DIP Episode 331 - The Clutch Lung Cancer Podcast

Okay, welcome. My name is divine. This is episode 331 of the Divine Intervention Podcast. And in today's podcast, we're going to be talking about long cancer. We're talking about long cancer. Again, for those of you that are taking, I know that August is a very busy month. With many people taking the USMEL exams. So if you plan to take your USMEL at least at two or three exams within this month, I do have courses coming up next week. I have an MBME Test Ticking Strategy course taking place on the 12th of August. It's going to be from 2 to 430 PM Pacific Standard Time. And we'll basically use a bunch of questions and go over some very tried and true MBME Test Ticking strategies. Again, I've had tons of people take this course and they've done extremely well on the exams. We talk about how to answer ethics questions, how to answer questions, even where you don't fully know the content of the question. So again, it's a very tried and true course and you'll learn again very systematic means of taking these MBME exams. Now, the second thing is between the 13th and the 14th, we have a review course. It's going to be 10 hours each day, basically on the 13th, which is a Friday and on the 14th, which is a Saturday. And essentially, what we're going to be doing is, we're going to be reviewing Peds, Surgery, IAM, OBGYN, Psych, Neural, FX, Biostatistics, Communications, Right, Professionalism, Healthcare Systems, Quality and Safety.

So review all those things, review about 1700 concepts within those two days. Again, I've had many people take the course. In fact, I've had people like literally, they took the course I held last weekend and they took the exam. So it's recently as like yesterday and they found it to be extremely, extremely helpful. So again, many people have attended these courses, don't really well with it. So if it's something you're interested in, just shoot me an email through the website. And I'll be more than happy to give you some more information. Okay, so let's go ahead and jump right into a long answer, right? So I know that long answer is a really bad kind of answer. I mean, like whenever a person has long answer, it's not always the best thing in the world, right? So we know that long answer many times, what are some classic things? The thing is, it's just one of these topics you know you're going to see on your exam. But it's something you kind of need to pay attention to, right? So one of some key things you want to keep in mind with long answer. Well, I will say the first thing is kind of like epidemiology, right? I don't know why that word is kind of hard to pronounce sometimes for me, right? But basically remember that long answer is the most common cancer that causes death, right? Is the leading cancer cause of death? And that obviously makes sense, right? Because it's very deadly when it happens.

I mean, the five-year survival in general for most long answers is around like is less than 20% just in general, right? So long answer is bad, right? Long answer is bad. And the thing is long answer though is not the most common cancer, right? So remember in men, right? Prosthetic answer is way more common than long answer. And women breast cancer is way more common than long answer. But again, those cancers are not as deadly as long cancer, right? So if the person has long answer, they're probably going to die from it, right? And what are some risk factors for long answer, right? Some risk factors, obviously the big, big one to keep in mind is smoking. Smoking is the biggest risk factor for long answer, right? But again, remember, smoking is not the only risk factor for long answer, right? So if, for example, they give you a question about a person that works as that has worked like a nuclear power plant or whatever for like 30 years. And then the person develops long answer. And then they mention it was the most important risk factor in this person developing long answer. It's going to be a radiation exposure, right? And also remember in certain places, if you're living basements and things like that, basements can expose you to like, radon, right? Radon is actually one of the, is actually one of the pretty important risk factors for long answer after smoking, right?

And then again, obviously if you've been exposed to like asbestos, that can also increase your risk of developing long answer. And then also do not forget second hand smoke, right? So if you're around people that smoke a lot, that can also increase your risk of having long answer, right? So the thing is long answer, one other thing our friends at the end of the day, we love to test with it is screening, right? So how do we screen people for long answer? So remember there were some old guidelines, but there are so much newer guidelines these days that actually kind of high up to now, right? So the new guideline is, you start at the age of 50, right? You start at the age of 50. Basically, if you have a person that has a 20-pack year smoking history, right? And they currently smoke, or they've quit within the last 15 years, right? So let's say for example, you're a 50-year-old guy, and you quit smoking 10 years ago, right? You qualify for this, right? Or you're a 50-year-old guy, and you currently smoke, you do qualify for this. But this also applies to women as well. This is not like a triple A, where you only screen men, and you don't screen women. For long answer, you also screen women, you screen men and women, right? So if you're a person that is between the ages of 50 to 80, you have like a 20-pack year-smoking history, so you must have that 20-pack year-smoking history, right?

