Any writer or designer will tell you that 90% of the creative process…
…is destructive.About Health procedures the same happens. -You need to obtain the necessary from the rock to delivery the BEST Art for your patients. So, we will discuss now through some examples what are the 5 necessary things all MDs and NPs need to know about Lung Cancer, which is a very important part of Pulmonary Section.
In other words, Your audience didn’t needto read 6,000 pages dissertation about Lung Cancer.So, the idea here was to give the Necessary things you need to know about Lung Cancer.
The first rule is: Treat General Concepts about LC as a king.
The second rule is: Spread ideas and move people.
Think Bronchogenic Types as the patents of an Company named “ Lung Cancer.” So, we have 4 patents: 1. Small Cell (C) 2. Squamous (C);3. Large Cell (P) 4. Adenocarcinoma (P). Remember: 1 and 2 beginning with “S” from Small/ Squamous “S sound of Central”COMMENTS: 1. SIADH Most common paraneoplastic syndrome in SCLC (5-10% cases). 40-50% can present subclinical SIADH; Finds hyponatremia, Increased urinary excretion of sodium, normal volume status and failure to excrete maximally diluted urine with water change.1.2 Cushing Syndrome 3-7% of the patients w SCLC. But 11-70% can present subclinical; * Clinical features of CS can be masked by anorexia & significant weigh loss. Severe weakness & mineralocorticoids’ effects of edema, hypertension, and hypokalemia (70%) & hyperpigmentation ( 25%), elevated calcitonin + Calciuresis. 3 Paraneoplastic Neurologic Syndromes Neuromyopathies are most common w SCLC. The incidence of NMP of all LC are 10%. 1.4 *** Peripheral Neuropathy Most Common neurologic syndrome in SCLC ( it has a link with Vinca alkaloids & Cis– platinum); **Dementia is the most common encephalopathy in SCLCEaton – Lambert’s clinical picture are very similar to myasthenia gravis, with proximal muscle weakness & easy fatigability. Symptoms are more pronounced at lower extremities difficult to walk, climbing stairs and getting up from a chair. Unlike other Neuromyopathies, EL Syndrome frequently respond the tumor treatment. 2.Parathyroidlike hormone Hypercalcemia is most common from his cause than from skeletal metastases. PTLH Syndrome is UNUSUAL in patients with SCLC. However, if Hypercalcemia is observed in this setting, consider a Squamous cell, or consider coexistent hyperparathyroidism; Pulmonary osteoarthropaty is seen more often in adenocarcinoma( 1- 10% of cases).
Large Cell Carcinoma & Adenocarcinoma the 2 Peripheral ones. Common in non smokers, but it still related to smoking. Bronchoalveolar carcinoma is a special type of Adenocarcinoma of low grade Lung Cancer, but it can occur in multiple sites on the same Lung or involving the both Lungs! It’s very important to remember it because sometimes you are presented to an X-Ray with multiples lesions and you think in infection or metastases but you have also to think in Bronchoalveolar carcinoma!Solitary Pulmonary Nodules (SPNs) are seen on plain chest radiograph, are < 3cm and there are no other associated abnormalities in the x- Ray. 40 – 60% of SPNs in person w < 35y are granulomas or hamartomas. In Older patients, mainly those w smoking story, the key concern is they are maligns..REMEMBER: Although SPNs especially those > 2cm can be definitely diagnosed a malignant by bronchoscopy (> 65% yield) or transthoracic fine needle biopsy ( > 85% yield), it is rare patient who will truly benefit from such an approach. Generally speaking, when SPN os strongly suspect o be malignant, it should be resected both for definitive diagnosis and for cure ( assuming it turns out to be malignant!)
The next Step is: You need to know about the most common symptoms and signals of Lung cancer: 1. Cough ( Most Common) 2. Weight Loss/ Dyspnea 3. Hemoptysis; 4. Hoarseness 5** Recurrent Pneumonia6. SVC Syndrome7. Pancoast Syndrome8. Horner Syndrome9. Effusion
Cough most common symptom. It’s not specific.Hoarseness in a patient with Lung cancer means metastasis to laryngeal nerves and vocal cords! So, it is unresectable this is not a candidate to surgery***Recurrent Pneumonia: A pneumonia that is not making better and repeat its occurrence with cough, and fever Post obstructive Pneumonia, mainly in the medium Lobe can be a carcinoma.SVC Syndrome: The mass is in the right apical area obstructing the Vena cava. Blurry vision, Headache, confusion… This is an Oncologic Emergency! So, you have to call the radiotherapist to radiate the lesion and shrunk the tumor and save the patient.But REMEMBER: if the patient have SVC but no symptoms, as headache, you may have a short window to try make a tissue diagnostic of the tumor. Because if you radiate the lesion you will lost the opportunity of discovering the histologic type of Lung cancer.Pancoast Syndrome Painful neuropathy because the Invasion from the tumor of brachial plexus.Horner Syndrome Obstruction of sympathetic chains : So, the patient presents Myosis, hydrosis and ptosis! All this 3 syndromes are potential treatable. Most Lung Cancer are unresectable at the moment of the diagnosis. Be careful, by definition these 3 syndromes when associated with Lung cancer can be resectable depending on the stage! For example SVC + Hoarseness from the lung cancer = Unresectable. Effusion + Lung Cancer = Most cases are Unresectable Because if the lung cancer goes for outside of the lung it is unresectable!Remember that you can have a patient with pneumonia + effusion, which is caused by pneumonia and not by lung cancer so in this case it can be resectable!
