Intensive Review of Internal Medicine Symposium
LUNG CANCER BOARD REVIEW The 40 Things You Need to Know
Intensive Review of Internal Medicine Symposium
Overview
Epidemiology –
Top 10
Presentation –
Top 10
Diagnosis and Staging –
Top 10
Treatment –
Top 10
Intensive Review of Internal Medicine Symposium
Epidemiology Top 10
Intensive Review of Internal Medicine Symposium
Epidemiology 1. Cancer is the second leading cause of death in the United States.
Jemal A, Ca Cancer J Clin 2010
Intensive Review of Internal Medicine Symposium
Epidemiology 2. Cancer is the leading cause of death in those under 85 years of age.
Jemal A, Ca Cancer J Clin 2010
Intensive Review of Internal Medicine Symposium
Epidemiology 3. Lung cancer is the second most diagnosed cancer in both men and women in the US.
Jemal A, Ca Cancer J Clin 2010
Intensive Review of Internal Medicine Symposium
Epidemiology 4. Lung cancer is the leading cause of cancer related mortality in both men and women in the US.
Jemal A, Ca Cancer J Clin 2010
Intensive Review of Internal Medicine Symposium
Epidemiology 5. Cigarette smoking and environmental smoke exposure are the most important risk factors for developing lung cancer. Public Health Service Publication 1103, 1964: Stated cigarette smoking is a cause of lung cancer in men 5 criteria of a causal relationship between cigarette smoking and lung cancer: Strength of association Time sequence Consistency upon repetition Specificity Coherence of explanation
Intensive Review of Internal Medicine Symposium
Epidemiology
Damber LA, Br J Cancer 1986.
Intensive Review of Internal Medicine Symposium
Epidemiology
Peto R, BMJ 2000.
Intensive Review of Internal Medicine Symposium
Epidemiology
Godtfredsen NS, JAMA 2005;294:1505-1510.
Intensive Review of Internal Medicine Symposium
Epidemiology
Vineis P, BMJ 2005;330:277-281.
Intensive Review of Internal Medicine Symposium
Epidemiology 6. Lung cancer is an important disease in never smokers. Rates of 14.4-20.8 per 100,000 women and 4.8-13.7 in men. Rates are similar to myeloma in men, cervical and thyroid in women. 3rd leading cause of cancer related mortality in the US. Women never smokers with lung cancer survive longer, and are more likely to have an adenocarcinoma. Wakelee, J Clin Oncol 2007.
Intensive Review of Internal Medicine Symposium
Epidemiology 7. Asbestos and radon exposure are two environmental – occupational risk factors for developing lung cancer. Arsenic Asbestos Beryllium Bis(chloromethyl)ether Cadmium
Chromium Nickel Polycyclic aromatic hydrocarbons Radon Vinyl chloride
Intensive Review of Internal Medicine Symposium
Epidemiology 8. Women have a greater risk of developing lung cancer than men.
Zang EA, J Natl Cancer Inst 1996.
Intensive Review of Internal Medicine Symposium
Epidemiology 9. Ethnicity influences the risk of developing lung cancer.
Haiman, N Engl J Med 2006.
Intensive Review of Internal Medicine Symposium
Epidemiology 10. The presence of other lung disease increases the risk of developing lung cancer.
Mannino, Arch Intern Med 2003.
Intensive Review of Internal Medicine Symposium
Presentation Top 10
Intensive Review of Internal Medicine Symposium
Presentation 1. Most patients with lung cancer present with non-specific symptoms such as cough and dyspnea. %1
