Cram The Pance - S1E31 Lung Cancer

Episode Date: July 21, 2021

Lung Cancer review for your Pance, Panre and Eor’s.►Paypal Donation Link: https://bit.ly/3dxmTql  (Thank you!)--- Support this podcast: https://anchor.fm/scott--shapiro/supportBecome a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right, so today's podcast is going to be on lung cancer. So a pretty high-year-old topic, there's some things that you should definitely know for the pants. Like always, I'm going to try to keep it focused into just the things that I really feel like you need to know. And as always, thank you so much for all the comments, the really nice comments you guys have been leaving. And if you haven't checked out the YouTube page yet, please do cram the pants on YouTube. So let's go ahead and get started with lung cancer. I feel like the first thing that I need to go over before we actually go into the different types of lung cancers is the starting point, which would be a pulmonary nodule.

So this is normally the incidental finding you're going to see on a chest x-ray that's going to lead you to the diagnosis of lung cancer. So what is a pulmonary nodule? Pulmonary nodule is defined as a small, well-defined lesion surrounded on all sides by pulmonary parankuma. Most nodules are going to be benign, about 75% of nodules. As far as the size, the size is important because it's only considered a pulmonary nodule if it's less than or equal to 30 millimeters. Any larger than this, it's no longer considered a nodule, but now it's a pulmonary mass.

So it needs to be less than or equal to 30 millimeters to be considered a pulmonary nodule. Now, as far as the malignancy risk with the nodules, there's a few things that you need to know that are going to be high risk and low risk findings. So first, let's go over the low risk features of a pulmonary nodule. You need to remember your four S's for this. So it's size, surface, smoking, smoking status, and seniority, aka the age of the patient. So in real life, when you're actually stratifying and your risk stratifying, you're going to use a calculator. They have plenty of pulmonary nodule calculators.

They have the Mayo Clinic has one. There's one known as the Fleischer criteria. You can use all of those. So, but for an exam, you need to know a few key points to know whether this is going to be a high-risk nodule or not. So first, you need to know the size. So size, smaller, better. The smaller it is, the less chance there is of a malignancy. There's really not a number to memorize here because all different resources are going to say all different sizes.

Some say less than 8mm, some say less than 6 millimeter. Some say less than a centimeter. Generally, I just remember less than one centimeter. There's a smaller risk. Less than one centimeter, the risk is around 2 to 6 percent chance of malignancy. Whereas larger nodules over 2 centimeters, then you get up to about a 50 percent chance of malignancy. So for the exam, if you see something really small less than a centimeter, like a, It's down to just a few millimeters.

Pretty low risk. If you see something larger that's over two centimeters, then you should be thinking a better chance, around a 50% chance of malignancy. So that's the first low risk feature. It's small. Then the next one is smooth borders around the actual nodule. So smooth borders on the nodule or something known as a popcorn calcification.

So if you see anything that describes popcorn pattern or popcorn calcification, it's this dense, diffuse calcification. and it's a classic finding in a benign tumor known as a hamartoma. So if you see anything that says, whether it says a smooth border or well-defined border or a popcorn calcification, you should be thinking benign. The other one, of course, this is just common sense, non-smoker. And then finally, the final S, which is seniority, young. So really, again, this is another one.

There's not a specific age, but the younger, the less chance of malignancy. The patients in their 30s have around a 3% chance of malignancy, patients that are 60 or over, it jumps to over 50%. So remember if they're in the vignette, it's like a 75-year-old, you should be thinking there's a pretty good chance. If it's like a young patient, 32 or even the 20s or something like that, you should think very, very low risk of malignancy in that nodule. And then I remember the four things, small, smooth, young nonsmoker.

Those are all your low-risk features. Now, as far as high-risk features, I'd add an extra S here. So size, surface, smoking, seniority, and then segment, which stands for lung, sake. So first size, large. Obviously, before I said there's not a specific size, but the bigger, the greater chance of malignancy. Generally, over two centimeters, you should be thinking a very good chance.

