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Pulmonary Week 4 > ICL 3.6: Pathology of Pulmonary Tumors > Flashcards

ICL 3.6: Pathology of Pulmonary Tumors Flashcards

1
Q

what are the 2 types of primary lung tumors?

A
  1. small cell lung cancer (SCLC)

treated with chemo, with or without radiation – usually when you discover them they’re at an advanced stage with mets

  1. non-small cell lung cancer (NSCLC)

treated with surgical resection if localized at the time of the diagnosis; less often metastatic

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2
Q

what is the relationship of primary lung tumors with smoking?

A

increases incidence of all types of primary lung tumors

strongest association with squamous cell and small cell carcinomas

cancer which most likely occurs in non-smokers is adenocarcinoma

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3
Q

what are the risk factors for developing primary lung tumor?

A
  1. smoking
  2. industrial hazards

asbestos, radiation, nickel, arsenic, chromium

  1. air pollution

second hand smoke

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4
Q

which genetic factors are associated with primary lung tumor?

A

oncogenes and tumor suppressor genes associated include:

  1. small cell carcinoma = p53, C-MYC, RB
  2. non-small cell carcinoma = p53, RAS, p16
  3. familial clustering = Polymorphism in the cytochrome P-450 gene CYP1A1
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5
Q

what are the precursor lesions associated with primary lung tumors?

A
  1. squamous dysplasia = cells have undergone aggressive changes, large nuclei, but only part of the surface epithelium is involved
  2. carcinoma in situ = entire surface epithelium is involved but dysplastic cells don’t cross BM
  3. atypical adenomatous hyperplasia = associated with adenocarcinoma
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6
Q

what is the morphology of primary lung tumors?

A

squamous and small cell carcinoma usually arise most often in and around the hilum

it begins as a small area of in-situ atypia and progress  <1.0 cm of mucosal thickening 

progresses to an irregular*, warty lesion which elevates or erodes lining epithelium

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7
Q

what is the location of primary lung tumors?

A

adenocarcinomas are mostly peripheral (25%)

squamous cell and small cell carcinomas are usually centrally located in the 1st, 2nd and 3rd order bronchi (75% of primary tumors)

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8
Q

what is squamous cell carcinoma?

A

primary lung tumors more common in men

close association with smoking

occurs in larger, more central bronchi, but incidence in periphery is increasing

paraneoplastic syndrome: hypercalcemia due to tumor producing parathyroid hormone like peptide

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9
Q

50 year old woman, non smoker, presents with cough and hemoptysis for three months. PE negative
Chest x ray peripheral coin lesion in RT middle lobe.

diagnosis?

tests?

A

adenocarcinoma of the lung

common in women non-smokers and presents with peripheral lesions

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10
Q

what are adenocarcinomas?

A

non-small cell lung cancer most common type in women and in nonsmokers

> 75% found in smokers

more peripherally located; arise from bronchi

80% mucin secreting

grow slower than squamous cell carcinomas; tend to be smaller so better prognosis

may be associated with scars

the majority are positive for TTF1 = thyroid transcription factor 1 –> can be used as a marker for diagnosing adenocarcinoma

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11
Q

what is a common mutation associated with adenocarcinoma?

A

EGFR mutations (epidermal growth factor receptor gene)

common in Asian women

can be treated with EGFR inhibitors (promising response)

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12
Q

what is a bronchioloalveolar carcinoma?

A

a subtype of adenocarcinoma with relatively good prognosis

1-9% of all lung cancers

arises in pulmonary parenchyma in terminal bronchioloalveolar regions

equal incidence in males and females

start in second decade of life

symptoms appear late and include cough, hemoptysis and pain

metastases – late; in 45% of cases

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13
Q

what are the gross and microscopic changes seen in bronchioloalveolar carcinoma?

A

gross = solid gray white area(s)

microscopic:
1. no evidence of stromal, vascular, or pleural invasion

  1. growth along preexisting bronchioles without destruction of alveolar architecture
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14
Q

60 year old female smoker presents with a seizure, she had a cough with blood streaked sputum for two months. CXR shows hilar lesion in the right lung.

diagnosis?

cause of seizure?

tests?

A

small cell-cancer of the lung

hyponitremia paraneoplastic syndrome causing seizure

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15
Q

what is small cell carcinoma?

A

occurs in cigarette smokers, only 1% in non-smokers

M > F

most aggressive of lung cancers, rapid growth, metastasize, widely and are incurable by surgical resection because by the time we’ve found it, it’s already metastasized –> metastasize early to lymph nodes and hematogenously

hilar or central location

most common pattern associated with ectopic hormone production (ACTH SIADH) = paraneoplastic syndrome

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16
Q

what is the histology of small cell carcinoma?