So if you smoked two packs of cigarettes every day for five years, you don't need this criteria, right? So you must have had a 20-pack year-smoking history, and you must either be smoking now, or you quit like within the past 15 years, right? Then those people deserve an annual Lodo CT scan, right? They deserve an annual Lodo CT scan for long answer. Well, here's one of the usual things your friends at the NBME can do to you on the exam, right? They can basically ask you about like, oh, let's say, for example, you have some person that is 55 years old, you know, the person qualifies for this screening. Within you notice that they have like pancreatic cancer, right? Some terminal malignancy, should you continue to screen this bill for long answer? The answer to that is no, right? So it's very high you to know. Whenever a person has like a very poor prognostic healthcare lesion, then in general, screenings should stop in that person, right? Screenings should stop in that person. And most times, those people are not going to be eligible for transplants, right? So let's say for example, a person has like, critical the acup disease. It makes absolutely no sense to try to give those people new organs, right? So again, it's just one of these things that kind of looks bizarre, but it's very high you to know, especially for the more recent NBME exams, right? So now let's talk about the two general kinds of long cancer, right?

So remember, there are two general classes of long cancer, right? There's going to be small cell, and then there's going to be non-small cell, right? There's going to be small cells, there's going to be non-small cell, right? So let's talk about small cell first, because it's a very high-yout one has many different primary or plastic syndromes, right? So it's kind of high you to know, right? So small cell long cancer, the classic classic thing they'll tell you on your exam is that one, it's a central lesion, that's very important. And then the second thing that they'll also tell you on your exam is that the person, when you do a biopsy of the lesion, they're going to see small round blue cells. You need to commit this to memory. If you see the term small round blue cells from the lungs, I want you to absolutely think about small cell long cancer, right? Remember, there is this numonic for the long cancers that are central, right? Central are the small cell and squamous cell. You see they have SM, they mean small cell, squamous cell, central, right? So those things are centrally located in the lungs, right? So small cell long cancer, keep things you want to know about it again. First things first, you want to know for sure, for sure, again, that those are small round blue cells. I'm telling you, even on step two, see case step three, that is a factor that they absolutely still test. You do need to know the stuff for the exam.

And then another thing they love you to know about small cell long cancer is that your only treatment option available for small cell long cancer is chemotherapy, right? Small cell long cancer does not, basically, radiation is not going to do squat for you, right? Surgery is not going to do squat for you on MDM exams, right? Because the thing is, when a person is diagnosed with small cell long cancer, it's already stage four, right? Long cancer is small cell long cancer when diagnosed is considered to be stage four a diagnosis, right? So in general, you only do chemotherapy for small cell long cancer. Now, what are some other high-yield things to keep in mind with small cell long cancer? Well, the big thing to know is the pineal plastic syndrome, right? So they can give you a question about a person that has like a long nodule and then they tell you that the person has been gaining weight and the person has like skin hyperpigmentation, the person has popolstriol in their skin, right? They may even have signs and symptoms of hyper-auto-steroanism because remember, cortisol can work like auto-steroan, right? So they may have signs and symptoms of hyper-auto-steroanism, they may have like elevated block pressures, they may have hypochylemia, they may have metabolic alkalosis, right? If you see all those things, I would really hope you're thinking about a topic ACTH production, right? Remember, that's the ACTH that does not suppress with high-dose dexamethasone therapy, right?

That's one of, remember when a person has small cell long cancer and they're producing ACTH in a pineal plastic fashion, that ACTH is basically, that's like an ACTH dependent cause of hyper-cortisolism, right? So again, this one, unlike Cushion's disease, the cortisol will not suppress with high-dose dexamethasone administration, right? So if you see that, if you see a person having long cancer and having no stuoporosis, I really want you to think about small cell long cancer, right? And the fact that the person is making a ton of a topic, ACTH, right? And then remember, another classic one is, they can give you a question about a person that has, you know, a long nodule and the person has hypochylemia, right? If you see that, that should really get you thinking about SIDH, right? SIDH, SIDH, right? So if you have SIDH, ADHD's job is to cause you to reabsorb a ton of water from free water from your urine, right? So those people's urine will be very concentrated, you'll have a high, very, you'll have a high urine-specific gravity, right? But the acerum or spolarity will be really low. And remember, we'll treat SIDH with fluid restriction, right? And then remember, they can also give you a question about a person that has a long nodule. And then they will tell you something about the person having trouble combing their hair, or climbing upstairs, or being able to get it, like, abduct their arm, right? That tells you that these people have proximal muscle weakness, right?