This could be a malignant nodule. Next, the surface. Now, you're going to be looking for a term called speculated. So the border of a malignant nodules are very commonly uneven. They almost look spiky, which is what speculated means. So this is a speculated pattern, and it's highly suspicious for malignancy. So compare that to the smooth borders, as I said, in benigny. nodules, the malignant nodules are more commonly going to be spiky, rough, or known as

speculated nodules. And then the third S, smoker, another common sense one, they're going to have some history of smoking. Age is going to be old. You know, again, there's not a specific guideline here. Some say over 40, some say over 70, but just know the older the patient, the higher the risk. And then we add the extra S here, which is going to be segment. So this is going to be the upper lobe segment, the upper lobe of the leg,

lungs because about two-thirds of all malignant nodules are found in the upper lobes of the lungs. So if you see they mention the nodule is in the upper lobe of the lung, you should be thinking a much higher chance of malignancy. So again, high-risk features, large, spiky, old smoker in the upper lobes. Now, as far as imaging for nodules, there's not too much to know here. Obviously, chest x-ray is normally your initial test, but this is normally where you incidentally found it, not so much that this is going to be diagnostic, but this is where you initially see the nodule, and then your imaging test of choice is going to be a CT of the chest.

So it's the preferred module, the preferred modality to evaluate the pulmonary nodule for the likelihood of malignancy. It could be because it can determine the edge characteristics to see if you have that speculated pattern, the pattern of calcification. It gets you a better idea of the size, the location, and the nodule. So CT chess will be your imaging test of choice. Now, clinical manifestations, there's really four things you'll likely see in a vignette or in real life. It's going to be a cough, chest pain, hemopatysis, which is coughing up of blood, and then

weight loss. So you're looking for those four things in the vignette. Now, when you see those, you don't necessarily always, you shouldn't always be thinking necessarily lung cancer. That can also be an infectious organism like tuberculosis. So you have to look for the kind of keys in the vignette. So are they mentioning any immunocompromise factors like do they have HIV? Are they homeless? Are they from a TB endemic country? So, are they have to be? then you should be thinking more tuberculosis, or if they mention a 30-year history of smoking, some perineoplastic syndrome,

maybe they mention like a superior venice syndrome, something like that to indicate lung cancer, then, of course, that'll guide you that way. So you just have to look for those keys in the vignette. Now, actually, let's actually go into the different types of lung cancer and break down the individual one. So first you need to know there's non-small cell versus small cell. So there are two different types with different prognosis,

different histologic findings, different treatment options. So we're going to break those down from non-small cell and small cell lung cancer. Let's start with small cell lung cancer. So this of the two is much more aggressive. It's very aggressive. It spreads fast. Most of the time at diagnosis in patients, it's already going to have metastasized. It's very common for this to already have metastasized on diagnosis.

So that's small cell, very aggressive. The other thing is it's very responsive. to chemotherapy, and that's often the treatment of choice. Surgery is rarely used. It's really not effective in small cell lung cancer, but again, you will use chemo. That's your number one treatment option for small cell lung cancer, plus or minus radiation. The unfortunate part is while small cell lung cancer is responsive to chemo as well as radiation, the cancer, even with, you know, treatment early on is usually going to relapse within two years,

despite the treatment. another thing to know about small cell is that it's commonly associated with Paraneoplastic syndrome. So like S-I-A-D-H, Lambert-Eaton syndrome, these are caused by the various hormones that are secreted during this type of cancer. And you're going to see all these different paraneoplastic syndromes, which I'll go over later. So just know if you see a paraneoplastic syndrome, it's a good chance if this patient may

have small-cell lung cancer. And then two more things. Need to know that smoking is a very big risk factor. Of course, for all lung cancers it is. But particularly with small-cell lung cancer, as well as squamous cell, which I'll go over. There's a very high incidence between smokers, like heavy smokers and small cell. Actually, about 98% of patients with small cell lung cancer are going to have a smoking history.

So that's really important to know for this. Small cell and squamous cell. Both have really big risk association with smokers. And then finally, the mass is going to be generally centrally located. So normally it's going to rise in the central airways. It's rare for the mass to be located perils. in the airway. So the way you need to remember the, basically the four things that you need to know is small cell lung cancer, S-C-L-C, small-cell lung cancer. Those four letters stand for smoking. Obviously,

