{"version":"1.0.0","segments":[{"startTime":7.96,"endTime":9.95,"body":"Welcome back to the Ninja Nerd Podcast."},{"startTime":10.02,"endTime":11.99,"body":"Today we're talking about lung cancer."},{"startTime":11.99,"endTime":16.28,"body":"We're continuing our conversations"},{"startTime":11.99,"endTime":16.28,"body":"throughout oncology and next up"},{"startTime":16.28,"endTime":18.38,"body":"is lung cancer and I'm pretty"},{"startTime":16.28,"endTime":18.38,"body":"sure it's going to be a behemoth."},{"startTime":18.725,"endTime":20.245,"body":"Yeah, this one's a huge one."},{"startTime":20.575,"endTime":23.405,"body":"Very common one but I think the"},{"startTime":20.575,"endTime":23.405,"body":"biggest thing to remember about lung"},{"startTime":23.405,"endTime":27.315,"body":"cancer, and this is why it's actually"},{"startTime":23.405,"endTime":27.315,"body":"a really scary one, is the most common"},{"startTime":27.315,"endTime":30.325,"body":"cause of malignancy related deaths."},{"startTime":30.544,"endTime":32.894,"body":"So when we think about any kind"},{"startTime":30.544,"endTime":32.894,"body":"of cancer that could actually kill"},{"startTime":32.894,"endTime":36.105,"body":"you and cause that higher chance"},{"startTime":32.894,"endTime":36.105,"body":"of mortality, this is the one."},{"startTime":36.404,"endTime":40.154,"body":"It's more common in men, but there is"},{"startTime":36.404,"endTime":40.154,"body":"an uptick in women for this condition."},{"startTime":40.154,"endTime":44.194,"body":"And when you put lung cancer under"},{"startTime":40.154,"endTime":44.194,"body":"a big umbrella, how would you"},{"startTime":44.194,"endTime":45.774,"body":"go about breaking this topic up?"},{"startTime":47.194,"endTime":50.784,"body":"So I think the biggest thing to think"},{"startTime":47.194,"endTime":50.784,"body":"about when we talk about lung cancer is"},{"startTime":50.784,"endTime":55.354,"body":"really breaking it into kind of screening,"},{"startTime":50.784,"endTime":55.354,"body":"because obviously just like we talked"},{"startTime":55.354,"endTime":59.184,"body":"about breast cancer, when we think about"},{"startTime":55.354,"endTime":59.184,"body":"it, it's like, how can we potentially"},{"startTime":59.234,"endTime":63.179,"body":"know, the way that we can prevent"},{"startTime":59.234,"endTime":63.179,"body":"breast cancer from when we identify"},{"startTime":63.179,"endTime":64.779,"body":"it from being stage three, stage four."},{"startTime":65.029,"endTime":68.359,"body":"How can we catch it a little early"},{"startTime":65.029,"endTime":68.359,"body":"and then come up with the next steps?"},{"startTime":68.399,"endTime":70.179,"body":"So that's the same thing for lung cancer."},{"startTime":70.429,"endTime":73.939,"body":"We should know which patients are"},{"startTime":70.429,"endTime":73.939,"body":"at the highest risk of lung cancer."},{"startTime":74.299,"endTime":77.799,"body":"How do we screen them if they end up"},{"startTime":74.299,"endTime":77.799,"body":"getting an image for some other reason?"},{"startTime":78.169,"endTime":81.089,"body":"And we see something weird on"},{"startTime":78.169,"endTime":81.089,"body":"their chest x ray or on their CT."},{"startTime":81.369,"endTime":83.039,"body":"How do we know what to do with that?"},{"startTime":83.049,"endTime":83.999,"body":"That's the first thing."},{"startTime":84.339,"endTime":88.719,"body":"And then the second thing is to know"},{"startTime":84.339,"endTime":88.719,"body":"if it's super, super aggressive, very"},{"startTime":88.719,"endTime":93.569,"body":"rapidly developing lung cancer, such"},{"startTime":88.719,"endTime":93.569,"body":"as small cell carcinoma, or if it's"},{"startTime":93.579,"endTime":97.119,"body":"one of the other ones that aren't as"},{"startTime":93.579,"endTime":97.119,"body":"rapid, but it can still be problematic"},{"startTime":97.159,"endTime":99.389,"body":"and that's non small cell lung cancer."},{"startTime":99.499,"endTime":100.829,"body":"How do we screen patients?"},{"startTime":100.849,"endTime":105.499,"body":"How do we know how to follow up on"},{"startTime":100.849,"endTime":105.499,"body":"a nodule that shows up on an image?"},{"startTime":105.799,"endTime":106.829,"body":"What do we do with it?"},{"startTime":106.889,"endTime":110.279,"body":"And then second is how do we really think"},{"startTime":106.889,"endTime":110.279,"body":"about small cell and how do we really"},{"startTime":110.279,"endTime":111.949,"body":"think about non small cell lung cancer?"},{"startTime":112.129,"endTime":114.789,"body":"So those are the two arms"},{"startTime":112.129,"endTime":114.789,"body":"of this discussion is non"},{"startTime":114.789,"endTime":116.169,"body":"small cell and small cell."},{"startTime":116.219,"endTime":117.079,"body":"Exactly."},{"startTime":117.179,"endTime":117.359,"body":"All right."},{"startTime":117.369,"endTime":117.579,"body":"Yep."},{"startTime":118.269,"endTime":118.899,"body":"Let's get into it."},{"startTime":118.939,"endTime":119.309,"body":"All right."},{"startTime":119.699,"endTime":124.939,"body":"Case one We have a 58 year old male"},{"startTime":119.699,"endTime":124.939,"body":"presents for routine annual lung cancer"},{"startTime":124.939,"endTime":129.859,"body":"screening- Hey, now getting an annual"},{"startTime":124.939,"endTime":129.859,"body":"screening, is that something you do"},{"startTime":129.859,"endTime":134.719,"body":"after a certain age or is this like,"},{"startTime":129.859,"endTime":134.719,"body":"Hey, we should be doing this every year?"},{"startTime":134.729,"endTime":134.989,"body":"I don't."},{"startTime":134.989,"endTime":139.339,"body":"So the USPSTF gave guidelines"},{"startTime":134.989,"endTime":139.339,"body":"on this and actually recently"},{"startTime":139.339,"endTime":144.699,"body":"changed a little bit, but 50 to"},{"startTime":139.339,"endTime":144.699,"body":"80 years of age is the timeframe."},{"startTime":145.049,"endTime":151.439,"body":"The risk like population is those who are"},{"startTime":145.049,"endTime":151.439,"body":"smokers, whether it be current or former."},{"startTime":151.489,"endTime":151.779,"body":"Yeah."},{"startTime":151.829,"endTime":154.639,"body":"But you have, if you're a current smoker."},{"startTime":155.019,"endTime":159.489,"body":"It usually needs to be greater than"},{"startTime":155.019,"endTime":159.489,"body":"or equal to a 20 pack year history."},{"startTime":159.869,"endTime":163.929,"body":"And the way that you determine that is"},{"startTime":159.869,"endTime":163.929,"body":"You look at the number of packs that are"},{"startTime":163.929,"endTime":167.919,"body":"usually smoked within a day, and then"},{"startTime":163.929,"endTime":167.919,"body":"you multiply that by the number of years"},{"startTime":167.919,"endTime":169.509,"body":"that the individual has been smoking."},{"startTime":169.969,"endTime":172.009,"body":"So let's just give an example."},{"startTime":172.009,"endTime":176.029,"body":"You smoke two packs a day, and"},{"startTime":172.009,"endTime":176.029,"body":"you've been smoking for 15 years."},{"startTime":176.049,"endTime":177.699,"body":"That's a 30 pack year history."},{"startTime":178.209,"endTime":182.839,"body":"they had greater than or equal to 20"},{"startTime":178.209,"endTime":182.839,"body":"pack year history, 50 to 80 years of age."},{"startTime":183.229,"endTime":186.349,"body":"Their current smoker or former smoker"},{"startTime":183.229,"endTime":186.349,"body":"and still meets that greater than"},{"startTime":186.349,"endTime":187.579,"body":"or equal to 20 pack your history."},{"startTime":187.949,"endTime":193.159,"body":"The little caveat to the former smoker"},{"startTime":187.949,"endTime":193.159,"body":"is you had to have quit within the"},{"startTime":193.159,"endTime":198.169,"body":"past 15 years after 15 years, you don't"},{"startTime":193.159,"endTime":198.169,"body":"really fit that high risk population."},{"startTime":198.169,"endTime":202.599,"body":"So current or former greater than"},{"startTime":198.169,"endTime":202.599,"body":"or equal to 20 pack your history."},{"startTime":202.599,"endTime":205.959,"body":"If you're a. Former than it"},{"startTime":202.599,"endTime":205.959,"body":"needs to be less than 15 years."},{"startTime":205.989,"endTime":210.249,"body":"And the age range that we start screening"},{"startTime":205.989,"endTime":210.249,"body":"annually is 50 to 80 years of age."},{"startTime":210.609,"endTime":210.869,"body":"Yep."},{"startTime":211.329,"endTime":214.559,"body":"So with our patient again, 58"},{"startTime":211.329,"endTime":214.559,"body":"year old male presents for his"},{"startTime":214.559,"endTime":215.889,"body":"annual lung cancer screening."},{"startTime":215.949,"endTime":216.099,"body":"Okay."},{"startTime":216.179,"endTime":217.359,"body":"So he falls within this range."},{"startTime":217.36,"endTime":218.034,"body":"Yep."},{"startTime":218.324,"endTime":222.174,"body":"It's because he is asymptomatic but"},{"startTime":218.324,"endTime":222.174,"body":"has a significant smoking history."},{"startTime":222.194,"endTime":224.684,"body":"This patient has a 35 pack year history."},{"startTime":225.014,"endTime":227.064,"body":"He had quit smoking five years ago."},{"startTime":227.714,"endTime":229.334,"body":"No previous imaging is available."},{"startTime":229.344,"endTime":233.394,"body":"He denies cough, shortness of"},{"startTime":229.344,"endTime":233.394,"body":"breath, hemoptysis, or weight loss."},{"startTime":234.484,"endTime":237.454,"body":"For our past medical"},{"startTime":234.484,"endTime":237.454,"body":"history, hypertension, type"},{"startTime":237.484,"endTime":240.834,"body":"2 diabetes, medications, he's"},{"startTime":237.484,"endTime":240.834,"body":"on metformin and amlodipine."},{"startTime":242.259,"endTime":245.669,"body":"Family history, his father was"},{"startTime":242.259,"endTime":245.669,"body":"diagnosed with lung cancer at age 60."},{"startTime":246.409,"endTime":248.209,"body":"For his exam, vitals are normal."},{"startTime":248.399,"endTime":249.799,"body":"Nothing out of the ordinary here."},{"startTime":250.159,"endTime":252.459,"body":"Exam, lungs are clear bilaterally."},{"startTime":252.864,"endTime":254.154,"body":"Otherwise unremarkable."},{"startTime":254.174,"endTime":256.224,"body":"So we're not really noticing"},{"startTime":254.174,"endTime":256.224,"body":"too much with this patient."},{"startTime":256.234,"endTime":257.694,"body":"He's overall asymptomatic."},{"startTime":257.744,"endTime":258.934,"body":"He's doing his annual screening."},{"startTime":259.354,"endTime":261.784,"body":"He has a pretty extensive"},{"startTime":259.354,"endTime":261.784,"body":"history of smoking."},{"startTime":261.824,"endTime":263.584,"body":"Yeah, and he had quit five years ago."},{"startTime":263.634,"endTime":264.134,"body":"Yeah."},{"startTime":264.794,"endTime":265.164,"body":"All right."},{"startTime":265.494,"endTime":268.424,"body":"So at this point, Zach, what do you do?"},{"startTime":268.424,"endTime":270.874,"body":"What's the recommendation at"},{"startTime":268.424,"endTime":270.874,"body":"this point for this patient?"},{"startTime":270.874,"endTime":273.754,"body":"Because right now he's"},{"startTime":270.874,"endTime":273.754,"body":"looking so far so good."},{"startTime":274.004,"endTime":274.394,"body":"Yeah."},{"startTime":274.394,"endTime":278.624,"body":"So we with this patient with the concern"},{"startTime":274.394,"endTime":278.624,"body":"I have is there a chance that I'll"},{"startTime":278.624,"endTime":280.864,"body":"find like a nodule or find a lung mass?"},{"startTime":281.434,"endTime":286.434,"body":"And so they meet the criteria, as we"},{"startTime":281.434,"endTime":286.434,"body":"discussed, 50 to 80, current, former,"},{"startTime":286.564,"endTime":288.814,"body":"greater than or equal to 20 pack"},{"startTime":286.564,"endTime":288.814,"body":"year history, if you're a former,"},{"startTime":289.194,"endTime":290.964,"body":"had to quit within the last 15 years."},{"startTime":291.334,"endTime":292.614,"body":"So he fits all the categories."},{"startTime":292.844,"endTime":297.594,"body":"He's between 50 to 80 he's been smoking,"},{"startTime":292.844,"endTime":297.594,"body":"he's got a 35 pack year history."},{"startTime":298.079,"endTime":300.659,"body":"Even though it's, he's not a"},{"startTime":298.079,"endTime":300.659,"body":"current, he is a former and"},{"startTime":300.659,"endTime":301.689,"body":"it's within the past five years."},{"startTime":301.699,"endTime":304.919,"body":"So he fits the category to,"},{"startTime":301.699,"endTime":304.919,"body":"to get a screening question"},{"startTime":304.919,"endTime":306.019,"body":"is, is how do we screen them?"},{"startTime":306.029,"endTime":306.299,"body":"Yeah."},{"startTime":306.329,"endTime":307.429,"body":"So we need to get chest imaging."},{"startTime":307.969,"endTime":310.539,"body":"We don't want to hit them with"},{"startTime":307.969,"endTime":310.539,"body":"higher radiation, especially if"},{"startTime":310.539,"endTime":312.409,"body":"they're getting annual screens."},{"startTime":312.689,"endTime":316.819,"body":"So we do a very low"},{"startTime":312.689,"endTime":316.819,"body":"dose radiation chest CT."},{"startTime":317.559,"endTime":321.449,"body":"And that's the first way that we have"},{"startTime":317.559,"endTime":321.449,"body":"to go about this is we need to say,"},{"startTime":321.449,"endTime":323.899,"body":"let's get a low dose annual CT scan."},{"startTime":324.269,"endTime":328.179,"body":"Look to see, do I see oh my gosh,"},{"startTime":324.269,"endTime":328.179,"body":"there's a goober hanging in your chest"},{"startTime":328.499,"endTime":332.809,"body":"or is there nothing or, oh man, this"},{"startTime":328.499,"endTime":332.809,"body":"looks a little I don't really know."},{"startTime":332.809,"endTime":334.809,"body":"Is it good, bad, ugly?"},{"startTime":335.089,"endTime":336.049,"body":"There's a nodule."},{"startTime":336.249,"endTime":339.049,"body":"So that's figuring out is that there"},{"startTime":336.249,"endTime":339.049,"body":"are nothing, is there a nodule or"},{"startTime":339.049,"endTime":340.659,"body":"is there a big honking lung mass?"},{"startTime":340.709,"endTime":342.959,"body":"For our patient here,"},{"startTime":340.709,"endTime":342.959,"body":"we get the low dose CT."},{"startTime":343.349,"endTime":345.909,"body":"It does reveal a new solitary."},{"startTime":346.104,"endTime":348.454,"body":"10 millimeter nodule in"},{"startTime":346.104,"endTime":348.454,"body":"the right upper lobe."},{"startTime":349.084,"endTime":350.714,"body":"No previous imaging is available."},{"startTime":351.034,"endTime":352.464,"body":"What's your thought process here?"},{"startTime":352.914,"endTime":354.344,"body":"Yeah, that's a concerning one."},{"startTime":354.344,"endTime":356.834,"body":"So when- it sounds like we're"},{"startTime":354.344,"endTime":356.834,"body":"catching it early though."},{"startTime":357.104,"endTime":358.184,"body":"Yeah, you are."},{"startTime":358.184,"endTime":359.424,"body":"And that's really good."},{"startTime":360.044,"endTime":365.784,"body":"So when I hear solitary 10 millimeters,"},{"startTime":360.044,"endTime":365.784,"body":"that's a little bit on the bigger side."},{"startTime":365.784,"endTime":370.064,"body":"It's not crazy, but what we do"},{"startTime":365.784,"endTime":370.064,"body":"is, is once we get a nodule."},{"startTime":371.404,"endTime":375.764,"body":"And if it's new, so always on the"},{"startTime":371.404,"endTime":375.764,"body":"exam, I'm telling you when you hear"},{"startTime":375.764,"endTime":379.414,"body":"the exam, patient has, let's say"},{"startTime":375.764,"endTime":379.414,"body":"that they didn't even mention that"},{"startTime":379.414,"endTime":381.034,"body":"this was their first screening."},{"startTime":381.504,"endTime":385.394,"body":"They got a chest x ray or low"},{"startTime":381.504,"endTime":385.394,"body":"dose annual CT, found the nodule."},{"startTime":385.814,"endTime":387.084,"body":"How do you know if it's new?"},{"startTime":387.614,"endTime":389.604,"body":"You have to compare to prior imaging."},{"startTime":390.144,"endTime":391.444,"body":"This one doesn't have any prior imaging."},{"startTime":391.454,"endTime":393.104,"body":"So we're going to consider it new."},{"startTime":393.634,"endTime":397.334,"body":"So in this case, when it's a new"},{"startTime":393.634,"endTime":397.334,"body":"nodule, we have to determine it"},{"startTime":397.334,"endTime":399.694,"body":"based upon risk stratification."