Or they may tell you that, oh, this person, they went, they go for repetitive nerve stimulation. And you notice that they get an incremental response, right? So it's almost like as you're keeping stimulating the nerves, their muscle weakness just keeps getting better, right? Or after a few tries, after a few tries, their muscle weakness gets better. If you see something like that, I want you to think about LAMBRE 18 Myesthenic Syndrome, right? LAMBRE 18 Myesthenic Syndrome. Remember, in this planet, your plastic syndrome, the thing that's happening is that, you're making autoantibodies against the pristine optic voltage-gated calcium channel, right? Pristine optic voltage-gated calcium channel. Again, those are the three pineoplastic syndrome associated with small cell lung cancer, right? So, a topic ACTH production, SIDH, right? And the production of those pristine optic voltage-gated calcium channel antibodies, right? So that's the big thing with those with a small cell lung cancer. And remember, again, they may put some tumor markers there. Remember, these things, you know, they tend to sting very nicely for like neuron-specific inolese or like chromogram in A. Those are just things to keep in mind. And sometimes they may have some gene amplifications like the MEC gene amplification. Actually, they are drugs that target those pathways, right? But those are largely beyond the scope of the USMEL exams.

And then, if we're going into the world of non-small cell lung cancer, the big, big, big one you want to keep in mind is squamous cell cancer of the lungs, right? Squamous cell cancer of the lungs. The big thing you want to keep in mind with squamous cell lung cancer is the fact that it loves to form cavities. Squamous cell lung cancer loves to cavitate, right? And again, it's a central lesion. It loves to cavitate. And the big thing they will tell you on biopsies that you're seeing keratin, right? If you see keratin or detail, talk about these intracellular bridges, right? You want to think about squamous cell lung cancer. And many times these people, they can actually present with like all treatment of status, severe abdominal pain and things like that, right? And like gyro psych symptoms from hypercalcemia, right? Because remember, squamous cell lung cancer, many times in a primary plastic fashion, is going to produce PT-HRP, right? Remember, PT-HRP is parathyracumum-related peptide, right? So that PT-HRP, the thing it does is it pretty much works like PT-H, right? So it's going to raise these people's blood calcium levels and it's going to trash the phosphate, right? So they're going to have low levels of phosphorus. But remember that these people's endogenous PT-H will be low, right? Because remember, PT-HRP, even if it acts like PT-H, it's not the same thing as PT-H.

So that hypercalcemia they have is going to cause a reduction in their endogenous PT-H as a form of negative feedback if you make, right? So that's something you definitely want to keep at the back of your mind, for example. That's pretty much about as much as you need to know with squamous cell lung cancer, right? And then the other ones, if they give you a question about lung cancer in a person that has never smoked or in a female, right? One thing I'll encourage you to really think about is abnucarcinoma, right? It's going to be a peripheral lesion. In fact, abnucarcinoma is the most common kind of lung cancer. I'll say that again, abnucarcinoma is the most common kind of lung cancer, right? Because many people just because we talk about small cell and squamous cell so much, they think that, oh, abnucarcinoma must be a distant third. The answer to that is no. Abnucarcinoma is actually the most common kind of, is the most common kind of lung cancer, right? And it's the one that actually has, it's going to be peripheral, right? So you see, it doesn't have that S sounding name, right? It's going to be peripheral. And the thing is, one thing about abnucarcinoma sometimes is it likes to grow around the walls of the alveoli, right? That's something called a lapidic, LEPIDIC. Believe it or not, that's a term you could see on your exam. That's a lapidic growth pattern, right? That's something we see many times with, with abnucarcinoma, right?