you remember the cigarette smoking strong association with this. The C for the cell in lung cancer stands for central because the mass is often located in the central part of the airway. L. stands for Lambert-Eaton syndrome because this is highly associated with perineoplastic syndromes like Lambert-Eaton syndrome as well as S-A-A-A-A-D-H. And so, some other ones. And then finally, the last C stands for chemo because remember, it's extremely responsive to chemo more than any other intervention. So again, small cell lung cancer, SCLC stands for smoking, Central Lambert Eaton syndrome, and chemo. So that's small cell lung cancer, not too much to know. Now let's go on to non-small cell cancer. So this is much more common

than small cell. It accounts for approximately 85% of all lung cancers. And it can be treated surgically in addition to chemo and radiation. And it's broken down into further subclasses. So there's going to be adenocarsinoma, squamous cell, and large cell. So there's a little bit that you need to know about each, and I'll go over those. So let's first start with adenocarsinoma. That's going to be your most common type of lung cancer overall. So your most common variant of non-small cell lung cancer and the most common type of lung cancer by far out of all of them. About half of the cases of lung cancer will be adenal carcinoma. Now, the main thing you need to know about this is that it's most common,

it's the most common type of lung cancer in non-smokers and women. So again, remember, it's the most common overall. So it's also common in men and smokers, but it's also the, it has the unique factor of being the most common type in non-smokers and women. So that's going to be the key, probably in a vignette, that's going to be the key that they're going to mention. So if it's a nonsmoker or a woman, they get lung cancer, it's most likely going to be a denal carcinoma. when you need to know that for your vignette for your exam question. Next, the mass, rather than centrally located, like in small cell, this mass is going to be peripherally located commonly.

So adenocarcinomas as well as large cell carcinomas tend to be more peripherally located in the lung. And then finally, on histologic findings, you're going to see something known as musin formation because this type of cancer arises in the bronchial mucosal gland. So if they mention biopsy findings with mucin production or gland formation, you should be thinking adenocarstic. So that's adenocarcinoma. So remember peripherally located, more common in non-smokers and women, and then your most common

type of lung cancer. So let's move on to squamous cell lung cancer. This type of cancer is going to be centrally located, about 60 to 80 percent that are going to rise in the proximal portions of the tracheo-bronchial tree. Remember, the only types that are peripherally located are going to be your large cell in a dional carcinoma. Again, remember, this is another one like small cell that's strongly associated with smoking. Remember, if the cancer starts with an S, you should be thinking smoking.

It says a high association to smokers to heavy smokers. Next thing you need to know, cavitory lesions. Scramicil carcinoma can often have this extensive necrosis, which leads to cavitation. And the classic manifestation in this type of cancer is a cavitory lesion in a proximal bronchus in that central location. Another thing you need to know as well is hypercalcemia can be seen in this type of lung cancer. It's the most common type of lung cancer associated with hypercalcemia. And it's because it has this abnormal secretion of a hormone known as parathyroid hormone-related protein, PTHRP.

It mimics the function of PTH, where it has increased calcium absorption from the bone, as well as retaining more calcium from the kidneys and it leads to this hypercalcemia. And then finally, on histologic findings, you may see something known as keratinization or keratin pearls. Maybe the key to diagnosis, if you see that mentioned, it's these abnormal squamous cell form, these concentric layers. So if you see keratin pearls or keratinization, you should be thinking squamous cell lung cancer. Now, one thing I'll mention also pancos tumors, which is also known as a superior sulcus tumor. It's this tumor that's located in the superior like sulcus, like the apocis of the lungs. It's commonly seen in squamous cell, but adenocarcinoma as well. You may

see some literature that's still less squamous cell as the most common type that it's associated with, but adenocarsinoma is kind of becoming the more common of the two to C. So I wouldn't necessarily narrow this down just to squamous cell. You can kind of be seen in all of your non-small lung cancers. All right. So what are you going to remember for squamous cell lung cancer? Well, squamous cell is spelled SQ, but for the mnemonic, I remember that squamous cell is instead it's spelled S.C. So instead of squamous spelled SQ, I remember it's spelled S-C, squamous, spelled with a C. And that helps me to remember all the Cs about squamous cell lung cancer. So the first C, centrally located. Second one, cigarettes. Remember squamous in small cell, strong association with cigarette smoking.

The third C stands for calcium elevation for your hypercalcemia. And then your fourth C stands for cavitory lesion. So remember, squamous cell lung cancer is not spelled with a cue. It's spelled with a C for essentially located, cigarettes, calcium elevation, and cavitary lesions. All right. The last one will go over. Not much to know with this one, but this is your large cell lung cancer, another type of non-small cell lung cancer. So really, this is just a diagnosis of exclusion.