},{"startTime":400.144,"endTime":401.734,"body":"So I'd probably have to get a CT."},{"startTime":401.754,"endTime":404.904,"body":"So I'd probably get a normal CT"},{"startTime":401.754,"endTime":404.904,"body":"for this patient first to better"},{"startTime":404.904,"endTime":409.114,"body":"quantify, better take a look"},{"startTime":404.904,"endTime":409.114,"body":"at it while they're doing that."},{"startTime":409.494,"endTime":411.884,"body":"I'm going to go into my calculator"},{"startTime":409.494,"endTime":411.884,"body":"and I'm going to look at their"},{"startTime":411.884,"endTime":413.884,"body":"risk and see where do they fall."},{"startTime":413.884,"endTime":416.404,"body":"Are they low, intermediate or high risk?"},{"startTime":417.024,"endTime":421.934,"body":"The way that we determine how they fit"},{"startTime":417.024,"endTime":421.934,"body":"in a risk category is based on age."},{"startTime":423.064,"endTime":424.834,"body":"If you're less than 40, low risk."},{"startTime":425.504,"endTime":427.274,"body":"40 to 60, intermediate risk."},{"startTime":427.514,"endTime":429.304,"body":"Greater than 60, high risk."},{"startTime":429.404,"endTime":430.534,"body":"So he would be intermediate."},{"startTime":430.694,"endTime":432.464,"body":"So this one would be within"},{"startTime":430.694,"endTime":432.464,"body":"the intermediate range."},{"startTime":432.704,"endTime":436.114,"body":"Second, is does this patient smoke?"},{"startTime":436.404,"endTime":438.674,"body":"If they don't smoke, low risk."},{"startTime":438.924,"endTime":440.934,"body":"Current smoker, intermediate high risk."},{"startTime":442.074,"endTime":446.354,"body":"Another thing that we look at"},{"startTime":442.074,"endTime":446.354,"body":"is the location of the nodule."},{"startTime":446.699,"endTime":448.249,"body":"And he was a right upper lobe."},{"startTime":448.319,"endTime":453.749,"body":"That's concerning upper lobes, more likely"},{"startTime":448.319,"endTime":453.749,"body":"to be more malignant, lower middle lobe."},{"startTime":454.139,"endTime":458.059,"body":"Those are likely to be more"},{"startTime":454.139,"endTime":458.059,"body":"possibly benign or they're low risk."},{"startTime":458.109,"endTime":461.999,"body":"Now with a upper lobe, is that where"},{"startTime":458.109,"endTime":461.999,"body":"you get a Horner syndrome involvement?"},{"startTime":462.159,"endTime":462.869,"body":"You definitely can."},{"startTime":462.869,"endTime":465.869,"body":"If, especially if it's near the"},{"startTime":462.869,"endTime":465.869,"body":"apex, like near the superior sulcus,"},{"startTime":466.169,"endTime":468.629,"body":"you can get some compression of a"},{"startTime":466.169,"endTime":468.629,"body":"lot of different things like nerves"},{"startTime":468.629,"endTime":469.779,"body":"and vessels and stuff like that."},{"startTime":469.779,"endTime":470.779,"body":"So 100%."},{"startTime":471.454,"endTime":474.424,"body":"The other thing here that's"},{"startTime":471.454,"endTime":474.424,"body":"really important is the look."},{"startTime":474.714,"endTime":476.054,"body":"So what does it look like?"},{"startTime":476.464,"endTime":482.914,"body":"The fact that it's solitary what we want"},{"startTime":476.464,"endTime":482.914,"body":"to look at, is it round, smooth borders?"},{"startTime":483.024,"endTime":485.534,"body":"Or is it more scalloped?"},{"startTime":485.634,"endTime":487.234,"body":"Where it looks like it's like wonky."},{"startTime":487.554,"endTime":490.084,"body":"Is it irregular and has like spiculations?"},{"startTime":490.424,"endTime":493.559,"body":"So if it's smooth and round"},{"startTime":490.424,"endTime":493.559,"body":"That's like the lower risk."},{"startTime":493.559,"endTime":497.789,"body":"If it's scalloped, if it's got"},{"startTime":493.559,"endTime":497.789,"body":"irregular borders, it's like poky and"},{"startTime":497.789,"endTime":499.269,"body":"looks like it could really stick you."},{"startTime":499.809,"endTime":501.309,"body":"That's more high risk."},{"startTime":502.189,"endTime":505.979,"body":"So what I see here is I'm"},{"startTime":502.189,"endTime":505.979,"body":"really seeing a patient who"},{"startTime":505.979,"endTime":507.779,"body":"fits age range of intermediate."},{"startTime":508.439,"endTime":514.889,"body":"I see a location that suggests more like"},{"startTime":508.439,"endTime":514.889,"body":"the intermediate range to high range."},{"startTime":515.479,"endTime":521.769,"body":"I see also another important thing here,"},{"startTime":515.479,"endTime":521.769,"body":"which is the current smoker that fits"},{"startTime":521.769,"endTime":523.449,"body":"them into the intermediate high range."},{"startTime":524.264,"endTime":529.664,"body":"The size, if it's less than"},{"startTime":524.264,"endTime":529.664,"body":"eight millimeters, that's low."},{"startTime":530.524,"endTime":534.744,"body":"If it's anywhere between eight"},{"startTime":530.524,"endTime":534.744,"body":"to 20, that's intermediate."},{"startTime":535.324,"endTime":539.914,"body":"If it's greater than or equal to"},{"startTime":535.324,"endTime":539.914,"body":"20 millimeters, that fits them"},{"startTime":539.914,"endTime":542.264,"body":"within the high risk category."},{"startTime":542.914,"endTime":549.254,"body":"So the big thing for me right here is"},{"startTime":542.914,"endTime":549.254,"body":"everything screams a intermediate risk."},{"startTime":549.789,"endTime":551.569,"body":"Next thing, upper lobe."},{"startTime":551.709,"endTime":554.829,"body":"A little bit concerning for"},{"startTime":551.709,"endTime":554.829,"body":"intermediate risk and what I would"},{"startTime":554.839,"endTime":558.699,"body":"do here is I would probably get"},{"startTime":554.839,"endTime":558.699,"body":"a PET CT scan before referring"},{"startTime":558.699,"endTime":560.439,"body":"them to a surgeon to get a biopsy."},{"startTime":560.699,"endTime":564.559,"body":"Some people, they may want to go"},{"startTime":560.699,"endTime":564.559,"body":"to a biopsy, but I think that this"},{"startTime":564.569,"endTime":568.359,"body":"person fits more of that intermediate"},{"startTime":564.569,"endTime":568.359,"body":"risk and I don't want to put them"},{"startTime":568.359,"endTime":571.939,"body":"in a need to get a procedure that's"},{"startTime":568.359,"endTime":571.939,"body":"not necessary and put them at risk."},{"startTime":572.129,"endTime":573.729,"body":"So I'm going to do a PET CT."},{"startTime":573.969,"endTime":575.409,"body":"It's going to take a better look."},{"startTime":576.269,"endTime":577.099,"body":"At the nodule."},{"startTime":577.429,"endTime":580.739,"body":"And so it's really cool when we"},{"startTime":577.429,"endTime":580.739,"body":"do PET CT, we use this thing."},{"startTime":580.739,"endTime":581.879,"body":"It's called FDG."},{"startTime":582.109,"endTime":587.189,"body":"It's called fluorodeoxyglucose and we take"},{"startTime":582.109,"endTime":587.189,"body":"that thing and we it's like a radio tracer"},{"startTime":587.219,"endTime":591.929,"body":"and basically cancerous lesions take that"},{"startTime":587.219,"endTime":591.929,"body":"and they light up like a Christmas tree."},{"startTime":592.369,"endTime":596.589,"body":"And it shows up that this, Oh, this area"},{"startTime":592.369,"endTime":596.589,"body":"is really has a lot of metabolic activity,"},{"startTime":596.949,"endTime":599.249,"body":"which you would see with a cancerous mass."},{"startTime":599.249,"endTime":600.789,"body":"If it's really likely to be malignant."},{"startTime":601.079,"endTime":603.549,"body":"If it's benign, it won't"},{"startTime":601.079,"endTime":603.549,"body":"take up as much of that."},{"startTime":603.819,"endTime":607.099,"body":"So can you see why if I say, all"},{"startTime":603.819,"endTime":607.099,"body":"right, I'm going to have you get"},{"startTime":607.099,"endTime":610.634,"body":"a biopsy of this lung, this like"},{"startTime":607.099,"endTime":610.634,"body":"this suspicious appearing nodule."},{"startTime":611.254,"endTime":612.554,"body":"That poses risk."},{"startTime":612.854,"endTime":615.874,"body":"If I do the PET CT and I say, Oh"},{"startTime":612.854,"endTime":615.874,"body":"man, this thing's lighting up."},{"startTime":615.884,"endTime":617.194,"body":"That's really concerning."},{"startTime":617.224,"endTime":619.474,"body":"Now I think we should go to do a biopsy."},{"startTime":619.764,"endTime":622.714,"body":"It just really makes sure that we"},{"startTime":619.764,"endTime":622.714,"body":"don't do something that could harm,"},{"startTime":622.734,"endTime":624.174,"body":"iatrogenically harm the patient."},{"startTime":624.174,"endTime":628.934,"body":"So that's what I would do is I get"},{"startTime":624.174,"endTime":628.934,"body":"the PET CT scan and go from there."},{"startTime":629.344,"endTime":632.844,"body":"We don't want to just go for being"},{"startTime":629.344,"endTime":632.844,"body":"completely aggressive, especially as you"},{"startTime":632.854,"endTime":634.434,"body":"said, he's in that intermediate stage."},{"startTime":634.914,"endTime":637.184,"body":"So what we do is we get"},{"startTime":634.914,"endTime":637.184,"body":"the PET CT, like you said."},{"startTime":637.624,"endTime":641.144,"body":"Now this PET CT does however"},{"startTime":637.624,"endTime":641.144,"body":"show an increased uptake"},{"startTime":641.184,"endTime":642.854,"body":"of that fluorodeoxyglucose."},{"startTime":642.904,"endTime":644.274,"body":"would you go to a biopsy now?"},{"startTime":644.284,"endTime":645.114,"body":"Yeah, I'd biopsy."},{"startTime":645.114,"endTime":648.204,"body":"And so depending upon the"},{"startTime":645.114,"endTime":648.204,"body":"location of it right upper lobe."},{"startTime":648.244,"endTime":650.244,"body":"You this is where a surgeon"},{"startTime":648.244,"endTime":650.244,"body":"has to get involved and your"},{"startTime":650.244,"endTime":651.464,"body":"pulmonary team has to get involved."},{"startTime":651.924,"endTime":655.234,"body":"So there's a lot of interdisciplinary"},{"startTime":651.924,"endTime":655.234,"body":"involvement here, but you have to figure"},{"startTime":655.234,"endTime":657.474,"body":"out the best target to get that biopsy."},{"startTime":657.574,"endTime":660.364,"body":"If it's like really close to the"},{"startTime":657.574,"endTime":660.364,"body":"periphery, you can actually stick a"},{"startTime":660.364,"endTime":665.494,"body":"needle through the periphery and it's"},{"startTime":660.364,"endTime":665.494,"body":"guided by like CT or sometimes even like"},{"startTime":665.504,"endTime":667.054,"body":"ultrasound or fleuro and stuff like that."},{"startTime":667.054,"endTime":671.114,"body":"But we guide a needle to show that"},{"startTime":667.054,"endTime":671.114,"body":"going into where that mass is and"},{"startTime":671.114,"endTime":672.464,"body":"we can aspirate off some of that."},{"startTime":672.565,"endTime":676.965,"body":"If it's more centrally located and I"},{"startTime":672.565,"endTime":676.965,"body":"can actually get a bronc down there to"},{"startTime":676.965,"endTime":680.825,"body":"find that mass and it's endobronchial"},{"startTime":676.965,"endTime":680.825,"body":"or it's even maybe a little bit"},{"startTime":680.825,"endTime":686.135,"body":"outside, I can use ultrasound in the"},{"startTime":680.825,"endTime":686.135,"body":"bronchus and go in there, take some"},{"startTime":686.135,"endTime":688.375,"body":"of that if they had a plural effusion."},{"startTime":688.91,"endTime":691.19,"body":"Believe it or not that stage"},{"startTime":688.91,"endTime":691.19,"body":"four, this was terrible."},{"startTime":691.19,"endTime":694.33,"body":"But if a big pleural fusion, you can stick"},{"startTime":691.19,"endTime":694.33,"body":"a needle right to the pleural effusion,"},{"startTime":694.35,"endTime":697.84,"body":"pull that off and send it off for"},{"startTime":694.35,"endTime":697.84,"body":"cytology and see if there's cancer cells."},{"startTime":698.15,"endTime":699.7,"body":"But that's definitely"},{"startTime":698.15,"endTime":699.7,"body":"what I would have to do."},{"startTime":699.7,"endTime":701.48,"body":"And it just depends on where it's located."},{"startTime":701.85,"endTime":703.96,"body":"Hopefully this won't be a"},{"startTime":701.85,"endTime":703.96,"body":"little bit more peripheral"},{"startTime":704.31,"endTime":705.51,"body":"given it's the right upper lobe."},{"startTime":705.54,"endTime":709.17,"body":"And maybe I could do like a"},{"startTime":705.54,"endTime":709.17,"body":"CT guided FNA for this one."},{"startTime":709.62,"endTime":709.93,"body":"All right."},{"startTime":710.15,"endTime":713.69,"body":"That kind of discusses what we would do"},{"startTime":710.15,"endTime":713.69,"body":"in this scenario of how we would go about."},{"startTime":713.795,"endTime":715.415,"body":"That diagnostic procedure there."},{"startTime":715.445,"endTime":716.155,"body":"Exactly."},{"startTime":716.155,"endTime":719.735,"body":"I think the whole goal to take away is"},{"startTime":716.155,"endTime":719.735,"body":"if it was low risk, let's say that this"},{"startTime":719.735,"endTime":724.105,"body":"patient was low risk, like they fit, like"},{"startTime":719.735,"endTime":724.105,"body":"they were younger, they weren't a smoker."},{"startTime":724.375,"endTime":725.495,"body":"It was round."},{"startTime":725.825,"endTime":726.845,"body":"It was smooth."},{"startTime":726.955,"endTime":727.905,"body":"It wasn't like huge."},{"startTime":727.905,"endTime":728.685,"body":"It was less than or equal."},{"startTime":728.695,"endTime":729.925,"body":"It was less than eight millimeters."},{"startTime":730.475,"endTime":733.705,"body":"I would just do another follow"},{"startTime":730.475,"endTime":733.705,"body":"up CT in six to 12 months."},{"startTime":734.395,"endTime":737.135,"body":"If it came back worse than this, like"},{"startTime":734.395,"endTime":737.135,"body":"the worst case scenario is if it came"},{"startTime":737.135,"endTime":739.085,"body":"back and it was like, this thing's."},{"startTime":739.64,"endTime":741.02,"body":"22 millimeters."},{"startTime":741.54,"endTime":743.36,"body":"It's they're a heavy smoker."},{"startTime":743.76,"endTime":744.9,"body":"They're greater than 60."},{"startTime":745.38,"endTime":748.23,"body":"They have speculated all over it."},{"startTime":748.23,"endTime":752.0,"body":"It's speculated and it's very irregular"},{"startTime":748.23,"endTime":752.0,"body":"appearing and it's upper lobe."},{"startTime":752.37,"endTime":754.2,"body":"I probably wouldn't even"},{"startTime":752.37,"endTime":754.2,"body":"bother with the PET CT."},{"startTime":754.2,"endTime":755.56,"body":"I would just say, let's"},{"startTime":754.2,"endTime":755.56,"body":"give a biopsy of this."},{"startTime":755.68,"endTime":757.15,"body":"At that point you could be aggressive."},{"startTime":757.26,"endTime":757.91,"body":"Exactly."},{"startTime":757.96,"endTime":760.98,"body":"And then to add one more thing, cause"},{"startTime":757.96,"endTime":760.98,"body":"we didn't see this in this patient"},{"startTime":762.03,"endTime":764.8,"body":"in your exam, you can't forget this."},{"startTime":764.99,"endTime":769.32,"body":"Let's say that this patient had another,"},{"startTime":764.99,"endTime":769.32,"body":"let's say that this wasn't as bad."},{"startTime":769.705,"endTime":772.525,"body":"Let's say that we had the patient"},{"startTime":769.705,"endTime":772.525,"body":"who was the low risk 10 millimeters."},{"startTime":773.185,"endTime":773.985,"body":"I'll say that was fine."},{"startTime":774.555,"endTime":778.045,"body":"We did an annual we do to repeat"},{"startTime":774.555,"endTime":778.045,"body":"CT in six to twelve months."},{"startTime":778.945,"endTime":785.225,"body":"If that thing increased in size or"},{"startTime":778.945,"endTime":785.225,"body":"doubled in size, I got to go to biopsy."},{"startTime":785.255,"endTime":785.455,"body":"Yeah."},{"startTime":785.805,"endTime":788.805,"body":"So that's another thing is that you"},{"startTime":785.805,"endTime":788.805,"body":"have to know if the actual mass or"},{"startTime":788.805,"endTime":794.575,"body":"the nodule got bigger, usually we say,"},{"startTime":788.805,"endTime":794.575,"body":"did it get bigger and I'm doubling"},{"startTime":794.575,"endTime":796.155,"body":"size, did it get significantly bigger?"