small cell

 

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Lung cancer is the third leading cause of cancer among men and women in the United States, but it is by far the deadliest of cancers with a death rate of approximately 50 per 100,000 people. Smoking is clearly the most important risk factor. Randomized controlled trials have failed to show a mortality benefit from screening with chest x-ray with or without sputum cytology. In August 2011, the National Cancer Institute published the results of the National Lung Screening Trial (NLST) that randomized heavy active or former smokers (>30 pack-year history) between 55 and 74 years of age to undergo either low-dose CT or PA chest x-ray. Screening with low-dose CT resulted in decreased lung cancer mortality. As a result of this trial, the American Lung Association (ALA) and the American Academy of Thoracic Surgery (AATS) have issued guidelines for screening patients for lung cancer. The ALA recommends screening with low-dose CT for patients meeting the following 4 criteria:

  1. Current or former smokers

  2. Ages 55 to 74

  3. Smoking history of at least 30 pack years

  4. No history of lung cancer

Other major organizations including the ACP and the USPSTF have not issued recommendations yet based on this new study. There is a concern that screening with low-dose CT will result in a significant number of repeated scans, procedures, and possible harm.

 

 

 

Treatment is based on staging and cell type; both anatomic (e.g., physical location of tumor) and physiologic (e.g., patient's ability to withstand treatment) factors are considered.

 

For staging purposes for NSCLC ??

  • CT chest scan with contrast, if there are no strong contraindications
  • FDG-PET from skull base to midthigh.
    • Use of FDG-PET has been shown to identify more patients with mediastinal and extrathoracic disease than conventional staging.14Although this approach spares more patients from stage-inappropriate surgery, the strategy appears to incorrectly upstage disease in some patients and, in one randomized controlled trial (RCT), did not affect overall mortality.15
  • If a patient has neurologic symptoms or an adenocarcinoma larger than 3 cm or mediastinal adenopathy, an MRI of the head without and with contrast are recommended.11
  • In addition, for patients with non–small cell tumors who may be candidates for curative surgery or radiotherapy, obtain pulmonary function tests, coagulation tests, and possibly cardiopulmonary exercise testing.5

For staging of patients with SCLC, ACR recommends:11

  • CT chest scan with contrast, if there are no strong contraindications, FDG-PET from skull base to midthigh, MRI of the head without and with contrast, and CT scan of the abdomen (liver metastases are common at diagnosis). The use of FDG-PET scanning is controversial for patients with SCLC as most chemoradiation studies were performed prior to use of this scan.8

Staging for patients with lung cancer is based on the TNM classification system where T describes the size of the tumor, N describes any regional lymph node involvement, and M notes the presence or absence of distant metastases (Box 58-1).16 At diagnosis, approximately 15% have localized disease, 22% have regional disease (spread to regional lymph nodes), and 56% have distant metastases.2

 

 

 

Metastases to Adrenal Gland

Treatment of Adrenal Metastases

The treatment recommended for adrenal metastases can vary depending on several factors. For all people supportive care is important. In people with symptoms such as hemorrhage, treatments such as surgery may be necessary to control symptoms.

  • Supportive Care - caring for your symptoms remains paramount. People with cancer deserve good pain management and control of other symptoms related to cancer.
  • Treatment of Symptoms - As noted above, adrenal metastases rarely cause symptoms. If a metastasis is bleeding (hemorrhaging) or is at high risk of bleeding, surgery to remove the tumor and adrenal gland (adrenalectomy) may be recommended. If the metastasis has resulted in adrenal insufficiency, treatment with steroids may be needed.
  • Treatment of the Primary Tumor and Other Metastases - This may include chemotherapy, targeted therapies or radiation therapy. Some people also participate in clinical trials studying new drugs and procedures. 
  • Treatment with Curative Intent - For people with an isolated adrenal metastasis, treatment may potentially result in long-term survival. Surgery - both open and laparoscopic adrenalectomy - may be done with a curative intent for some people  If surgery isn't possible, studies suggest that stereotactic body radiotherapy (SBRT) may be effective and well tolerated.  

 

Hemoptysis

Bevacizumab, an antibody to vascular endothelial growth factor (VEGF) that inhibits angiogenesis, has been associated with life-threatening hemoptysis in patients with non-small-cell lung cancer, particularly of squamous cell histology. Non-small-cell lung cancer patients with cavitary lesions or previous hemoptysis (≥2.5 mL) within the past 3 months have higher risk for pulmonary hemorrhage.

 

Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.

 

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A 60-year-old woman presents with a solid, nontender, movable mass on her upper chest that's been there for 6 months. It began as a dime-size mass and has been growing more rapidly over the past month (Figure 58-1A).

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She has lost 10 pounds over the last year without dieting. She has smoked 1 pack of cigarettes per day since age 18 years and gets short of breath easily. Her “smoker's cough” has gotten worse in the last few months and occasionally she coughs up some blood-tinged sputum. Her family physician excised the mass in the office and sent it to pathology (Figure 58-1B). When the result demonstrated squamous cell carcinoma of the lung, a chest x-ray (CXR) was ordered (Figure 58-2A). The radiologist suggested a CT to confirm the diagnosis (Figure 58-2B). The patient chose to have no treatment and passed away in 10 months of her lung cancer.

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