Updated: 10/10/2019

Lung Cancer

Topic
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Questions
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Evidence
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Videos
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Snap Shot
  • A 69-year-old male with a 50-pack-year smoking history presents with worsening cough, weight loss, and repeated episodes of hemoptysis. A chest radiograph is taken and shown at right.
Overview
  • Lung cancer is the leading cause of malignancy-related mortality
  • There are several types of lung cancer (ordered from most to least common)
    • adenocarcinoma
    • squamous cell carcinoma
    • small cell carcinoma
    • large cell carcinoma
    • carcinoid tumor
    • mesothelioma
  • Epidemiology
    • highest incidence between 5th and 6th decade
    • rates are increasing in women and declining in men
    • risk factors are type specific (see below)
  • Presentation
    • symptoms
      • cough
      • dyspnea
      • hemoptysis
    • physical exam
      • bronchial obstruction
      • wheezing
      • weight loss
  • Evaluation
    • imaging
      • chest radiograph
        • "coin" lesion
        • important to compare to previous films if available
      • CT
    • sputum cytology
    • fine-needle aspiration (FNA)
    • bronchoscopy +/- lavage
  • Differential diagnosis
    • hamartomas
    • granulomatous disease
      • e.g. histoplasmosis and tuberculosis
  • Complications
    • superior vena cava syndrome
    • paraneoplastic syndromes
    • hoarseness (recurrent laryngeal nerve involvement)
    • pleural or pericardial effusions
    • Pancoast tumor
      • Horner syndrome
Squamous Cell Carcinoma
  • squamous cellIntroduction
    • strong link to smoking
    • more common in men
  • Presentation
    • central (hilar) cavitating lesion
    • can ectopically secrete PTH-related protein (PTHrP)
      • results in parathyroid-like hypercalcemia and hypophosphatemia
      • calcium will be increased, PTH decreased, and vitamin D will be low to normal 
  • Histology 
    • keratin pearls and intercellular bridges
    • may stain with Pap stain (as with squamous cell carcinoma of the cervix)
  • Treatment
    • surgical resection
      • indications
        • if early stage
    • chemotherapy and/or radiation
      • indications
        • late stage
Adenocarcinoma
  • Introduction
    • there are two subtypes
      • bronchial
        • most common lung cancer in non-smokers and females
        • can develop in site of prior inflammation or injury
        • cancer of neuroendocrine origin
        • no association with smoking
      • bronchioalveolar
        • cancer of Clara cells, mucin-secreting cells, or type II pneumocytes
        • most cases have an association with smoking
  • Presentation
    • peripheral lesions
    • bronchial
      • most commonly presents with hemoptysis
    • bronchioalveolar 
      • can present like pneumonia
        • consolidation on chest radiograph and copious sputum production 
      • can result in hypertrophic osteoarthropathy
  • Histology
    • bronchial
      • varies
    • bronchioalveolar 
      • growth along preexisting structures
      • destruction of alveolar architecture or invasion
  • Treatment
    • surgical resection
      • indications
        • if early stage
    • chemotherapy and/or radiation
      • indications
        • late stage
Small Cell Carcinoma
  • Small cellIntroduction
    • more common in men
    • strong association with smoking
    • very aggressive
  • Presentation
    • central lesions
    • associations
      • ectopic production of ACTH or ADH 
      • Lambert-Eaton syndrome
  • Histology
    • stain positive for enolase, chromogranin, and synaptophysin 
      • neuroendocrine markers
    • Kulchitsky cells 
      • small, dark blue cells
    • undifferentiated appearance
  • Treatment 
    • chemotherapy and/or radiation
      • indications
        • nearly all are metastatic prior to diagnosis and therefore inoperable 
Large Cell Carcinoma
  • large cellIntroduction
    • strong relationship to smoking
    • poor prognosis
  • Presentation
    • peripheral or central lesion
    • associated with gynecomastia and galactorrhea
  • Histology
    • pleomorphic giant cells
    • very anaplastic
  • Treatment
    • surgical resection
      • indications
        • preferred modality
    • chemotherapy and radiation
      • indications
        • are less effective and used less often
Carcinoid Tumor
  • carcinoidIntroduction
    • more common in the GI tract but may arise in the lung (endobronchial)
  • Presentation 
    • can cause carcinoid syndrome
      • flushing, diarrhea, wheezing, and salivation
Mesothelioma
  • mesotheliomaIntroduction
    • cancer of the pleura
    • associated with asbestosis
  • Presentation
    • hemorrhagic pleural effusions
  • Histology 
    • psammoma bodies
  • Diagnosis
    • imaging
      • shows pleural thickening 
    • electron microscopy
      • gold standard
      • shows cells with large number of long, slender microvilli
      • tonofilaments also present
  • Treatment
    • surgery
      • indications
        • early stage and lesion is localized
    • radiation and/or chemotherapy
      • indications
        • if lesion is diffuse/metastatic
Metastases
  • Introduction
    • primary cancers are most commonly 
      • breast
      • colon
      • kidney
  • Presentation
    • most commonly presents with dyspnea
 