},{"startTime":796.155,"endTime":798.985,"body":"So there was the rapid growth"},{"startTime":796.155,"endTime":798.985,"body":"within the past two years."},{"startTime":799.48,"endTime":801.73,"body":"If there's been rapid growth"},{"startTime":799.48,"endTime":801.73,"body":"in the past two years."},{"startTime":802.515,"endTime":805.025,"body":"You don't even want to, you probably"},{"startTime":802.515,"endTime":805.025,"body":"just go straight to biopsy that day."},{"startTime":805.345,"endTime":806.875,"body":"I want to move on to case number two now."},{"startTime":807.075,"endTime":807.305,"body":"All right."},{"startTime":807.655,"endTime":811.625,"body":"We have a 64 year old male presents"},{"startTime":807.655,"endTime":811.625,"body":"with chronic cough, hemoptysis, weight"},{"startTime":811.625,"endTime":813.965,"body":"loss, and a new hoarseness to his voice."},{"startTime":814.075,"endTime":817.59,"body":"He has had a persistent cough"},{"startTime":814.075,"endTime":817.59,"body":"for four months now, recently"},{"startTime":817.59,"endTime":819.244,"body":"with blood streaked sputum."},{"startTime":819.895,"endTime":823.095,"body":"He had an unintentional 15"},{"startTime":819.895,"endTime":823.095,"body":"pound weight loss and hoarseness"},{"startTime":823.115,"endTime":824.355,"body":"over the past two weeks."},{"startTime":824.945,"endTime":829.855,"body":"He has a heavy smoking history,"},{"startTime":824.945,"endTime":829.855,"body":"50 pack years, occupational"},{"startTime":829.855,"endTime":831.975,"body":"asbestos exposure for 25 years."},{"startTime":831.975,"endTime":832.875,"body":"Oh my gosh."},{"startTime":833.395,"endTime":833.955,"body":"That's not good."},{"startTime":834.775,"endTime":838.845,"body":"For his past medical history,"},{"startTime":834.775,"endTime":838.845,"body":"pertinent for COPD, hypertension."},{"startTime":838.945,"endTime":839.715,"body":"Medications."},{"startTime":839.855,"endTime":842.685,"body":"He takes an albuterol"},{"startTime":839.855,"endTime":842.685,"body":"inhaler and lisinopril."},{"startTime":843.125,"endTime":847.325,"body":"For his family history, his father"},{"startTime":843.125,"endTime":847.325,"body":"died from lung cancer at age 67."},{"startTime":847.995,"endTime":850.375,"body":"Let's get  vitals, BP is 130 over 80."},{"startTime":850.715,"endTime":852.204,"body":"Heart rate is 84."},{"startTime":852.205,"endTime":854.065,"body":"Temp is 37 degrees Celsius."},{"startTime":855.535,"endTime":859.425,"body":"For pulmonary, we have decreased"},{"startTime":855.535,"endTime":859.425,"body":"breath sounds, dullness to"},{"startTime":859.425,"endTime":861.165,"body":"percussion, right upper lung."},{"startTime":861.935,"endTime":863.205,"body":"Hoarseness is noted."},{"startTime":863.895,"endTime":867.095,"body":"What would that be significant"},{"startTime":863.895,"endTime":867.095,"body":"for, Zach if hoarseness is noted?"},{"startTime":867.465,"endTime":868.275,"body":"That's a good one."},{"startTime":868.305,"endTime":870.245,"body":"You remember he brought"},{"startTime":868.305,"endTime":870.245,"body":"up like a Pancoast tumor?"},{"startTime":870.325,"endTime":870.875,"body":"Yes."},{"startTime":870.975,"endTime":874.805,"body":"So sometimes if like, apical tumors"},{"startTime":870.975,"endTime":874.805,"body":"are near the recurrent laryngeal"},{"startTime":874.815,"endTime":876.595,"body":"nerve, they can smash that puppy."},{"startTime":877.115,"endTime":880.155,"body":"If you, if I had a tumor near the apex,"},{"startTime":877.115,"endTime":880.155,"body":"the recurrent laryngeal nerve actually,"},{"startTime":880.195,"endTime":882.195,"body":"you get a right vagus and a left vagus."},{"startTime":882.755,"endTime":886.235,"body":"The right vagus comes down and swoops"},{"startTime":882.755,"endTime":886.235,"body":"underneath the subclavian artery."},{"startTime":886.305,"endTime":889.425,"body":"The right subclavian artery comes back up"},{"startTime":886.305,"endTime":889.425,"body":"as the right recurrent laryngeal nerve."},{"startTime":889.785,"endTime":892.985,"body":"The left vagus comes down swoops"},{"startTime":889.785,"endTime":892.985,"body":"underneath the aortic arch and comes back"},{"startTime":892.985,"endTime":894.735,"body":"as the left recurrent laryngeal nerve."},{"startTime":895.175,"endTime":898.905,"body":"And as they come up, they go and they"},{"startTime":895.175,"endTime":898.905,"body":"supply your larynx, which is your vocal"},{"startTime":898.905,"endTime":901.925,"body":"cords and controls the movement of"},{"startTime":898.905,"endTime":901.925,"body":"airflow across those with your speech."},{"startTime":902.325,"endTime":907.765,"body":"If I had any point mash on one of those,"},{"startTime":902.325,"endTime":907.765,"body":"I decreased the supply to my vocal cords."},{"startTime":908.095,"endTime":911.125,"body":"And so sometimes you can get vocal"},{"startTime":908.095,"endTime":911.125,"body":"cord paralysis, which is scary, or you"},{"startTime":911.125,"endTime":912.425,"body":"could have hoarseness of the voice."},{"startTime":913.325,"endTime":918.835,"body":"With the next part here, labs and"},{"startTime":913.325,"endTime":918.835,"body":"imaging, we get a CBC, CMP, normal."},{"startTime":919.335,"endTime":922.145,"body":"Chest x ray, we have right hilar opacity."},{"startTime":922.625,"endTime":927.075,"body":"Chest CT, we note a four"},{"startTime":922.625,"endTime":927.075,"body":"centimeter central spiculated"},{"startTime":927.095,"endTime":930.175,"body":"mass, ipsilateral hilar nodes."},{"startTime":932.435,"endTime":933.075,"body":"Not too good?"},{"startTime":933.135,"endTime":933.715,"body":"No."},{"startTime":934.395,"endTime":934.755,"body":"Okay."},{"startTime":935.845,"endTime":936.535,"body":"Where do we go from here?"},{"startTime":936.565,"endTime":940.345,"body":"We have a lot of information, we've"},{"startTime":936.565,"endTime":940.345,"body":"got some rough diagnostic imaging."},{"startTime":940.465,"endTime":941.145,"body":"What's the next step?"},{"startTime":941.235,"endTime":943.335,"body":"You gave me everything that"},{"startTime":941.235,"endTime":943.335,"body":"I would have started off."},{"startTime":943.335,"endTime":946.435,"body":"So if the patient just came in with cough,"},{"startTime":943.335,"endTime":946.435,"body":"hemoptysis and weight loss I would have"},{"startTime":946.435,"endTime":947.585,"body":"done everything you just did, which is."},{"startTime":948.045,"endTime":950.415,"body":"Get a chest x ray first,"},{"startTime":948.045,"endTime":950.415,"body":"see what's going on there."},{"startTime":951.315,"endTime":953.785,"body":"And it doesn't always"},{"startTime":951.315,"endTime":953.785,"body":"have to be lung cancer."},{"startTime":953.795,"endTime":955.375,"body":"So this could patient"},{"startTime":953.795,"endTime":955.375,"body":"could have pneumonia."},{"startTime":955.375,"endTime":957.065,"body":"They could have something"},{"startTime":955.375,"endTime":957.065,"body":"else weird tuberculosis."},{"startTime":957.065,"endTime":958.955,"body":"So it's always good to start"},{"startTime":957.065,"endTime":958.955,"body":"off and just get a chest x ray"},{"startTime":959.095,"endTime":960.435,"body":"with the past military of CFPD."},{"startTime":960.445,"endTime":963.595,"body":"So initially it's always important to"},{"startTime":960.445,"endTime":963.595,"body":"just get a chest x ray, take a look."},{"startTime":963.595,"endTime":965.105,"body":"It's not the best test."},{"startTime":965.125,"endTime":966.805,"body":"It's just the best initial test."},{"startTime":967.405,"endTime":968.725,"body":"It showed some abnormalities."},{"startTime":969.12,"endTime":973.43,"body":"But the best test is the chest"},{"startTime":969.12,"endTime":973.43,"body":"CT that was concerning when I"},{"startTime":973.44,"endTime":975.25,"body":"see a mass that's four cents."},{"startTime":975.26,"endTime":977.6,"body":"So usually anything greater"},{"startTime":975.26,"endTime":977.6,"body":"than three centimeters."},{"startTime":977.67,"endTime":979.13,"body":"That's probably where I'd"},{"startTime":977.67,"endTime":979.13,"body":"start getting concerned."},{"startTime":979.13,"endTime":983.35,"body":"Because that's now considered a"},{"startTime":979.13,"endTime":983.35,"body":"mass, a lung mass and on a nodule."},{"startTime":983.61,"endTime":987.26,"body":"The fact that it's a regular, it's"},{"startTime":983.61,"endTime":987.26,"body":"speculated, that's concerning."},{"startTime":987.26,"endTime":988.85,"body":"And then you told me that they"},{"startTime":987.26,"endTime":988.85,"body":"got some node involvement."},{"startTime":988.85,"endTime":992.37,"body":"So MC lateral higher nodes that put"},{"startTime":988.85,"endTime":992.37,"body":"them in one stage in the TNM staging."},{"startTime":992.89,"endTime":994.03,"body":"This is pretty concerning, man."},{"startTime":994.03,"endTime":997.4,"body":"So I think like with"},{"startTime":994.03,"endTime":997.4,"body":"all of this right here."},{"startTime":997.895,"endTime":1002.035,"body":"I have a lot of confidence that at"},{"startTime":997.895,"endTime":1002.035,"body":"this point we just need to start"},{"startTime":1002.035,"endTime":1005.305,"body":"getting ready and say, Hey, we"},{"startTime":1002.035,"endTime":1005.305,"body":"need to do a biopsy of this mass."},{"startTime":1005.315,"endTime":1006.735,"body":"I was going to say, we've done an x ray."},{"startTime":1006.735,"endTime":1007.675,"body":"We've done the CT."},{"startTime":1007.875,"endTime":1009.795,"body":"At that point, you kind of have to."},{"startTime":1009.825,"endTime":1010.065,"body":"Yeah."},{"startTime":1010.065,"endTime":1012.455,"body":"At this point, this is"},{"startTime":1010.065,"endTime":1012.455,"body":"a central lesion too."},{"startTime":1012.845,"endTime":1016.335,"body":"So remember the last one, it was"},{"startTime":1012.845,"endTime":1016.335,"body":"upper lobe, maybe peripheral."},{"startTime":1016.335,"endTime":1017.825,"body":"I could do a CT guided FNA."},{"startTime":1018.385,"endTime":1019.615,"body":"This one is, it's central."},{"startTime":1019.805,"endTime":1020.665,"body":"You can't do that."},{"startTime":1021.015,"endTime":1022.835,"body":"So for this one, you do a bronchoscopy."},{"startTime":1023.095,"endTime":1024.705,"body":"You go down bronchoscopy."},{"startTime":1024.785,"endTime":1027.175,"body":"Sometimes you can do it with"},{"startTime":1024.785,"endTime":1027.175,"body":"an endobronchial ultrasound."},{"startTime":1027.595,"endTime":1030.275,"body":"And I would try to get to that"},{"startTime":1027.595,"endTime":1030.275,"body":"mass and biopsy the mass there."},{"startTime":1030.295,"endTime":1031.935,"body":"And I would even try to get"},{"startTime":1030.295,"endTime":1031.935,"body":"to the lymph node there."},{"startTime":1032.185,"endTime":1035.145,"body":"That's why you use the -they call"},{"startTime":1032.185,"endTime":1035.145,"body":"it EBUS: Endobronchial Ultrasound."},{"startTime":1035.295,"endTime":1037.525,"body":"So you can take this thing down and"},{"startTime":1035.295,"endTime":1037.525,"body":"you can say, Oh shoot, there it is."},{"startTime":1037.545,"endTime":1041.595,"body":"There's that lymph node pop right into it"},{"startTime":1037.545,"endTime":1041.595,"body":"and take some of the tissue there as well."},{"startTime":1041.725,"endTime":1042.435,"body":"All right, cool."},{"startTime":1042.775,"endTime":1043.845,"body":"We do the biopsy."},{"startTime":1043.935,"endTime":1044.225,"body":"Okay."},{"startTime":1044.305,"endTime":1044.645,"body":"All right."},{"startTime":1044.645,"endTime":1049.305,"body":"We note the biopsy for squamous"},{"startTime":1044.645,"endTime":1049.305,"body":"cell carcinoma showing keratin"},{"startTime":1049.315,"endTime":1053.225,"body":"pearls, Intercellular bridges"},{"startTime":1049.315,"endTime":1053.225,"body":"and a positive P40 stain."},{"startTime":1053.855,"endTime":1054.485,"body":"How do we stage it?"},{"startTime":1054.865,"endTime":1059.425,"body":"Yeah, so this is a good also talking"},{"startTime":1054.865,"endTime":1059.425,"body":"point because when you see central,"},{"startTime":1059.425,"endTime":1064.595,"body":"at least for your exams, central"},{"startTime":1059.425,"endTime":1064.595,"body":"screams squamous cell or small cell."},{"startTime":1064.645,"endTime":1069.205,"body":"Peripheral tumors are"},{"startTime":1064.645,"endTime":1069.205,"body":"usually adeno and large cell."},{"startTime":1069.355,"endTime":1072.695,"body":"So we'll talk about this a little later"},{"startTime":1069.355,"endTime":1072.695,"body":"because this one is definitely what's"},{"startTime":1072.695,"endTime":1074.575,"body":"called a non small cell lung cancer."},{"startTime":1074.575,"endTime":1079.595,"body":"So non small cell lung cancer consists"},{"startTime":1074.575,"endTime":1079.595,"body":"of adeno, large cell and squamous cell."},{"startTime":1079.985,"endTime":1082.345,"body":"So those are the three most common ones."},{"startTime":1083.185,"endTime":1086.585,"body":"And so squamous out of those, the"},{"startTime":1083.185,"endTime":1086.585,"body":"only one that's usually centrally"},{"startTime":1086.585,"endTime":1088.855,"body":"located and it's usually cavitary."},{"startTime":1089.205,"endTime":1093.435,"body":"And then as you said here, the keratin"},{"startTime":1089.205,"endTime":1093.435,"body":"pearls squamous cells are like epithelial"},{"startTime":1093.435,"endTime":1094.935,"body":"cells and they love to make keratin."},{"startTime":1094.995,"endTime":1096.925,"body":"So that's probably why you're"},{"startTime":1094.995,"endTime":1096.925,"body":"going to have a lot of keratin, but"},{"startTime":1097.255,"endTime":1099.245,"body":"and then they stain P40 positive."},{"startTime":1099.555,"endTime":1105.04,"body":"If it was like Adeno, that has mucin"},{"startTime":1099.555,"endTime":1105.04,"body":"staining with the TTF-1 positive staining."},{"startTime":1105.42,"endTime":1107.46,"body":"If it was large cell, they"},{"startTime":1105.42,"endTime":1107.46,"body":"don't stain with anything."},{"startTime":1107.46,"endTime":1108.57,"body":"They're just weird looking cells."},{"startTime":1108.57,"endTime":1110.27,"body":"You're like, I don't know"},{"startTime":1108.57,"endTime":1110.27,"body":"what the heck these cells are."},{"startTime":1110.71,"endTime":1113.37,"body":"So that's kind of the nice thing is"},{"startTime":1110.71,"endTime":1113.37,"body":"this definitely tells a squamous, but"},{"startTime":1113.86,"endTime":1116.51,"body":"at this point my concern is, okay,"},{"startTime":1113.86,"endTime":1116.51,"body":"I got an Olymp know what if it's"},{"startTime":1116.51,"endTime":1119.21,"body":"somewhere else or what if it's in"},{"startTime":1116.51,"endTime":1119.21,"body":"lymph nodes that I can't even see?"},{"startTime":1119.71,"endTime":1121.26,"body":"Like I see the lymph node"},{"startTime":1119.71,"endTime":1121.26,"body":"that's involved there."},{"startTime":1121.26,"endTime":1122.16,"body":"That ipsilateral hilar."},{"startTime":1122.23,"endTime":1124.09,"body":"What if it's higher up"},{"startTime":1122.23,"endTime":1124.09,"body":"in a supraclavicular?"},{"startTime":1124.41,"endTime":1126.26,"body":"What if this is in the"},{"startTime":1124.41,"endTime":1126.26,"body":"contralateral nodes?"},{"startTime":1126.71,"endTime":1130.06,"body":"What if this is in the liver,"},{"startTime":1126.71,"endTime":1130.06,"body":"the adrenal, the bones?"},{"startTime":1130.41,"endTime":1131.39,"body":"I don't know, right?"},{"startTime":1131.72,"endTime":1133.89,"body":"So a PET CT would probably"},{"startTime":1131.72,"endTime":1133.89,"body":"be what I'd go with to see."},{"startTime":1135.26,"endTime":1136.03,"body":"So here's the tough thing."},{"startTime":1136.74,"endTime":1141.06,"body":"Some practitioners, and you're"},{"startTime":1136.74,"endTime":1141.06,"body":"not wrong, you can do either."},{"startTime":1141.48,"endTime":1142.94,"body":"It's just you have to be careful."},{"startTime":1143.72,"endTime":1149.02,"body":"CT scan of the chest, abdomen,"},{"startTime":1143.72,"endTime":1149.02,"body":"and pelvis with IV contrast."},{"startTime":1149.455,"endTime":1153.285,"body":"It can be an alternative"},{"startTime":1149.455,"endTime":1153.285,"body":"instead of doing a PET scan."},{"startTime":1153.845,"endTime":1154.725,"body":"So you could do that."