So this is going to be a lung cancer that lacks differentiating features on microscopy. So there's going to be no evidence of characterization, like in squamous cell. You're not going to see any gland or mucin formation like an endocarsinoma. No cytologic features of small cell. So it lacks all these differentiating features. and generally represents a diagnosis of exclusion. The only things you need to know about this, like I said before, it's normally peripherally located, like your adenocarsinoma,

and it accounts for about 10 to 15% of lung cancers. So those are the only things you really need to know about the cancers. Let's just go over a few miscellaneous topics slash perineoplastic syndromes. So we're going to go over some disorders that can present a patients with lung cancer, either cause from an abnormal immune response, from these hormones being released, and cytokines from the growing mess. mass or from the mass itself,

compressing nearby vessels and nerves leading to these specific clinical manifestations. I'm going to keep them brief, just a few high-yield things you need to know about each. So first, Lambert Eaton Myasthenic syndrome. So this is a disorder of reduced acetylcholine release from the presynaptic nerve terminals. The reason this happens is you have these antibodies against the presynaptic voltage-gated calcium channels that prevents the release of acetylcholine. Just remember there's less acetylcholine. because of the decreased acetylcholine, you're going to have this limb weakness, this proximal limb weakness,

without significant muscle atrophy. So it's a common finding in the vignette. They're going to describe someone who has difficulty maybe getting out of a chair, walking upstairs, things that are going to be from the proximal limb weakness. You may see this in small cell lung cancer. This is going to be the most common associated tumor. It can be seen in a number of other malignancies, but small cell lung cancer is going to be the most common associated tumor. The key here, because myisthenegravis has similar symptoms,

but the key to Lambert-Eaten myisynic syndrome is that the muscle weakness that these patients have actually improves. It gets better with activity, whereas myasthenia-gravis is worse with continued activity, repeated muscle use. This actually improves with activity. So the way that I used to remember that, Lambert-E-M-E-M-I-I-I-I-I-I-I-I-M-S stands for lunges ease my symptoms. Lunges ease my symptoms. You think of a patient doing lunges. Their symptoms are actually going to get better.

And that helps you remember LEMS, Lambert Eaton, my stynic syndrome, lunges, ease my symptoms. So you remember that it gets better, whereas myisthenic gravity gets worse with activity. Treatment, you're really going to treat the underlying malignancy. And then symptomatic relief can be with a class known as three, four DAPs. The main medication you'll hear about is MFampradine. that's the best medication for this for symptomatic relief. Periodostigmine, which is a cytokolonesterase inhibitor, doesn't really work that well.

You may see it mentioned, but it only has like a marginal efficacy in treating Lambert Eden syndrome. So really, the 3-4 DAPs is going to be the main one. The MFAMPradine will be the main medication. But really, it's just treating the underlying malignancy. All right, next one we're going to talk about is superior vina-Cava syndrome. So this is an obstruction of blood flow through the. SVC, the Superior v. Inacaba, due to the tumor, which is directly invading or pushing on the SVC, so that nearby tumor is pushing on the SVC. Now, small cell lung cancer is going to be the one you're

commonly going to hear about with this. Happens in about 10% of the cases of small cell lung cancer. It can be seen in non-small cell lung cell carcinoma, but only around 2% or less of the cases. So more common to see this in small cell lung cancer, about 10% of the cases. Now, the two common things you'll see on presentation or in your vignette are going to be facial and neck swelling, which gets worse when they bend over, and then dyspnea. So they'll have trouble breathing. It's because the edema from the area can narrow the lumen of the nasal passages and larynx, and it can compromise the function of the larynx or the pharynx. It can cause dyspnea, stride, or cough. Sometimes they'll have hoarseness, dysphasia.

