First Aid Pathology Pt 3: Lung cancer and abscess

Question 1

What symptoms does lung cancer present with?

Answer 1

Cough, hemoptysis, bronchial obstruction and wheezing

Question 2

How does lung cancer appear on a CXR and CT scan?

Answer 2

CXR: pneumonic “coin” lesion

CT: noncalcified nodule

Question 3

What are the common sites of metastasis for lung cancer?

Answer 3

“Lung mets ‘Love Affective Boneheads And Brainiacs’”

Liver, adrenals, bone, brain

Question 4

What might happen if lung cancer metastasizes to the liver?

Answer 4

Jaundice and hepatomegaly

Question 5

Which types of cancers tend to spread to the lung?

Answer 5

Breast, colon, prostate and bladder

Question 6

What are the complications of lung cancer?

Answer 6

SPHERE

Superior vena cava/thoracic outlet syndromes
Pancoast tumour
Horner’s syndrome
Endocrine (paraneoplastic)
Recurrent laryngeal nerve compressions (voice hoarseness)
Effusions (pleural or pericardial)

Question 7

How might lung cancer cause horner syndrome?

Answer 7

The growing tumour can cause compression of the sympathetic ganglion (the stellate ganglion), resulting in a range of symptoms known as Horner’s syndrome.

Question 8

What are the risk factors for lung cancer?

Answer 8

Smoking, secondhand smoke, radon, asbestos and FH

Question 9

What commonly causes squamous and small cell carcinomas?

Answer 9

“Squamous and Small cell carcinomas are Sentral (central) and caused by Smoking”

Question 10

List the different types of primary lung cancers, which is the most common? Which parts of the lung does each affect?

Answer 10

Small cell: small cell (oat cell) carcinoma: central

Non-small cell:

• adenocarcinoma (most common): peripheral
• SCC: central
• large cell carcinoma: peripheral
• bronchial carcinoid tumour: central or peripheral

Question 11

Describe the histological appearance of small cell (oat cell) carcinomas
*including what lab tests are positive

Answer 11

It’s a neoplasm of neuroendocrine Kulchitsky cells (small dark blue cells)

Positive lab tests: chromogranin A, neuron-specific enolase, synaptophysin

Question 12

Describe the pathology of small cell (oat cell) carcinoma, what can it produce?

Answer 12

Can be undifferentiated to very aggressive and produces (4 As)
1. ACTH: causing Cushing’s syndrome

2. ADH: body retains too much water
3. Antibodies against presynaptic Ca2+
   a) channels: lambert Eaton myasthenic syndrome - interferes with the ability of nerve cells to send signals to muscle cells
   a) neurons: paraneoplastic myelitis, encephalitis, subacute cerebellar degeneration
4. Amplification of myc oncogenes is common

Question 13

How is a small cell (oat cell) carcinoma managed?

Answer 13

Chemotherapy with/without radiotherapy

Question 14

Who is more commonly affected by adenocarcinomas? What genetic mutations and symptomatic feature is it associated with?

Answer 14

Women, more likely to arise in nonsmokers

Activating mutations include KRAS< EGFR and ALK
Associated with hypertrophic osteoarthropathy (clubbing)

Question 15

What would a bronchoalveolar subtype (adenocarcinoma in situ) CXR show?

Answer 15

Hazy infiltrates similar to pneumonia

Question 16

Describe the histological appearance of adenocarcinomas and its bronchoalveolar subtype

Answer 16

Adenocarcinoma: glandular pattern, often stains mucin +

Bronchoalveolar subtype: grows along the alveolar septa creating an apparent “thickening” of the alveolar walls, has tall columnar mucus containing cells

Question 17

Describe the histological appearance of SCCs in the lung

Answer 17

Keratin pearls and intracellular bridges

Question 18

Describe the pathology characteristics of SCCs in the lung

Answer 18

Arises from the bronchus, associated with the 3 Cs:

Cavitation, cigarettes, hyperCalcemia (which produces PTHrP)

Question 19

Describe the histological appearance of large cell carcinomas in the lung

Answer 19

Pleomorphic giant cells

Question 20

Describe the pathology characteristics of large cell carcinomas in the lung, what is it associated with, how is it treated and what is the prognosis like?

Answer 20

It is a highly anaplastic undifferentiated tumour with a poor prognosis. It is less responsive to chemo and must be removed surgically, has a strong association with smoking

Question 21

Describe the histological appearance of bronchial carcinoid tumours in the lung, what positive lab test can be found?

Answer 21

Nests of neuroendocrine cells, positive chromogranin A

Question 22

How is the prognosis for bronchial carcinoid tumours? Name three symptoms and what causes them

Answer 22

Good prognosis as it rarely metastasizes, the symptoms can be due to mass effect or carcinoid syndrome and can include wheezing, diarrhea and flushing (what da fuc)

Question 23

What is a lung abscess and what causes one?

Answer 23

A localized collection of pus within the parenchyma which can be caused by
1. Aspiration of oropharyngeal contents (especially in patients predisposed to going unconscious like alcoholics and epileptics)

2. Bronchial obstruction (i.e in cancer)

Question 24

What do air-fluid levels on a CXR investigating a lung abscess suggest? What are some plausible causative agents?

Answer 24

Cavitation, can be caused by anaerobes (i.e Bacteroides, fusobacterium) or S.aureus

Question 25

How is a lung abscess treated?

Answer 25

Antibiotics, drainage or surgery

Question 26

Where is a lung abscess secondary to aspiration more commonly found? Describe how the location differs depending on the patient’s position

Answer 26

More commonly found in the R lung:
RLL: if the patient is upright
RUL or RML: if the patient is lying down

Question 27

What is a Pancoast tumour and what else is it known as?

Answer 27

A tumour in the lung’s apex, also known as superior sulcus tumour

Question 28

What can a Pancoast tumour cause and what are resulting complications?

Answer 28

Can cause Pancoast syndrome by compressing/invading the surrounding local structures: LSSBBP

1. Recurrent laryngeal nerve ->hoarseness
2. Stellate ganglion -> horner’s
3. SVC -> SVC syndrome
4. Brachiocephalic vein -> brachiocephalic syndrome
5. Brachial plexus -> sensorimotor deficits
6. Phrenic nerve -> hemidiaphragm paralysis

Question 29

How would compression of the phrenic nerve in Pancoast syndrome be evident on a CXR?

Answer 29

Would see hemidiaphragm elevation

Question 30

Name three findings associated with Horner’s syndrome

Answer 30

Ipsi/unilateral ptosis (droopy eyelid), miosis (excessive constriction of the pupil), anhidrosis (inability to sweat normally)

Question 31

Describe what happens in superior vena cava syndrome

Answer 31

Obstruction of the SVC impairs the drainage from the

• Head: Facial plethora
• Neck: jugular venous distension
• Upper extremities: edema

Question 32

What commonly causes SVC syndrome?

Answer 32

Malignancy (i.e mediastinal tumour, Pancoast tumour), thrombosis

Question 33

Why is SVC syndrome considered a medical emergency?

Answer 33

If the obstruction is severe it can raise the intracranial pressure (causing headaches and dizziness), increasing the risk of an aneurysm/rupture of the intracranial arteries