Lung Neoplasms

foreign engineers in this video today we are going to be talking about lung masses we're primarily going to focus on lung cancer but we'll sprinkle in a couple other things in there like solitary pulmonary nodules and we'll briefly talk about mediastinal masses let's go ahead and get started so when we talk about neoplasia's pretty much within the chest obviously one of the big things is like this little cavity kind of situated in the center so you obviously have your thoracic cavity and in the thoracic cavity kind of in the midline you have something called the mediastinum so sometimes masses can appear in the mediastinum that can distort the abnormality of normal structures when you look at it on a chest x-ray and it's important to quickly be able to associate what are some of those things that could actually be causing this Mass so you have to quickly remember your actual anatomy of the media center we're not going to spend a ton of time I want to briefly go through this but when we look at the meaty side and we're going to take a cross section here so here's going to be the right lung here's going to be the left lung here's going to be the vertebrae this structure here is the sternum okay there's three main compartments of the mediast item that I want you to know the anterior mediastinum which is going to go from the sternum all the way up into the anterior points portion of the pericardium of the heart So within this area just right here what are some tissue structures that could actually become abnormal cause masses to appear in your chest x-ray big thing to think about remember the four T's so one is thymoma terrible lymphoma because there's lymph node tissue in there retro sternal thyroidal goiter okay so some of the big old thyroid goiter and it's actually going downwards into the actual posterior part of the sternum so again thymoma terrible lymphoma retro sternal thyroidal goiter and then one more thing you know tumors germ cell tumors called teratomas can also sometimes appear in here so I'll represent that as kind of like a little a blackish tumor here sometimes teratomas can also extend into the anterior mediastinum so think about those things now the middle medius item is generally going to go from the anterior portion of the pericardium to around this area you see right here we have the trachea where it bifurcates into the primary bronchi that area from here to here is the middle mediastinum so any kind of structures in there that actually develop tumors could obviously cause Distortion there so think about sometimes a tracheal tumor a bronchial tumor and what is all this green stuff around there lymph node tissue so lymphoma those are other big things to be thinking about within the middle mediastinum the posterior mediast item is going to go generally right behind the bifurcation of the trachea all the way to your vertebra so all the things in this posterior mediastinum can also become abnormal grow masses and distort the anatomy what are those things esophageal tumors what are these green things lymph node tissue so lymphomas you also have a lot of nerve sheaths around here so nerve sheath tumors particularly the sympathetic plexus of the vagus nerve and then you know sometimes there's a tumor that can actually extend into the actual bone marrow and cause all these bone marrow neoplasms such as multiple myeloma so these are the big things to be able to think about so there's a quick recap here whenever we have patients who have mediastinal masses it's important to be able to understand the anatomy and what are the structures within them anterior what are they terrible Force retro sternal thyroidal goiter lymph terrible lymphoma thymoma teratoma for Middle bronchial tumors tracheal terms and Lymphoma for posterior lymphoma esophageal tumors nerve sheath tumors and multiple myeloma but here's the last thing big thing kind of leading us into the next topic is that sometimes a patient has a lung cancer so they have a lung Mass some type of lung cancer we're going to talk about that next guess what was one of the most common causes of extension into like the middle mediastinum posterior mediastinum or anterior mediastinum some type of lung met so remember lung is a very common lung cancer is a very common type of cancer that can metastasize to the mediastinum and distort that structure let's talk about lung cancer now all right my friend so now let's talk about lung cancer we talk about lung cancer we can easily divide these now most of the time it's divided into two types small cell lung cancer and non-small cell lung cancer there's one other less common tumor so we're going to briefly pass over that quickly but when we talk about small cell carcinoma or small cell lung cancers one of the big things is that this is a part of a neuroendocrine tumor group okay and there's two main neuroendocrine tumors that you guys should know for your step two one is the big one small cell lung cancer okay this accounts for about 25 of the actual lung cancers that you'll see now one of the big things I think is really important especially for understanding features and what to look for on the actual Imaging studies is where these actual carcinomas primarily situate themselves within the lung tissue and small cell lung cancer tends to be more of a centrally located type of tumor so that's what I really want you guys to remember whenever you think about small cell lung cancer I want you to think about a centrally located it's going to be more involving the central part of the lungs near the actual bronchi neither medial portion of the lungs again that's the primary thing with small cell lung cancer answer now there's another one called carcinoid tumor now carcinoid tumor is another type of neural endocrine tumor meaning that they have the ability to produce hormones you'll see later that small cell lung cancer can produce something called perineoplastic syndrome where it releases tons and tons of different hormones a really interesting process same thing with carcinoid tumors carcinoid tumors tend to have a little bit of a mixture so you can also find them primarily most of the time centrally located type of tumors so they're primarily centrally located but on some small percentage they do have some peripheral involvement so it is important to remember that they are primarily essentially located tumor near the actual bronchial system but on the small occasion they can also be located peripherally okay now when we talk about these this gives us the conversation of the neuroendocrine tumors small cell lung cancer is the big one I really want you guys to remember this one and carcinoid tumors big thing these are tumors that can release hormones very very this one very nasty type of lung cancer again small cell centrally located carcinoid more centrally has a little bit of peripheral involvement key here okay let's now talk about the next component which is the non-small cell lung cancer so they're not small cell lung cancers okay there's a couple different types here and the big thing to remember for this one is this accounts for most of our lung cancers like 75 percent of the cases so 75 percent of the cases that we'll see with lung cancer just likely non-small cell now what are the different types of non-small cell now one of those is squamous cell carcinoma so squamous cell carcinoma is just the configuration so it takes over some of the you know pseudostratified cilia to columnar epithelial tissue that we have within our bronchial system or simple you know generally some of that structures that we have there and turns it into more of a squamous type of tissue but it's a neoplasia and usually what I want you to remember is this is primarily centrally located type of tumor big big things man I'm telling you it's really important because this is going to help us to determine the features and complications because more centrally located tumors will have very specific features and complications whereas the peripheral ones will have very specific features and complications and things that we can pick up on their Imaging studies all right there's squamous cell the next one is adenocarcinoma adenocarcinoma I do want you to remember that this is the most common maybe accounting for upwards of 40 of the non-small cell lung cancers in comparison to Swami cell large cell and bronchial alveolar carcinoma so big thing that may come up in the exam or if you're trying to figure it out which is this non-smile which nonsense cell small cell lung cancer is this well the most common one is like one that they're likely going to test you on so it would be adenocarcinoma now adenocarcinoma usually is going to be involving some of the actual mucinous producing cells whereas large cells this these again are very big types of tumors thus the name large cell carcinoma where are these primarily located again guess what these are primarily peripherals so you're like oh okay finally we got a peripheral located one so whenever you think about adenocarcinoma or large cell carcinoma think about tumors that are going to be more involving the periphery of the lungs rather than the central location that you see in squamous small cell and again more carcinoid but a little bit of peripheral the last one here my friends is called bronchial alveolar carcinoma so this is kind of like a subset of Adeno and usually you know the highest risk factor for this one is we'll talk about in a second asbestos explosion we'll talk about the causes that are big reasons for lung cancer but bronchoabiola is a mixture it's just like carcinoid tumor so you're going to see it mainly Central but guess what you also will see you can see some peripheral involvement as well so it's important to remember that for this one you can see it both Central and peripheral for the Bronco alveolar carcinoma all right so when we have these all situated together we got squamous cell carcinoma primarily Central we have adenocarcinoma large cell carcinoma we've got to write these down that this is primarily peripheral and then we have the bronchial alveolar carcinoma which is going to be a mixture of Central and peripheral the last thing that we have to talk about now that we understand the different types of lung cancers where they're primarily situated their most common types of cancers that you'll see within this we have to talk about what are the things that can actually cause these cancers let's go over that quick all right so when we talk about causes I think this is really important most of the causes if you guys are going to see them it's going to be a patient who smokes cigarette smoking is going to be the most common cause you know how important this is 82 90 of the case is going to be due to cigarette smoking but there's one exception that you may see on the exam that you have to know do not forget this is why I kind of made this red I'm going to asterisk that it's not an adenocarcinoma so adenocarcinoma is one of the only lung cancers that have no association with smoking it's more likely associated with genetics or some type of going off of that family history so if they have a genetic predisposition so some type of mutation or they have a family history that's allowed for them to pass on that particular mutation these are the things that puts patients for adenocarcinoma at high risk okay again smoking most common cause for most of these lung cancers the only one that is not adenocarcinoma don't forget that the other things is like rat radon exposure asbestos exposure any other kinds of Occupational types of like you know hazardous materials but I think one of the big things with asbestos exposure is that this really has a high Association of Broncho alveolar carcinoma like I told you but guess what else it also has a very high risk of mesothelioma we're not going to talk about this as a part of the lung cancer category we already talked about in the interstitial lung disease and we talked about asbestosis but mesothelioma would be a cancer that's involving the pleura okay so it's going to be causing inflammation of the visceral chloridoplora and causing cancerous cells to develop there remember what else is asbestos cause because the pleural plaques at the basis of the lungs so again big things to be thinking about the reason I drew these I just wanted to test your memory if we took a bronchial lavage or a sputum sample of a patient with asbestosis what would these things be called on the actual microscopy for organist bodies remember the little dumbbell things that we saw anyway I thought that would be a cool little test of your memory but we have the basic causes the understanding of lung cancer before we go on to the features and complications we now have to have a very brief discussion about when we see maybe a chest x-ray or a CT scan and we see what looks like a mass how do we know if it's actually not a malignant type of neoplasia so in other words some type of lung cancer that we just