So remember, facial and neck swelling dyspnea. And then finally, it's possible also to see distension of neck and chest wall. all veins. They basically have like these varicocities on their chest. You'll see these almost like varicose veins on their chest from this. So those are the main things you'll see on clinical presentation. Treatment is going to be supportive care like steroids, diuretics, hydration. If they're having any breathing problems, obviously you want to treat that. And then to treat the underlying cause, so to treat the mass and to help them improve with that. The last one I want to go over is something known as superior pulmonary sulcus tumors, also known as pancoast tumors, which I went over briefly

before. So these are pulmonary neoplasms, which are located at the apices of the lung. So the apical pluripulmonary groove is what it's known as, the superior sulcus. So it's a tumor located at the top of the lung, like at the apex. And because of the location where it's growing, it starts to compress the nearby structure. So you have your brachial plexus there, your cervical thoracicic nerve roots, and it can lead to the symptoms we see in this type of tumor. So it's commonly seen in non-small-cell lung cancer, non-small cell lung carcinoma. Like I said before, it used to be squamous cells most commonly seen in, but now adenocarcinoma is kind of taking over as the most common cause.

But any of the non-small, non-small lung carcinomas can cause superior pulmonary or sulcus or pancoast tumors. The two important clinical manifestations you need to know with this is shoulder pain. This is by far the most common initial symptom of this type of tumor. And it's present in anywhere from 44 to 96% of patients. It's mainly caused from the compression of the tumor on the brachial plexus, which is causing that shoulder pain. Second manifestation you need to be aware of is something known as Horner syndrome. It's due to the compression of the cervical and the thoracic ganglia.

These patients can develop ipsylateral, so same side, tosis, anhydrosis, and meiosis. So they're going to have a droopy eye. They're going to have dry skin. Anthydrosis is no like sweat. And then constricted pupil, that's the myosis on the same side as the compressed nerve. So ifseilateral toosis, anhydrosis, which is known as Horner syndrome. The way that I used to remember that, this is better with the visual I have on YouTube. But so PanCo syndrome, I think of a pan.

And then I think of somebody holding a pan, like cooking stir fry, kind of like throwing it up in the air, flipping it over. And they're flipping the pan so long that they start to have shoulder pain. So like kind of flipping the veggies in the air, but their shoulder starts to hurt after a while. And then before they start cooking, they spray the pan with Pam, like Pam cooking. spray P-A-M that stands for Tosis anhyrosis myosis. Remember, Tosis is spelled P-T-O-S-I-S-S. So remember, they spray the pan with PAM and that's Tosis and Hydrosis meiosis and they're cooking, flipping the veggie so long that their shoulder starts to hurt. Just one of those visuals that hopefully helps you. Treatment for this, really just you're treating the tumor. So chemo,

radiation, surgical resection, reduce the size of the mass, you improve the symptoms because it's impingement of the mass on all these structures. All right. So that's all you need to know about lung cancer, I feel like. Those are the important things. Let's do five quick questions to test what you retain. First question, what treatment option is most effective in patients with small cell carcinoma? What treatment option is most effective in patients with small cell carcinoma? It's going to be chemotherapy. Remember, your SCLC, small cell lung cancer, that last C stand for chemotherapy. Question two, musin or gland formation visualized on histology. Sorry, on histology. for which type of pulmonary neoplasm. So that's going to be an adenocarsinoma. If you see musin

or gland formation on those microscopic findings, that's going to be adenal carcinoma likely. Question three, the majority of malignant lung nodules are found in what region of the lungs? Majority of malignant lung nodules are found in what region of the lungs. So that's going to be the upper lobe. So two-third of all malignant nodules are found in the upper lobes of the lungs. Remember, that's one of your suspicious malignant signs when you see a nodule in the upper lobes. So question four, what type of cancer is most commonly seen in non-smokers? So which type of cancer is most commonly seen in non-smokers? That's going to be adenocarsinoma.

So it's the most common pathology among non-smokers. And then question five, last question, a patient presents with a cavitory lesion and a proximal bronchist visualized on imaging. Labs show an elevation in serum calcium levels. Which type of lung malignancy does this patient likely have? So cavitory lesion, proximal bronchus, lab show an elevation and serum calcium levels. You should be thinking of squamous cell carcinoma. Remember the pneumonic, squamous cell, not spelled with a Q, but spelled with a C.

And that SC stands for your cavitory lesions, your calcium increased central located. And those are the findings that you need to know in squamous cell carcinoma. And then, of course, cigarettes as well. That's your fourth C. So those were your five questions. Hopefully that was helpful. Please let me know if it has been. And again, thank you so much for listening to the people.

podcast and thank you so much for all the support. I really do appreciate it. And good luck on your pants, your panery or EORs, and good luck in PA school.