A

very undifferentiated; looks like purple cells everywhere

round, blue cells with “salt and pepper” chromatin

neurosecretory granules (EM) because it’s a neuroendocrine tumor

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17
Q

where do small cell carcinomas spread to?

A

more than 50% spread to lymph nodes: tracheal, bronchial and mediastinal

can extend to the pleural surface and then pleural cavity or into the pericardium

distant spread; favorite sites include:
1. adrenal (>50%)

  1. liver (30-50%)
  2. brain (20%)
  3. bone (20%)

metastases may be first sign of disease**

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18
Q

A 70 year old lady present with ptosis of her left eye for two weeks. She has been coughing for the last three months.
PE: miosis of the left pupil.

What would you like to ask her?

diagnosis?

A

lung cancer pressing on the sympathetic ganglion = Horner syndrome

miosis = pupil constriction

ptosis = droopy eyelid

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19
Q

what are the local effects of a small cell carcinoma spreading to other parts of the body?

A
  1. pneumonia*, abscess, lobar collapse –> tumor obstruction of airway
  2. lipoid pneumonia –> tumor obstruction, accumulation of cellular lipid in foamy macrophages
  3. pleural effusion –> tumors spread into pleurae
  4. hoarseness –> recurrent laryngeal nerve invasion
  5. diaphragm paralysis –> phrenic nerve invasion
  6. rib destruction –> chest wall invasion
  7. SVC syndrome* –> SVC compression by tumor; patient presents with face and arm swelling with purple discoloration
  8. Horner syndrome* –> ptosis, miosis and anhydrous due to sympathetic ganglion invasion
  9. pericarditis, tamponade
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20
Q

what is a paraneoplastic syndrome?

A

clinical syndromes that cannot readily be explained, either by the local or distant spread of the tumor or by the elaboration of hormones indigenous to the tissue from which the tumor arose

they occur in 1 to 10% of patients with lung cancer

may precede the development of a gross pulmonary lesion

may cause significant clinical problems

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21
Q

what are some of the paraneopalstic syndromes associated with lung cancer?

A
  1. SIADH*
  2. parathormone, parathyroid hormone-related peptide, prostaglandin E* –> cause hypercalcemia and is associated with squamous cell carincoma
  3. calcitonin-hypocalcemia
  4. gonadotropins - gynecomastia
  5. serotonin-carcinoid syndrome
  6. adrenocorticotrophic hormone (ACTH)* –> Cushing’s syndrome; small cell carcinoma
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22
Q

what is SIADH?

A

secretion of inappropriate ADH

patient will have hyponatremia which is associated with small cell carcinoma

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23
Q

what are the systemic manifestations of small cell lung cancer?

A
  1. Lambert-Eaton
  2. dermatologic changes (acanthosis nigricans)
  3. hypertrophic pulmonary osteoarthropathy
  4. infiltration of the sympathetic plexus causing Horner’s related to Pancoast tumors
24
Q

what is Lambert-Eaton?

A

antibodies to neuronal calcium channels

muscles weakness that gets better with use (MG gets worse with use!)

this is a systemic manifestation of small cell lung cancer

25
Q

what metastatic disease is associated with lung cancer?

A

common sites of metastases include:

  1. brain
  2. bone
  3. adrenal
  4. liver

cervical and supraclavicular (Virchow’s node) lymphadenopathy

26
Q

what are the complications of lung cancer?

A
  1. atelectasis if obstructing the main bronchus
  2. pneumonia
  3. lung abscess
  4. bleeding
  5. esophago-pleural fistula
  6. effects of metastases on other organs
  7. compression of the superior vena cava (Pancoast tumor)
27
Q

Horner’s syndrome

A

pancoast tumor

28
Q

what are neuroendocrine tumors of the lungs? what are the 2 types?

A

they are tumors that arise form neuroendocrine cells

two types:
1. carcinoid

2 small cell carcinoma

29
Q

what is a carcinoid lung tumor?

A

most patients < 40 yrs.; M=F;

20-40% non-smokers

generally located in the main stem bronchus

30
Q

what are the microscopic changes seen in carcinoid lung tumors?

A

arise from neuroendocrine cells in the bronchial epithelium

  1. contain dense neurosecretory granules in the cytoplasm
  2. cells grow in clusters, uniform round nuclei
  3. epithelial cells twice the size of lymphocytes, round or oval, scant cytoplasm
  4. in some cases spindle shaped or polygonal
31
Q

what is carcinoid syndrome?

A

intermittent attacks of:
1. flushing

  1. diarrhea
  2. cyanosis because they get asthmatic
  3. right sided heart lesions
32
Q

what causes carcinoid tumors?

A
  1. intraluminal growth – dyspnea, infections, bronchiectasis, etc.
  2. capacity to metastasize – distant metastases rare.
  3. ability to elaborate vasoactive amines – carcinoid syndrome –rare
33
Q

what is the most common tumor of the lung?