talked about or something benign so we'll talk about that now all right so the next thing that we have to talk about is something called a solitary pulmonary nodule this will come up on your exam so you have to be able to recognize you get a patient who comes in they're asymptomatic more likely they get a chest x-ray CT scan something of that nature and incidentally they find a what looks like a mass in their lung tissue but it may not be malignant it may honestly just be a benign type of tissue there and so we have to be able to differentiate what is the likelihood of this being a solitary pulmonary nodule and then having a differential on our head could this be benign if it is benign what are the things to think about what's the likelihood of it being benign what's the likelihood of it being malignant if it is malignant what kind of things could it potentially be so first thing we let's have here a pulmonary nodule so here we're going to have just like a nodule of tissue definitely looks abnormal in comparison to the surrounding lung tissue how do we Define a pulmonary nodule one of the key things is that it is less than three centimeters that's one big thing second thing is that all the tissue surrounding the actual pulmonary nodule is normal lung tissue so normal lung surrounding the pulmonary nodule that's huge all right and then last thing is that there is no lymphadenopathy so no nearby lymph nodes that are being involved from the tumor okay this is key things to be able to think about whenever you're likely suspicious that this is a benign finding a benign solitary pulmonary nodule okay less than three centimeters normal surrounding lung tissue and no lymphadenopathy now when we think about pulmonary nodules we have the thought is this a you know a malignant or a benign type of tumor and so oftentimes you can kind of rest at ease that it is likely 70 of the time benign and when they think it is benign to have a differential so things that you're going to potentially test for if you're going to go down the route of doing a bronchoscopy doing a biopsy whatever it may be the big thing is if you see a pulmonary nodule and it kind of fits the category of less than three centimeters normal surrounding lung tissue no lymphadenopathy think about granulomatous diseases so granulomas can definitely cause this kind of like nodular appearance and so think about things that cause granulomas one of the big things would be tuberculosis so tuberculosis could be one particular disease another one would be your fungal infection so this will definitely come up on your exam so it may be histo histoplasmosis or coccidiomycosis so these are big things to think about so histo or coccidio mycoses so those fungal infections that you guys remember that we talked about before all right so granulominus diseases 80 percent of the time it's likely going to be something like TB fungal infections the other time it can be 10 of the time hammered homeless so these are kind of like these abnormal collection or mixture of abnormal tissues that is a benign type of like nodule ten percent of the time it could be Hammer Thomas whenever they say okay you think it's benign definitely has the characteristics to suggest a benign type of mass what are the differential you say granulominus diseases most of the time TB histo or coccidio the other 10 likely hamartoma and then for the remaining 10 because we had 80 10 there's like something missing here it would be any kind of other miscellaneous causes that are not worth even us mentioning it in this video okay now the next thing is it could be malignant what's the chances that it could be malignant there is a chance so 70 remaining a percentage is 30 so there still is a chance you have to be on alert for that now if you think it's malignant we will talk about things that are more suspicious for malignancy such as what's the age of the patient has the nodule changed over the previous couple of years maybe two years does it have irregular borders does it have asymmetric calcifications is there other types of particular things that are very concerning for malignity and we will discuss that later in the diagnostic section but for right now you have a suspicion that it could be potentially malignant or you're thinking about your deferential guess what it's relatively easy if there's a nodule that you suspect is malignant go back to all the ones that we just talked about unlikely that it's small cell because when people find small cell it's usually too late they have about a two year survival rate at that point time because it's usually extensive so think about all the bronchogenic carcinomas that we talked about such as squamous cell carcinoma adenocarcinoma large cell carcinoma maybe bronchial alveolar carcinoma as well but again these are the big things to think about 75 of the time it actually is one of these malignant neoplesias and then could it be metastatic could it have come from a breast cancer could it have come from some type of colorectal cancer could have come from somewhere else and that it spread to the lungs oftentimes if it's metastatic it's less likely because you'll have multiple pulmonary nodules if it's metastatic usually not just one solitary nodule so that's the big things to think about so we got a pulmonary nodule as a part of our other types causes pathophys for these kind of thoracic or respiratory neoplases that I want you guys remember less than three centimeters normal surrounding lung tissue no lymphadenopathy could be benign think about granulomas TB histococcidio Hammer Tomas is the remaining if you have a suspicion that's malignant we'll talk about what things are suspicious for malignancy for pulmonary nodules think about the lung cancers that we just talked about with the exception unlikely small cell because of how extensive that disease is or metastatic less likely though because usually if it's metastatic you have multiple nodules all over the place it's more of a kind of a distance spread and usually more than one nodule all right beautiful that covers the types the causes the pathophys for our actual chest or respiratory neoplases let's now go over really key thing here features and complications all right so when we talk about the features complications we're going to primarily talk about lung cancer it's going to be the big big thing for us to discuss oftentimes solitary pulmonary nodules that are asymptomatic they're incidental findings mediastinal masses often they're due to compression so you might get some of the similar effects that you'll see in lung cancer but we're not going to harp on that too much I just want us to primarily focus on the features and complications of the lung cancers that we discussed that being the small cell non-small cell lung cancer and then carcinoid tumors all right so General features that you may see from all of these cancers is that they may have a general sense of maybe low-grade fevers weight loss and some generalized fatigue or malaise why it could be a couple reasons one of the reasons the tumor may actually gain the capacity to make specific types of cytokines maybe things like interleukin-1 tumor necrotic Factor Alpha and stimulate the hypothalamus and when it stimulates the hypothalamus it can actually cause the temperature center the thermal regulation Center within the hypothalamus and our hunger centers and our hypothalamus to be undergo a dysregulation process so then what can do is it can jack up our temperature because it controls our thermoregulation so if it jacks up our temperature can lead to these low-grade fevers it also can affect our hunger Center which may decrease the ability or the desire to want to eat so there's a decreased appetite therefore leading to weight loss here's the other thing because the cancer is getting so much types of like blood flow there's lots of blood flow to these actual bad boys what happens is that these cancer cells consume massive amounts of oxygen and glucose and so they are just chewing through our energy reserves if you chew through the energies or reserves that can actually lead to a big kind of caloric deficit as well as leading to weight loss and since your tumor is consuming a lot of the oxygen glucose rather than your muscles and other tissues that need to be utilizing it to perform normal daily functions you may have some generalized fatigue and weakness so these are two of the theories behind why these patients develop this one is going to be due to a cytokine release that tells the hypothalamus to change the thermoregulation center and the hunger Center causing us to develop fever and weight loss the other theory is that this could be due to the tumor consuming lots of oxygen and nutrients that are in other body tissues are supposed to be consuming but it has less of it because it's consuming most of that energy what are some other features that are really important here's the big thing when you have a tumor that is centrally located you know most of these tumors are centrally located do you guys remember which one that would be small cell lung cancer squamous cell lung cancer and maybe even a carcinoid tumors or bronchial alveolar carcinomas which have Central and peripheral the only ones that we said that were not pretty much Central would be the adenocarcinomas and the large cell carcinomas since they have tumors that are more centrally located they can either be present inside the bronchioles or they can be outside of the bronchials and compressing the actual bronchioles nearby so you can get an endobronchial growth which can lead to these features or you can have a tumor on the outside that's compressing on the bronchial system just as the same as if there was a tumor inside the Lumen so you guys get the point there's either tumor in the Lumen or there's a tumor outside of it compressing on the Lumen what are some features that you can see with that well think about this if you have a cancer here what this how what happens is this can cause some localized inflammation and increased blood vessel flow whenever that localized inflammation is there guess what it stimulates these nearby cough receptors and these cough receptors when they're agitated or activated by inflammation what do you think they produce a cough reflex so oftentimes these patients may present with a cough due to the localized inflammation caused by the actual neoplasia second thing is that these neoplasians imagine here you have kind of an actual bronchial tissue here and then you know it's in the bronchial tissue here we're going to have let's say the tumor is endobronchial so here's our tumor now what happens is we know that you get lots of blood supply neoplesias definitely increase the angiogenesis process so that they can get more blood supply to be able to get more oxygen more nutrients to continue to grow what happens now is that sometimes there can be an erosion of some of these vessels within the bronchial wall and then these blood vessels can start to oops right into the actual Lumen of the bronchial system and then that can be coughed up what is that called when you're coughing a blood hemoptysis so we got cough reflex activated from local activation we got neoplases having increased vascularity chewing away at the actual vessels sometimes can lead to blood moving into the Lumen causing hemoptysis what else imagine that this tumor obstructing the Lumen what's supposed to be moving through there air air is supposed to be moving in and out but now you have an obstruction which is going to be decreasing airflow through this bronchial system decreasing airflow through this bronchial system if I can't have a good amount of air coming in what am I going to try to do to augment that I'm not bringing in adequate tidal volumes I'm going to try to breathe faster or deeper and so this makes the patients look like they're very short of breath because they're working really hard to take in deeper breaths because they have an obstruction within their Airway and so they may have this the other thing is when they exhale if you have a tumor here it's not completely obstructing the Lumen but you have a tumor here and you're trying to Exhale now that air has to move through that tiny little area of the Lumen during exhalation when the air is moving out during exhalation it may cause a wheezing type of response so again think about activated inflammation cough reflex increased vascular supply enough that it actually starts kind of getting pushed into the lumen hemoptysis third thing is you have less airflow coming in because of obstruction of the airway leading to dyspnea and then less air getting out during expiration causing wheezing one other thing is that normally if I have an obstruction within the actual bronchial system normally mucus is supposed to move up through the bronchials and be coughed out but if I have some type of big obstruction that's preventing this mucus from being able to be expelled outward because it's obstructing