},{"startTime":1154.725,"endTime":1157.415,"body":"And as long as you do a contrast,"},{"startTime":1154.725,"endTime":1157.415,"body":"you may be able to pick up"},{"startTime":1157.595,"endTime":1160.675,"body":"an adrenal met a liver met."},{"startTime":1160.865,"endTime":1165.655,"body":"Maybe you can pick up some lymph nodes"},{"startTime":1160.865,"endTime":1165.655,"body":"or, Oh shoot, the tumor was here in"},{"startTime":1165.655,"endTime":1167.315,"body":"that, or was it their right side?"},{"startTime":1167.315,"endTime":1171.135,"body":"Oh, there's another tumor in the"},{"startTime":1167.315,"endTime":1171.135,"body":"left side, and I didn't see that one."},{"startTime":1171.535,"endTime":1173.505,"body":"So you can still do that."},{"startTime":1173.985,"endTime":1178.295,"body":"It's just the evidence has shown that"},{"startTime":1173.985,"endTime":1178.295,"body":"PET CT has a higher sensitivity for"},{"startTime":1178.295,"endTime":1183.825,"body":"identifying distant metastasis and It's"},{"startTime":1178.295,"endTime":1183.825,"body":"better at identifying node involvement"},{"startTime":1184.345,"endTime":1186.865,"body":"And it's better at identifying bone mets."},{"startTime":1187.175,"endTime":1191.125,"body":"So that's why I would probably just go"},{"startTime":1187.175,"endTime":1191.125,"body":"with the PET CT to stage this patient"},{"startTime":1191.125,"endTime":1192.765,"body":"and figure out, is this anywhere else?"},{"startTime":1192.785,"endTime":1195.935,"body":"Because right now, all I have"},{"startTime":1192.785,"endTime":1195.935,"body":"is they got a node involvement."},{"startTime":1196.445,"endTime":1197.275,"body":"They got a size."},{"startTime":1197.285,"endTime":1199.695,"body":"So I have the T and M of my TNM staging."},{"startTime":1200.095,"endTime":1203.275,"body":"I don't have the M, which is"},{"startTime":1200.095,"endTime":1203.275,"body":"there distant metastasis or not?"},{"startTime":1203.495,"endTime":1206.725,"body":"Because that's going to change"},{"startTime":1203.495,"endTime":1206.725,"body":"drastically how I treat this patient."},{"startTime":1206.995,"endTime":1210.385,"body":"But with a PET CT, you could"},{"startTime":1206.995,"endTime":1210.385,"body":"check for distant metastasis."},{"startTime":1210.405,"endTime":1211.015,"body":"Exactly."},{"startTime":1211.315,"endTime":1212.515,"body":"You could do with the CT."},{"startTime":1212.95,"endTime":1215.12,"body":"of the chest abdomen"},{"startTime":1212.95,"endTime":1215.12,"body":"pelvis with IV contrast."},{"startTime":1215.14,"endTime":1218.85,"body":"It's just, it may miss something"},{"startTime":1215.14,"endTime":1218.85,"body":"so sometimes even if the chest CT"},{"startTime":1219.22,"endTime":1222.73,"body":"abdomen pelvis comes back negative"},{"startTime":1219.22,"endTime":1222.73,"body":"with the contrast study, we may"},{"startTime":1222.73,"endTime":1225.33,"body":"still just do a PET CT to be safe to"},{"startTime":1222.73,"endTime":1225.33,"body":"make sure we didn't miss anything."},{"startTime":1225.58,"endTime":1227.66,"body":"That's why it's just"},{"startTime":1225.58,"endTime":1227.66,"body":"oftentimes just get the PET CT."},{"startTime":1227.71,"endTime":1229.86,"body":"Let's say that there is"},{"startTime":1227.71,"endTime":1229.86,"body":"no distant metastasis."},{"startTime":1229.88,"endTime":1230.32,"body":"Okay."},{"startTime":1230.37,"endTime":1231.54,"body":"Then how would you stage it?"},{"startTime":1232.31,"endTime":1233.04,"body":"That's a good question."},{"startTime":1233.04,"endTime":1235.72,"body":"So now staging is always"},{"startTime":1233.04,"endTime":1235.72,"body":"a son of a gun, man."},{"startTime":1235.75,"endTime":1237.74,"body":"I always hated it when I was in school."},{"startTime":1237.74,"endTime":1240.32,"body":"I'd be like, Huh, how the frick am"},{"startTime":1237.74,"endTime":1240.32,"body":"I going to remember these things?"},{"startTime":1240.32,"endTime":1241.43,"body":"It's a lot of information."},{"startTime":1241.44,"endTime":1247.39,"body":"And so the easiest thing to remember"},{"startTime":1241.44,"endTime":1247.39,"body":"is don't, size is important, but"},{"startTime":1247.6,"endTime":1249.67,"body":"not as important in this case."},{"startTime":1249.75,"endTime":1250.21,"body":"All right."},{"startTime":1250.56,"endTime":1252.31,"body":"The nodes are the important thing."},{"startTime":1252.41,"endTime":1254.05,"body":"And that's what I want you to remember."},{"startTime":1254.47,"endTime":1258.05,"body":"For example, N0 means that"},{"startTime":1254.47,"endTime":1258.05,"body":"no nodes are involved."},{"startTime":1258.05,"endTime":1260.97,"body":"There's just a tumor that's isolated"},{"startTime":1258.05,"endTime":1260.97,"body":"into the lung tissue, lung parenchyma."},{"startTime":1261.53,"endTime":1266.16,"body":"N1 is if you have a tumor on the"},{"startTime":1261.53,"endTime":1266.16,"body":"right side, the ipsilateral hilar"},{"startTime":1266.16,"endTime":1268.61,"body":"or like peribronchial, which is"},{"startTime":1266.16,"endTime":1268.61,"body":"all the ones that are in that lung"},{"startTime":1268.61,"endTime":1270.805,"body":"tissue, those got involved as well."},{"startTime":1272.615,"endTime":1275.395,"body":"N2 is you spread here to the central part."},{"startTime":1275.695,"endTime":1281.145,"body":"So now the tumor started here, went here"},{"startTime":1275.695,"endTime":1281.145,"body":"to your parabronchial, and to your hilar,"},{"startTime":1281.305,"endTime":1283.035,"body":"and then it moved into the mediastinum."},{"startTime":1283.375,"endTime":1284.565,"body":"So that's now N2."},{"startTime":1286.225,"endTime":1290.625,"body":"N3 is from here, it could"},{"startTime":1286.225,"endTime":1290.625,"body":"have gone to this mediastinum,"},{"startTime":1291.055,"endTime":1292.355,"body":"and it could have spread."},{"startTime":1292.67,"endTime":1296.4,"body":"Up to your supraclavicular, or"},{"startTime":1292.67,"endTime":1296.4,"body":"it's spread to the other side,"},{"startTime":1296.75,"endTime":1297.88,"body":"so now it's contralateral."},{"startTime":1298.43,"endTime":1301.75,"body":"That is the best way, because the"},{"startTime":1298.43,"endTime":1301.75,"body":"way I look at these is it just makes"},{"startTime":1301.75,"endTime":1303.24,"body":"it easier for me to figure out."},{"startTime":1303.505,"endTime":1309.775,"body":"For example, stage 1, I just look"},{"startTime":1303.505,"endTime":1309.775,"body":"at what's the N. In this case, stage"},{"startTime":1309.785,"endTime":1312.575,"body":"1, it could be N0 or it could be N1."},{"startTime":1313.215,"endTime":1316.635,"body":"Stage 2, is it's N1, right?"},{"startTime":1317.085,"endTime":1320.015,"body":"And then stage three, it"},{"startTime":1317.085,"endTime":1320.015,"body":"just varies a little bit."},{"startTime":1320.245,"endTime":1323.975,"body":"So there's stage 3a and stage 3b and"},{"startTime":1320.245,"endTime":1323.975,"body":"that depends upon the end as well."},{"startTime":1324.265,"endTime":1328.135,"body":"Right here, this patient is"},{"startTime":1324.265,"endTime":1328.135,"body":"in one that fits stage two."},{"startTime":1328.775,"endTime":1334.205,"body":"So I would say that this patient has"},{"startTime":1328.775,"endTime":1334.205,"body":"stage two non small cell lung cancer, and"},{"startTime":1334.205,"endTime":1337.175,"body":"it's the type is squamous cell carcinoma."},{"startTime":1337.435,"endTime":1341.395,"body":"If they have a lung tumor, I'm not going"},{"startTime":1337.435,"endTime":1341.395,"body":"to worry about the size of it, the T part."},{"startTime":1341.655,"endTime":1343.215,"body":"I want to know the node involvement."},{"startTime":1343.505,"endTime":1345.295,"body":"In this case, it's N1."},{"startTime":1345.575,"endTime":1347.365,"body":"N1 will fit with my stage 2."},{"startTime":1347.875,"endTime":1351.895,"body":"And then the TNM, of course, we said"},{"startTime":1347.875,"endTime":1351.895,"body":"before, there is no distant metastasis."},{"startTime":1351.895,"endTime":1353.625,"body":"So we know that's not even involved."},{"startTime":1353.635,"endTime":1354.265,"body":"So we're good."},{"startTime":1354.275,"endTime":1357.725,"body":"Cause if it came back, I had some distant"},{"startTime":1354.275,"endTime":1357.725,"body":"metastasis we're stage four, done."},{"startTime":1357.915,"endTime":1358.295,"body":"Okay."},{"startTime":1358.665,"endTime":1359.985,"body":"So that's why we look at the end."},{"startTime":1359.995,"endTime":1364.265,"body":"The end tells us if we fall"},{"startTime":1359.995,"endTime":1364.265,"body":"really within stage 1 to stage 3."},{"startTime":1364.665,"endTime":1367.945,"body":"And then that metastasis tells"},{"startTime":1364.665,"endTime":1367.945,"body":"me if I fall in that stage 4,"},{"startTime":1367.965,"endTime":1369.135,"body":"you're up to the 4 immediately."},{"startTime":1369.345,"endTime":1370.075,"body":"Exactly."},{"startTime":1370.125,"endTime":1374.755,"body":"For our patient now, since you have"},{"startTime":1370.125,"endTime":1374.755,"body":"considered this to be stage two, non small"},{"startTime":1374.765,"endTime":1376.995,"body":"cell lung cancer, what is the treatment?"},{"startTime":1377.59,"endTime":1380.23,"body":"So stage two is actually"},{"startTime":1377.59,"endTime":1380.23,"body":"potentially resectable."},{"startTime":1380.5,"endTime":1380.78,"body":"Okay."},{"startTime":1380.79,"endTime":1383.29,"body":"So you can still cut this thing"},{"startTime":1380.79,"endTime":1383.29,"body":"out and then you can go in"},{"startTime":1383.29,"endTime":1384.97,"body":"there and cut the nodes out too."},{"startTime":1385.42,"endTime":1387.99,"body":"So the first thing I would"},{"startTime":1385.42,"endTime":1387.99,"body":"do is I do some usually we do"},{"startTime":1388.02,"endTime":1390.2,"body":"PFTs on these patients first."},{"startTime":1390.56,"endTime":1392.4,"body":"We want to know what"},{"startTime":1390.56,"endTime":1392.4,"body":"their lung, function is."},{"startTime":1392.875,"endTime":1394.885,"body":"Because if we're cutting out"},{"startTime":1392.875,"endTime":1394.885,"body":"tissue, we need to make sure that"},{"startTime":1394.885,"endTime":1397.625,"body":"what they're left with is enough"},{"startTime":1394.885,"endTime":1397.625,"body":"for them to properly function."},{"startTime":1398.025,"endTime":1401.415,"body":"So we have to determine if they're"},{"startTime":1398.025,"endTime":1401.415,"body":"medically operable or inoperable."},{"startTime":1401.785,"endTime":1402.875,"body":"And so that's the first thing I would do."},{"startTime":1402.875,"endTime":1405.905,"body":"If they're medically inoperable, I"},{"startTime":1402.875,"endTime":1405.905,"body":"may not be able to do surgery on them."},{"startTime":1406.285,"endTime":1408.415,"body":"And then sometimes we, there's a"},{"startTime":1406.285,"endTime":1408.415,"body":"newer thing, it's called Stereotactic"},{"startTime":1409.595,"endTime":1412.555,"body":"ablative radiation therapy."},{"startTime":1412.945,"endTime":1417.265,"body":"And so they can use that and it's a"},{"startTime":1412.945,"endTime":1417.265,"body":"focused high dose beam of radiation"},{"startTime":1417.575,"endTime":1420.715,"body":"that just jams right into the tumor"},{"startTime":1417.575,"endTime":1420.715,"body":"and it could potentially kill it."},{"startTime":1421.165,"endTime":1424.005,"body":"You sometimes have to follow"},{"startTime":1421.165,"endTime":1424.005,"body":"up with some adjuvant chemo."},{"startTime":1424.295,"endTime":1427.215,"body":"But that's an alternative if"},{"startTime":1424.295,"endTime":1427.215,"body":"you can't get operated on."},{"startTime":1427.355,"endTime":1427.625,"body":"Okay."},{"startTime":1427.775,"endTime":1432.625,"body":"But I would do PFTs, make sure that their"},{"startTime":1427.775,"endTime":1432.625,"body":"PFTs, their FEV falls within a predicted"},{"startTime":1432.625,"endTime":1434.855,"body":"value that's acceptable afterwards."},{"startTime":1434.855,"endTime":1436.675,"body":"And if they, Oh, they're"},{"startTime":1434.855,"endTime":1436.675,"body":"medically operable."},{"startTime":1436.725,"endTime":1439.295,"body":"Okay, let's send them to get"},{"startTime":1436.725,"endTime":1439.295,"body":"a surgery, cut that thing out."},{"startTime":1439.975,"endTime":1443.375,"body":"And then potentially depending upon the"},{"startTime":1439.975,"endTime":1443.375,"body":"amount that we want to do, sometimes you"},{"startTime":1443.375,"endTime":1445.045,"body":"can just do a little wedge resection."},{"startTime":1445.525,"endTime":1449.025,"body":"Sometimes you have to do a lobectomy"},{"startTime":1445.525,"endTime":1449.025,"body":"depending upon how big it is."},{"startTime":1449.445,"endTime":1453.285,"body":"This would not warrant pneumonectomy"},{"startTime":1449.445,"endTime":1453.285,"body":"is you remove the entire lung."},{"startTime":1453.335,"endTime":1457.915,"body":"But it seems for him, it's still"},{"startTime":1453.335,"endTime":1457.915,"body":"somewhat localized to a certain extent."},{"startTime":1458.285,"endTime":1458.975,"body":"And so it depends."},{"startTime":1459.025,"endTime":1462.045,"body":"I, you'd have to obviously have a surgeon"},{"startTime":1459.025,"endTime":1462.045,"body":"at this point, really decide on what's"},{"startTime":1462.045,"endTime":1465.985,"body":"the best course of action, but sometimes"},{"startTime":1462.045,"endTime":1465.985,"body":"you may just have to do a lobectomy and"},{"startTime":1465.985,"endTime":1467.325,"body":"that might be the way to go about this."},{"startTime":1467.325,"endTime":1470.495,"body":"And when you do the lobectomy, you also"},{"startTime":1467.325,"endTime":1470.495,"body":"get rid of those nodes that were involved."},{"startTime":1470.505,"endTime":1470.845,"body":"Sure."},{"startTime":1471.155,"endTime":1474.155,"body":"So cut those puppies out so that"},{"startTime":1471.155,"endTime":1474.155,"body":"it doesn't continue to spread along"},{"startTime":1474.155,"endTime":1475.555,"body":"the other lymph node passages."},{"startTime":1475.595,"endTime":1478.615,"body":"How about any complications"},{"startTime":1475.595,"endTime":1478.615,"body":"associated with non small cell?"},{"startTime":1479.145,"endTime":1480.035,"body":"Anything in particular?"},{"startTime":1480.685,"endTime":1482.795,"body":"Squamous cell has its own"},{"startTime":1480.685,"endTime":1482.795,"body":"kind of complications."},{"startTime":1482.795,"endTime":1483.145,"body":"Okay."},{"startTime":1483.245,"endTime":1486.825,"body":"Any lung cancer, you can have,"},{"startTime":1483.245,"endTime":1486.825,"body":"sometimes they're asymptomatic,"},{"startTime":1486.825,"endTime":1487.695,"body":"sometimes you just don't know."},{"startTime":1487.985,"endTime":1492.195,"body":"Sometimes it's very mild, like a"},{"startTime":1487.985,"endTime":1492.195,"body":"weird symptoms, like just a cough."},{"startTime":1492.235,"endTime":1492.435,"body":"Yeah."},{"startTime":1492.83,"endTime":1495.03,"body":"Sometimes you can actually"},{"startTime":1492.83,"endTime":1495.03,"body":"cough up blood, right?"},{"startTime":1495.06,"endTime":1496.09,"body":"Which I think this patient did."},{"startTime":1496.09,"endTime":1496.94,"body":"They had hemoptysis."},{"startTime":1496.98,"endTime":1497.27,"body":"He did."},{"startTime":1497.54,"endTime":1500.09,"body":"Sometimes you can obstruct the"},{"startTime":1497.54,"endTime":1500.09,"body":"airway and then get wheezing."},{"startTime":1500.09,"endTime":1503.82,"body":"So any kind of central mass is"},{"startTime":1500.09,"endTime":1503.82,"body":"more likely to obstruct airflow."},{"startTime":1504.38,"endTime":1509.79,"body":"Funny enough, the most common"},{"startTime":1504.38,"endTime":1509.79,"body":"presentation of a patient with a"},{"startTime":1509.79,"endTime":1512.96,"body":"central mass is recurrent pneumonia."},{"startTime":1513.42,"endTime":1516.95,"body":"So let's say that a patient had,"},{"startTime":1513.42,"endTime":1516.95,"body":"pneumonia in their right middle lobe."},{"startTime":1517.435,"endTime":1519.355,"body":"Three times this past"},{"startTime":1517.435,"endTime":1519.355,"body":"year, bro, what's going on?"},{"startTime":1519.585,"endTime":1520.205,"body":"You know what I mean?"},{"startTime":1520.425,"endTime":1521.055,"body":"It's not normal."},{"startTime":1521.325,"endTime":1524.495,"body":"Sometimes if the tumor is in one of"},{"startTime":1521.325,"endTime":1524.495,"body":"those bronchi and it's big enough"},{"startTime":1524.495,"endTime":1530.345,"body":"that it's obstructing the bronchus,"},{"startTime":1524.495,"endTime":1530.345,"body":"you can't pass mucus and bacteria"},{"startTime":1530.405,"endTime":1532.365,"body":"across that for you to spit that up."