A

metastatic tumors

can be spread hematogenous, lymphatics or direct spread

34
Q

what are the 3 patterns of metastatic tumors in the lungs?

A
  1. multiple nodules in the lung periphery
  2. peribronchiolar and perivascular lymphatics

diffuse infiltration of lung septa and connective tissue

lymphangitis carcinomatosis – subpleural lymphatics

  1. no macroscopic change, microscopic only at autopsy
35
Q

what is a coin lesion of the lung?

A

a solitary, circumscribed mass greater than 1.5 cm in diameter on a chest x-ray

can be malignant or benign

malignant = bronchogenic carcinoma, metastasis

benign = hamartomas, granulomas, abscess

36
Q

what is malignant mesothelioma?

A

tumor involving the visceral or parietal pleura usually caused by asbestos exposure

90% asbestos related; lifetime risk 7-10%

late period 25-45 years after exposure

risk not increased in smokers** –> risk of lung cancer with asbestos exposure IS increased in smokers

37
Q

what is the clinical presentation of mesothelioma?

A

dyspnea, chest pain, recurrent pleural effusions

pulmonary asbestosis in 20%

death within 12 months of diagnosis in 50%

invades lung directly

metastases to hilar LN, liver

38
Q

what are the central tumors of the lungs?

A
  1. small cell (pst aggressive, hilarious, smoking, usually metastasized by the time we find it, SIADH, hyponitremia, Lambert-Eaton, Cushing Syndrome)
  2. squamous cell (smoking, hilar, paraneoplastic parathyroid hormone peptide with hypercalcemia and constipation)

usually associated with smoking

39
Q

what are the peripheral tumors of the lungs?

A
  1. adenocarcinoma (usually nonsmoker, women, +TTF1, mutation of EGF)
  2. bronchioalveolar carcinoma (nonsmoker, very young males, good prognosis)
40
Q

what are the 3 paraneoplastic syndromes associated with small cell carcinoma?

A
  1. SIAHD = hyponatremia
  2. Lambert-Eaton
  3. ACTH: Cushing Syndrome
41
Q

A six year old child puts the contents of a bag of peanuts in his mouth and then takes a deep breath with the idea of blowing the peanuts out all over his sister. However, he aspirates a peanut during this maneuver. One day later, he has slight dyspnea. On physical examination, his temperature is 36.8° C, pulse 70/min, respirations 17/min, and blood pressure 90/60 mm Hg. There are decreased breath sounds on auscultation and increased tympany on percussion over the right lower lung posteriorly. A chest CT scan shows a hemicircular area of density in the right lower lobe. Laboratory studies show a hemoglobin concentration of 13.6 g/dL and WBC count of 6175/mm3 . Gram stain of sputum shows normal flora. Which of the following complications has this child most likely developed?

A

atelectasis due to inhaled peanut obstructing bronchiole

42
Q

what is atelectasis?

A

incomplete expansion or collapse of previously inflated lung, producing areas of relatively airless pulmonary parenchyma

can occur at birth or anytime afterwards

reversible, since collapsed lung can be reinflated EXCEPT with contraction atelectasis associated with scaring

43
Q

what are the 3 types of atelectasis?

A
  1. obstructive
  2. compression
  3. contraction

local or diffuse fibrotic changes in the lung or pleura prevent lung expansion

44
Q

what is obstructive atelectasis?

A

complete obstruction of an airway causes resorption of oxygen distally

can occur due to excessive bronchial secretions and mucus plugging (bronchial asthma, chronic bronchitis, post-op complication) or aspirated foreign bodies

tumors produce incomplete obstruction and localized emphysema

mediastinum may shift toward affected lung**

45
Q

what is compression atelectasis?

A

filled pleural cavity (fluid, tumor, blood clot, or air)- partial or complete like from cardiac failure or neoplastic effusions or neumothorax

abnormally elevated diaphragm -basal atelectasis

mediastinum may shift away affected lung**

46
Q

sand blaster

A

silicosis

47
Q

shipyard worker

A

asbestos

48
Q

pleural plaque

A

asbestos

49
Q

increased REID index

A

chronic bronchitis

50
Q

acute CORE pulmonale

A

PE

51
Q

aspirin

A

intrinsic asthma

52
Q

foul smelling sputum

A

bronchiestasis

53
Q

failure to clear surfactant

A

pulmonary alveolar proteinosis

54
Q

mucin, young age, good prognosis

A

bronchoalveolar carcinoma

55
Q

hypercalcemia

A

squamous cell carcinoma of the lung

and sarcoidosis

56
Q

most common lung cancer in women

A

adenocarcinoma

Pulmonary Week 4 (6 decks)

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