it now bacteria can just multiply and thrive in this mucous Rich area and then now I create an opportunity for an infection which is called pneumonia so we call this post-obstructive pneumonia big things that I want you guys to think about with this is that this is more common with Central tumors so Central tumors do you guys remember why I harped on that okay so cough hemoptysis dyspnea wheezing post-obstructive pneumonia I hope that part made sense the second thing is nearby compression so if I have a tumor that again is more centrally located and what it starts doing is is it starts crowding around the mediastinum and compressing on structures near the mediastinum what are some of the effects that I can start to see all right so same thing Central tumors so think about Central tumors with the actual nearby compression of structures in the mediastinum well one is you have this nerve called the recurrent laryngeal nerve you know if you compress that it actually can lead to hoarsions of the voice you can also compress the esophagus if you compress the esophagus now there's difficulty in being able to swallow this leads to dysphagia and then you can compress onto this big structure here which brings venous blood from above the diaphragm this can compress the super vena cava latest SVC syndrome where they have upper extremity edema discoloration chest wall edema discoloration massive jvd think about these things in central tumors all right so we got again endobronchial growth or compression Central tumors nearby mediastinal compression Central tumors these are the big things I need you to think about okay now let's move over and talk about a couple other features that you can see with these and one of the big things that I want you to think about is things that you could see with the peripheral tumors all right so the next thing that we need to talk about we said you know generally plural disorders that's going to be near your periphery right so when we talk about pleural disorders that are associated with lung cancer you'd be associating this more with the peripheral lung cancers or peripheral lung tumors so pleural disorders think about these more particularly in those peripheral types of lung tumors so again think about which ones those were we said adenocarcinoma large cell and then technically you could even consider a little bit of the carcinoid a little bit of the bronchial alveolar but not squamous cell and not small cell okay now with these generally as you have a tumor that gets close to the actual visceral and parietal plural what can lead to well one is the lead to pleural effusion second it can lead to pneumothorax brief little discussion because we'll go over these impleural disorders and we'll talk about a separate lecture but when you have malignancy obviously there's going to cause an increase inflammation so malignancies can actually release certain types of chemicals that can increase the inflam inflammation nearby and cause the blood vessels to become super leaky if the blood vessels become super leaky they can leak a lot of that fluid some of the plasma fluid and proteins and different cells into the actual pleural cavity and lead to a pleural effusion so think about that with these patients more likely peripheral tumors now at the same situation if you had a tumor that's near the actual visceral parietal pleura and it's trying to grow and grow and grow and what it does is it has the opportunity that it actually starts eating away at the visceral pleura then you can create like a fistula if you will between the parenchyma and the pleural cavity and then air is going to easily enter into the pleural cavity and as air enters into the pleural cavity this is known as a pneumothorax so think about these two types of disorders that you would likely more see with peripheral lung tumors plural fusions more of an exudative type of effusion due to increased capillary permeability or you know what else lymphatic vessels they can compress lymphatic glasses you know you have lymphatic vessels that are actually located within the pleural cavity and they're supposed to take some of the fluid out sometimes if you have a tumor that's large enough that's actually compressing on this lymphatic vessel it can actually do what decrease the drainage of the pleural fluid and that can also lead to this problem too so it could be due to oxidative due to increased capillary permeability or decrease fluid clearance because of compression of lymphatic vessels all right that would cover the pleural disorders associated with lung tumors now let's talk about one special type of appearance that you can see with two types of tumors pancos tumors you can see this with two types and we'll talk about that in just a second one is Adeno carcinoma and the other one is squamous cell so this one you're probably like wait I thought there's usually like a central peripheral this one's very interesting so squamous cell we obviously know is more centrally located and then adenocarcinoma we know is more peripherally located when we look at pankos tumors pankos tumors are tumors that can develop right on the apex of the lung so usually if you see a pankos tumor it's going to be right here at the apexes or the apices of the lungs and technically if it's more centrally located that's definitely close to the apexes and again peripheral you see adenocarcinoma so big things to think about with pankos tumors usually tumors near the apices of the lungs associated with Adeno and squamous cell used to be primarily squamous cell but we've seen a higher incidence with adenocarcinoma let's talk about the presentation of pankos tumors now all right so if you guys remember when we talk about the apices we have like you generally you have your serum right here but you're going to have a rib here this would be your first rib and right around the area of the first rib you're going to have your apices of the lungs but you know what else you have you have like a lot of neurovascular bundle so you have a lot of nerves that are going to be running within this vicinity here's lots and lots of nerves running within this vicinity here and then also you're going to have lots of blood vessels that are running within this vicinity here so definitely lots of blood vessels and a nice neurovascular bundle if you will running near the Apes uses of the lungs near the first rib if this tumor is growing near the apices it can compress onto these blood vessels and compress onto these neural bundles what would be the features that we would see if it's compressing on the nerves and compressing on the vasculature great question if it's compressing on the nerves you need to know what nerves are in that vicinity of the lung apices one is the recurrent laryngeal nerve you compress it you get hoarseness to The Voice the other one is the phrenic nerve Frederick nerve surprised that supplies the diaphragm so if you had a right pankos tumor you would have hemip paralysis of the you had a paralysis of the right hemidiaphragm if the right Hemi diaphragm isn't working it can't Dome down you won't get as good of a chest expansion on the right side so you have unilateral decreased chest expansion on that right side the other thing is if you look at the chest x-ray because it can contract and come down their diaphragm is super elevated on that side that's affected so look for hemidiaphragm elevation and decrease chest expansion on the affected side the other thing is it can compress the sympathetic nerves you know the sympathetic plexus specifically supplies the upper eyelid helps to be able to supply the pupil and supplies the sweat glands around the actual head face neck area guess what if you compress that you won't allow for them to be able to dilate the pupil guess what they'll do constrict this is called meiosis they won't be able to keep their upper eyelid elevated it will droop this is called ptosis and they won't be able to sweat around their forehead and near their face that's called anhidrosis This is a Triad for the sympathetic plexus compression called Horner syndrome okay the last thing is there's the brachial plexus near this area guess what happens if you smash on that brachial plexus it's supposed to supply the muscles and also provide sensation to the upper limbs you can develop paresthesias you could develop even pain if it's really bad and on top of that weakness of the upper extremity muscles so those are big things to think about what the nerve compression aspect what about the vascular compression you could compress the artery so if you did compress like the subclavian artery or near the axillary artery you could develop reduced perfusion to the Skin So decrease pulses on the affected side is a possibility but you're more likely to see venous compression because it's easier to collapse those and so there's the brachiocephalic vein that runs in this area and the superior vena cava just the tip of it and so you can compress these two bad boys if you can compress the brachiocephalic vein or potentially the top of the superior vena cava you're not going to drain into the right atrium so all the blood flow will back up into the upper extremities the neck the chest and you'll develop upper extremity neck chest while edema discoloration and significant plumped up jvd okay big things to think about with panko temperatures as you see with Adeno squamous used to be squamous is the most common adenos becoming the more common one that we see all right the next thing that we have to talk about is perineoplastic syndromes all right my friend so now perineoplastic syndrome is a huge thing that they definitely will likely test you on on the exam so you have to know it all right so the first thing we want to think about is if we have a patient that we suspect has some type of lung cancer right we look at their potential etiology they definitely smoke a lot of cigarettes they have some type of lung Mass on their Imaging and you have a concern that they may have a perineoplastic syndrome what are the things to think about and which lung cancer is it associated with so squamous cell carcinoma was really interesting in the fact that it gains the ability to be able to produce a very special type of hormone called parathyroid hormone related peptide acts just like parathyroid hormone so what it does is it'll help to be able to act at the kidney and really cause the kidney to increase increase the reabsorption of calcium into the blood and an excrete phosphate into the urine that's one thing the other thing as it'll also act on the bone tissue and cause the activation of osteoclasts to be able to increase osteoclastic activity breaking down the bone to liberate more calcium and liberate more phosphate from the bone the end result is that now you're pushing a lot of calcium into the blood via reabsorption or via bone bone resorption if that happens what happens to the calcium levels in the blood they increase so if you have a patient you're ordering some routine blood work for them and you notice that they have hypercalcemia consider if they have a lung Mass checking a pthrp level as well as a normal pth level to say is this a hypercalcemia due to hyperparathyroidism elevated pth or is it a hypercalcemia of malignancy due to a squamous cell carcinoma all right next one adenocarcinoma the primary one that I want you to remember is this top one here it gains the ability to produce a very specific type of hormone that activates fibroblasts you know fibroblasts they love to respond to transforming growth factor beta and so we have tissue in our bone that have fibroblasts or the dense connective tissue the periosteum around the bone that have lots of fibroblast tissue these fibroblasts become activated when the fibroblasts become activated they start increasing the periosteal deposition making the actual thickness around the bones like a way way thicker especially near the fingers and so what you see is you see some hypertrophic osteoarthropathy I'll show you guys a picture of this of sometimes patients fingers how they can actually look whenever you have a significant hypertrophic osteoarthropathy it looks like this all right that's one big thing that I really want you to remember the adenocarcinoma the second thing that we have seen somewhat I don't want you to go too crazy and remember these last two but think about it possibly if they present on the exam with adenocarcinoma it also has the ability to increase the production of pro-coagulants so actual molecules that want to induce clotting and so if I increase the pro coagulants I'm going to increase the clot formation if I increase clot formation this can create a hyper coagulable State putting the patient at risk for things like an acute ischemic stroke putting them at risk for an acute myocardial infarction putting them at risk of an acute limb ischemia acute mesenteric ischemia Etc these are big things to think about as well as maybe even dvts DVT PE so really really