},{"startTime":1533.055,"endTime":1537.405,"body":"And so if you obstruct the mucus"},{"startTime":1533.055,"endTime":1537.405,"body":"and like the ciliary flow of things"},{"startTime":1537.805,"endTime":1542.515,"body":"that will cause an obstruction just"},{"startTime":1537.805,"endTime":1542.515,"body":"post or after where that tumor is."},{"startTime":1542.835,"endTime":1545.045,"body":"And so it's called post"},{"startTime":1542.835,"endTime":1545.045,"body":"obstructive pneumonia."},{"startTime":1545.045,"endTime":1546.875,"body":"We see it a lot of time"},{"startTime":1545.045,"endTime":1546.875,"body":"when people get a big enough"},{"startTime":1546.875,"endTime":1548.945,"body":"obstruction and you get no airflow."},{"startTime":1548.945,"endTime":1550.415,"body":"What would you think would"},{"startTime":1548.945,"endTime":1550.415,"body":"happen to the air sac?"},{"startTime":1550.425,"endTime":1551.145,"body":"It would shrink."},{"startTime":1551.435,"endTime":1553.235,"body":"So it's called post"},{"startTime":1551.435,"endTime":1553.235,"body":"obstructive atelectasis."},{"startTime":1553.645,"endTime":1556.485,"body":"In this case, they just let"},{"startTime":1553.645,"endTime":1556.485,"body":"all the bacteria and mucus sit"},{"startTime":1556.485,"endTime":1557.635,"body":"there and it gets infected."},{"startTime":1557.975,"endTime":1559.495,"body":"And so they get a post"},{"startTime":1557.975,"endTime":1559.495,"body":"obstructive pneumonia."},{"startTime":1559.495,"endTime":1561.705,"body":"So recurrent pneumonia"},{"startTime":1559.495,"endTime":1561.705,"body":"is in the same lobe."},{"startTime":1562.305,"endTime":1566.765,"body":"For your exam, it's always going to be"},{"startTime":1562.305,"endTime":1566.765,"body":"concerning and suspicious for malignancy."},{"startTime":1567.28,"endTime":1568.61,"body":"So that's something that"},{"startTime":1567.28,"endTime":1568.61,"body":"I would think about."},{"startTime":1568.75,"endTime":1570.85,"body":"The other thing is compressive effects."},{"startTime":1571.12,"endTime":1574.92,"body":"So they had recurrent laryngeal"},{"startTime":1571.12,"endTime":1574.92,"body":"nerve compression, right?"},{"startTime":1575.32,"endTime":1578.33,"body":"So there's a shat ton of nerves"},{"startTime":1575.32,"endTime":1578.33,"body":"that run through this area"},{"startTime":1578.33,"endTime":1579.95,"body":"into the mediastinum, right?"},{"startTime":1580.33,"endTime":1581.33,"body":"So you can think about it."},{"startTime":1581.33,"endTime":1582.73,"body":"You got the phrenic nerve running down."},{"startTime":1583.14,"endTime":1584.23,"body":"That could get compressed."},{"startTime":1584.47,"endTime":1586.05,"body":"So then you get phrenic nerve paralysis."},{"startTime":1586.28,"endTime":1586.9,"body":"That's not good."},{"startTime":1587.0,"endTime":1590.46,"body":"No, it's because your"},{"startTime":1587.0,"endTime":1590.46,"body":"diaphragm is dookie now."},{"startTime":1590.46,"endTime":1593.37,"body":"Yeah, so that's a tough one to diagnose."},{"startTime":1593.37,"endTime":1596.47,"body":"but the right phrenic nerve,"},{"startTime":1593.37,"endTime":1596.47,"body":"imagine that thing got compressed."},{"startTime":1596.7,"endTime":1600.1,"body":"So then what would happen is this"},{"startTime":1596.7,"endTime":1600.1,"body":"diaphragm, it, when it's supposed to"},{"startTime":1600.1,"endTime":1601.79,"body":"contract, it's supposed to drop down."},{"startTime":1602.04,"endTime":1603.14,"body":"It won't be able to do that."},{"startTime":1603.56,"endTime":1606.43,"body":"And so when you get a chest x ray,"},{"startTime":1603.56,"endTime":1606.43,"body":"what happens is this diaphragm"},{"startTime":1606.43,"endTime":1607.49,"body":"is elevated a little bit."},{"startTime":1607.49,"endTime":1610.56,"body":"Because the diaphragm, if it, when"},{"startTime":1607.49,"endTime":1610.56,"body":"it's contracting, it drops down."},{"startTime":1610.98,"endTime":1612.76,"body":"If it can't contract,"},{"startTime":1610.98,"endTime":1612.76,"body":"it's going to be boop."},{"startTime":1613.33,"endTime":1614.97,"body":"And you're going to have"},{"startTime":1613.33,"endTime":1614.97,"body":"an elevated hemidiaphragm."},{"startTime":1615.52,"endTime":1616.33,"body":"So you know what we do?"},{"startTime":1616.61,"endTime":1617.56,"body":"It's called a sniff test."},{"startTime":1617.87,"endTime":1621.36,"body":"You have them under floral,"},{"startTime":1617.87,"endTime":1621.36,"body":"and you have them go like this."},{"startTime":1621.36,"endTime":1623.86,"body":"And if you do that, your"},{"startTime":1621.36,"endTime":1623.86,"body":"diaphragm should do what?"},{"startTime":1623.92,"endTime":1624.99,"body":"Naturally drop down."},{"startTime":1625.62,"endTime":1628.91,"body":"One this one will drop down this one"},{"startTime":1625.62,"endTime":1628.91,"body":"will not and so that's a way that you"},{"startTime":1628.91,"endTime":1632.6,"body":"can see phrenic nerve paralysis This"},{"startTime":1628.91,"endTime":1632.6,"body":"one doesn't have it, but that's one."},{"startTime":1632.69,"endTime":1632.91,"body":"Yeah."},{"startTime":1633.01,"endTime":1637.57,"body":"Another one is you could compress"},{"startTime":1633.01,"endTime":1637.57,"body":"the sympathetic chain ganglia, and"},{"startTime":1637.57,"endTime":1640.6,"body":"so that's the ones that are this"},{"startTime":1637.57,"endTime":1640.6,"body":"particular one the superior cervical"},{"startTime":1640.62,"endTime":1644.635,"body":"kind of stellate ganglia They go up"},{"startTime":1640.62,"endTime":1644.635,"body":"and they supply your eye, particularly"},{"startTime":1644.995,"endTime":1649.285,"body":"the, levator palpebrae superioris and"},{"startTime":1644.995,"endTime":1649.285,"body":"then this supplies the pupil and then"},{"startTime":1649.355,"endTime":1650.935,"body":"some of the eccrine sweat glands."},{"startTime":1651.195,"endTime":1655.215,"body":"And so if you compress them puppies"},{"startTime":1651.195,"endTime":1655.215,"body":"they smash what I was talking about."},{"startTime":1655.265,"endTime":1655.905,"body":"Yeah."},{"startTime":1656.135,"endTime":1660.365,"body":"If you smash them bad boys,"},{"startTime":1656.135,"endTime":1660.365,"body":"then your pupil won't be able to"},{"startTime":1660.365,"endTime":1662.245,"body":"dilate instead, it'll constrict."},{"startTime":1663.195,"endTime":1664.175,"body":"And so it's called meiosis."},{"startTime":1664.685,"endTime":1669.195,"body":"The levator palpebrae superioris won't be"},{"startTime":1664.685,"endTime":1669.195,"body":"able to contract so you'll get a droopy."},{"startTime":1669.715,"endTime":1669.965,"body":"Right."},{"startTime":1670.305,"endTime":1671.375,"body":"And then you can't sweat."},{"startTime":1671.475,"endTime":1671.755,"body":"Yep."},{"startTime":1671.755,"endTime":1673.875,"body":"So ptosis, and then you can't sweat."},{"startTime":1673.875,"endTime":1674.825,"body":"So anhidrosis."},{"startTime":1675.145,"endTime":1679.105,"body":"So the mnemonic is Pam, Pam,"},{"startTime":1675.145,"endTime":1679.105,"body":"Pam, Pam, Pam, this is for the"},{"startTime":1679.105,"endTime":1684.129,"body":"office people in there, but it's"},{"startTime":1679.105,"endTime":1684.129,"body":"a ptosis, anhidrosis, and meiosis."},{"startTime":1684.179,"endTime":1687.549,"body":"Another nerve is going to be"},{"startTime":1684.179,"endTime":1687.549,"body":"the recurrent laryngeal nerve."},{"startTime":1687.549,"endTime":1689.219,"body":"Talked about that with"},{"startTime":1687.549,"endTime":1689.219,"body":"our patient, hoarseness."},{"startTime":1689.249,"endTime":1689.619,"body":"Yep."},{"startTime":1690.029,"endTime":1693.129,"body":"And then one more would"},{"startTime":1690.029,"endTime":1693.129,"body":"be the brachial plexus."},{"startTime":1693.799,"endTime":1697.489,"body":"That's really a tough one, but if you"},{"startTime":1693.799,"endTime":1697.489,"body":"have your nerve roots right around that"},{"startTime":1697.489,"endTime":1702.989,"body":"thoracic outlet it's, I think it's C8"},{"startTime":1697.489,"endTime":1702.989,"body":"to T2 nerve roots can get compressed."},{"startTime":1703.339,"endTime":1706.929,"body":"And so you can get shoulder pain and then"},{"startTime":1703.339,"endTime":1706.929,"body":"it hits the ulnar nerve distribution."},{"startTime":1706.979,"endTime":1709.829,"body":"But those are the biggest things"},{"startTime":1706.979,"endTime":1709.829,"body":"with the nerve compression."},{"startTime":1711.199,"endTime":1714.599,"body":"If it's really big and in the"},{"startTime":1711.199,"endTime":1714.599,"body":"center the superior vena cava comes"},{"startTime":1714.599,"endTime":1717.869,"body":"down and so it could mash in the"},{"startTime":1714.599,"endTime":1717.869,"body":"superior vena cava and then blood"},{"startTime":1717.869,"endTime":1719.059,"body":"can't drain into the right atrium."},{"startTime":1719.059,"endTime":1722.659,"body":"So you could get like a JVD, you"},{"startTime":1719.059,"endTime":1722.659,"body":"could get swelling of the face"},{"startTime":1722.659,"endTime":1723.729,"body":"and some right heart failure."},{"startTime":1723.729,"endTime":1724.099,"body":"Yeah."},{"startTime":1724.389,"endTime":1728.569,"body":"Except a lot of it will stay in"},{"startTime":1724.389,"endTime":1728.569,"body":"the upper extremities of the lower."},{"startTime":1728.619,"endTime":1732.219,"body":"So that's another one is SVC syndrome"},{"startTime":1728.619,"endTime":1732.219,"body":"could be a pretty scary one, but"},{"startTime":1732.599,"endTime":1733.419,"body":"those are the biggest things."},{"startTime":1733.419,"endTime":1737.239,"body":"And then the last thing that's important"},{"startTime":1733.419,"endTime":1737.239,"body":"is that these tumors, they're funky."},{"startTime":1737.569,"endTime":1739.619,"body":"They may gain the"},{"startTime":1737.569,"endTime":1739.619,"body":"capacity to make hormones."},{"startTime":1740.294,"endTime":1743.094,"body":"And so you remember hypercalcemia bro?"},{"startTime":1743.434,"endTime":1744.074,"body":"I sure do."},{"startTime":1746.724,"endTime":1753.284,"body":"So hypercalcemia malignancy, you always"},{"startTime":1746.724,"endTime":1753.284,"body":"think PTHRP, vitamin D or lytic lesions."},{"startTime":1753.744,"endTime":1756.844,"body":"This one can cause high PTHRP secretion."},{"startTime":1756.844,"endTime":1758.944,"body":"So the tumors literally make PTHRP."},{"startTime":1759.224,"endTime":1763.574,"body":"Tell the bones to resorb calcium and then"},{"startTime":1759.224,"endTime":1763.574,"body":"they also tell the kidneys to reabsorb"},{"startTime":1763.604,"endTime":1764.724,"body":"calcium so they can get hypercalcemia."},{"startTime":1765.414,"endTime":1768.054,"body":"All I know is the stones, bones,"},{"startTime":1765.414,"endTime":1768.054,"body":"groans, psychiatric overtones."},{"startTime":1768.084,"endTime":1769.294,"body":"That's all you got to know."},{"startTime":1769.314,"endTime":1770.044,"body":"That's all I got."},{"startTime":1770.054,"endTime":1772.504,"body":"That's all they could present"},{"startTime":1770.054,"endTime":1772.504,"body":"with stones, bones, groans,"},{"startTime":1772.514,"endTime":1773.794,"body":"thrones, psychiatric overtones."},{"startTime":1773.804,"endTime":1774.554,"body":"You like that one, huh?"},{"startTime":1774.554,"endTime":1779.124,"body":"I like, yeah, I know my stuff,"},{"startTime":1774.554,"endTime":1779.124,"body":"but that's one thing there."},{"startTime":1779.514,"endTime":1781.224,"body":"So that, that would be"},{"startTime":1779.514,"endTime":1781.224,"body":"what I would look at."},{"startTime":1781.224,"endTime":1784.414,"body":"Actually, I'd actually order"},{"startTime":1781.224,"endTime":1784.414,"body":"a calcium on this patient."},{"startTime":1784.614,"endTime":1786.704,"body":"If I had any kind of concerns like that."},{"startTime":1787.134,"endTime":1790.234,"body":"And did they get a they got a CMP."},{"startTime":1790.234,"endTime":1790.684,"body":"It was normal."},{"startTime":1790.684,"endTime":1792.434,"body":"So the calcium would have"},{"startTime":1790.684,"endTime":1792.434,"body":"came up, normal on this."},{"startTime":1792.514,"endTime":1793.034,"body":"Oh, true."},{"startTime":1793.094,"endTime":1793.344,"body":"True."},{"startTime":1793.354,"endTime":1793.374,"body":"Yeah."},{"startTime":1793.644,"endTime":1795.834,"body":"So with adenocarcinoma, one of the"},{"startTime":1793.644,"endTime":1795.834,"body":"things about this one is it can release"},{"startTime":1795.854,"endTime":1797.164,"body":"transformative growth factor beta."},{"startTime":1797.374,"endTime":1801.514,"body":"And now this guy, this one acts on"},{"startTime":1797.374,"endTime":1801.514,"body":"like fibroblasts and periosteal cells."},{"startTime":1801.844,"endTime":1803.104,"body":"And it makes, I'm not even kidding, man."},{"startTime":1803.104,"endTime":1804.444,"body":"It makes your fingers look like."},{"startTime":1804.819,"endTime":1808.329,"body":"Like spoons, you could literally like"},{"startTime":1804.819,"endTime":1808.329,"body":"scoop mashed potatoes with them bad boys."},{"startTime":1808.329,"endTime":1809.319,"body":"You don't need utensils."},{"startTime":1809.319,"endTime":1810.089,"body":"You got them on your freaking fingers."},{"startTime":1810.089,"endTime":1811.049,"body":"Oh gosh."},{"startTime":1812.099,"endTime":1814.709,"body":"But in all seriousness,"},{"startTime":1812.099,"endTime":1814.709,"body":"it is really terrible."},{"startTime":1814.989,"endTime":1819.209,"body":"It's called hypertrophic"},{"startTime":1814.989,"endTime":1819.209,"body":"pulmonary osteoarthropathy and"},{"startTime":1819.209,"endTime":1820.259,"body":"it's where I'm not even kidding."},{"startTime":1820.259,"endTime":1821.569,"body":"You get like finger clubbing."},{"startTime":1822.329,"endTime":1824.399,"body":"And that would be one"},{"startTime":1822.329,"endTime":1824.399,"body":"potential sign of adeno."},{"startTime":1824.979,"endTime":1827.459,"body":"I can't say this is all too"},{"startTime":1824.979,"endTime":1827.459,"body":"common with adeno, but sometimes"},{"startTime":1827.489,"endTime":1830.709,"body":"adenocarcinoma, certain tumors,"},{"startTime":1827.489,"endTime":1830.709,"body":"especially pancreatic tumors, they"},{"startTime":1830.709,"endTime":1832.339,"body":"can pump out a lot of tissue factor."},{"startTime":1832.789,"endTime":1835.579,"body":"And tissue factor is a part of our"},{"startTime":1832.789,"endTime":1835.579,"body":"extrinsic pathway for coagulation."},{"startTime":1835.999,"endTime":1839.249,"body":"They can activate factor VII, they"},{"startTime":1835.999,"endTime":1839.249,"body":"can trigger a lot of clots to form."},{"startTime":1839.589,"endTime":1842.959,"body":"Sometimes this can be in form"},{"startTime":1839.589,"endTime":1842.959,"body":"of superficial thrombophlebitis."},{"startTime":1843.164,"endTime":1846.704,"body":"So you get these red, tender cords"},{"startTime":1843.164,"endTime":1846.704,"body":"that are clothed within veins in the"},{"startTime":1847.024,"endTime":1850.574,"body":"extremities, usually in the arms,"},{"startTime":1847.024,"endTime":1850.574,"body":"or it could be full on DVTs, PE."},{"startTime":1850.634,"endTime":1853.984,"body":"The last one is a paraneoplastic"},{"startTime":1850.634,"endTime":1853.984,"body":"syndrome is large cell."},{"startTime":1855.009,"endTime":1856.929,"body":"Especially for the non"},{"startTime":1855.009,"endTime":1856.929,"body":"small cell lung cancers."},{"startTime":1856.929,"endTime":1858.609,"body":"And this one, they can"},{"startTime":1856.929,"endTime":1858.609,"body":"actually release HCG."},{"startTime":1858.609,"endTime":1860.139,"body":"This can cause breast tissue enlargement."},{"startTime":1860.219,"endTime":1861.699,"body":"So you end up with orangutan titties."},{"startTime":1861.819,"endTime":1862.459,"body":"You know what I mean?"},{"startTime":1862.489,"endTime":1863.219,"body":"The torpedo titties."},{"startTime":1863.249,"endTime":1864.699,"body":"Yeah, exactly."},{"startTime":1864.699,"endTime":1866.289,"body":"So that's another one."},{"startTime":1866.289,"endTime":1869.349,"body":"Gynecomastia is a pretty concerning"},{"startTime":1866.289,"endTime":1869.349,"body":"feature that can happen with large cell."