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Questions (11)
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
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(M1.ON.36) An ill-appearing 70-year-old male smoker presents to your office at 4:00 p.m. The left panel of Figure A shows the patient's appearance when he wakes up in the morning and the right panel shows the patient as he appears after walking around during the day. He complains of dyspnea and cough for several weeks, and on examination you also note his distended neck veins. What is the most likely cause of this patient's illness? Review Topic

QID: 100839
FIGURES:
1

Congestive heart failure

20%

(29/148)

2

Pancoast tumor (bronchogenic carcinoma)

55%

(82/148)

3

ACE inhibitor therapy

4%

(6/148)

4

Type I hypersensitivity reaction

0%

(0/148)

5

Subclavian steal syndrome

20%

(29/148)

M1

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SUBMIT RESPONSE 2

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(M1.ON.39) A lung mass of a 50 pack-year smoker is biopsied. If ADH levels were grossly increased, what would most likely be the histologic appearance of this mass? Review Topic

QID: 100842
1

Tall columnar cells bordering the alveolar septum

2%

(2/93)

2

Sheets of small round cells with hyperchromatic nuclei

80%

(74/93)

3

Layered squamous cells with keratin pearls

8%

(7/93)

4

Hyperplasia of mucin producing glandular tissue

8%

(7/93)

5

Pleomorphic giant cells with leukocyte fragments in cytoplasm

1%

(1/93)

M1

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(M1.ON.121) A 55-year-old male smoker presents to your office with hemoptysis, central obesity, and a round face with a "moon-like" appearance. He is found to have a neoplasm near the hilum of his left lung. A biopsy of the tumor reveals small basophilic cells with finely granular nuclear chromatin (a "salt and pepper" pattern). Which of the following is the most appropriate treatment for this patient? Review Topic

QID: 100924
1

Tamoxifen

2%

(3/136)

2

Prednisone

7%

(10/136)

3

Surgical resection

21%

(28/136)

4

Cisplatin and radiotherapy

68%

(92/136)

5

Watchful waiting

1%

(2/136)

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(M1.ON.68) A 54-year-old female is admitted to the hospital for progressive exertional dyspnea and cough productive of tan-colored liquid for 6 months. She has never smoked a day in her life. A lung biopsy is shown in Figure A that demonstrates tall, columnar cells that line the alveoli septa. The most likely diagnosis for this patient is: Review Topic

QID: 100871
FIGURES:
1

Mesothelioma

0%

(0/23)

2

Squamous cell carcinoma

13%

(3/23)

3

Small cell carcinoma

0%

(0/23)

4

Adenocarcinoma

78%

(18/23)

5

Metastatic breast cancer

9%

(2/23)

M1

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SUBMIT RESPONSE 4
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