And because it's an abnucarcinoma, that's a lesion, right? Many times this thing can produce a ton of mucin, right? So if you tell you that the person has like a lung malignancy and you do a biopsy and you see like a ton of mucin, ton of mucinose material, right? A lot of PAS positive material, I really want you to think about abnucarcinoma, right? And again, many times abnucarcinoma has this association with a pyranyoplastic syndrome, although this is much of a specific to abnucarcinoma. You may find this a specific pyranyoplastic syndrome with small cell lung cancer and scream cell lung cancer. And that's this factor they can give you like, oh, some guy that has smoked for a long time and then over the last three, four weeks he has developed like digital clubbing and he has like pinning his fingers and he has like pinning his joints. If you see stuff like that, I absolutely want you to think about something called hypertrophic pulmonary osteoarthropathy, hypertrophic pulmonary osteoarthropathy, right? It's a pyranyoplastic syndrome that's associated with lung cancer many times. If a person has those symptoms and they've smoked and they ask you for your next best step on an exam, you want to go ahead and get some kind of chest imaging like a chest x-ray or a chest CT to find that lung cancer that they have, right? I remember abnucarcinoma many times tends to have these gene mutations like Keras, remember we find Keras mutations in colon cancer as well, right?

But it also has these EGFR mutations, these ALK mutations, right? Those are just things you want to be able to recognize on an exam, right? So again, very high yield to keep these things in mind and then just to kind of wrap up the other types of lung cancer, I mean there's like large cell cancer, this one is again also going to be in the periphery of the lungs, right? So just something to keep in mind for exams. Now one other thing I would say is there are some things that can happen with lung cancer that, you know, you kind of want to know for an MBM exam, right? So what if they give you a question about a person, a person has like a history of lung cancer and you notice that wow, this person has like over the like a few days, they have like GVD developing, pinning their hands, swelling, bulging of their face. If you see that, you want to think about superior vein accava syndrome, SVC syndrome, right? SVC syndrome is most commonly associated with small cell lung cancer, right? So again, the cancer is involving the superior vein accava, right? So everything that drains into the SVC is bulging, right? Because things are backing up in them, right? And the way we treat SVC syndrome, an MBM exam, this actually would really therapy, right? It's actually with really therapy. And then another thing that could happen, right, we can give your person that has like, like unilateral, popularly myosis, right?

And then you'll tell you that they have like this like neuropathy in their upper extremities. If you see that, I really, really want you to think about a pancus tumor, remember, pancus tumors are most commonly associated with squamous cell lung cancer, right? So pancus tumors, right? Those pancus tumors, they are compressing those nerve fibers that are going to the superior cervical ganglia, right? So because they are compressing those nerve fibers, right? They can cause a hunger syndrome. Remember, in hunger syndrome, you're going to see toses, meiosis and hydroces, right? So again, SVC syndrome, you don't need to know about, uh, pancus tumors you need to know about. And remember, sometimes, right? These cancers can get so big, they can involve the recurrently in your nerve. So if they give you a question about a person that has lung cancer and it's having like swallowing difficulties, or the person is having, um, uh, like hoarseness, right? They're having like, you know, like hoarse speech. If you see stuff like that, I really want you to think about a problem potentially with the recurrently in your nerve, right? So the big thing I want to see then is how do we diagnose lung cancer? In general, CT, CT, CT, CT, CT scan. Get that CT scan. It'll help you better characterize the mass, right? And then most times if you want to do a biopsy, the biopsy method you choose depends on what kind of malignant, what kind of lesion you have. Right?

So if you have like a central lesion, you're going to do either a brancoscopy or you're going to do a mediascanoscopy with biopsy, right? But if it's a peripheral lesion, you're going to call interventional radiology or interventional pulmonology to do a precutinious CT guided biopsy, right? So that's how you do those things, right? And again, remember when you're doing a biopsy, you want to go above the margin of the rib, right? Because you want to avoid that intercostal vein, artery and nerve bond, right? So it's kind of high you to keep those things in mind. And one thing I'll also say is if they tell you that, oh, you get a chest x-ray or chest CT and you notice popcorn calcifications in the lungs. That's very high up. Popcorn calcifications in the lungs. You want to think about a hemartoma. A hemartoma is a completely benign lesion, right? So the thing is, if for example, a person has lung cancer and you need to recite their lungs, what do you need to do before you send them to the OR? The thing you need to do on an in-beam exam is you need to get the FVV1. You need to do pre-op PF Ts. The FVV1 has to be greater than 1.5 liters. If it's less than 1.5 liters, that's a contraindication to these people getting surgery, right? And another thing to also keep in mind with staging of lung cancers is, if a person has a lung cancer and they have a plural of fusion, and in that plural of fusion, say you do a thoracin T Cs to find malignant cells, that's stage 4 lung cancer.

