10. Lung Cancer – Clinical Presentation 10 % asymptomatic at presentation
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Editor's Notes
Talked about UMN signs vs. LMN signs.
7/8/09: TWO VIEWS OF THE CHEST ARE COMPARED TO 10/28/2007. IN THE INTERVAL, THERE HAS BEEN DEVELOPMENT OF A LARGE, WELL CIRCUMSCRIBED FLUID AND GAS COLLECTION, WHICH PROJECTS OVER THE SUPERIOR SEGMENT OF THE LEFT LOWER LOBE. THE APPEARANCE IS NONSPECIFIC BUT IS CONCERNING FOR INFECTION, POSSIBLY A PULMONARY ABSCESS OR FLUID FILLING A LARGE PNEUMATOCELE. THIS IS SLIGHTLY LATERAL OF MIDLINE TO REPRESENT A DUPLICATION CYST OR GASTROINTESTINAL DIVERTICULA. THERE IS NO ASSOCIATED PLEURAL EFFUSION OR PNEUMOTHORAX. HEART SIZE IS NORMAL.
CT head (non contrast): 9/14/09: There is a high left frontal white matter 4.5 x 4 cm low-attenuation area, most compatible with white matter edema. Further evaluation with MRI of the brain with contrast is advised to rule out a left frontal lobe neoplasm. There is no intracranial hemorrhage. There is no midline shift or hydrocephalous. There is no abnormal extra-axial fluid collection. The basilar cisterns are patent. Mucosal thickening of both ethmoid sinuses.
CT chest 7/8/09: 7.8-CM CIRCUMSCRIBED NECROTIC MASS IN THE SUPERIOR SEGMENT OF THE LEFT LOWER LOBE. LESS LIKELY ABSCESS. 3.2-CM LOW DENSITY LEFT ADRENAL MASS. OTHERWISE UNREMARKABLE. REPORT: AXIAL SCANS OF THE CHEST WITH CORONAL RECONSTRUCTIONS WERE OBTAINED USING INTRAVENOUS CONTRAST. THERE IS A 7.8-CM PROBABLE NECROTIC MASS IN THE SUPERIOR SEGMENT OF THE LEFT LOWER LOBE. IT ABUTS THE PLEURA. IT COULD REPRESENT A LUNG ABSCESS BUT THERE IS NO SURROUNDING INFLAMMATORY LUNG CHANGES. NO EFFUSIONS. THERE ARE NO OTHER LUNG NODULES. THERE ARE SMALL MEDIASTINAL AND HILAR LYMPH NODES. NO ENLARGED NODES ARE SEEN. THERE NO PULMONARY EMBOLI. THE THORACIC AORTA IS WITHOUT EVIDENCE OF ANEURYSM OR DISSECTION. THERE IS A 3.2-CM ROUNDED WATER DENSITY LEFT ADRENAL MASS. RIGHT ADRENAL NORMAL. UPPER ABDOMEN OTHERWISE UNREMARKABLE. NO OBVIOUS BONE LESIONS.
MRI: 9/15/09: lesion is noted in the left posterior frontal parasagittal lobe with moderate degree of perilesional edema. This could represent metastatic deposit. Differential diagnoses includes infectious etiology.
Squamous cell cancer
Lung ca – MC cause of cancer mortality, both men and women, Age-adjusted cancer death rates among US men for selected cancers In the United States, in 2007, there will have been an estimated 215,000 new cases of lung cancer and 162,000 deaths [2]. In contrast, colorectal, breast, and prostate cancers combined will have been responsible for only 124,000 deaths. Both the absolute and relative frequency of lung cancer have risen dramatically. As an example, the age-adjusted death rates from lung cancer were similar to that of pancreatic cancer prior to 1930 for men and prior to 1960 for women (show figure 1 and show figure 2) [2].
Cough with increasing frequency or severity needs investigation. 10% asymptomatic and found incidentally on imaging. Hoarseness – vocal cord paresis or paralysis when tumors or lymph node metastases compress/invade the recurrent larnyngeal nerve.
Most frequent sites of distant metastatsis are liver, adrenal glands, bones, and brain,. Autonomic dysfx (urinary retention, decreased anal sphincter tone). Prostate, breast, lung- mc cause spinal cord compression Visual field loss, hemiparesis, seizures, etc.
Synergistic affect with smoking and asbestos
Histologically distinct but grouped together b/c similar in presentation, tx, and natural hx. Adenocarcinoma – MC lung cancer in US and MC among never smokers.
Common sites of spread of a non-small cell lung cancer include the liver and adrenals; hence, a CT scan of the chest and upper abdomen, to include the liver and adrenals, is the minimum standard for a staging workup for a person newly diagnosed with non-small cell lung cancer. Need to assess for tumor w/in mediastinal lymph nodes, pleural effusion, or distant sites – pushes into higher stage
Simplified..I – tumor surrounded by lung or pleural, IIA - ipsilateral node, tumor <3 cm, IIB – w/in 2cm carina, invasion of chest wall, diaphragm, pericardium. Stage III- mediastinum, A and B – B: more invasive – invasion of mediatinum, heart/great vessels, trachea, veretral body or carina, effusion, contralateral nodes
Early-stage Non-small Cell Lung Cancer Adjuvant Chemo is a new standard of care Absolute overall survival 4% to 15% at 5 years after adjuvant chemo
Poor performance status Widely metastatic NSCLC
Stage I and II – goal is cure. Stage III combined modalities. In patients with early-stage resectable non–small-cell lung cancer, the use of adjuvant chemotherapy is a new standard of care replacing the former approach of providing no further therapy.
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