A 76-year-old woman presents to the primary care office for her yearly visit. She is due for her annual low-dose screening chest CT. She is feeling well and has no current complaints. She has a 45-pack-year smoking history but quit 8 years ago. She has no ongoing medical problems and takes no medications. Exam is within normal limits. CT shows a 4.1 cm spiculated lung mass in the left lower lobe with a small pleural effusion adjacent to the mass and metastases to the chest wall. Bronchoscopy is performed with a biopsy showing malignancy arising from the squamous epithelium. A sample from the effusion also contains malignant cells. Which of the following is the best treatment plan?

Lung cancer or bronchogenic carcinoma is defined as a tumor originating in the lung parenchyma or within the bronchi. It typically arises from lung, epithelial gene mutations due to long term exposure to cancer causing agents, mainly tobacco use, but also exposure to asbestos or radon.

Based on histopathological findings. Lung cancer is classified into two main groups, small cell lung cancer or S CLC and non small cell lung cancer or NS CLC, which includes adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and bronchial carcinoid tumor.

If a patient presents with a chief concern, suggesting lung cancer first, you should perform an ABCD E assessment to determine whether the patient is unstable or stable.

Unstable patient0:51–1:30

If the patient is unstable, such as from severe respiratory distress or hypotension, then you must first stabilize the patient's airway breathing and circulation, provide supplemental oxygen to maintain oxygen saturation.

Above 90%. In severe cases, you may even need to intubate the patient next, establish intravenous access for fluids and medications.

Finally, don't forget to put your patient on continuous vital sign monitoring, including heart rate, BP and pulse oximetry.

Stable patient1:30–2:17

All right. Now, let's go back to the ABCD E assessment and discuss stable patients.

First obtain a focused history and physical examination. Order labs like a CBC and C MP and finally order imaging primarily a chest X ray and a chest CT scan.

Here's a clinical pearl yearly lung cancer screening with CT scan is recommended for individuals who are 50 to 80 years of age who either currently smoke or have quit smoking within the past 15 years and have at least a 20 pack year smoking history, history typically reveals cough, shortness of breath, pleuric chest pain, as well as unintentional weight loss and fatigue.

H&P, labs, imaging2:17–6:16

If the lung cancer invades surrounding vessels, the patient could report hemoptysis or coughing up blood. Some patients may also have a history of recurrent episodes of pneumonia involving the same spot.

Next check the patient's history for occupational and environmental risk factors. The most important ones include tobacco use and asbestos exposure.

Other risk factors that you should know include marijuana, cocaine vaping with electronic cigarettes as well as exposure to radon gas and air pollution.

But that's not all underlying lung conditions such as COPD, pulmonary fibrosis and tuberculosis can also increase the risk of lung cancer.

On the other hand, the physical examination findings in a patient with lung cancer are often nonspecific but might include tachypnea or distal extremity clubbing.

The same goes for lab results which are also nonspecific but could reveal anemia, thrombocytopenia, low serum glucose hypercalcemia, hyponatremia and hypokalemia.

Finally, the chest X ray and CT scan will show a pulmonary nodule or mass. Now, here's a high yield fact, certain findings can give you clues as to the type of lung cancer.

For instance, tumors located at the apex of the lung called pancoast tumors or superior sulcus tumors can compress adjacent structures like the brachial plexus, leading to ipsilateral shoulder and arm pain, paresthesia, or even atrophy of the hand muscles and can also compress sympathetic nerve fibers leading to Horner syndrome with ipsilateral ptosis, miosis and facial anhidrosis.

Keep in mind that the majority of pancoast tumors are adenocarcinomas. Moreover, lung cancers can cause different paraneoplastic syndromes.

For instance, squamous cell carcinomas may produce p th related peptide, which in turn can lead to hypercalcemia. On the other hand, bronchial carcinoid tumors can release serotonin and cause Carcinoid syndrome, which can present with flushing, diarrhea, wheezing and even right-sided valvular heart disease.

Lastly, small cell lung cancer may cause a variety of other paraneoplastic syndromes. Firstly, they can produce a DH leading to syndrome of inappropriate antidiuretic hormone secretion or SI A DH, which is characterized by euvolemic hyponatremia and decreased serum osmolality as well as inappropriately elevated urine osmolality.

With high sodium small cell lung cancer can also produce ACTH, which in turn stimulates cortisol production. Leading to Cushing's Syndrome, characterized by moon facies, weight gain with increased abdominal fat and stria but thin limbs and muscle weakness as well as osteoporosis, hypertension and diabetes, mellitus, lastly small cell lung cancer can trigger the production of antibodies against presynaptic voltage gated calcium channels in the neuromuscular junction leading to Lambert Eaton Syndrome, which presents with muscle weakness that gets better with exertion or repetitive nerve stimulation.

Ok. At this point, you should suspect that your patient may have lung cancer.

Your next step is to order a bronchoscopy with biopsy for centrally located tumors or a CT guided transthoracic needle aspiration biopsy for peripherally located tumors that cannot be reached with bronchoscopy.

Bronchoscopy / TTNA6:16–6:56

In transthoracic needle aspiration biopsy, an ultrasound or CT scan is used to guide the needle to the tumor. Once you set the needle into the tumor, take the biopsy sample and send it to your pathology.

Team. Next, assess the biopsy results.

If the biopsy results show histopathologic findings specific for small cell carcinoma or combined small cell carcinoma, diagnose small cell lung cancer.

Next, proceed to TNM staging to determine the appropriate treatment plan if the patient's small cell lung cancer is stage 12 or three, treat with chemotherapy and radiation therapy and obtain surgical consultation.

SCLC6:56–7:39

If the small cell lung cancer is stage four, meaning that there's distant metastasis or malignant pleural effusion, you can treat the patient with chemotherapy alone.

Now, let's go back to the biopsy result. If histopathology reveals findings specific to adenocarcinoma, squamous cell carcinoma, large cell carcinoma or bronchial carcinoid tumor, you can make a diagnosis of nonsmall cell lung cancer.

NSCLC7:39–8:36

Next, proceed to TNM staging to determine the appropriate treatment plan if the patient's non small cell lung cancer is stage one or two, obtain a surgical consultation for a video assisted lobectomy and mediastinal lymph node dissection once the cancer is removed, continue the treatment with postoperative chemotherapy.

On the other hand, treat stage three cancer with a combination of chemotherapy and radiation therapy and stage four with chemotherapy only.

Finally, if the histopathologic findings are inconsistent with small cell lung carcinoma and non small cell lung carcinoma.

You should consider alternative diagnoses. All right, as a quick recap lung cancer or bronchogenic carcinoma is defined as a tumor originating in the lung parenchyma or within the bronchi based on histopathological findings.

Alternative diagnosis8:36–8:54

Lung cancer is classified into two main groups, small cell lung cancer or S CLC and non small cell lung cancer or NS CLC, which includes adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and bronchial carcinoid tumor.

Review8:54–9:33

If you suspect lung cancer based on history, physical exam labs and imaging findings, obtain a biopsy sample with bronchoscopy for central tumors or with CT guided transthoracic needle aspiration for peripheral tumors.

Once you get the biopsy, results determine the type of lung cancer and use TNM staging to choose the optimal treatment which may include chemotherapy, radiation therapy, surgical intervention or a combination of these options.