Once you can find cancer cells in a plural of fusion, that's stage 4 lung cancer because it means that those things have got into lymphatic vessels, right? It means those things have got into lymphatic vessels, right? And most times, if you want to evaluate, after let's say you've done like the CT, you've done the biopsy, you want to evaluate for MEDS, the best thing to do on an in-beam exam is to get a PET scan, right? The best thing to do on an in-beam exam is to get a PET scan. So I think I'm going to go ahead and pause here. Again, I know some people may be like, oh, the one you didn't talk about the algorithm for a solitary pulmonary nodule, blah, blah, blah, blah. So we're going to just review all those things, do not matter for the most part, for the USMLA exams, right? So I'm just focusing on things that are high yield and important. This is a very high yield, very high level podcast and I can pretty much promise you, you'll see a question or two on this stuff when you're taking your USMLA exams. Again, as I do at the end of every podcast, I do a full one or one tutoring for many exams, step one, step two, CK, step three, pre clinical medical exams, 30-ishelf exams. And then if you're interested in helping your ERAS application, I just shook me an email through the website again, I've worked with tons of people that have much into many disciplines, Durham, New York surgery, plastic surgery, general surgery, I am family-made.

People that have failed USMLA exams have worked with and now residents, right? So again, I have a lot of experience with this process. I can really touch up your application and make it what it needs to be, right? And then I have all these podcasts on Apple podcasts, on Google podcasts, on Spotify, at least the most recent 150. It's a Word Press rule. If you want all the podcasts from episode one, all the way to I guess 331, which is this one I'm making, then you need to go on the website and find and just type in episode one and you will come up as a search, right? And then on the website, I have this thing called exam topics list. If you want to click on that, it will lead you to a Google spreadsheet that shows you for issue SMLA exam broken down by topic and podcasts you should listen to. So let's say you want to study internal medicine for step two, CK step three, you go to the step to the step two CK column and you see on the internal medicine, you'll see some things that I definitely recommend that you should consider reviewing, right? And then I have a You Tube channel, Divine Intervention, USMLA podcast and videos. If you want that, if you go there, you'll find the videos that I have made. And then another thing I'll also say is that, you know, if you go on the website, Divine Intervention Podcast.com, I do actually have, if you subscribe to the website, you'll get an email notification whenever I make a new podcast.

And again, don't forget about the course, the step two CK step three review course I have coming up next week and the MBA Me testing and strategies course. And then finally, for those that love my life lessons, I've actually studied like a unique life lessons at website discord, Divine Intervention Life Lessons.com. I even have the podcast on the on Apple podcast, Divine Intervention Life lessons. And you can learn a ton from those podcasts. They are like life lessons, they are Bible based teachings and they are all less than 10 minutes. I've made 10 episodes so far. And I, you know, hope to make a few pretty much every every week. So thank you for listening to me today. I'll see you next time. Have a wonderful day. God bless you. Thank you.

ACTH production (Cushing's), SIADH, and Lambert-Eaton Myasthenic Syndrome (LEMS).

Adenocarcinoma.

Keratinization, intracellular bridges, or cavitation.

Lambert-Eaton Myasthenic Syndrome (LEMS).

Chemotherapy only. Surgery and radiation are generally ineffective because the diagnosis is often already Stage IV.

Low serum osmolarity and highly concentrated urine (high urine-specific gravity).

Small round blue cells.

Lung cancer (overall leading cause of cancer mortality).

Squamous cell carcinoma.

Annual Low-Dose CT scan (LDCT) starting at age 50, for those with a $\ge$ 20 pack-year smoking history who currently smoke or quit within 15 years.

The ACTH produced by SCLC does not suppress with high-dose dexamethasone administration.

Squamous cell carcinoma.

Small round blue cells.

Lung cancer (overall leading cause of cancer mortality).

Squamous cell carcinoma.

Annual Low-Dose CT scan (LDCT) starting at age 50, for those with a $\ge$ 20 pack-year smoking history who currently smoke or quit within 15 years.

The ACTH produced by SCLC does not suppress with high-dose dexamethasone administration.

Squamous cell carcinoma.