What are the different types of coin lesions you can see on CXR?
Smooth walled (benign), calcium spicules (granuloma, malignant tumors are rarely calcified), bull's eye (benign), spiculated surface (malignant, especially if > 3cm) and popcorn (benign hamartoma).
Chance of malignancy in a coin lesion in a patient age 50
50%. It increases with age.
Regions with coin lesions commonly due to coccidioidomycosis
Regions with coin lesions commonly due to histoplasmosis
Mid Atlantic and Ohio Valley.
Tumors that commonly metastasize to the lungs and their 5-year survival
Testicular, breast (27-50%), renal (24-54%) and colon cancer (13-38%)
Next step in a patient with a SPN that is new from a prior CXR
CT to better characterize the lesion and look for lymphadenopathy. If suspicious CT-guided biopsy gets definitive dx 90% of the time.
Next step when CXR and CT reveal bronchial tree mass
Bronchoscopy for tissue sample and mediastinoscopy for assessment of lymph node involvement
What lung masses can simulate malignancy? How do you r/o malignancy with these masses?
ACTINOMYCOSIS: associated w/dental or sinus abscess and involves chest wall. COCCIDIOMYCOSIS: thin-walled cavity w/air-fluid level. HISTOPLASMOSIS: concentric or homogenous calcifications. BLASTOMYCOSIS: associated w/chronic skin ulcers. CRYPTOCOCCUS: superinfection in immunocompromised patient, meningeal involvement. ASPERGILLOSIS: mycetoma w/air crescent sign. HAMARTOMA: well defined border with slight lobulations (popcorn). ROUND ATELECTASIS: adjacent to thickened pleura w/comet tail vessel pattern.
Staging for non-small cell lung cancer and associated 5-year survival rates
Stage IA (50%): T1a/T1bN0M0 ( 2cm from main bronchus)
Stage IB (45%): T2aN0M0: 3-5cm, involves a main bronchus but > 2cm distal to carina, involves visceral pleura and/or partially obstructing airway.
Stage IIA (30%): T1a/T1bN1M0: < 3cm, does not involve visceral pleura or mainstem bronchi w/+ ipsilateral hilar LNs. OR T2aN1M0: 3-5cm, involves mainstem brochus but > 2cm distal to carina, involves visceral pleura and/or partially obstructing airway w/+ ipsilateral hilar LNs. OR T2bN0M0: 5-7cm, involves mainstem bronchus but > 2cm distal to carina, grown into visceral pleura and blocks the airways w/o LN spread.
Stage IIB (30%): T2bN1M0: 5-7cm, involves mainstem bronchus but > 2cm distal to carina, grown into visceral pleura and blocks the airways w/+ ipsilateral hilar LNs. OR T3, N0, M0: > 7cm, involves chest wall, diaphragm, mediastinal pleural, parietal pericardium, main bronchus < 2 cm from carina, airway obstruction leading to lung collapse or 2+ separate tumor nodules in same lobe. No +LNs.
Stage IIIA (15%): T1-T3N2M0: Any size, does not involve mediastinum, heart, great vessels, trachea, esophagus, spine, carina or different lobes. + ipsilateral hilar and/or mediastinal LNs. OR T3N1M0: > 7cm, involves chest wall, diaphragme, mediastinal pleura, parietal pericardium, main bronchus < 2cm to carina, 2+ nodules in same lobe, obstruction leading to lung collapse. +ipsilateral hilar LNs. OR T4N0/N1M0: Any size involving mediastinum, heart, great vessels, trachea, esophagus, spine carina and/or 2+ nodules in different lobes of same lung. +/- ipsilateral LNs.
Stage IIIB (5%): TanyN3M0: any size, obstruction leading to lung collapse, + supraclavicualr contralateral/ipsilateral mediastinal and hilar LNS. OR T4N2M0: any size involving mediastinum, heart, great vessels, trachea, esophagus, spine, carina, 2+ nodules in different lobes of same lung w/+ peribronchial LNs.
Stage IV (1%): TanyNanyM1a: metastasis to pleural and/or pericardial fluid. OR TanyNanyM1b: Metastasis to distant LNs, bone, brain, liver etc.