%2
Cough
46
44
Weight loss
32
26
Dyspnea
30
42
Chest pain
30
13
Hemoptysis
27
19
Asymptomatic
15
14
Symptom
1. Huhti, Thorax 1980. 2. CCF data, Chest 2006.
Intensive Review of Internal Medicine Symposium
Presentation 2. Syndromes related to regional spread of lung cancer include Horner’s, Pancoast, and SVC syndromes. Local growth Cough, hemoptysis, shortness of breath, chest pain Regional spread Dysphagia, hoarseness, shortness of breath Horner’s syndrome, Pancoast syndrome, SVC sydrome Effusions, hypoxia Distant spread Neurologic symptoms, pain
Intensive Review of Internal Medicine Symposium
Presentation 3. Mental status changes, hyponatremia, inappropriately concentrated urine, adenopathy on chest imaging in a smoker should make one consider small cell carcinoma with SIADH. Cause – Synthesis and secretion of ADH by tumor cells Incidence of Clinical Syndrome – 7-16% Most common tumor type – Small cell Symptoms/Signs – Mental status change, lethargy, seizures Findings – Hyponatremia, plasma hypoosmolality, inappropriately concentrated urine Prognosis – No different than small cell without SIADH
Intensive Review of Internal Medicine Symposium
Presentation 4. Squamous cell carcinoma of the lung can present with symptoms and signs of hypercalcemia due to the secretion of PTH-related protein. Cause – Synthesis and secretion of PTH-related protein by tumor cells Incidence of Clinical Syndrome – 8-12.5% Most common tumor type – Squamous cell Symptoms/Signs – Mental status change, fatigue, gastrointestinal symptoms, polyuria Findings – Hypercalcemia, hypophosphatemia, EKG changes Prognosis – Very poor, median survival 1 month
Intensive Review of Internal Medicine Symposium
Presentation 5. Small cell carcinoma can secrete ACTH leading to an ectopic Cushing’s syndrome. Cause – Synthesis and secretion of ACTH and its precursors by tumor cells Incidence of Clinical Syndrome – 1.6-4.5% of small cell carcinoma Most common tumor types – Small cell Symptoms/Signs - myopathy, moon facies Findings – increased urine free cortisol and serum ACTH levels, hypokalemia, hyperglycemia Prognosis - poorer prognosis, median survival 4 months
Intensive Review of Internal Medicine Symposium
Presentation 6. Small cell carcinoma can present with the anti-Hu syndrome, a paraneoplastic neurologic syndrome manifest by a variety of otherwise unexplained neurologic symptoms and signs. Immune response to tumor antigens Symptoms and signs vary with the area of the nervous system affected Behavior changes, memory problems, seizures, ataxia, dysarthria, diplopia, etc.
Intensive Review of Internal Medicine Symposium
Presentation 7. Small cell carcinoma can present with proximal muscle weakness that lessens with repetitive effort. This termed the Lambert-Eaton myasthenic syndrome.
Intensive Review of Internal Medicine Symposium
Presentation 8. Screening consists of applying a test to a group at risk for developing a disease before they develop manifestations of the disease. The goal is to detect the disease at a point in which it can be cured. The results of a successful screening program are fewer disease specific deaths.
Intensive Review of Internal Medicine Symposium
Presentation 9. Screening for lung cancer is not currently recommended. National Lung Screening Trial 53,000 age 55-74, 30+ pyrs Randomized to chest CT screen vs. CXR screen at baseline and annually for 2 years 442 lung cancer deaths in CXR arm and 354 in chest CT arm over 6-8 years of f/u (20% reduction) False positives, procedures for benign lesions, QOL changes, and cost-effectiveness not reported
Intensive Review of Internal Medicine Symposium
Presentation 10. Three biases influence the results of screening studies that reported survival as the primary outcome: lead-time bias, length-time bias, and overdiagnosis bias.
Patz, N Engl J Med 2000.
Intensive Review of Internal Medicine Symposium
Presentation
Patz, N Engl J Med 2000.
Intensive Review of Internal Medicine Symposium
Presentation
Patz, N Engl J Med 2000.
Intensive Review of Internal Medicine Symposium
Diagnosis and Staging Top 10
Intensive Review of Internal Medicine Symposium
Diagnosis and Staging 1. When a lung nodule is found, the only clinical features that can obviate the need for further evaluation are an age < 30 in a lifelong never smoker. Clinical Criteria Age Tobacco smoking status Prior malignancy Others
Intensive Review of Internal Medicine Symposium
Diagnosis and Staging 2. The radiographic finding of a benign pattern of calcification in a lung nodule or the absence of growth over a 2 year period obviate the need for further evaluation.
A. Central, B. Laminated, C. Diffuse, D. Popcorn, E. Stippled, F. Eccentric. Mazzone, Semin Thorac Cardiovasc Surg 2002.
Intensive Review of Internal Medicine Symposium
Diagnosis and Staging 3. Larger nodules, those with irregular or spiculated edges, and those in the upper portions of the lung are more likely to be malignant.
Furuya, Acta Radiologica 1999.
Intensive Review of Internal Medicine Symposium
Diagnosis and Staging 4. PET imaging of a lung nodule can be falsely positive in inflammatory or infectious nodules, and falsely negative in small tumors (