important thing to consider the last thing is they can actually increase the activation of plasma cells to increase the production of antibodies and antibodies that are actually going to attack skeletal muscle tissue as well as cutaneous tissues and so this can cause something called inflammatory myopathies this is specifically dermatomyositis so they develop inflammation of their actual skeletal muscle cells and a lot of proximal muscle weakness so usually you'll see weakness particularly of the shoulder joint and hip joint but also they'll have a lot of skin findings go Trends papules they'll have like the shawl sign they may have some like inflammation or kind of like rashes around their actual face as well some kind of like a heliotrope rash on their on their eyelids but big thing to think about here with adenocarcinoma is hypertrophic osteoarthropathy due to increased fibroblast tissue as well as increased risk of hypercoagulable states and last one dermatomyositis all right the next one is carcinoid tumor so carcinoid tumors are one of those neuroendocrine tumors that gain the ability to make serotonin serotonin is a very interesting type of hormone that whenever it's released it can act on the smooth muscle of our bronchioles it can act on the smooth muscle of our GI tract they can act on the smooth muscle of the blood vessels on the skin and what it does on the smooth muscle and the bronchials is cause bronchoconstriction if you cause bronchoconstriction of the actual bronchials less air is going to be able to move out during expiration this will produce wheezing it'll produce contraction of the smooth muscle within the git if you have increased smooth muscle git contraction what is that going to do it's going to cause things to move quicker through the git you'll be peeing at your bunghole this is diarrhea and then it'll also cause the smooth muscle within the the actual vasculature supplying the skin to dilate and there'll be increased capillary blood flow of the skin which produce a flushing type of appearance don't forget this classic try with carcinoid syndrome increase serotonin they present with wheezing diarrhea flushing of the skin and if you were to check their serotonin levels or a breakdown metabolite of it it would be elevated as well or you notice that I didn't mention large cell we're going to have to talk about small cell here in just a second but you're like wait what happened to large cell carcinoma what that one doesn't really have much of it there's one theory behind that it actually can increase the production of what's called um HCG so human chorionic gonadotropin which may cause gynecomastia or gynecomastia males or galactorrhea and females but that's kind of like it's not actually completely evidence-based so we're not going to mention that one it's not usually tested that often I see the big ones to be thinking about is squamous cell carcinoid and this next one called small cell lung cancer so really focus on these perineoplastic syndromes let's talk about small cell now all right so like I told you when perineoplastics the big ones that I want to remember are squamous cell carcinoma hypercalcemia Adeno you can consider the hypertrophic osteoarthropathy that's the big one for that one carcinoid syndrome particularly wheezing diarrhea and again some type of flushing that you would see of carcino tumors but this is going to be the real real big one that you may get tested on which is the small cell lung cancer so really focus here guys so this tumor May gain the ability to release a couple different hormones one of them is called adrenal corticotropic hormone if you release adrenal corticotropic hormone you have to remember that ACTH actually stimulates the actual uh adrenal glands the adrenal cortex to make cortisol if cortisol levels are super super elevated they can cause lipolysis they can increase your blood glucose levels they can cause hypertension they can cause fat kind of deposition in weird areas specific especially in the face and on the back where they cause the swollen moon face the buffalo hump they depress your immune system and all of these things can lead to the presentation of Cushing syndrome so if a patient presents with features of Cushing syndrome hyperglycemia hypertension hypernatremia they have a lot of Edema they have fat deposition in weird areas such as the buffalo hump swole moon face striae due to the pendulum type of abdominal obesity really stretching out that tissue causing abdominal stride think about this type of cancer small cell lung cancer okay the next one it has the ability to produce lots of ADH so whenever you produce lots of ADH ADH generally works at the kid needs to be able to do what increase water reabsorption so it'll basically take and say hey let's increase the amount of water that's being reabsorbed from the kidneys and that means less water will show up in the urine if that happens and you just keep increasing your water reabsorption guess what you have so much water that it actually drowns out or dilutes your sodium and so what will actually cause like a dilutional type of effect of the sodium and this will lead to hyponatremia low serum levels of sodium within the blood but that hyponatremia is due to an elevated amount of ADH and so we call this syndrome of inappropriate ADH secretion this is a tumor where it's making lots of ADH so if you see a patient with hyponatremia think about this where they'll have less water in their actual urine okay they have a tumor and they're pumping out this ADH levels okay so big thing so Cushing syndrome syndrome of inappropriate ADH secretion the next one is they can stimulate plasma cells to make antibodies and these antibodies like to go and attack various tissues one of them is they can attack the central nervous system when they attack the central nervous system they can attack the cortex and if they attack the cortex this can lead to agitation of the cortex if you agitate the cerebral cortex this can lead to increased Action potentials leading to seizures they also love to attack the cerebellum and so they can cause cerebellum degeneration leading to Ataxia nystagmus think about that in a patient okay so again if they attack the CNS seizures super tutorial if they attack the cerebellum infantatorial think about Ataxia nystagmus the other thing is that these antibodies can attack these calcium channels that are present on synaptic on these um somatic motor neurons that are supplying skeletal muscles so you know these somatic motor neurons they have on this kind of tip here at the synaptic terminal they have these voltage-gated calcium channels I'm going to put CA V these are voltage-gated calcium channels these antibodies will actually go and attack and bind onto these calcium channels now they can't work why is that important because the calcium channels are supposed to allow for calcium to flow into the neuron and if calcium flows into these terminals it'll increase the acetylcholine production cause the muscle cell to become stimulated and contract but if you block these calcium channels you prevent calcium from coming into the synaptic terminal you prevent the release of acetylcholine and then you have less acetylcholine that can act in the synapse leading to weakness and this is called myasthenia gravis but it's a very special subtype and we have to remember this it's actually called Lambert eaten Lambert eaten subtype of Myasthenia graph so to present just like it but again think about that all right so we have the perineoplastic syndromes that we've discussed remember squamous cell hypercalcemia remember Adeno hypertrophic osteoarthropathy if you want to remember the hypercoagula will stay great if you also want to remember potentially that they have the dermatomyocyte is great carcinoid syndrome remember wheezing diarrhea flushing small cell remember Cushing syndrome of inappropriate ADH secretion as well as CNS attack so seizures cerebellar degeneration or Lambert eaten myasthenia gravis okay the last thing that I want to quickly talk about is if the actual cancer that is situated within the lungs starts seeding and seeding into the actual vasculature and spreads throughout the body what are the most common locations that you want to think about because if the patient comes to you and obviously they have all the features of it that we just talked about but then they have some additional features which are a little odd you want to be thinking about Mets so where are the most common locations that this cancer spread to remember blab brain liver adrenals and Bone adrenal is usually going to be asymptomatic you won't know but the brain think about seizures okay think about some type of altered mental status these are huge or some type of neurode deficit so if the patient's also presenting with neurode deficits or they're presenting with seizures think about that metastasis to the brain liver oftentimes this may cause hepatomegaly but again maybe some ascites nothing super obvious but think about potentially hepatomegaly or ascites adrenal asymptomatic bones pain they're gonna have lots of pain particularly within areas of the joints or wherever that actual Met has spread to so if the patient has additional features and what we did what we just talked about such as neurode deficits seizures hepatomegalior ascites asymptomatic and bone pain think about it possibly of spreading outside of the lung now and metastasizing to other organs all right my friends now we're going to do is move on to the diagnosis of lung cancer all right so we're now at diagnosis you have a patient who you have a suspicion that they may have lung cancer they're coming in with some of the features of weight loss some low-grade fevers they have some fatigue maybe they have some of the compressive symptoms right into bronchial growth or outside of it compressing the actual bronchial system they have some of the nearby mediastinal compression they have some of the pleural diseases they got a pankos tumor they got a perineoplastic syndromes they got symptoms that are also concerning maybe for some metastasis to either the brain the liver the adrenals the bone and you're trying to figure out do they have something in their lungs or maybe you're trying to rule out that it's something else and it has nothing to do with lung cancer maybe they have an ammonia maybe they have something else that's going on that has nothing to do with lung cancer the initial test to start off with these patients is a chest x-ray it may give you just a generalized look it's not going to be the best test but it should be the initial kind of like screening test to start off saying is this maybe lung cancer or is it something else and we'll take a look at a bunch of different chest exterias to kind of give you an idea of what something could look like if it's lung cancer and then we'll also talk about pulmonary nodules the next thing is if you think that it could be some type of odd shaped mass or it could be malignant and they have some of the risk factors they smoke cigarettes they have radon exposure they have asbestosis exposure or asbestos exposure they have a family history Etc then it might be warranted to say let's go ahead and take a better look at this and let's do a CT of the chest with IV contrast and it'll really help me to get a good look at that Mass from there if you think that it definitely is a mass what I would say next is could it have spread is this a solitary Mass that's only kind of localized to the lungs or did it decide to spread to the brain to the liver to the adrenals to the Bone to the nearby lymph nodes so how do I do that sometimes what may be best is doing one of two things you may start off with a CT scan of the head the chest the abdomen and the pelvis and take a look and say is these actual lung cancer did it metastasize to the brain so do I have any Mets in the brain is it in the liver is there any hepatic Mets look at the bones maybe you might be able to pick that up on CT again is there any kind of bony Mets is there any adrenal mats so this may be a good thing another thing that we may actually do and it's kind of more preferred because it really gives us a good look is we can use what's called a radio Tracer so we can give them a special type of like isotope of glucose and it'll kind of light up different areas where there's Mets that metastasize again from the lung cancer and it's called a PET CT scan and so those are really two of the tests that we could do if we think oh this definitely looks like a lung cancer or we biopsy and we confirm that it's lung cancer we can then do a pan CT scan or a PET CT to look for distant Mets now you know these are just speculation so without true pathological data I can't say it's lung cancer and I can't tell you what kind of lung cancer it is based upon the suspicion of a chest x-ray or a CT scan or a PET CT I can have an idea but I can't guarantee which type it is until I take a piece of the