Lung cancer type with chemotherapy as the primary treatment
Small-cell carcinoma is a systemic disease at diagnosis because it has usually already spread beyond the lung and is not amenable to resection.
Lung cancer type with surgical resection as the primary treatment
Non-small cell carcinoma (adenocarcinoma and epidermoid carcinoma...aka squamous-cell carcinoma) are local diseases that spread to local and region LNs before becoming systemic.
What patients require a pneumonectomy over a lobectomy?
Centrally located tumors that involve mainstem bronchi. Note that pneumonectomy has a higher initial mortality rate and sleeve lobectomy, although more difficult, is an option if local invasion of the main pulmonary artery is not present.
Tx for stage I and II lung cancer
Tx for stage III and IV lung cancer
Chemotherapy + radiation, then resection if chemoradiation sufficiently shrinks the tumor.
What is a pancoast tumor?
A tumor that grows in the superior sulcus of the lung. It invades the chest wall, lower cords of brachial plexus, subclavian artery and sympathetic ganglia. This can result in SOB, radiculopathies, peripheral limb ischemia and Horner's syndrome.
Work up of a pancoast tumor
CT then bronchoscopy to check for bronchial invasion and get tissue if possible, mediastinoscopy to assess for LN spread and needle biopsy if tissue is still needed.
Tx for pancoast tumors
6 weeks radiation followed by surgical resection, patients do surprisingly well
Differential for small hemoptysis in a 25 year old non-smoker
Bronchial adenoma, atelectasis and Tb. These can all cause obstruction of a bronchus and bleeding.
Types of bronchial adenomas
These actually have considerable malignant potential: 1) Carcinoid, more benign when originating in lung, more malignant when originating from small bowel, may present with carcinoid syndrome. 2) Adenocystic carcinomas, which tend to invade locally.
Tx for bronchial adenomas
Lobectomy tends to be curative (except for when carcinoid metastasizes widely)
What do you worry about when you see a pleural effusion in an elderly patient?
Although effusions from CHF are more common, this is cancer (bronchogenic carcinoma or mesothelioma) until proven otherwise. After r/o cancer with thoracentesis and pleural biopsy you can consider other diagnoses like pneumonia, empyema or tuberculosis.
Mesothelioma on CT
Thick-walled tumor that is pleurally based
Tx for mesothelioma
En bloc pneumonectomy w/parietal and visceral pleura +/- pericardium and diaghragm. Morbidity and mortality rates are greater than 10%, but 30% of patient can recover. Chemorads is not an option.
How do you place a chest tube (tube thoracostomy)?
Make an incision between ribs 4 & 5 (at nipple line) above the rib. Finger dissect into the extrapleural space, then place a 24 Fr chest tube directed toward the apex and attach it to a water-seal-type drainage. If it is a patient's 1st time pneumothorax you can consider a polyethylene tube with a one-way valve (Heimlich) over the 24 Fr tube and water seal.
Most common cause of the lung not expanding after placement of chest tube for pneumothorax?
Improperly placed chest tube. Try replacing the chest tube. If this does not fix the problem you then need to consider a parenchymal cause like leaking from large blebs/bronchi that need to be treated with pleurodesis to cause visceral and parietal pleura to adhere to each other.
Most common cause of empyema in the elderly
Strep pneumo in the community setting, Staph and gram-negs in the hospital setting. Anaerobes if pt has hx of aspiration pneumonia.
How do you treat a patient with empyema?
Abs, pus evacuation and lung re-expansion
Why is rapid tube thoracostomy important in the treatment of empyema
Over time the empyema can become loculated as fibrin organizes. If this occurs, the patient will require thoracotomy and decortication to re-expand the lung.
A patient presents with unstable angina. How do you treat him initially and how do you work him up?
Start with bed rest, sedation, 02, beta-blockers, nitroglycerin, aspirin and/or heparin. Check cardiac enzymes to r/o MI then do cardiac cath to check patency of coronary vessels.
90% in kids, 70-80% in young adults and 50-60% in older people. < 40-50% is abnormal