},{"startTime":1869.729,"endTime":1873.169,"body":"So that's, I'd say the biggest"},{"startTime":1869.729,"endTime":1873.169,"body":"things to take away from this is"},{"startTime":1873.229,"endTime":1876.689,"body":"what happens if they're central"},{"startTime":1873.229,"endTime":1876.689,"body":"and they obstruct an airway, right?"},{"startTime":1876.719,"endTime":1877.919,"body":"You can get pneumonia."},{"startTime":1878.269,"endTime":1880.229,"body":"What happens if they're peripheral?"},{"startTime":1880.229,"endTime":1881.509,"body":"You can get pleural effusions."},{"startTime":1882.439,"endTime":1887.749,"body":"A third is what happens if these"},{"startTime":1882.439,"endTime":1887.749,"body":"things are secreting hormones, you"},{"startTime":1887.749,"endTime":1889.499,"body":"can get perineoplastic syndromes."},{"startTime":1889.809,"endTime":1894.509,"body":"So those, and then also if they're a"},{"startTime":1889.809,"endTime":1894.509,"body":"little bit more central and apical, you"},{"startTime":1894.509,"endTime":1896.199,"body":"can get nerve and vessel compression."},{"startTime":1896.259,"endTime":1896.619,"body":"All right."},{"startTime":1896.649,"endTime":1897.869,"body":"That does it for case two."},{"startTime":1897.989,"endTime":1898.369,"body":"All right."},{"startTime":1898.429,"endTime":1901.849,"body":"We got one left and it's on"},{"startTime":1898.429,"endTime":1901.849,"body":"the big mama, small cell lung"},{"startTime":1901.849,"endTime":1903.249,"body":"cancer, small cell lung cancer."},{"startTime":1903.249,"endTime":1903.679,"body":"All right."},{"startTime":1903.679,"endTime":1904.999,"body":"So we have a 60 year old male."},{"startTime":1905.394,"endTime":1909.224,"body":"With acute facial swelling, severe"},{"startTime":1905.394,"endTime":1909.224,"body":"dyspnea and persistent cough."},{"startTime":1909.254,"endTime":1911.274,"body":"That sounds like SVC syndrome right away."},{"startTime":1911.644,"endTime":1912.634,"body":"100 percent though."},{"startTime":1912.814,"endTime":1913.224,"body":"Okay."},{"startTime":1913.784,"endTime":1915.794,"body":"Now this patient has rapid onset."},{"startTime":1915.804,"endTime":1919.594,"body":"He notes to be less than two weeks"},{"startTime":1915.804,"endTime":1919.594,"body":"of facial swelling, shortness"},{"startTime":1919.594,"endTime":1921.204,"body":"of breath and worsening cough."},{"startTime":1921.494,"endTime":1925.174,"body":"He is a heavy smoker,"},{"startTime":1921.494,"endTime":1925.174,"body":"currently 45 pack years."},{"startTime":1926.264,"endTime":1929.554,"body":"Past medical history is"},{"startTime":1926.264,"endTime":1929.554,"body":"pertinent for coronary artery"},{"startTime":1929.554,"endTime":1931.364,"body":"disease and hyperlipidemia."},{"startTime":1931.464,"endTime":1934.004,"body":"He's currently taking"},{"startTime":1931.464,"endTime":1934.004,"body":"aspirin and atorvastatin."},{"startTime":1934.454,"endTime":1937.984,"body":"For his exam, his vitals,"},{"startTime":1934.454,"endTime":1937.984,"body":"BP is 145 over 92."},{"startTime":1938.394,"endTime":1939.494,"body":"Heart rate is 92."},{"startTime":1939.984,"endTime":1941.744,"body":"Respirations is 22 per minute."},{"startTime":1941.814,"endTime":1944.264,"body":"SpO2 is 91 percent on room air."},{"startTime":1945.199,"endTime":1949.599,"body":"General, we note significant"},{"startTime":1945.199,"endTime":1949.599,"body":"facial edema and a prominent"},{"startTime":1949.599,"endTime":1952.679,"body":"JVD, SVC syndrome to the max."},{"startTime":1952.689,"endTime":1953.719,"body":"Yeah, for real."},{"startTime":1954.219,"endTime":1957.909,"body":"In this scenario, this patient,"},{"startTime":1954.219,"endTime":1957.909,"body":"his SVC is just getting cut off."},{"startTime":1957.959,"endTime":1960.809,"body":"there's probably massive like"},{"startTime":1957.959,"endTime":1960.809,"body":"central compression somewhere in"},{"startTime":1960.809,"endTime":1962.379,"body":"the mediastinum for this bad boy."},{"startTime":1962.479,"endTime":1966.679,"body":"And then for pulmonary, he has"},{"startTime":1962.479,"endTime":1966.679,"body":"mild bilateral wheezing, diminished"},{"startTime":1966.679,"endTime":1967.979,"body":"breath sounds bilaterally."},{"startTime":1968.079,"endTime":1969.109,"body":"We do labs and imaging."},{"startTime":1969.119,"endTime":1972.839,"body":"We get the following"},{"startTime":1969.119,"endTime":1972.839,"body":"back, CBC, BMP, normal."},{"startTime":1972.929,"endTime":1975.919,"body":"Chest x ray, we have a"},{"startTime":1972.929,"endTime":1975.919,"body":"central mediastinal mass."},{"startTime":1976.599,"endTime":1980.549,"body":"We follow that up with a chest CT,"},{"startTime":1976.599,"endTime":1980.549,"body":"and we have a large central mass"},{"startTime":1980.569,"endTime":1982.749,"body":"compressing the superior vena cava."},{"startTime":1982.769,"endTime":1983.419,"body":"Look at you, dude."},{"startTime":1983.419,"endTime":1984.609,"body":"You're a diagnostician."},{"startTime":1984.659,"endTime":1986.039,"body":"I'm pretty good."},{"startTime":1986.039,"endTime":1988.189,"body":"I'm not going to lie."},{"startTime":1988.199,"endTime":1988.769,"body":"I'm pretty good."},{"startTime":1989.199,"endTime":1990.009,"body":"I'm the real deal."},{"startTime":1990.339,"endTime":1995.139,"body":"So Zach, our final case, 60"},{"startTime":1990.339,"endTime":1995.139,"body":"year old smoker, 45 pack years."},{"startTime":1995.589,"endTime":2000.899,"body":"We've got facial swelling, prominent"},{"startTime":1995.589,"endTime":2000.899,"body":"JVD, dyspnea, and this pretty large"},{"startTime":2000.939,"endTime":2003.379,"body":"central mass compressing the SVC."},{"startTime":2003.409,"endTime":2003.869,"body":"Yeah."},{"startTime":2004.249,"endTime":2004.749,"body":"Thoughts."},{"startTime":2004.749,"endTime":2005.259,"body":"What do you do?"},{"startTime":2005.679,"endTime":2009.509,"body":"I think you said, I think like you got"},{"startTime":2005.679,"endTime":2009.509,"body":"definitely a concern for SVC syndrome."},{"startTime":2009.549,"endTime":2012.579,"body":"So this is like somewhat"},{"startTime":2009.549,"endTime":2012.579,"body":"of an oncologic emergency."},{"startTime":2012.769,"endTime":2015.239,"body":"So that's definitely one of the"},{"startTime":2012.769,"endTime":2015.239,"body":"things that makes you start working"},{"startTime":2015.239,"endTime":2016.489,"body":"up what's going on in the chest."},{"startTime":2016.519,"endTime":2018.579,"body":"You already got that already started."},{"startTime":2018.909,"endTime":2021.559,"body":"You get the chest x ray that"},{"startTime":2018.909,"endTime":2021.559,"body":"showed that there's a big mass"},{"startTime":2021.559,"endTime":2022.659,"body":"inside of the mediastinum."},{"startTime":2023.159,"endTime":2026.729,"body":"Followed it up with a chest CT that shows"},{"startTime":2023.159,"endTime":2026.729,"body":"us, there's a really large central mass"},{"startTime":2026.729,"endTime":2028.299,"body":"that's compressing the superior vena cava."},{"startTime":2028.979,"endTime":2033.249,"body":"The thing that's concerning me is"},{"startTime":2028.979,"endTime":2033.249,"body":"the rapidity of how this formed."},{"startTime":2033.794,"endTime":2036.944,"body":"Like they got SVC syndrome"},{"startTime":2033.794,"endTime":2036.944,"body":"in like less than two weeks."},{"startTime":2036.964,"endTime":2037.874,"body":"It was really quick."},{"startTime":2037.894,"endTime":2040.544,"body":"And then usually SVC"},{"startTime":2037.894,"endTime":2040.544,"body":"syndrome with central masses."},{"startTime":2040.544,"endTime":2043.084,"body":"You can get it with a squamous cell"},{"startTime":2040.544,"endTime":2043.084,"body":"because that's also a central tumor."},{"speaker":"So remember central","startTime":2043.084,"endTime":2045.884,"body":"squamous, small cell."},{"speaker":"Peripheral","startTime":2046.174,"endTime":2048.214,"body":"adeno, large cell."},{"speaker":"Peripheral","startTime":2048.544,"endTime":2052.484,"body":"And so this definitely could be squamous,"},{"speaker":"Peripheral","startTime":2048.544,"endTime":2052.484,"body":"but I think usually squamous doesn't"},{"speaker":"Peripheral","startTime":2052.484,"endTime":2056.934,"body":"get as big to cause, and then it does"},{"speaker":"Peripheral","startTime":2052.484,"endTime":2056.934,"body":"not that rapid to, to be like this."},{"speaker":"Peripheral","startTime":2056.944,"endTime":2059.654,"body":"So this is definitely just I don't"},{"speaker":"Peripheral","startTime":2056.944,"endTime":2059.654,"body":"know, scream small cell lung cancer."},{"speaker":"Peripheral","startTime":2060.079,"endTime":2063.399,"body":"And really the only thing I got to do with"},{"speaker":"Peripheral","startTime":2060.079,"endTime":2063.399,"body":"this one is I got to go and do a biopsy."},{"speaker":"Peripheral","startTime":2063.719,"endTime":2065.349,"body":"And so this one, it's central."},{"speaker":"Peripheral","startTime":2065.399,"endTime":2068.646,"body":"So a bronchoscopy with a biopsy"},{"speaker":"Peripheral","startTime":2065.399,"endTime":2068.646,"body":"via that route would probably"},{"speaker":"Peripheral","startTime":2068.646,"endTime":2069.696,"body":"be the way that I would go here."},{"speaker":"Peripheral","startTime":2070.046,"endTime":2071.336,"body":"And I look to see what that would show."},{"speaker":"Peripheral","startTime":2072.046,"endTime":2075.876,"body":"The big thing here is whenever"},{"speaker":"Peripheral","startTime":2072.046,"endTime":2075.876,"body":"you do a biopsy for a small cell,"},{"speaker":"Peripheral","startTime":2075.876,"endTime":2082.096,"body":"what you would want to see is"},{"speaker":"Peripheral","startTime":2075.876,"endTime":2082.096,"body":"these poorly differentiated cells."},{"speaker":"Peripheral","startTime":2082.451,"endTime":2088.601,"body":"Very like small, round filled with like"},{"speaker":"Peripheral","startTime":2082.451,"endTime":2088.601,"body":"height, like lots and lots of chromatin."},{"speaker":"Peripheral","startTime":2088.921,"endTime":2092.111,"body":"And so it just shows that they're not"},{"speaker":"Peripheral","startTime":2088.921,"endTime":2092.111,"body":"really like very well differentiated."},{"speaker":"Peripheral","startTime":2092.581,"endTime":2096.321,"body":"The cells that these form from are"},{"speaker":"Peripheral","startTime":2092.581,"endTime":2096.321,"body":"what's called neuroendocrine cells."},{"speaker":"Peripheral","startTime":2096.331,"endTime":2098.698,"body":"So when you look at the lung epithelium,"},{"speaker":"Peripheral","startTime":2096.331,"endTime":2098.698,"body":"there's always the Pseudostratified"},{"speaker":"Peripheral","startTime":2098.698,"endTime":2101.951,"body":"ciliated columnar epithelial tissue."},{"speaker":"Peripheral","startTime":2101.951,"endTime":2104.841,"body":"Then you got these little basal cells,"},{"speaker":"Peripheral","startTime":2101.951,"endTime":2104.841,"body":"which are like the progenitor cells."},{"speaker":"Peripheral","startTime":2105.301,"endTime":2108.501,"body":"And then you got a lot of"},{"speaker":"Peripheral","startTime":2105.301,"endTime":2108.501,"body":"your cells that produce mucin."},{"speaker":"Peripheral","startTime":2108.501,"endTime":2109.851,"body":"So you have the goblet cells."},{"speaker":"Peripheral","startTime":2110.171,"endTime":2112.671,"body":"And then you also have neuroendocrine"},{"speaker":"Peripheral","startTime":2110.171,"endTime":2112.671,"body":"cells, and they make some hormones."},{"speaker":"Peripheral","startTime":2112.981,"endTime":2115.981,"body":"Whenever you have a malignancy for a small"},{"speaker":"Peripheral","startTime":2112.981,"endTime":2115.981,"body":"cell, it's a malignant transformation"},{"speaker":"Peripheral","startTime":2115.981,"endTime":2117.511,"body":"of those neuroendocrine cells."},{"speaker":"Peripheral","startTime":2117.836,"endTime":2119.686,"body":"They're called the Kulchitsky cells."},{"speaker":"Peripheral","startTime":2120.106,"endTime":2122.476,"body":"And so whenever you have rapid"},{"speaker":"Peripheral","startTime":2120.106,"endTime":2122.476,"body":"proliferation of those, they like"},{"speaker":"Peripheral","startTime":2122.486,"endTime":2127.026,"body":"poorly differentiate, they stain with"},{"speaker":"Peripheral","startTime":2122.486,"endTime":2127.026,"body":"particularly on immunohistochemistry."},{"speaker":"Peripheral","startTime":2127.026,"endTime":2130.696,"body":"You use immunohistochemistry to look"},{"speaker":"Peripheral","startTime":2127.026,"endTime":2130.696,"body":"for a very specific protein called"},{"speaker":"Peripheral","startTime":2130.716,"endTime":2134.106,"body":"chromogranin A. And so that would"},{"speaker":"Peripheral","startTime":2130.716,"endTime":2134.106,"body":"be what I'd be looking for here."},{"speaker":"Peripheral","startTime":2134.396,"endTime":2138.096,"body":"So that's what I'd be looking for is"},{"speaker":"Peripheral","startTime":2134.396,"endTime":2138.096,"body":"the staining positive for chromogranin."},{"speaker":"Peripheral","startTime":2138.126,"endTime":2141.951,"body":"I'd look for like the a"},{"speaker":"Peripheral","startTime":2138.126,"endTime":2141.951,"body":"small, round, hyperchromatic,"},{"speaker":"Peripheral","startTime":2141.991,"endTime":2143.531,"body":"poorly differentiated cells."},{"speaker":"Peripheral","startTime":2143.881,"endTime":2147.351,"body":"And that would really be the way that"},{"speaker":"Peripheral","startTime":2143.881,"endTime":2147.351,"body":"we would confirm small cell lung cancer."},{"speaker":"Peripheral","startTime":2147.681,"endTime":2148.581,"body":"We do the biopsy."},{"speaker":"Peripheral","startTime":2148.621,"endTime":2151.331,"body":"It does confirm the"},{"speaker":"Peripheral","startTime":2148.621,"endTime":2151.331,"body":"small cell lung cancer."},{"speaker":"Peripheral","startTime":2151.401,"endTime":2151.761,"body":"Okay."},{"speaker":"Peripheral","startTime":2151.891,"endTime":2154.091,"body":"What would be your next"},{"speaker":"Peripheral","startTime":2151.891,"endTime":2154.091,"body":"diagnostic steps here?"},{"speaker":"Peripheral","startTime":2154.611,"endTime":2157.851,"body":"The big thing here is you gotta know"},{"speaker":"Peripheral","startTime":2154.611,"endTime":2157.851,"body":"if it's like limited or extensive."},{"speaker":"Peripheral","startTime":2158.041,"endTime":2160.521,"body":"So we see that it's like"},{"speaker":"Peripheral","startTime":2158.041,"endTime":2160.521,"body":"large, it's central."},{"speaker":"Peripheral","startTime":2160.901,"endTime":2162.781,"body":"I don't really know how many"},{"speaker":"Peripheral","startTime":2160.901,"endTime":2162.781,"body":"lymph nodes are involved."},{"speaker":"Peripheral","startTime":2162.841,"endTime":2165.031,"body":"If they're pretty extensive in that sense."},{"speaker":"Peripheral","startTime":2165.606,"endTime":2167.346,"body":"So I'd probably do a PET CT."},{"speaker":"Peripheral","startTime":2167.816,"endTime":2168.626,"body":"That'd be the first thing."},{"speaker":"Peripheral","startTime":2168.626,"endTime":2171.546,"body":"It would show me like if it's"},{"speaker":"Peripheral","startTime":2168.626,"endTime":2171.546,"body":"isolated to the hemithorax."},{"speaker":"Peripheral","startTime":2171.566,"endTime":2174.856,"body":"If I got like limited,"},{"speaker":"Peripheral","startTime":2171.566,"endTime":2174.856,"body":"that's you're lucky."},{"speaker":"Peripheral","startTime":2174.886,"endTime":2176.906,"body":"You caught this early and"},{"speaker":"Peripheral","startTime":2174.886,"endTime":2176.906,"body":"there's more that we can do."},{"speaker":"Peripheral","startTime":2176.906,"endTime":2182.616,"body":"If it's extensive, that means it's beyond"},{"speaker":"Peripheral","startTime":2176.906,"endTime":2182.616,"body":"the, this ipsilateral thorax, hemithorax."},{"speaker":"Peripheral","startTime":2183.346,"endTime":2184.226,"body":"It's in the other one."},{"speaker":"Peripheral","startTime":2184.616,"endTime":2187.036,"body":"It's in multiple lymph"},{"speaker":"Peripheral","startTime":2184.616,"endTime":2187.036,"body":"nodes on the other side."},{"speaker":"Peripheral","startTime":2187.056,"endTime":2188.306,"body":"It's a spread to the brain."},{"speaker":"Peripheral","startTime":2188.306,"endTime":2190.626,"body":"It's spread to the adrenals,"},{"speaker":"Peripheral","startTime":2188.306,"endTime":2190.626,"body":"the liver, the bones."