tissue look under the microscope and say oh that's small so oh that's Adeno and we're not going to go over the histology of these that's more of a step one thing but for right now what I want you to understand is biopsy is truly the key to determining the type of cancer you have a suspicion of cancer it's chest x-ray you see something you want to get a better look at it CT the chest with IV contrast do you think that it metastasized to other organs PET CT pan CT let's take a look at a bunch of those images and get a better idea all right so let's take a look at some images we're going to take a look at some chest x-rays some CT scans Etc so first thing we get a chest x-ray for a patient who's coming in with maybe some concerning features of something pathologically going on inside of their chest right we get the chest x-ray we get an initial look and we see this big old goombok inside of their chest obviously we see some type of mass here we have no idea how extensive it is some of the other Anatomy like the heart and highlighter area may be kind of obstructing our view of it but we definitely see some type of like pretty and large mass here in that left hemithorax so that would be one kind of clue so again think about that if the patient is coming in with those classic symptoms or features complications that we discussed now that could be one potential finding that might not be the only finding that you see to find or diagnose a patient who has lung cancer you know what else you could potentially do we could get another chest x-ray maybe this is the only finding but it leads you down kind of a series of tests that ultimately helps with the diagnosis of lung cancer what other kind of images or findings could we see on chest x-ray let me show you all right so we have another chest x-ray we have a patient here who we're concerned they may have something going on pathologically within their chest we get a chest x-ray we see this and you see this whoa what is all this I can't see my costophrenic angle here like there's no complete kind of delineation you see over here we have our diaphragm and then it kind of comes down nicely this is our costophrenic angle you see it's just obliterated or blunted and we see there's like this like meniscus sign this is a pleural fusion this patient actually has an underlying mass as the potential cause for this pleural effusion how can we prove that we can take a needle tap it in there pull some of that fluid off and send it off for some cytology and if we're concerned we can even do a plural biopsy so those could be potential findings that would make us lead us down the road of saying hey this pleural fusion is actually due to an underlying lung cancer what other kind of finding CPC in chest x-ray all right we got another chest X right here the patient we have is complaining of some dyspnea we obviously get a chest x-ray we're concerned that maybe they have some concerning findings of kind of thoracic pathology and we see here oh they got a pneumothorax well this is a pneumothorax on that left side what could be the potential etiology we obviously we're going to talk about that in pleural disorders it could be due to a primary disorder it could be due to some type of like secondary problem like COPD or malignancy where it's near the actual periphery eating through the pleura and creates an opportunity for pneumothorax to be formed if we were to actually get a CT scan they would actually find that this patient had an underlying mass that was very close to the periphery that led to this patient's pneumothorax so again the not only are you always going to find a very perfect lung Mass on the chest x-ray you may have other findings on their chest x-ray that is concerning of lung cancer such as a pleural effusion a pneumothorax or again maybe just a perfect like mass that you'll actually see there now the next thing is what if it's actually not like a very large mass it's more of on that area of a pulmonary nodule what would that kind of look like do you guys remember let's take a look at that chest x-ray all right so here we have a patient who has again some no specific kind of like symptoms but we get a chest x-ray because we're working them up for something else and then oh we see something on their chest X right here you see how it's like very round it actually doesn't have a lot of calcifications that are asymmetric size wise hopefully it's I can't I don't have like the actual calipers that I could actually extend out and measure but let's say that it's actually less than three centimeters there's normal lung tissue surrounding it there's no Associated lymphadenopathy this is a pulmonary nodule and if we have a pulmonary nodule what is the differential seventy percent of the time it's benign so something like a granuloma from TB histio coccidio or a hamartoma guess what this patient ended up having they ended up having a hammer Toma you want to know how I'll show you in a second because we ended up getting a CT to get a better look at this and we'll be able to see that it's very nicely round dense central calcifications less than two centimeters they were less than 50 they did not smoke it wasn't getting any bigger on serial uh chest x-rays or CT scans so again this would be very very perfect finding of a pulmonary nodule and then again know how to be able to have a suspicion for malignancy versus benign all right that takes our chest x-ray findings now let's go ahead and move into some of the CT findings that give us a better look at these lung masses all right so we have a patient we got that chest x-ray we saw that big kind of like lung Mass on their chest x-ray we want to get a better look at it when we get a better look at it we can do a CT scan of the chest with IV contrast and when we do that guess what we end up kind of finding on this patient you get a CT scan it just gives you a way better look here and you're going to see that they have a pretty decent sized Mass you see that thing right there in that posterior part of their chest that's definitely a pretty big long Mass if you wanted to get in another view we could actually put in a Long window look at that that's a huge like centrally located Mass if you want to look at another view you can see here this is a large Sentry located Mass so you see how this helps us to get a really really good look at the chest and get a better idea of what this actual mass looks like helping us to have a better degree of Suspicion if this is benign or malignant I would definitely go as far as to say this is irregular that has asymmetrical calcifications it's extremely large and the patient's history is more suggestive of it being malignant so definitely a concerning finding here and again because it's more centrally located we would want to think about what could it be could it be squamous cell could it be some type of small cell lung cancer those would be the things to be thinking about all right so another CT scan we have a patient's chest right so we're trying to determine is this some type of like lung cancer is this a pulmonary nodule do you guys see here we took a kind of a snap picture here at one point look at this you see how there's like this dense central calcification it's nice and round nice and circular probably less than three centimeters I'd say what do you think about this this definitely looks like more of a pulmonary nodule so think about your differential what's the differentials is it a granuloma is it a hammer Toma or is it some type of malignancy I would go more on the line of this being more likely benign so it's either a granuloma or hematoma this actually happened to be a hammer Toma we can get a better look at this so what I'm going to do is I'm going to show you guys a better look at this actual Hammer Toma so when we do that look at this we got the lung window on for this patient and you're going to be able to see look at that actual dense kind of like opacity there that we see in that right lobe boom that is a hammer Toma and what we could do is if we had a degree of Suspicion is this malignant is this benign what could we do if we have an intermediate pre-test probability or intermediate probability of it being malignant we could do a PET CT scan see if that lights up see if we have any distant Mets if we do we could biopsy if we have a very high degree of probability that that's it then we can go ahead and biopsy right off the get-go but again these are findings that you may see off the CT scan of the chest now we did a chest x-ray we had a good look we had an initial look at the actual mass or some other Associated findings like pleural effusion pneumothorax we also get a CT scan to get a better look at the mass any other kind of like size of the Mask get a little better look if we think it's a pulmonary nodule versus a malignant type of mass the next thing we should do is a CT of the chest abdomen pelvis head to be able to do what look for any metastasis right so that's a really big test to be able to do so if I were to go ahead and actually pull up this scan here this happened to be a seat we did a pan CT on this patient but I'm going to show you one portion of it look what happens here with this patient we're coming down into the abdomen and pelvis area do you see their liver you see all these like hypodensities there this patient has hepatic Mets so we know that if their primary problem this actually happened to be a pan a patient with small cell lung cancer and then it metastasized to their actual liver to their adrenal glands to their bones and we can see evidence of that here so this would be one of the things I could do that pan CT scan to look to see did it metastasize I could also pull it up on the head CT do they have any Mets inside of the brain so again start off with your chest x-ray to get an initial look you see it is it more nodule is it more malignant again look at the history look at the size look at the borders look at the calcifications get a ctd of the chest with IB contrast to get a better look at it you do that you have a degree of Suspicion that's malignant maybe you need to biopsy it maybe you need to do a pan CT or a PET CT to look for distant Mets you do a pan CT you see Mets in particular locations that it should go bone brain liver adrenal or you can do a PET CT scan to look for also distant Mets as well let's take a look at a PET CT scan now so here we have a PET CT scan of a patient that has again some type of cancer what we're looking for is did it metastasize and you see how we're going to have some lymph nodes that are actually kind of like lighting up here and then look at the humerus you see the bone here the humeral bone is lighting up like a Christmas tree this happened to be a patient who had Mets that spread to their actual right humerus and even look look at their vertebrae they have some mess that extended to their vertebrae as well so you see these like really red hot spots this happens to be the bladder this is clearing out of the contrast but so that's not actually a malignant area but look here at the vertebrae the the bones in the vertebrae and look here at the humerus they're lighting up here and then the lymph nodes as well so this is definitely some Mets that we're able to see that came from a primary lung cancer so again start off with your chest x-ray then get the CT of the chest with IV contrast look for distant Mets with a pan CT head chest abdomen pelvis with IV contrast or a PET CT to look for any distant Mets and then follow up with the next step which we're going to get back at the Whiteboard for which is the biopsy all right so we looked at the images we have a suspicion that they have lung cancer maybe it has a metastasized maybe it has a metastasized regardless we don't know which kind it is the only way that we can truly definitively determine which kind it is is to send it off the pathology to under the microscope so we have to get a biopsy of some kind or some type of cytological uh you know piece for us to be able to examine and figure out is this small so is this Adeno is this squamous cell and again we're not going to go over what that looks like histologically that's more of a kind of a step one thing I think the big thing is understanding that you need a biopsy to determine the actual type of cancer that it is because that's going to determine how aggressive you're going to be with treatment so I think the big thing to think about is where is the tumor so if the tumor is in the Lumen it's actually in the Lumen of the bronchus I can do a bronchoscopy I can stick a camera down through the trachea down through the actual primary bronchi I find in one of the bronchials where this tumor is I can take a piece of that send it off to pathology see what kind it is so for tumor and the Lumen you can do what's called a bronchoscopy and you can biopsy it via what's called a trans bronchial biopsy now what if the tumor is kind of invaded into the actual wall of the actual bronchial