Rule number 4: HowSputum Cytology In 1/3rd of the cases you can make diagnosis. If you have a cancer diagnosis in the SC, end the diagnostic procedureBronchoscopy for CENTRAL “S” LESIONS Squamous/ Small Cell LC.
NeedleBx for peripheral lesions can be done by invasive radiologist or pulmonologist. Most of the Diagnosis can be made for Bronchoscopy and NB.Remember : If a person has a Lung massEffusions: However, the Cytology made after Effusion drainage can be the way for the LC diagnosis. You can obtain 2 answers here: 1)The diagnostic and also 2)stage the LC, because most Effusions associated with Lung Cancer are Unressectable Cancer. Mediastenoscopy is agrressive and is reserved for mediastinal masses that you could not acess by bronchoscopy. Remember that you can obtain other diagnostics beside LC, as Tuberculosis, Sarcoidosis or Lymphoma.
1st question: Is the Lung Tumor Resectable?Look for metastatic lesions in order to know if the LC is ressectable or not.Please, You don’t need to know the all the stage in LC, But you MUST need to Remember the 4 UNRESECTABLE LC possibilities:a) If a patient has LC and has metastatic lesions Outside the Lung anywhere UNRESECTABLEPleura with Effusion UNRESSECTABLEOther Lung UNRESSECTABLEClose to Carina region UNRESSECTABLE*** The only exception is a small lesion of LC in the Lung & a small lesion in the Brain Ressectable!PET Scan: It’s not the way to confirm diagnosis! The PS localizes the glucose uptake, that generally is high and quickly uptake. But,Please be careful about evaluated Lung Mass with Pet Scan, because there are Types of LC that have a slow uptake of glucose, so it gives a false idea that the Pet scan is normal and the lesion is a benign one. The best typical example of slow growing is Bronchoaveolar carcinoma. Please the PET scan is not a way to confirm LC diagnosis! b) If the LC is confined to the Lung, then the LC is resectable! So, what is the next step? A: PFTs is the next step for pre- operatory because you need to know if the patient will support the surgery procedure.A predicted postoperative FEV1 or DLCO < 40% indicates an increased risk for perioperative complications, including death from lung cancer resection. Remember: Because a lot of patients with LC has advanced COPD ( Reduced FEV1), they are not a candidate to LC surgery.
Along the way we’ve discovered… The 5 necessary Rules about Lung Cancer.
…Along this presentation we remember five simple rules that MDs and NPs need to know about Lung Cancer and benefit your patient. But if you really wanna to change the world you have to engage the huge to work to know the LC cure. But now at the present you can also change the world if you engage the Tobacco cessation cause, warning everybody about the risk, mainly the children and their parents because there is no future with smoking!
So these are the rules!
If you give the priority, organize and mobilize yourselves for the quit smoking cause… Maybe you can not change all the world,…. but at least you can change YOUR part of the world!
You can also change the world. (Well, at least your part of the world!)
For more information, go to www.pulmaosa.com.br or email me at email@example.com.
General Concepts Lung Cancer• Leading death cause from cancer• 90% Smoking related• ALL LC are associated w Smoking• Nonsmoker = Adenocarcinoma• Smokers = 10 times higher risk than Nonsmokers• Smoking Cessation decreases the risk, but NEVER to a Non Smoker!• No screening tests N Engl J Med 2008, 359: 1367-1380
MANAGEMENT QUESTIONS AFTER LCDIAGNOSIS:• Is the LC Ressectable?1. Thorax CT2. MRI3. PET Scan• If the LC is ressectable, is the patient a surgical candidate?1. PFTs: FEV1> 50%?• Remember: Many LC are also COPD patientsLung Cancer screening results: Easily Misunderstaood. Mayo Clin Proc 2007;82: 14-15 / BTS Guidelines on the selection of patients with Lung Cancer forsurgery. Thorax 2001; 56: 89-108
Annotated BibliographyClinical Guidelines:• Alberts WM, American College of Chest Physicians. Diagnosis and management of lung cancer. ACCP evidence- based guidelines. Chest 2007; 132: 1S- 422SScreening• Survival of patients with stage I Lung Cancer detected of CT screening. N Engl J Med 2006, 355: 1763-1771Smoking• Wilson JF. In the Clinic. Smoking Cessation. Ann Intern Med 2007; 146:ITC2-1 – ITC2-16
THANK YOU Dr. Marcos Nascimento, Md UCF Voluntary Professor www.pulmaosa.com.br