},{"speaker":"Peripheral","startTime":2191.026,"endTime":2194.906,"body":"I start with a PET CT and then you"},{"speaker":"Peripheral","startTime":2191.026,"endTime":2194.906,"body":"have to do an MRI of the brain."},{"speaker":"Peripheral","startTime":2195.386,"endTime":2198.806,"body":"The reason why is that this spreads,"},{"speaker":"Peripheral","startTime":2195.386,"endTime":2198.806,"body":"you can remember the mnemonic BLAB."},{"speaker":"Peripheral","startTime":2199.126,"endTime":2203.506,"body":"So with lung cancer, it"},{"speaker":"Peripheral","startTime":2199.126,"endTime":2203.506,"body":"metastasizes to the brain, the"},{"speaker":"Peripheral","startTime":2203.506,"endTime":2205.696,"body":"lungs, the adrenals, and the bone."},{"speaker":"Peripheral","startTime":2206.206,"endTime":2208.416,"body":"Those are the locations"},{"speaker":"Peripheral","startTime":2206.206,"endTime":2208.416,"body":"that I'm concerned about."},{"speaker":"Peripheral","startTime":2208.686,"endTime":2212.226,"body":"The one with the highest risk"},{"speaker":"Peripheral","startTime":2208.686,"endTime":2212.226,"body":"of mortality is the brain."},{"speaker":"Peripheral","startTime":2212.396,"endTime":2214.756,"body":"Because if that thing gets"},{"speaker":"Peripheral","startTime":2212.396,"endTime":2214.756,"body":"into the brain small cell lung"},{"speaker":"Peripheral","startTime":2214.756,"endTime":2216.026,"body":"cancer can bleed in the brain."},{"speaker":"Peripheral","startTime":2216.446,"endTime":2217.926,"body":"So you can get hemorrhage."},{"speaker":"Peripheral","startTime":2218.326,"endTime":2220.656,"body":"It can also cause seizures."},{"speaker":"Peripheral","startTime":2220.686,"endTime":2222.636,"body":"It can increase intracranial pressure."},{"speaker":"Peripheral","startTime":2223.016,"endTime":2226.316,"body":"So there's a lot more chances"},{"speaker":"Peripheral","startTime":2223.016,"endTime":2226.316,"body":"of neuro deficits, et cetera."},{"speaker":"Peripheral","startTime":2226.316,"endTime":2229.626,"body":"So that's the things I would do is"},{"speaker":"Peripheral","startTime":2226.316,"endTime":2229.626,"body":"I would start off, get a PET CT,"},{"speaker":"Peripheral","startTime":2229.626,"endTime":2231.346,"body":"see how extensive this thing is."},{"speaker":"Peripheral","startTime":2231.376,"endTime":2235.776,"body":"If it is extensive or did I get lucky"},{"speaker":"Peripheral","startTime":2231.376,"endTime":2235.776,"body":"and it's limited to that ipsilateral"},{"speaker":"Peripheral","startTime":2235.776,"endTime":2238.416,"body":"hemithorax and get a brain MRI to make"},{"speaker":"Peripheral","startTime":2235.776,"endTime":2238.416,"body":"sure that it's not spread to the brain."},{"speaker":"Peripheral","startTime":2238.626,"endTime":2241.066,"body":"For our patient must've been"},{"speaker":"Peripheral","startTime":2238.626,"endTime":2241.066,"body":"caught a little earlier."},{"speaker":"Peripheral","startTime":2241.866,"endTime":2243.766,"body":"It does show limited stage small cell."},{"speaker":"Peripheral","startTime":2244.646,"endTime":2247.196,"body":"What's our best treatment"},{"speaker":"Peripheral","startTime":2244.646,"endTime":2247.196,"body":"approach knowing this information?"},{"speaker":"Peripheral","startTime":2247.246,"endTime":2248.396,"body":"So it's still going to be aggressive."},{"speaker":"Peripheral","startTime":2248.396,"endTime":2251.006,"body":"So the diagnosis of small"},{"speaker":"Peripheral","startTime":2248.396,"endTime":2251.006,"body":"cell lung cancer, it's, again,"},{"speaker":"Peripheral","startTime":2251.356,"endTime":2252.256,"body":"you can catch it limited."},{"speaker":"Peripheral","startTime":2252.286,"endTime":2254.776,"body":"That's a great chance that you can"},{"speaker":"Peripheral","startTime":2252.286,"endTime":2254.776,"body":"maybe prolong survival, but the"},{"speaker":"Peripheral","startTime":2254.776,"endTime":2256.666,"body":"prognosis is still poor overall."},{"speaker":"Peripheral","startTime":2257.296,"endTime":2259.366,"body":"So you're going to do probably"},{"speaker":"Peripheral","startTime":2257.296,"endTime":2259.366,"body":"some type of platinum based"},{"speaker":"Peripheral","startTime":2259.366,"endTime":2260.696,"body":"chemotherapy for this patient."},{"speaker":"Peripheral","startTime":2261.046,"endTime":2265.086,"body":"So usually cisplatin is a common one"},{"speaker":"Peripheral","startTime":2261.046,"endTime":2265.086,"body":"and then you're going to combine that"},{"speaker":"Peripheral","startTime":2265.086,"endTime":2266.786,"body":"with another agent like a toposide."},{"speaker":"Peripheral","startTime":2267.126,"endTime":2269.476,"body":"And so that's usually you're"},{"speaker":"Peripheral","startTime":2267.126,"endTime":2269.476,"body":"going to be doing those things in"},{"speaker":"Peripheral","startTime":2269.476,"endTime":2271.606,"body":"combination with radiation therapy."},{"speaker":"Peripheral","startTime":2272.026,"endTime":2274.786,"body":"The point of this is that you're"},{"speaker":"Peripheral","startTime":2272.026,"endTime":2274.786,"body":"going to use these agents to try"},{"speaker":"Peripheral","startTime":2274.826,"endTime":2277.886,"body":"and kill some of the cancer and"},{"speaker":"Peripheral","startTime":2274.826,"endTime":2277.886,"body":"prevent it from continuing to grow."},{"speaker":"Peripheral","startTime":2278.336,"endTime":2280.546,"body":"The radiation therapy is also"},{"speaker":"Peripheral","startTime":2278.336,"endTime":2280.546,"body":"going to try to kill some of"},{"speaker":"Peripheral","startTime":2280.546,"endTime":2282.256,"body":"that micrometastasis as well."},{"speaker":"Peripheral","startTime":2282.636,"endTime":2285.946,"body":"You're just trying to hopefully"},{"speaker":"Peripheral","startTime":2282.636,"endTime":2285.946,"body":"improve their chances of"},{"speaker":"Peripheral","startTime":2286.106,"endTime":2287.356,"body":"living a little bit longer."},{"speaker":"Peripheral","startTime":2287.696,"endTime":2289.236,"body":"And trying to limit the spread."},{"speaker":"Peripheral","startTime":2289.726,"endTime":2292.406,"body":"The other thing is when you try"},{"speaker":"Peripheral","startTime":2289.726,"endTime":2292.406,"body":"to limit the spread, again, a"},{"speaker":"Peripheral","startTime":2292.406,"endTime":2294.236,"body":"very important area is the brain."},{"speaker":"Peripheral","startTime":2294.536,"endTime":2297.416,"body":"So sometimes we do prophylactic"},{"speaker":"Peripheral","startTime":2294.536,"endTime":2297.416,"body":"cranial irradiation."},{"speaker":"Peripheral","startTime":2297.766,"endTime":2299.976,"body":"see how they respond to the"},{"speaker":"Peripheral","startTime":2297.766,"endTime":2299.976,"body":"chemo and the radiation."},{"speaker":"Peripheral","startTime":2300.451,"endTime":2302.761,"body":"If they had a pretty good response,"},{"speaker":"Peripheral","startTime":2300.451,"endTime":2302.761,"body":"I think no matter what you should try"},{"speaker":"Peripheral","startTime":2302.761,"endTime":2307.341,"body":"to prophylactically cranially radiate"},{"speaker":"Peripheral","startTime":2302.761,"endTime":2307.341,"body":"to prevent that potential metastasis"},{"speaker":"Peripheral","startTime":2307.361,"endTime":2308.401,"body":"to the brain for this patient."},{"speaker":"Peripheral","startTime":2308.411,"endTime":2310.511,"body":"So that's the way that I"},{"speaker":"Peripheral","startTime":2308.411,"endTime":2310.511,"body":"would go about this one."},{"speaker":"Peripheral","startTime":2310.521,"endTime":2312.291,"body":"How about high yield complications?"},{"speaker":"Peripheral","startTime":2312.301,"endTime":2316.301,"body":"Anything we need to know, big"},{"speaker":"Peripheral","startTime":2312.301,"endTime":2316.301,"body":"complications for small cell lung cancer?"},{"speaker":"Peripheral","startTime":2316.401,"endTime":2318.561,"body":"It's all the same stuff that"},{"speaker":"Peripheral","startTime":2316.401,"endTime":2318.561,"body":"you get with a central mass."},{"speaker":"Peripheral","startTime":2318.571,"endTime":2321.201,"body":"So with the central mass, you can get"},{"speaker":"Peripheral","startTime":2318.571,"endTime":2321.201,"body":"post obstructive pneumonia, you can"},{"speaker":"Peripheral","startTime":2321.201,"endTime":2325.091,"body":"get wheezing, you can get coughing,"},{"speaker":"Peripheral","startTime":2321.201,"endTime":2325.091,"body":"you can get hemoptysis, right?"},{"speaker":"Peripheral","startTime":2325.231,"endTime":2328.081,"body":"If it's big enough and it's in the"},{"speaker":"Peripheral","startTime":2325.231,"endTime":2328.081,"body":"central portions where the superior"},{"speaker":"Peripheral","startTime":2328.081,"endTime":2331.001,"body":"vena cava or some of those nerves"},{"speaker":"Peripheral","startTime":2328.081,"endTime":2331.001,"body":"run through you may get compression"},{"speaker":"Peripheral","startTime":2331.001,"endTime":2334.011,"body":"symptoms It's not peripheral."},{"speaker":"Peripheral","startTime":2334.021,"endTime":2337.091,"body":"So you don't get plural effusions with"},{"speaker":"Peripheral","startTime":2334.021,"endTime":2337.091,"body":"this one too often unless it spreads"},{"speaker":"Peripheral","startTime":2337.261,"endTime":2341.981,"body":"and it spreads it can but the last thing"},{"speaker":"Peripheral","startTime":2337.261,"endTime":2341.981,"body":"is paraneoplastic this one has the most"},{"speaker":"Peripheral","startTime":2342.001,"endTime":2346.581,"body":"like variations of its paraneoplastic"},{"speaker":"Peripheral","startTime":2342.001,"endTime":2346.581,"body":"syndrome and it's funny because It's"},{"speaker":"Peripheral","startTime":2346.651,"endTime":2347.101,"body":"derived from neuroendocrine cells."},{"speaker":"Peripheral","startTime":2347.101,"endTime":2349.301,"body":"Neuroendocrine cells make hormones."},{"speaker":"Peripheral","startTime":2349.411,"endTime":2350.451,"body":"These make a couple of them."},{"speaker":"Peripheral","startTime":2350.761,"endTime":2352.191,"body":"First one is ADH."},{"speaker":"Peripheral","startTime":2353.911,"endTime":2357.081,"body":"I know you remember from the hyponatremia,"},{"speaker":"Peripheral","startTime":2353.911,"endTime":2357.081,"body":"or the sodium disorders lecture, right?"},{"speaker":"Peripheral","startTime":2357.171,"endTime":2357.721,"body":"Of course I do."},{"speaker":"Peripheral","startTime":2357.721,"endTime":2359.591,"body":"You thought I forgot?"},{"speaker":"Peripheral","startTime":2359.591,"endTime":2364.141,"body":"So, SIADH."},{"speaker":"Peripheral","startTime":2364.141,"endTime":2365.881,"body":"Syndrome of Inappropriate ADH Secretion."},{"speaker":"Peripheral","startTime":2366.341,"endTime":2368.161,"body":"A common cause of malignancy."},{"speaker":"Peripheral","startTime":2368.691,"endTime":2369.931,"body":"It could be drugs, right?"},{"speaker":"Peripheral","startTime":2369.931,"endTime":2370.811,"body":"That could definitely be one."},{"speaker":"Peripheral","startTime":2370.811,"endTime":2376.311,"body":"Sometimes pain and lung diseases can"},{"speaker":"Peripheral","startTime":2370.811,"endTime":2376.311,"body":"cause that, pituitary to produce ADH."},{"speaker":"Peripheral","startTime":2376.361,"endTime":2379.221,"body":"But sometimes it could be"},{"speaker":"Peripheral","startTime":2376.361,"endTime":2379.221,"body":"ectopically produced from a cancer."},{"speaker":"Peripheral","startTime":2379.631,"endTime":2382.991,"body":"Small cell lung cancers"},{"speaker":"Peripheral","startTime":2379.631,"endTime":2382.991,"body":"actually can make ADH."},{"speaker":"Peripheral","startTime":2383.381,"endTime":2385.861,"body":"If you make too much ADH, it"},{"speaker":"Peripheral","startTime":2383.381,"endTime":2385.861,"body":"goes to the collecting duct."},{"speaker":"Peripheral","startTime":2386.361,"endTime":2389.951,"body":"Acts on those vasopressin receptors"},{"speaker":"Peripheral","startTime":2386.361,"endTime":2389.951,"body":"and reabsorbs tons of water."},{"speaker":"Peripheral","startTime":2390.351,"endTime":2393.441,"body":"Water gets into the bloodstream, dilutes"},{"speaker":"Peripheral","startTime":2390.351,"endTime":2393.441,"body":"down the sodium, you can get hyponatremia."},{"speaker":"Peripheral","startTime":2393.861,"endTime":2397.041,"body":"And so that's one thing that we can"},{"speaker":"Peripheral","startTime":2393.861,"endTime":2397.041,"body":"see is SIADH in these patients via"},{"speaker":"Peripheral","startTime":2397.041,"endTime":2399.021,"body":"the presentation of hyponatremia."},{"speaker":"Peripheral","startTime":2399.021,"endTime":2400.121,"body":"Hyponatremia can present variably."},{"speaker":"Peripheral","startTime":2400.421,"endTime":2402.691,"body":"Maybe headaches, maybe"},{"speaker":"Peripheral","startTime":2400.421,"endTime":2402.691,"body":"nausea, maybe vomiting."},{"speaker":"Peripheral","startTime":2403.201,"endTime":2406.601,"body":"Sometimes it can cause enough edema in the"},{"speaker":"Peripheral","startTime":2403.201,"endTime":2406.601,"body":"brain that it can cause the ICP to go up."},{"speaker":"Peripheral","startTime":2406.601,"endTime":2409.171,"body":"If it's severe and acute"},{"speaker":"Peripheral","startTime":2406.601,"endTime":2409.171,"body":"enough, it can cause seizures."},{"speaker":"Peripheral","startTime":2409.241,"endTime":2410.291,"body":"That's a big concern."},{"speaker":"Peripheral","startTime":2411.041,"endTime":2412.831,"body":"Another one is Cushing's."},{"speaker":"Peripheral","startTime":2412.971,"endTime":2415.741,"body":"So not Cushing's syndrome,"},{"speaker":"Peripheral","startTime":2412.971,"endTime":2415.741,"body":"even though people want to call"},{"speaker":"Peripheral","startTime":2415.741,"endTime":2417.131,"body":"that it's Cushing's disease."},{"speaker":"Peripheral","startTime":2417.141,"endTime":2419.861,"body":"So Cushing's syndrome is when it's"},{"speaker":"Peripheral","startTime":2417.141,"endTime":2419.861,"body":"coming from the adrenal gland."},{"speaker":"Peripheral","startTime":2419.861,"endTime":2420.391,"body":"That's the problem."},{"speaker":"Peripheral","startTime":2420.391,"endTime":2421.761,"body":"It's the one pumping out cortisol."},{"speaker":"Peripheral","startTime":2422.101,"endTime":2426.561,"body":"Cushing's disease is when it's coming"},{"speaker":"Peripheral","startTime":2422.101,"endTime":2426.561,"body":"from another source that's producing ACTH."},{"speaker":"Peripheral","startTime":2426.601,"endTime":2427.681,"body":"Usually that's the pituitary."},{"speaker":"Peripheral","startTime":2427.681,"endTime":2429.091,"body":"It's like a pituitary adenoma."},{"speaker":"Peripheral","startTime":2429.451,"endTime":2432.251,"body":"Those micro adenomas can pump out ACTH."},{"speaker":"Peripheral","startTime":2432.901,"endTime":2436.261,"body":"If I were to do this patient, what"},{"speaker":"Peripheral","startTime":2432.901,"endTime":2436.261,"body":"I would have is I'd have a patient"},{"speaker":"Peripheral","startTime":2436.261,"endTime":2437.211,"body":"who would have high cortisol."},{"speaker":"Peripheral","startTime":2437.816,"endTime":2440.726,"body":"So they would present"},{"speaker":"Peripheral","startTime":2437.816,"endTime":2440.726,"body":"with a swollen moon face."},{"speaker":"Peripheral","startTime":2441.046,"endTime":2442.776,"body":"They present with a buffalo hump."},{"speaker":"Peripheral","startTime":2443.186,"endTime":2447.746,"body":"They present with the abdominal"},{"speaker":"Peripheral","startTime":2443.186,"endTime":2447.746,"body":"striae and a lot of central obesity."},{"speaker":"Peripheral","startTime":2448.036,"endTime":2449.336,"body":"Maybe even like high blood pressure."},{"speaker":"Peripheral","startTime":2449.386,"endTime":2450.556,"body":"You would check their cortisol."},{"speaker":"Peripheral","startTime":2450.736,"endTime":2451.481,"body":"It'd be elevated."