system and then it looks like it's even seeded or maybe you just see a lymph node a big kind of like higher lymph node that looks like it has a mass type of appearance to it so a nearby lymph node has actually been invaded and you have some lymphadenopathy what if I want to be able to test to see did the cancer spread to the lymph node but it's outside the Lumen if I want to be able to test that then I have to take and stick a needle through the wall of the bronchial into the lymph node but I got to be careful so how do I do that I use a ultrasound while I'm in the bronchus to guide the needle through the wall of the bronchus out into the lymph node so we do a bronchoscopy but we needle aspirate parts of the tumor out of the lymph node via what's called an endobronchial ultrasound guidance it's actually pretty cool but again this would be more for your central tumors right so you see how if it's a tumor kind of within the bronchus system it's likely a central tumor small cell squamous cell maybe carcinoid maybe one of the bronchial alveolar less likely Adeno less likely large cell so that would be for these now if you have a tumor that's toward the periphery it's not safe to be able to send a bronchus a bronchoscopy to send a camera all the way down through these tiny little bronchials you won't be able to find it and it's not safe so from that we take a outside approach we want to go through the chest wall and so sometimes what we'll do is we have to get into this actual tumor and aspirate part of the tumor out but in order for us to do that we need to be very careful so sometimes we'll do this under CT guided kind of like uh using a CT scan step by step as we guide our needle to the tumor to aspect some of the tumor cells out so that we can send it to pathology if that's not best sometimes what we can do is we can actually go in with cameras into the actual chest so actually stick kind of like these cameras into the chest wall and we'll actually watch on video as the needle goes and we take a piece of the actual tissue of that cancer that we see on the lung okay so if it's a peripheral tumor there's two options one CT guided needle aspiration or what's called a video assisted thoracostomy thoracoscopy or sometimes we actually refer to this as a Vats procedure so you may see that as well a Vats procedure all right so peripheral tumors Adeno peripheral maybe bronchial alveolar maybe Carson or because they can be both the last thing is what if we don't really have any of these but we have a patient who has a big Wap in pleural effusion and here's the key thing malignant pleural effusion so it keeps happening so even though they have we've proved that it has nothing to do with their you know an underlying kind of cause such as congestive heart failure or cirrhosis or nephrotic syndrome or any other kind of thing we can actually go in do a thoracentesis so maybe there was a mass that's near the periphery remember I told you if you have a mass near the periphery it's going to increase the capillary permeability cause fluid to leak into this or it can compress a lymphatic vessel and decrease the clearance but either way maybe some of these cells of the cancer may be mixed into that Pleural fluid so I may have cancer cells in that Pleural fluid if I take a needle and I go into the pleural cavity aspirate some of that off and I pull back all this fluid I may pull back fluid that's going to be a mixture right so obviously there may be protein there may be plasma there may be some cells and things like that there may be blood but what else will I pull back maybe some cells I can send that to pathology and have them check out the cells and say oh is there any types of malignant cells there and if I'm curious what I could do is I could actually go in and take a piece I could biopsy a piece of the pleura and really confirm that so if I had some suspicion I could follow up on this with what's called a plural biopsy but either way you guys get the point that all of these we require a biopsy to determine the type of malignancy or type of cancer it is now that we've gone through this we've figured out the different ways that we can confirm the next thing that I really want us to talk about is we have a mass on the chest x-ray or the CT scan but it doesn't you're not sure is this benign is this malignant did they have it before oh they did have it before did it get bigger it's important to understand this I'm serious this is a huge point for your step to exam we have to know if this pulmonary nodule is benign malignant how to work it up how to follow up and when to be suspicious for malignancy let's talk about that now all right so you get a chest x-ray you see that nodule that we talked about right what looks like a pulmonary nodule less than three centimeters normal surrounding lung printama no lymphadenopathy you have a degree of suspicion that is benign but you're not completely sure if it's malignant one of the best things to do is when you see a pulmonary nodule solitary pulmonary nodule is to compare it to Prior films so do they have a previous chest x-ray do they have a previous CT that I can look at to see was that nodule there prior that's the first thing because if it's new that's a whole different story second is the nodule was there on the prior chest x-ray is it bigger has it gotten bigger within the past maybe year or two years or do they have no prior films that actually show that nodule that's a very first question so you see the nodule three questions do they have a prior film if they do is it bigger second is it a new one third I have no prior films to compare once you do that that leads you to the next step okay you see it you say oh I see that they did have a prior nodule about maybe a year or two back it's gotten bigger it's actually gotten bigger okay and then I actually look at it and I say oh well this is actually completely new this wasn't there on the prior image okay so it's a new nodule or it's a nozzle that's gotten bigger if that's the case you need to get a better look at it so you want to get a CT scan and get thin sections of it to be able to get a better look at the actual mass or that nodule and once you look at it then that can lead you to the question is this more malignant or is this more benign because it's malignant I may have to go on biopsy that if I have a high degree suspicion that it's malignant or resect a piece of it depending upon where it is which we just talked about but if it's benign I could probably just like follow up and how frequent would I follow up maybe I would just follow up in like maybe a you know a couple months three months okay take a look at it does it get any bigger does it look any different it's the same thing okay this is the big kind of Step here so I want you to remember this part you have a nodule old chest x-ray old image is it bigger is it new if the answer is yes you go to a CT scan okay after you get the CT within sections you can get a better look at it to say is this more likely malignant is this more likely benign if I think it's malignant we'll talk about what are the suspicious factors for that your biopsy it or resect it if it's likely benign you follow up in three months and just see if it got any bigger or if you have a new nodule that pops up now if the nodule hasn't changed hasn't gotten any bigger it's not a new nodule then what you can do is follow up in a year and just see has it gotten any bigger have you developed any new nodules that's it so if it is not change in size from prior films you just follow up in a year if you had no prior films you have to assume that it's a new nodule okay or that if they did have it and you just can't find the films that has gotten bigger so you go straight to the same concept get a CT within sections if it's suspicious for malignancy biopsy resect if it's more likely benign fall up in three months okay nodule looks new or bigger don't have prior films CT if it's suspicious from malignancy what are those things we'll talk about your biopsy if it's not you just follow up in a year if you have a prior image you look at it it's no different has gotten any bigger in the past two years you follow up in a year all right now the question is is what are those factors that make me more suspicious for a malignant nodule than a benign nodule let's talk about that all right so let's assume the worst let's assume that we think that this is malignant if that's the case what are the factors that should come up in your head to make you think malignant first thing is age how old is the patient the older they are the more likely it's malignant generally we say if they have an A to greater than 50 they have a high likelihood of it being malignant okay that's one thing second thing is do they smoke if they do smoke it has a higher incidence of malignancy what's the only cancer that it is not associated with malignancy though adenocarcinoma so this would not really apply to an adenocarcinoma think about that the next thing is when we look at the chest x-ray we actually want to get a better look at this nodule so chest x-ray CT scan when you look at it you really want to get an idea of this nodule so the first thing is you see the nodule and you see it on the chest x-ray you see it in the thin sections of the CT scan what's the size so the size does matter in this situation is it greater than two centimeters if it is greater than two centimeters then you definitely should have more of a likelihood of suspicion that this is malignant so the larger it is greater than two centimeters more likely it is malignant the next thing is the borders if you look at the borders and they're irregular so in other words it's not like a perfect circle it looks like like this it's kind of like wonky looking right that is way more suspicious for a malignancy so if it has like all these different projections off of it's not kind of like a nice circular type of structure more likely that this is malignant so if they have irregular borders this is another big thing all right the next component here is calcifications so if you look at it and you notice that they have calcifications let's draw this here and this pinkish color but you notice that usually it's kind of like asymmetric so it's like right here maybe some here there's no complete symmetry to it that is a huge situation so classification for this component here calcification I mean if it is asymmetric this is a huge one the reason why is if it's more benign oftentimes benign nodules will be again smaller they'll be more circular they won't have irregular types of borders and their calcification is usually dense and centrally located they usually have a dense central kind of calcification that's more likely to be benign so less than two centimeters very perfect circular structure no regular borders and dense central calcification rather than asymmetric calcification with the regular borders in larger than two centimeters the next thing is it changed in size if it has gotten bigger it is likely malignant so has it enlarged if it is enlarged it is likely malignant these are the things that you should be thinking about when you're going through this algorithm what's their age what's their smoking history what's the size of it what's the borders look like what's the calcification look like and again has it gotten bigger if these answers are yes or what we just put down have a degree of Suspicion for malignancy and then go to biopsy if most of these aren't answered and you're saying oh a lot of these are actually not the case they're actually less than 50. they don't smoke it's less than two centimeters it's regular borders they have dense central calcification it's not getting any bigger within the past two years guess what likely benign follow up in a couple months okay so that's the bit or hasn't changed in general then you can follow up in a year okay but again these are the big things that you want to be able to kind of can think about whenever you're working up a patient with a pulmonary nodule all right and again what would I say if this is a benign it's more likely a granduloma from TB histococcidio maybe a prior infection so look for an infectious history or think Hammer Toma all right let's move on to the treatment and prevention process all right so we're going to talk about treatment it's gonna be pretty quick should be easy this isn't a super high yield Port there's one point out of this that I really want you guys to understand so we're going to kind of blow through the tree because it's not going to be something that you guys will see too much of on the actual exam but quickly the other patient has a pulmonary nodule we already have an idea a lot of the time it's follow-up or biopsy so if it's low probability you know less than 50 less than two centimeters regular borders Central disc calcifications they don't smoke and again it's not getting any bigger low probability just follow up serial CT scans right so get a