (review "screening" in the introduction)
      • to further evaluate pulmonary nodule found on radiography
Studies
  • Laboratory testing
    • complete blood count
    • liver function tests (e.g., alanine aminotransferase, aspartate aminotransferase, and total bilirubin)
      • abnormalities may suggest liver metastasis
    • alkaline phosphatase
      • abnormalities may suggest liver or bone metastasis
        • a gamma-glutamyl transpeptidase (GGT) should be obtained to differentiate between liver or bone involvement
    • calcium
      • abnormalities may suggest bone metastasis or paraneoplastic syndromes
  • Pulmonary function tests
  • Evaluation of an incidental solitary pulmonary nodule
    • introduction
      • benign features
        • diffuse
        • central
        • popcorn
        • concentric
      • malignant features
        • ground-glass
        • eccentric
    • chest CT should be obtained for all patients with an unclearly characterized solitary pulmonary nodule seen on radiography 
    • solitary pulmonary nodule < 8mm
      • if there are or aren't risk factors, one typically does surveillance with a chest CT in a few months depending on the size of the lesion
    • solitary pulmonary nodule > 8mm
      • very low probability of malignancy
        • CT surveillance 
      • low/moderate probability of malignancy
        • positron emission tomography (PET) scan  
          • if absent or mild uptake
            • CT surveillance
          • if moderate or intense uptake
            • biopsy or video-assisted thoracoscopic surgery
      • high probability of malignancy
        • staging evaluation with or without PET scan
Differential
  • Tuberculosis (Tb)
    • differentiating factors
      • abnormal quantiferon or purified protein derivative (PPD) test
      • history of increased risk of exposure (e.g., household contact with someone with diagnosed Tb and travel to Tb endemic area)
Treatment
  • SCLC
    • most cases are non-resectable and thus require chemotherapy (e.g., carboplatin and etoposide)
  • NSCLC
    • treatment includes surgical removal, lymph node sampling or dissection, radiation, and chemotherapy
      • depends on the staging
Complications
  • Superior vena cava syndrome 
  • Pancoast tumor
  • Metastasis 
  • Horner syndrome  
  • Pericardial effusion
  • Pleural effusion
  • Paraneoplastic syndromes
    • Lambert-Eaton syndrome
    • SIADH
    • Cushing syndrome

 

Please rate topic.

Average 4.9 of 8 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (12)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.ON.0) A 50-year-old man presents to his primary care physician for management of a lung nodule. The nodule was discovered incidentally when a chest radiograph was performed to rule out pneumonia. The nodule is 8.5 mm in size and was confirmed by CT. The patient is otherwise healthy, has never smoked, and exercises regularly. The patient works in a dairy factory. He has had no symptoms during this time. His temperature is 97.6°F (36.4°C), blood pressure is 122/81 mmHg, pulse is 83/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam including auscultation of the lungs is unremarkable. Which of the following is the most appropriate next step in management? Review Topic

QID: 108420
1

Biopsy and lymph node dissection

0%

(0/0)

2

CT scan in 6 months

0%

(0/0)

3

No further workup indicated

0%

(0/0)

4

PET scan

0%

(0/0)

5

Surgical excision

0%

(0/0)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 4
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M3.ON.23) A 68-year-old female presents to your office for her annual check-up. Her vitals are HR 85, T 98.8 F, RR 16, BP 125/70. She has a history of smoking 1 pack a day for 35 years, but states she quit five years ago. She had her last pap smear at age 64 and states all of her pap smears have been normal. She had her last colonoscopy at age 62, which was also normal. Which is the following is the next best test for this patient? Review Topic

QID: 102964
1

Abdominal ultrasound

0%

(0/0)

2

Chest CT scan

0%

(0/0)

3

Pap smear

0%

(0/0)

4

Colonoscopy

0%

(0/0)

5

Chest radiograph

0%

(0/0)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 2

You have 100% on this question.
Just skip this one for now.

(M2.ON.75) A 62-year-old Caucasian male presents to his primary care physician following a week long history of abdominal pain, nausea and vomiting. The patient also reports reduced appetite, fatigue, polyuria, and pain in his lower back. The patient has a 40-pack year history of smoking. Laboratory values are notable for the following: Serum calcium: 12.2 mg/dL, Serum phosphorus: 2.4 mg/dL, and Alkaline phosphatase: 80 U/L. Chest radiograph shows a left middle lobe mass that was not present on prior chest radiograph 2 years ago. Serum parathyroid hormone-related peptide is elevated. Serum electrophoresis is shown in Figure A. Which of the following is the most likely diagnosis?
Review Topic

QID: 104400
FIGURES:
1

Multiple myeloma

0%

(0/18)

2

Small cell lung cancer

22%

(4/18)

3

Adenocarcinoma of the lung

0%

(0/18)

4

Squamous cell lung cancer

72%

(13/18)

5

Sarcoidosis

0%

(0/18)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 4

You have 100% on this question.
Just skip this one for now.

(M2.ON.4) A 40-year-old man is brought to the emergency room after being struck by an automobile. He complains of left-sided chest pain. He denies chest discomfort on exertion, shortness of breath, and coughing. His temperature is 37 C (98.6 F), blood pressure 130/70 mm Hg, heart rate 90/min, and respiratory rate 16/min. On physical exam, he has bruising over the left chest wall. Cardiac, pulmonary, and abdominal exams are within normal limits. His chest radiograph shows no rib fractures, but reveals a single round lesion as shown in Figure A. He denies any previous chest radiographs. He also denies any history of weight loss, fatigue, or hemoptysis. He says he has never smoked cigarettes. What is the best next step in the management of this patient's pulmonary lesion? Review Topic

QID: 105821
FIGURES:
1

Reassurance

56%

(9/16)

2

CT scan of the chest

31%

(5/16)

3

Bronchoscopy

0%

(0/16)

4

CT guided biopsy

6%

(1/16)

5

PET scan

0%

(0/16)

M2

Select Answer to see Preferred Response

SUBMIT RESPONSE 2
ARTICLES (9)
Topic COMMENTS (12)
Private Note