},{"speaker":"Peripheral","startTime":2451.481,"endTime":2454.251,"body":"And you do all those workups that you"},{"speaker":"Peripheral","startTime":2451.481,"endTime":2454.251,"body":"would be doing for Cushing's syndrome,"},{"speaker":"Peripheral","startTime":2454.251,"endTime":2458.591,"body":"you do your low dose dexamethasone, you"},{"speaker":"Peripheral","startTime":2454.251,"endTime":2458.591,"body":"do the urinary cortisol, you check all"},{"speaker":"Peripheral","startTime":2458.601,"endTime":2463.811,"body":"these things, salivary cortisol, and"},{"speaker":"Peripheral","startTime":2458.601,"endTime":2463.811,"body":"then once you find that, okay, cool,"},{"speaker":"Peripheral","startTime":2463.821,"endTime":2466.251,"body":"let's figure out, is it coming from"},{"speaker":"Peripheral","startTime":2463.821,"endTime":2466.251,"body":"the adrenal, or is it coming from the"},{"speaker":"Peripheral","startTime":2466.251,"endTime":2470.331,"body":"pituitary, or is it coming from somewhere"},{"speaker":"Peripheral","startTime":2466.251,"endTime":2470.331,"body":"else like the lung, you check the ACTH"},{"speaker":"Peripheral","startTime":2470.331,"endTime":2474.371,"body":"levels, alright, and so the ACTH levels"},{"speaker":"Peripheral","startTime":2470.331,"endTime":2474.371,"body":"in this case would be through the roof."},{"speaker":"Peripheral","startTime":2475.251,"endTime":2477.811,"body":"And then what you would do is"},{"speaker":"Peripheral","startTime":2475.251,"endTime":2477.811,"body":"you would then say, okay, how do"},{"speaker":"Peripheral","startTime":2477.811,"endTime":2480.471,"body":"I know if it's coming from the"},{"speaker":"Peripheral","startTime":2477.811,"endTime":2480.471,"body":"pituitary or coming from the lung?"},{"speaker":"Peripheral","startTime":2480.991,"endTime":2484.221,"body":"And so then you do what's called a high"},{"speaker":"Peripheral","startTime":2480.991,"endTime":2484.221,"body":"dose dexamethasone suppression test."},{"speaker":"Peripheral","startTime":2484.581,"endTime":2487.361,"body":"And if you do that, you would"},{"speaker":"Peripheral","startTime":2484.581,"endTime":2487.361,"body":"suppress the pituitary, but you"},{"speaker":"Peripheral","startTime":2487.361,"endTime":2489.521,"body":"would not suppress the lung tumor."},{"speaker":"Peripheral","startTime":2489.841,"endTime":2493.291,"body":"And so the ACTH levels and"},{"speaker":"Peripheral","startTime":2489.841,"endTime":2493.291,"body":"cortisol levels will still be high."},{"speaker":"Peripheral","startTime":2493.731,"endTime":2497.819,"body":"That would make me think about a Cushing's"},{"speaker":"Peripheral","startTime":2493.731,"endTime":2497.819,"body":"disease due to an ectopic ACTH secretion."},{"speaker":"Peripheral","startTime":2498.489,"endTime":2502.319,"body":"The last one, I've never seen"},{"speaker":"Peripheral","startTime":2498.489,"endTime":2502.319,"body":"this- is Lambert Eaton syndrome."},{"speaker":"Peripheral","startTime":2502.729,"endTime":2504.719,"body":"It's just something that's been"},{"speaker":"Peripheral","startTime":2502.729,"endTime":2504.719,"body":"associated with lung cancer."},{"speaker":"Peripheral","startTime":2505.579,"endTime":2509.169,"body":"Lung cancer has antigens and"},{"speaker":"Peripheral","startTime":2505.579,"endTime":2509.169,"body":"these are abnormal tumor antigens."},{"speaker":"Peripheral","startTime":2509.589,"endTime":2511.999,"body":"And so your plasma cells"},{"speaker":"Peripheral","startTime":2509.589,"endTime":2511.999,"body":"will see those antigens."},{"speaker":"Peripheral","startTime":2512.479,"endTime":2514.939,"body":"And what will happen is you'll have"},{"speaker":"Peripheral","startTime":2512.479,"endTime":2514.939,"body":"interaction with other cells that"},{"speaker":"Peripheral","startTime":2514.939,"endTime":2516.429,"body":"will communicate to the plasma cells."},{"speaker":"Peripheral","startTime":2516.619,"endTime":2519.859,"body":"Let me make antibodies against those"},{"speaker":"Peripheral","startTime":2516.619,"endTime":2519.859,"body":"tumor antigens to try to get rid of them."},{"speaker":"Peripheral","startTime":2520.219,"endTime":2522.429,"body":"Those antibodies that you"},{"speaker":"Peripheral","startTime":2520.219,"endTime":2522.429,"body":"make towards the tumor."},{"speaker":"Peripheral","startTime":2522.429,"endTime":2523.859,"body":"Antigens may mimic."},{"speaker":"Peripheral","startTime":2524.309,"endTime":2529.039,"body":"or look similar to some of the antigens"},{"speaker":"Peripheral","startTime":2524.309,"endTime":2529.039,"body":"that are present on nerves, especially"},{"speaker":"Peripheral","startTime":2529.039,"endTime":2530.619,"body":"the nerves that go to our muscles."},{"speaker":"Peripheral","startTime":2530.969,"endTime":2534.719,"body":"There are the voltage gated calcium"},{"speaker":"Peripheral","startTime":2530.969,"endTime":2534.719,"body":"channels that are on the axon terminal."},{"speaker":"Peripheral","startTime":2535.009,"endTime":2537.669,"body":"Those antibodies can go and"},{"speaker":"Peripheral","startTime":2535.009,"endTime":2537.669,"body":"attach onto them, block them."},{"speaker":"Peripheral","startTime":2537.929,"endTime":2539.089,"body":"Calcium can't come in."},{"speaker":"Peripheral","startTime":2539.139,"endTime":2540.609,"body":"Your nerve can't release acetylcholine."},{"speaker":"Peripheral","startTime":2540.879,"endTime":2542.349,"body":"Your muscles can't contract."},{"speaker":"Peripheral","startTime":2542.659,"endTime":2544.249,"body":"You get proximal muscle weakness."},{"speaker":"Peripheral","startTime":2544.694,"endTime":2547.527,"body":"You'd be like, Oh, shoot, this"},{"speaker":"Peripheral","startTime":2544.694,"endTime":2547.527,"body":"looks like myasthenia gravis."},{"speaker":"Peripheral","startTime":2547.607,"endTime":2551.867,"body":"It's kind of like myasthenia gravis"},{"speaker":"Peripheral","startTime":2547.607,"endTime":2551.867,"body":"except with Lambert Eaton syndrome,"},{"speaker":"Peripheral","startTime":2551.917,"endTime":2553.957,"body":"it gets better with exertion."},{"speaker":"Peripheral","startTime":2553.958,"endTime":2558.197,"body":"Myasthenia gravis, it gets worse"},{"speaker":"Peripheral","startTime":2553.958,"endTime":2558.197,"body":"with exertion, the weakness."},{"speaker":"Peripheral","startTime":2558.497,"endTime":2560.587,"body":"So that's something that you would"},{"speaker":"Peripheral","startTime":2558.497,"endTime":2560.587,"body":"also be thinking about in this one."},{"speaker":"Peripheral","startTime":2561.157,"endTime":2561.497,"body":"All right."},{"speaker":"Peripheral","startTime":2561.637,"endTime":2566.017,"body":"In summation, Zach, that covers all"},{"speaker":"Peripheral","startTime":2561.637,"endTime":2566.017,"body":"three cases we had today on lung cancer."},{"speaker":"Peripheral","startTime":2566.157,"endTime":2569.707,"body":"If you had to send our audience"},{"speaker":"Peripheral","startTime":2566.157,"endTime":2569.707,"body":"away with a final high yield"},{"speaker":"Peripheral","startTime":2569.707,"endTime":2571.362,"body":"recap, What would you say?"},{"speaker":"Peripheral","startTime":2572.332,"endTime":2575.322,"body":"I think the biggest thing is to make sure"},{"speaker":"Peripheral","startTime":2572.332,"endTime":2575.322,"body":"that you follow the screening protocol."},{"speaker":"Peripheral","startTime":2575.402,"endTime":2579.912,"body":"According to the 80, greater than or"},{"speaker":"Peripheral","startTime":2575.402,"endTime":2579.912,"body":"equal to 20 pack your history, current,"},{"speaker":"Peripheral","startTime":2579.932,"endTime":2583.632,"body":"former, and former less than 15,"},{"speaker":"Peripheral","startTime":2579.932,"endTime":2583.632,"body":"you screen them low dose annual CTs."},{"speaker":"Peripheral","startTime":2584.172,"endTime":2587.812,"body":"If you get a nodule, risk stratify"},{"speaker":"Peripheral","startTime":2584.172,"endTime":2587.812,"body":"them, get a CT scan to get a"},{"speaker":"Peripheral","startTime":2587.812,"endTime":2588.922,"body":"better characteristic of it."},{"speaker":"Peripheral","startTime":2589.322,"endTime":2592.722,"body":"So you want to look at the characteristics"},{"speaker":"Peripheral","startTime":2589.322,"endTime":2592.722,"body":"of it to know, is it smooth, round,"},{"speaker":"Peripheral","startTime":2593.022,"endTime":2594.862,"body":"irregular, speculated, things like that."},{"speaker":"Peripheral","startTime":2595.192,"endTime":2596.212,"body":"You want to look at their risk."},{"speaker":"Peripheral","startTime":2596.292,"endTime":2596.872,"body":"Do they smoke?"},{"speaker":"Peripheral","startTime":2596.882,"endTime":2597.732,"body":"What's their age?"},{"speaker":"Peripheral","startTime":2598.127,"endTime":2602.667,"body":"And then also take into consideration"},{"speaker":"Peripheral","startTime":2598.127,"endTime":2602.667,"body":"of all of these things and the location"},{"speaker":"Peripheral","startTime":2602.667,"endTime":2604.777,"body":"as well and say, what should I do?"},{"speaker":"Peripheral","startTime":2604.847,"endTime":2605.747,"body":"Are they low risk?"},{"speaker":"Peripheral","startTime":2605.917,"endTime":2608.087,"body":"Just get another CT in six to 12 months."},{"speaker":"Peripheral","startTime":2608.637,"endTime":2609.907,"body":"Are they intermediate risk?"},{"speaker":"Peripheral","startTime":2609.917,"endTime":2610.547,"body":"Let's be safe."},{"speaker":"Peripheral","startTime":2610.567,"endTime":2611.657,"body":"Let's do a pet CT."},{"speaker":"Peripheral","startTime":2612.087,"endTime":2612.937,"body":"Are they high risk?"},{"speaker":"Peripheral","startTime":2613.007,"endTime":2614.167,"body":"Just go straight to biopsy."},{"speaker":"Peripheral","startTime":2614.167,"endTime":2616.497,"body":"So that's really important"},{"speaker":"Peripheral","startTime":2614.167,"endTime":2616.497,"body":"for non small cell."},{"speaker":"Peripheral","startTime":2616.497,"endTime":2617.787,"body":"Remember that there's only three."},{"speaker":"Peripheral","startTime":2617.887,"endTime":2621.417,"body":"There's squamous cell, there's"},{"speaker":"Peripheral","startTime":2617.887,"endTime":2621.417,"body":"adeno, and there's large cell."},{"speaker":"Peripheral","startTime":2622.132,"endTime":2626.842,"body":"They all have their distinct kind of"},{"speaker":"Peripheral","startTime":2622.132,"endTime":2626.842,"body":"characteristics in the sense that squamous"},{"speaker":"Peripheral","startTime":2626.842,"endTime":2628.892,"body":"is central, adeno, large cell, peripheral."},{"speaker":"Peripheral","startTime":2629.432,"endTime":2631.692,"body":"When you think about these, it helps"},{"speaker":"Peripheral","startTime":2629.432,"endTime":2631.692,"body":"you think about the way that they"},{"speaker":"Peripheral","startTime":2631.692,"endTime":2635.442,"body":"would present, but perineoplastic"},{"speaker":"Peripheral","startTime":2631.692,"endTime":2635.442,"body":"syndromes are commonly utilized"},{"speaker":"Peripheral","startTime":2635.472,"endTime":2639.802,"body":"on exams to differentiate these"},{"speaker":"Peripheral","startTime":2635.472,"endTime":2639.802,"body":"squamous cell, hypercalcemia, adeno,"},{"speaker":"Peripheral","startTime":2640.482,"endTime":2645.682,"body":"clotting, and also consider clubbing,"},{"speaker":"Peripheral","startTime":2640.482,"endTime":2645.682,"body":"the hypertrophic osteoarthropathy."},{"speaker":"Peripheral","startTime":2645.682,"endTime":2647.222,"body":"Large cell, tits."},{"speaker":"Peripheral","startTime":2647.567,"endTime":2651.567,"body":"Gynecomastia, so those are, I'm just"},{"speaker":"Peripheral","startTime":2647.567,"endTime":2651.567,"body":"trying to help you remember, but that's"},{"speaker":"Peripheral","startTime":2651.567,"endTime":2653.327,"body":"a, that's something to think about here."},{"speaker":"Peripheral","startTime":2653.857,"endTime":2662.227,"body":"Small cell, super, super aggressive,"},{"speaker":"Peripheral","startTime":2653.857,"endTime":2662.227,"body":"rapid, central mass that causes massive"},{"speaker":"Peripheral","startTime":2662.247,"endTime":2666.652,"body":"presentation almost all the time for"},{"speaker":"Peripheral","startTime":2662.247,"endTime":2666.652,"body":"your exams- superior Vena Cava Syndrome."},{"speaker":"Peripheral","startTime":2667.032,"endTime":2671.002,"body":"Remember the paraneoplastic syndrome"},{"speaker":"Peripheral","startTime":2667.032,"endTime":2671.002,"body":"for this one, SIADH, Cushing's"},{"speaker":"Peripheral","startTime":2671.002,"endTime":2672.942,"body":"disease, Lambert Eaton syndrome."},{"speaker":"Peripheral","startTime":2673.622,"endTime":2678.042,"body":"The other thing for these ones is"},{"speaker":"Peripheral","startTime":2673.622,"endTime":2678.042,"body":"that non small cell, it has a chance"},{"speaker":"Peripheral","startTime":2678.052,"endTime":2682.292,"body":"of being treated a little bit better"},{"speaker":"Peripheral","startTime":2678.052,"endTime":2682.292,"body":"based upon if it's stage 1 and 2."},{"speaker":"Peripheral","startTime":2682.292,"endTime":2684.312,"body":"You can actually surgically resect those."},{"speaker":"Peripheral","startTime":2684.642,"endTime":2686.442,"body":"Stage 3, it depends."},{"speaker":"Peripheral","startTime":2686.442,"endTime":2690.532,"body":"You might have to do chemo before it"},{"speaker":"Peripheral","startTime":2686.442,"endTime":2690.532,"body":"to shrink it, see if you can resect it."},{"speaker":"Peripheral","startTime":2690.532,"endTime":2695.052,"body":"If it's not, It's chemo radiation and"},{"speaker":"Peripheral","startTime":2690.532,"endTime":2695.052,"body":"you're probably doing targeted therapy"},{"speaker":"Peripheral","startTime":2695.052,"endTime":2701.102,"body":"depending upon the type of if there is any"},{"speaker":"Peripheral","startTime":2695.052,"endTime":2701.102,"body":"oncogenic drivers there for small cell,"},{"speaker":"Peripheral","startTime":2701.122,"endTime":2702.622,"body":"you just need to determine is it limited."},{"speaker":"Peripheral","startTime":2702.622,"endTime":2706.552,"body":"If it is limited, chemo radiation,"},{"speaker":"Peripheral","startTime":2702.622,"endTime":2706.552,"body":"prophylactic cranial irradiation."},{"speaker":"Peripheral","startTime":2706.987,"endTime":2707.857,"body":"It's extensive."},{"speaker":"Peripheral","startTime":2708.137,"endTime":2709.157,"body":"You don't really got much help."},{"speaker":"Peripheral","startTime":2709.707,"endTime":2710.667,"body":"It's probably just chemo."},{"speaker":"Peripheral","startTime":2711.837,"endTime":2712.167,"body":"All right."},{"speaker":"Peripheral","startTime":2712.577,"endTime":2713.267,"body":"That wraps it up."},{"speaker":"Peripheral","startTime":2713.267,"endTime":2715.657,"body":"That's all I had as far as"},{"speaker":"Peripheral","startTime":2713.267,"endTime":2715.657,"body":"questions for lung cancer."},{"speaker":"Peripheral","startTime":2715.657,"endTime":2716.557,"body":"That was a great episode."},{"speaker":"Peripheral","startTime":2716.557,"endTime":2716.947,"body":"Thank you."},{"speaker":"Peripheral","startTime":2717.207,"endTime":2717.637,"body":"Yeah, man."},{"speaker":"Peripheral","startTime":2717.637,"endTime":2718.027,"body":"Thank you."},{"speaker":"Peripheral","startTime":2718.077,"endTime":2720.787,"body":"And I hope that you guys liked it"},{"speaker":"Peripheral","startTime":2718.077,"endTime":2720.787,"body":"and I hope you liked this episode"},{"speaker":"Peripheral","startTime":2720.787,"endTime":2722.547,"body":"and you learned a lot and enjoyed it."},{"speaker":"Peripheral","startTime":2722.927,"endTime":2724.467,"body":"And again, if you guys do."},{"speaker":"Peripheral","startTime":2724.822,"endTime":2729.422,"body":"Help us out, support us on the"},{"speaker":"Peripheral","startTime":2724.822,"endTime":2729.422,"body":"platforms subscribe, comment, tell"},{"speaker":"Peripheral","startTime":2729.422,"endTime":2732.292,"body":"your friends, tell other individuals"},{"speaker":"Peripheral","startTime":2729.422,"endTime":2732.292,"body":"about what Ninja Nerd is doing."},{"speaker":"Peripheral","startTime":2732.292,"endTime":2734.602,"body":"And if it's helping, we'd love"},{"speaker":"Peripheral","startTime":2732.292,"endTime":2734.602,"body":"to continue to help others."},{"speaker":"Peripheral","startTime":2734.922,"endTime":2738.042,"body":"Also, on our website, if you guys are"},{"speaker":"Peripheral","startTime":2734.922,"endTime":2738.042,"body":"interested, we've got notes, we've"},{"speaker":"Peripheral","startTime":2738.042,"endTime":2740.462,"body":"got illustrations, we've got quiz"},{"speaker":"Peripheral","startTime":2738.042,"endTime":2740.462,"body":"questions, we've got a lot to offer."},{"speaker":"Peripheral","startTime":2740.832,"endTime":2741.682,"body":"So go check that out."},{"speaker":"Peripheral","startTime":2741.772,"endTime":2744.932,"body":"But, without further ado, love"},{"speaker":"Peripheral","startTime":2741.772,"endTime":2744.932,"body":"you guys, thank you guys, and"},{"speaker":"Peripheral","startTime":2744.932,"endTime":2746.192,"body":"as always, until next time."}]}