Serial image in about three months or a year again it depends upon if it got bigger prior but again usually it's just follow-up if it's intermediate so some of those questions are actually answered so maybe they smoke maybe they are greater than 50. but maybe it doesn't have a regular borders maybe it has asymmetric calcification but again it's not complete well-defined suspicious for malignancy then you can have an intermediate probability I'd say go next to say let's get a PET CT scan if there is that the case where you actually do look at it you're not completely sure but then let's say let's say that we do think it's malignant if it is malignant usually those cancers have a higher risk of Mets but you know benign they don't they don't metastasize so if you get a PET CT and it is positive and they've actually metastasized to other areas then you know it's malignant then you're going to go ahead and biopsy it and figure out what kind it is okay so intermediate probability you're not completely sure you think it could be could not be get a PET CT scan look to see if it's metastasized or a pan CT one of the two PET CT is probably a little bit better if it's positive biopsy high probability they answer all those questions you go straight to a biopsy okay pretty straightforward all right let's now talk about the treatment for non-small cell lung cancers so it's unlikely that you get questions on staging so I don't want to go too crazy I want to make it super easy there's a simplified schema to staging and treatment respectively this is the way I like it I think it's the easiest to remember when we think about stage one it's just an isolated tumor it hasn't involved any kind of like nearby lymph nodes for that situation that's easy to be able to resect so you can do surgery and then maybe shrink any of the actual or kill any of the other surrounding cells there with chemo therapy okay so if it's very localized isolated surgery chemo now if it has spread some higher lymph nodes okay then it's a little bit of a different story so you can still resect that tumor but hit some chemo therapy and radiation therapy to really kill any of the remaining cells if it's now spread to the hilar lymph nodes and the mediastinum that's a little bit more specific you have to ask the question can it be resected if it can be resected it's stage 3A if it cannot be resected it's stage 3B what does that mean if it can can be resected that means you can do surgery but what you should do is try to shrink it down the best that you can so start with chemo radiation and if it's possible to safely be resected surgery for stage three where it's unresectable do you see surgery as an option here no surgery can't be resected safely shrink it down as much as you can and then if you get the actual pathology and you test for any specific mutation this is past the scope of this lecture but sometimes they may have a very special type of mutation that you can give them specific biologic agents immunotherapy to Target the actual cancer cells that's what I want you to remember unresectable you can't do surgery though shrink it consider biologics if they have the mutation last one stage four it's metastasized it's all over the place if that's the case you cannot do any surgery at that point it's just chemo and you can consider some monoclonal antibody therapy as well some biologics that would be the big things that I want you guys to remember for this one all right let's now work our way up back up to small cell lung cancer all right so this one's a little bit of a beast small cell lung cancer I think one of the big things to know for the prognosis of this one it's very very poor by the time somebody has been diagnosed with small cell lung cancer their five-year survival rate is like very low they might have like you know it's it's pretty much like they're not going to survive past it it's about one to two year uh lifespan whenever they're diagnosed it's so extensive by the time it's actually found so the prognosis for small cell lung cancer is very very poor if you buy some amazing chance catch it at The Limited stage meaning that it's only occupying one of the part of the thorax and the hilar lymph nodes you can consider chemo radiation to really try to shrink that down and then what you can do is prevent one of the scariest locations for this to metastasize is the brain because you're going to have focal neural deficits seizures a lot of nasty problems even potential hemorrhages so because of that it's really good to prophylactically do cranial irrading radiation to the brain in this situation so limited small cell lung cancer where it's only in one side of the lung only the same location of the hilar lymph nodes unilateral you can consider chemo radiation and prophylacticranial radiation but if it's extensive meaning it's in both thoraxes both bilateral hylar lymph nodes and Mets there's no benefit to this situation for radiation chemo and you can consider prophylactic granular radiation as well to prevent if it hasn't already spread to the brain at this point in time okay that small cell I think one of the biggest points that I really need you guys to get out of the whole treatment second is this section is this because these cancers oftentimes are caught late one of the biggest things to do is prevent obviously smoking cessation is a huge Factor here but what if we could catch it before it's getting too extensive and so because patients who are smokers specifically a 30 or more pack year history so if they have a 30 or more pack your history or they're a current smoker they're still smoking with a greater than 30 pack your history or they were a former smoker so don't count these people out less than 15 years ago so if they actually quit but it's still less than 15 years ago they still qualify for getting these low dose yearly CT scans and in the age range that you should start screening these patients and this is very very important for those Primary Care Facilities is 55 to 80 years of age some will say um so sometimes they'll actually say like 74 but again for the most part most of the recommendations and say 55 to 80 years of age that you want to consider getting yearly low-dose CT scans to look for any types of pulmonary nodules or lung masses that you can catch them early do not forget this current former less than 15 years greater than or equal to 30 pack year history age 55 to 80 yearly low-dose CT scans to prevent Lung Cancer alright now let's do some cases all right my friends let's do a case so here we have a 66 year old male presented to the ninja hospital with fatigue cough dysthysphagia hoarse voice it's a lot of symptoms patient state has been going on for the past three months past medical history pertinent for tobacco abuse physical exam when we got SP2 is a little low 92 percent respiratory rates 20 is appropriate heart rate's appropriate temperature just low grade fever and then blood pressure is 138 over 70 which is appropriate all right physical exam findings are interesting so they have wheezing that could be due to the endobronchial tube like if there is a tumor here like a lung cancer in this situation if it's within the bronchus or it's outside the Broncos compressing on it could be responsible for the wheezing abdominal obesity swollen moon face buffalo hump edematous and discolored upper Limbs and chest that's interesting that could be potentially due to a perineoplastic syndrome like Cushing syndrome you can see that with the small cell carcinomas and then the object of the venous distension that could be due to like a superior vena cava syndrome like compression of the Supreme that's causing like a jvd and some of the discoloration of the upper Limbs and chest and edema so I could see a superior vena cava syndrome A perineoplastic syndrome a bronchial tube either obstruction or compression from the outside then they have fatigue that's just generalized from the actual um from the lung cancer dyspnea dysphagia that could actually be due to esophageal compression and a hoarse voice which could be the recurrent laryngeal nerve compression and they have a past medical issue of tobacco abuse which is their risk factor for lung cancer so I think that this is pointing obviously towards a small cell lung cancer with a lot of like nearby compression so you can see what kind of compressive symptoms they have they have some type of like if they had Strider it could be due to a tracheal compression it could have esophagus esophageal compression this could be causing dysphagia which we see here if they have recurrent laryngeal nerve compression that could be causing hoarseness of the voice if they're like in a bronchial obstruction whether it be and the Lumen of the bronchus aren't compressing on the outside of the bronchus that can cause wheezing during expiration and even a degree of dyspnea and then on top of that if you compress the superior vena cava that could actually cause some type of like super vena cava syndrome so definitely things to watch out for in this patient so how do we go about kind of diagnosing this so we think the patient has some type of like lung cancer with nearby compressive symptoms I think getting a chest x-ray or a CT scan would kind of be nice so if I start off with a chest x-ray I'll be able to see that this is a centrally located mass and that's really important because there's only certain types of masses that are more centrally located small cell lung carcinomas one sometimes carcinoids and carcinoid tumors and squamous cell carcinoma are also those so you can think about that think about small cell squamous and Carson wave now perineoplastic wise small cell lung cancer would make the most sense but squamous cell carcinoma is a possibility carcinoid usually you see that with having like wheezing diarrhea maybe like a serotonin syndrome squamous cell they have kind of like an elevated pth RP which causes like hypercalcemia I think that this one makes more sense to be a small cell but again I wouldn't be able to guarantee that until I actually go in and biopsy and look at that under the pathology but with that being said what are some of the perineoplastic syndromes to watch out for with these diseases you see Cushing syndrome due to elevated levels of cortisol being produced in small cell lung cancer which this patient really presents with similar symptoms of saadh so due to ADH production from the tumor Lambert eaten syndrome where they actually produce like you know a reaction that actually can cause antibodies to attack the neuromuscular Junction particularly the calcium channels on the neuromuscular Junction or the neurons on the skeletal muscles and the neurons that actually supplying the skeletal muscles of the diaphragm and and other parts and then it can also cause like cerebellar degeneration and seizures to potentially occur as well so I think that that's one big thing to think about and then squamous cell they cause a lot of what's called pthrp release which can actually cause hypercalcemia and then carcinoid tumors can actually cause a lot of like serotonin to be released which can cause serotonin syndrome and carcinoid syndrome like wheezing diarrhea um and and also you know elevated serotonin levels that can cause other symptoms so things to watch out for such as what we've talked about all right here and again if we really wanted to we can check this actual level here we could actually go and we can say hey let's check the five hydroxy indole acetic levels here and see if they're five hiaa is elevating their urine that may be somewhat supportive of carcinoid syndrome we can check the pthrp levels and the calcium levels and squamous cell carcinoma and again small cell lung cancer you can consider checking their cortisol may be elevated and you can also check their ACTH and then for saadh check the sodium levels whenever you reabsorb a lot of like water you can actually kind of dilute up the sodium and then again Lambert eaten syndrome you can actually check for these patients and look to see if they have any kind of like positivity on their myasthenia gravis testing processes but this is how I would kind of go about looking at this getting my chest x-ray CT scan to find a mass come up with a differential of what in my head of which one of these it likely could be look at some of the actual characteristics of those and I think if we look at these carcinoid syndrome doesn't seem to be the case squamous cell doesn't seem to be the case but small cell does seem to be the case especially with the evidence of Cushing syndrome in this patient so I think it's small cell lung cancer so how do I would really confirm this as a biopsy actually I need to go and find where this tumor is is it in the bronchus is it outside the bronchus is it in the periphery if it's inside of the bronchus it's more centrally located usually we can do something like a a bronchoscopy and go and remove the tumor or we may have to do an e-bus where we