2. JZ
82 y/o WM prior smoker (40
pack-years, quit age 65) with
PMH of COPD, HTN, HLD,
CAD, PVD, Carotid Stenosis, 4
cm AAA, Colon Cancer s/p
resection 1999 and TIA…
Presented to outpatient
pulmonary office 9/7/2011 for
ongoing evaluation of COPD &
RLL 1 cm pulmonary nodule.
3. JZ
Pertinent ROS:
Admits chronic cough productive
of clear sputum. Increasing DOE
and vague right-sided CP.
Denies SOB at rest. Denies
hemoptysis, fevers, chills,
night-sweats or weight loss.
4. JZ
CT scan done same day showed a
new (compared to 9/21/2010)
right upper lobe nodule.
2.3 CM, spiculated RUL nodule.
Scheduled to undergo navigational
bronchoscopy 9/13/2011.
PET/CT scheduled 9/16/2011.
5. Physical Exam
VS: Afeb, HR 59, BP 105/65, RR 20,
SpO2 98% RA.
GEN: A&A&Ox3. NAD, ASA class II.
HEAD: NC, AT.
EENT: PERRL. Ears/Nose wnl.
Edentulous. Mallampati 2.
NECK: Supple, full ROM.
CV: RRR with grade 2/6 SEM over
tricuspid area.
LUNGS: Scattered rhonchi,
otherwise CTAB with wheezing or
rales.
ABD: Soft, NT, ND. BS present.
NEURO: CN II-XII intact.
EXT: No CCE. Radial pulse 1+/4
equal bilaterally
8. CT/PET 9/16/2011
Enlarged (1.5 x 1.4 cm) 2A LN
with increased SUV 6.6.
RUL nodule (2.4 cm) SUV 14.4.
Right hilar LN SUV 10.5.
Paratracheal LN SUV 6.9.
9. PFT’s 9/7/2011
FVC: Pre 3.51(102%)
& Post 3.46(101%)
FEV1: Pre 1.90 (79%) & Post 1.95(81%)
FVC/FEV1:
Pre (54%)
&
Post (57%)
TLC: 5.86, Ref 5.61 (104%)
DLCO: 11, Ref 17.9 (61%)
“Moderate obstructive disease w/o
bronchodilator response”. Decreased
diffusion capacity impairment.
10. NSCLC
Any type of epithelial lung
cancer other than small cell
lung cancer (SCLC).
3 most common types of
NSCLC are:
1) Squamous cell carcinoma
2)Adenocarcinoma
3)Large cell carcinoma, and
adenocarcinoma
11. NSCLC
There are several other
types which occur less
frequently, and all types
can occur in unusual
histologic variants
See figure on next slide
12.
13. Sarcomatoid carcinomas are a group of
poorly differentiated non-small cell lung
carcinomas that contain a component of
sarcoma or sarcoma-like (spindle and/or
giant cell) differentiation.
14. Sarcomatoid carcinomas
Rare accounting for ~0.31.3% of all lung
malignancies
Average age onset 60 y/o
Male:Female = nearly 4:1
Etiology ~smoking,
carcinogens
15. Sarcomatoid carcinomas
Sarcomatoid carcinomas can
arise in the central or
peripheral lung, though a
predilection for the upper
lobes has been reported
16. Sarcomatoid carcinomas
Signs and symptoms are
related to tumor location
Eg: Central endobronchial
tumors tend to protrude
into the lumen of large
airways, causing cough,
hemoptysis, progressive
dyspnea and postobstructive pneumonia
17. Sarcomatoid carcinomas
Signs and symptoms are
related to tumor location
Eg: Peripheral tumors,
(especially pleomorphic
carcinoma) grow to large
sizes and often present
with chest pain due to
pleural or chest wall
invasion
18. Giant Cell Carcinoma
Characterized as “Very
aggressive” and
metastasize.
Survival depends on staging.
Note, the pulmonary nodule had been stable since 1/25/2006 thru 9/21/2011 (per report)…
Spiriva, Singulair is current regimen. Plan is to add Advair or Symbacort
ASA= American Society of Anesthesiologists (ASA) status for pre-op fitness.
Adenocarcinoma, arising from the bronchial mucosal glands, is the most frequent non-small cell lung cancer in the United States, representing 35-40% of all lung cancers. It usually occurs in a peripheral location within the lung. Adenocarcinoma is the most common histologic subtype, and may manifest as a “scar carcinoma.” This is the subtype observed most commonly in persons who do not smoke. This type may manifest as multifocal tumors in a bronchoalveolar form.
SCC accounts for 25-30% of all lung cancers. Whereas adenocarcinoma tumors are peripheral in origin, SCC is found in the central parts of the lung. The classic manifestation is a cavitary lesion in a proximal bronchus. This type is characterized histologically by the presence of keratin pearls and can be detected with cytologic studies because it has a tendency to exfoliate. It is the type most often associated with hypercalcemia.
Large cell carcinoma accounts for 10-15% of lung cancers, typically manifesting as a large peripheral mass on chest radiograph; it appears to be decreasing in incidence because of improved diagnostic technique. Histologically, this type has sheets of highly atypical cells with focal necrosis, with no evidence of keratinization (typical of SCC) or gland formation (typical of adenocarcinomas).
http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/healthprofessional/#Section_27: NSCLC arises from the epithelial cells of the lung of the central bronchi to terminal alveoli. The histological type of NSCLC correlates with site of origin, reflecting the variation in respiratory tract epithelium of the bronchi to alveoli. Squamous cell carcinoma usually starts near a central bronchus. Adenocarcinoma and bronchioloalveolar carcinoma usually originate in peripheral lung tissue
Sarcomatoid carcinomas are a group of poorly differentiated non-small cell lung carcinomas that contain a component of sarcoma or sarcoma-like (spindle and/or giant cell) differentiation. Five subgroups representing a morphologic continuum are currently recognized: Pleomorphic carcinoma:, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma and pulmonary blastoma.
Carcinogens= second-hand smoke, radon, arsenic, asbestos, chromates, chloromethyl ethers, nickel, polycyclic aromatic hydrocarbons, radon progeny, other agents, and air pollution.
A large central endobronchial tumor can occlude the airway causing cough, hemoptysis, SOB and obstructive PNA.
The 5-year relative survival rate varies markedly depending on the stage at diagnosis, from 49% to 16% to 2% for patients with local, regional, and distant stage disease, respectively
Mallinpati, Supraclavicular adenopathy
Rapaflo (silodosin) is BPH Rx.
Singulair (montelukast) is a leukotriene inhibitor.
Rapaflo (silodosin) is BPH Rx.
Singulair (montelukast) is a leukotriene inhibitor.