Monday, July 28, 2014

Neoplastic Disease

Neoplastic Disease-

-Carcinoid Tumors-


-Carcinoid lung tumors (such as bronchial) are uncommon and characterized by neuroendocrine differentiation and relatively indolent clinical behavior

-Were originally called bronchial adenomas

-Carcinoid tumors are considered malignant tumors with the potential to metastasize

-Bronchial carcinoid tumors derive from neuroendocrine cells that have migrated from the embryologic neural crest

-Bronchial carcinoid tumors are the most common primary lung neoplasm in children and usually present in late adolescence

-It is unclear if there is a correlation between smoking and bronchial carcinoid tumors

-Ten percent of neuroendocrine tumors have hereditary origin

-The majority of tumors arise in the proximal airways and are symptomatic from an obstructing tumor mass or bleeding due to hypervascularity

-The majority of carcinoid tumors will have an abnormal chest x ray

-Carcinoid tumors can produce vasoactive substances such as serotonin and other bioactive amines.  Symptoms of carcinoid crisis include cutaneous flushing, diarrhea, bronchospasm, and may cause venous telangectasia

-The best way to diagnose carcinoid tumors of the lung are by CT scan and confirmation by bronchoscopy with biopsy

-PET scanning is helpful for staging of carcinoid tumors

-Patients with typical or atypical bronchial carcinoid tumors, surgical resection is the best treatment for those who can tolerate it.  Endobronchial management for resection is an option if those cannot tolerate the procedure of resection

-Radiation therapy can provide some palliation if not resectable but is not curative for carcinoid tumors

-Chemotherapy has shown minimal activity for carcinoid tumors in the lung


-Lung Cancer-


-Lung cancer is the most leading cause of cancer deaths worldwide

-Lung cancer, also known as bronchogenic carcinoma, is the group of malignancies that originate from from the lung parenchyma

-Ninety five percent of all lung cancers are either small cell carcinoma or non small cell carcinoma

-The other 5 percent of cell types arise from the lung.  This become important for staging, treatment and prognosis

-Risk factors for lung cancer:  smoking, second hand smoke, asbestos or radon exposure, formaldehyde exposure, radiation exposure, various benign inflammation and lung disease, COPD, genetic factors, and dietary factors

-Four types of lung cancer:  adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and small cell carcinoma

-Adenocarcinoma is the most common type of lung cancer

-Most common symptoms of lung caner include:  cough, weight loss, dyspnea, chest pain, hemoptysis, bone pain, and hoarseness

-Complications of lung cancer include superior vena cava syndrome and pancoast syndrome

-The most frequent sites of distant metastasis include:  liver, bone, adrenal glands, and brain

-Cancer is staged using the TMN system

-Paraneoplastic effects of the tumor are:  hypercalcemia, SIADH secretion, and neurologic symptoms, anemia, leukocytosis, thrombocytosis, eosinophilia, hypercoagulable disorders, hypertrophic osteoarthropathy, dermatomyositis, and Cushing's syndrome

-Need to biopsy lesion to get tissue type to help determine treatment either by bronchoscopy or by CT guided biopsy.

-Ultimate goal of lung cancer treatment is resection if possible and appropriate

-Treatment will can involve surgery, chemotherapy, or radiation therapy or any combination of those


-Pulmonary Nodules-



-Pulmonary nodules are defined as a single lesion measuring less than 30 mm and well circumscribed radiographic lesion surrounded by lung parenchyma.

-Pulmonary lesions measuring greater than 30 mm are considered masses

-Spiculated nodules are said to have malignant characteristics

-Common causes of malignant pulmonary nodules are lung cancer, lung metastasis, and carcinoid tumors

-Common causes of benign pulmonary nodules include hamartoma, infectious causes, vascular AV malformations, and inflammatory lesions (Wegner's Granulomatosis)

-For nodules less than 4 mm, CT scans are not required to monitor

-Nodules 4 mm-6 mm should have a CT scan at 12 months in low risk individuals and follow up at 18-24 months in a high risk individual

-Nodules 6-8mm should have a CT scan at 6-12 months, and repeat scan at 18-24 months in low risk individuals and in high risk individual repeat at 3-6 months, 9-12 months, and at 24 months

-Multiple nodules should be worked up for malignancy in a smoker but are likely benign

-Non surgical biopsy such as CT guided biopsy or bronchoscopy is indicated in patients with intermediate risk

-Surgical excision is the gold standard for treatment for malignant pulmonary nodules






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