actually use ultrasound to guide us there so in this situation here what we find is that the actual tumor is actually located in the Lumen of the bronchial system and if that's the case then how do I actually go about doing that you can do a bronchoscopy with a transbronchial biopsy and you can also do a needle aspiration of the lymph node via ebus so I could throw it to a broncore we actually go down through the actual bronchi and then we can actually take a piece of tissue from the the actual Lumen of the bronchial if the tumor is kind of in in the actual Lumen of the bronchial and then if it did spread to the nearby lymph node just outside of the bronchial system then what I could use I could actually use a needle and Via ultrasound guidance guide myself into the actual lymph node and suck some of the actual tumor out of that as well so that's ways that we could do that if it's kind of essentially located tumor now we see here a CT scan to give us a better idea of the tumor and it's centrally located presentation and then we can also do things called pet scans or pan CT scans as well to really help us to Stage the adenocarcinoma so looking to see has it spread anywhere has it metastasized I could do a pan CT scan so I could scan their head their chest their abdomen their pelvis and look for any distant Mets or I can do a PET CT to see if I see any hot spots where it does spread I don't think that's important when I do think that may come up in the exam is where does these actual lung cancers actually spread and if they spread they usually spread to blab so brain liver and then adrenal and Bones so think about that my friends all right how do we treat this patient so I think it's important to remember if this tumor is actually located on the periphery so towards the pleura how do we actually approach that and generally that's a fine needle aspiration but you'll do that via C T guidance or you can do what's called video assisted thoroscopic kind of like surgery there as well so you can do a Vats so either way utilizing fine needle aspiration of the tumor from the peripheral kind of plural area or peripheral kind of like plural parenchyma area we can do a fine needle via CT guidance or you can do video assisted kind of like thoroscopic kind of removal of the tumor what if they had a plural effusion that was actually related to their malignancy what could I do then I could actually do a thoracentesis and send off the uh the pleural fluid for cytology to look for see what kind of actually like malignancy pops up there as well all right we move on to the next case here we got a 45 year old female with no pertinent past medical history presents to the ninja nerd hospital for a deep laceration to the chest she receives a chest x-ray and incidentally shows a coin-shaped nodule in the right upper lobe very interesting so I think this is trying to point us towards a pulmonary nodule versus a actual true lung Mass that's a cancer type so is this benign or malignant is the question that we're trying to figure out here so when we look at the vitals we see relatively everything is normal no kind of abnormalities pop up we go to look at the chess X-ray and when we look at it here's what we note we note a very kind of like small Nodge of 1.5 centimeter circular nodule with a dense central calcification that's good and when comparing to the prior films from two years ago she actually never had this nodule so that's interesting so when we see a new nodule that is somewhat concerning but just because it's new does not mean that it's actually malignant it could still be benign so I think one of the big things to think about is how do we actually kind of continue to follow up on this nodule I really think a chest CT is going to be the best situation with thin slices to really get a good look at this nodule if it's a new nodule and so let's actually say that we do that when we do that what we see is we see the nodules present here it's about 1.6 centimeter circular nodule with a dense central calcification and then there's no nearby lymphadenopathy and all the actual lung during the lung window examination shows no abnormal lung parenchyma that's super super critical my friends and so I think it's really important to think about that so would you say that this pulmonary nodule is suspicious for malignancy or it being benign I think it's benign and how do we think about this again look at the age she's less than 50 so that's one thing does she smoke she has no pert and past medical history of smoking what's the size it's 1.6 centimeters that means it's less than two centimeters is the borders irregular or regular it said that it was actually gen decently regular was their calcification Central or asymmetric it was centrally located that's good and was there a change in size no but it was there was a new if you want to say technically yes there was a new nodule so one one of these factors was potentially concerning but out of everything else here it definitely does not seem to be malignant I think the best thing to consider here is really following up in a couple months and getting another low-dose CT scan and making sure that that hasn't gotten any bigger or that new nodules have formed so I would repeat a CT scan in about three months to see what does it look like now and I think the next question is what could it be if we think that it's benign what is the responsibility of thinking what else could it be it could be a granuloma like sarcoidosis or a hammertona so those are things to think about and if it's in the rare occasion it could be like a histo or coccidiomycosis but not too common I would think about you know things like sarcoid or you know Hammer Tomas likely being the likely cause here all right we go into the next case here we get a 70 year old male presents to the engineered hospital with this neopluritic chest pain horse voice numbness and weakness of the right arm no pertinent past medical history is here so we look at their vitals everything looks good nothing really pops out as concerning except for one thing spo2 is a little bit low so the spo2 is a tad bit low showing us mild mild hypoxemia when we examine them we notice that they have decreased breath sounds on the right okay with decreased tactile fremitus and dullness to percussion so whenever we hear decreased breast sounds that means they're not inflating a part of the lung well we have decreased tactile firmness meaning there's fluid usually in the pleural fluid and dullness to percussion likely Pleural fluid so there's a pleural fusion most likely as the etiology here when we also examine the patient we notice that they have a right eye ptosis we notice meiosis of their right eye and we notice anhydrosis on the forehead of their right side we notice edema and discoloration of their upper extremities their trunk and they have a bulbous kind of jugular vein that's distended they also have weakness of their right upper extremity and less sensation to light touch on the right upper extremity and then you notice on their fingers they got like these swollen and spoon-like appearance of their digits which is very interesting so things that we're starting to see here which is really really odd is we see that they have likely a pleural effusion Horner syndrome SVC syndrome brachial plexus compression and some type of weird spooning of the digits which could be like what's called a hypertrophic osteoarthropathy so very interesting so I think that we got to look on that chest x-ray or CT scan and really look at the Apex and the right lung to make sure that they don't have something called a pankos tumor so let's go ahead and check that out so look at that right Apex Boom Big honking tumor here so this would be right in the vicinity of where the brachial plexus is this would be in the vicinity of the sympathetic kind of like fibers this would be in the vicinity of the superior vena cava so we're and we're also seeing here look at this pleural effusion here as well so they got pleural effusion they got a big old pancos tumor they get a lot of the symptoms I think that would explain this with them having a pankos tumor so I think again pankos tumor and usually the two types of tumors that will cause this is a squamous cell carcinoma usually they're more centrally located but they can be near the Apex or adenocarcinomas as well so I think one of the big things to think about are what are some of the other features does this patient have with the panchose we already kind of talked about this but they have horners because you're compressing their sympathetic plexus they have hoarseness due to recurrent laryngeal nerve compression we actually see that right here they also have some degree of upper extremity swelling discoloration jvd due to superior vena cava compression and we also probably see some Horner syndrome as we talked about due to compression of the actual sympathetic fibers and plexus and then we also see compression of the brachial plexus as well which is causing some of their weakness on the right upper and decreased sensation on the right upper extremity as well and then here's the thing this is actually likely the cause of the spooning of the digits this is called hypertrophic osteoarthropathy and it's usually seen with adenocarcinoma so we may be likely seeing that as a potential effect here and maybe is more likely to support Adeno but again you need to really biopsy that to really see if that's truly the case um and again we also see that they have that pleural effusion plump in there so which tumors I think are important to remember we talked about the ones that are centrally located that's usually small cell that's usually carcinoid that's usually squamous the ones that are more peripherally located is usually going to be like adenocarcinoma usually like large cell carcinoma is another one that I would actually think about as well so think about those I think one of the big questions that you may actually see on the exam is which one out of all of the tumors small cells squamous cell large cell carcinoid Adeno is not associated with smoking and it's adenocarcinoma and then how do I prove its add note you got a biopsy it and so this is actually kind of more peripherally located so because of that I would do like a fine needle aspiration with CT guidance or a Vats as the potential opportunity here and if they have any Pleural fluid that I could actually tap off that's likely from their malignancy I could go ahead and do a thoracentesis and then send off some cytology there as well and then again staging I think it's important to remember is to look for any Mets so scan their head their chest their abdomen their pelvis you can even do a pet scan to look for any hot spots as well and again I think that's the big big location but remember where do they commonly metastasize to blab brain liver adrenal and bones if this patient did have if we were to quickly quickly say that they had stage 3A adenocarcinoma what does that mean for their stages that wouldn't work too hard on this I'll bring up the kind of diagram that we talked about in the Whiteboard but stage one is it's usually going to be kind of like localized to one hemithorax if it goes to the hemithorax and the ipsilateral lymph nodes that's stage two if it goes here to the other lymph nodes as well and it starts getting a lot bigger then we're starting to see stage 3A and in this case we're starting to see again as we go stage 3B and then stage four we're starting to see it spread into the actual systemic circulation so I think that's kind of the big thing to think about here is that in this patient I think that what we'll see is what does that stage mean and what would the treatment be well in this case the mass is actually spread to their mediastinum so it's actually gone from being in the lung it's spread all the way to the nearby lymph nodes and then from the lymph nodes it spread into the actual mediastinum as well and then from there we started seeing that it actually starts spreading of n further off because generally we have it localized then to the lymph nodes then to lymph nodes and mediastinum where it can still potentially be resected then into the nearby lymph nodes mediastinum where it cannot be resected and then usually into the lung parenchyma lymph nodes media stem cannot be resected and systemic metastasis as well so in this situation here it's still possible for you to resect it but you're going to need a lot of chemo radiation to really shrink the tumor as well all right my friends so that would cover this kind of lecture and cases on lung masses I hope it made sense I hope that you guys enjoyed it love you thank you and as always until next time [Music]

Channel: Ninja Nerd

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Keywords: Ninja Nerd Lectures, Ninja Nerd, Ninja Nerd Science, education, whiteboard lectures, medicine, science

Id: 3iJ8XyxaUu8

Length: 95min 2sec (5702 seconds)

Published: Tue Apr 04 2023