Lung Cancer Flashcards
Adenocarcinoma cell markers
TTF-1, napsin A, cytokeratin 7, CK20-, MOC-31
- TTF thyroid and lung, ADENO
- overexpression is favorable prognosis
- Napsin A- regulated by TTF.
- If TTF1 and Napsin A positive, highly likely AdenoCA with lung primary (vs mets)
- MOC 31 can differentiate AdenoCA from meso
Squamous cell markers
p63, cytokeratin 5/6
Treatment NSCLC stage 1
surgery alone, chemo only in 1B if tumor >4cm
Treatment NSCLC stage 2
Surgery (lobectomy), adjuvant chemo. Radiation reserved for poor surgical candidates or positive surgical margins.
Treatment NSCLC stage 3
Chemoradiotherapy
Treatment NSCLC stage 4
chemotherapy alone + radiation for palliation
Driver mutations that effect treatment in NSCLC
- EGF-single agent EGF-R TKI (erlotinib, getinib, afatinib)
2. ALK- Crizotinib
Treatment Pancoast tumor
The one exception for neoadjuvant chemotherapy + radiation and then resection
Treatment SVC syndrome.
- small cell- chemo
2. NSCLC- chemo + XRT
Treatment of Carcinoid
Typical: segmentectomy and regional LN dissection
-mets: no known benefit of chemo or XRT
Markers Small Cell
TTF-1, CD 56, Ki 67, synaptophysin, 1/3 chromogranin
Treatment of small cell
- Limited (one radiation portal or hemithorax): chemo (Pt + etoposide)+ XRT x4-6 cycles
- 50% with complete clinical response - Extensive: chemotherapy. Radiation strictly palliative.
Role of prophylactic whole brain radiation in SCLC
added if there is complete or partial response in both limited and extensive disease
Adenocarcinoma: send molecular testing
EGFR, KRAS, ALK
Marker for Carcinoid
CD 56, synaptophysin, chromogranin
Path buzzwords: SCC
keratinization, intracellular bridges
Path buzzwords: Adenocarcinoma
glandular architecture, cytoplasmic mucin on PAS
Path buzzwords: small cell
small/round fusiform shape, scant cytoplasm, “salt and pepper” chromatin
Path buzzwords: Carcinoid
Round, oval nuclei, finely dispersed chromatin, inconspicuous nucleoli
Adenocarcinoma mutations.
- EGFR- women, E Asian, nonsmoker
- high response to EGF TKI - KRAS- white, smokers- resist TKI and assoc with worse outcomes
- ALK- young, nonsmoker.
Erlotinib, gefitinib
EGF TKI
Crizotinib, ceritinib
ALK inhibitor
EGFR, KRAS, ALK: simultaneous?
almost always mutually exclusive
Markers for Pleural Lesion
Meso: +vimentin, +calretinin, -PAS, -CEA
Adeno: -vimentin, -calretinin, + PAS, +CEA, MOC 31
When to get screening CT or MRI brain?
If neuro sx, and all patients with stage III/IV disease (3% risk of brain mets in asx individual, 14% all patients)
T1 tumor
-subdivide
< or = 3cm -surrounded by lung or visceral pleural -without bronchoscopic evidence of invasion to mainbronchus 1a= < or = 1cm 1b>1cm 2cm but
T2 tumor
-subdivide
Tumor >3cm but < or = 5cm or any tumor:
- Involves main bronchus, regardless of distance to carina (without involvement of carina)
- Invades visceral pleural
- Assoc with atelectasis or obstructive pneumonitis that extends to hilar region, involving part or all of lung
T3
> 5cm but < or = 7cm or any tumor with:
- associated nodule in same lobe as primary.
- Chest wall (parietal pleura, superior sulcus)
- Phrenic nerve
- Parietal pericardium
T4
Tumor >7cm or associated nodule in different ipsilateral lobe or invades:
- Diaphragm
- Mediastinum
- Heart
- Great vessels
- Trachea
- Recurrent laryngeal nerve
- Esophagus
- Vertebral body
- Carina
N0
No regional LN involvement
N1
Mets to ipsilateral peribronchial and/or ipsilateral hilar and intrapulmonary nodes
N2
ipsilateral mediastinal and/or subcarinal LN
N3
Mets to contralateral mediastinal, contralateral hilar, ipsilateral/contralateral scalene or supraclavicular
If you have N2 involvement, lowest possible stage:
IIIA
If you have N3 involvement, lowest possible stage
IIIB
If you have T4 tumor, lowest possible stage
IIIA
If you have T3 tumor, lowest possible stage
IIB
Treatment of NSCLC with checkpoint inhibitor
(PD-1 and PD-L1 inhibitor) help immune system recognize cancer as foreign and attack it.
First Line: if 50% of cancer cells have positive PD-L1 stain, pembrolizumab is 1st line
Second Line: if 1% of cancer cells have positive PD-L1–> pembrolizumab
-Nivolumab and atezolizumab second-line therapy for progression of NSCLC after receiving Pt-based chemo, regardless of cancer histology or need for PD-L1 testing
If you have N1 involvements, at least:
Stage II B
Low Dose Screening CT- Who to screen
55-74yo, asymptomatic patients
- at least 30 pack year smoking history
- current or quit within the last 15 years
Most common benign lung neoplasm:
- Pathology
- Tx
Hamartoma
- mature hyaline cartilage with fat, fibromyxoid tissue, and/or smooth muscle
- Tx if symptomatic
Benign lung neoplasm associated with TS (and sometimes LAM)
micronodular pneumocyte hyperplasia
N1 at least:
IIB
T3 at least:
IIB
N2 at least:
III A
T4 at least:
III A
N3 at least
IIIB
-also T3 or T4 with N2
Masses in ____ mediastinum are more likely to be malignant:
Anterior
Boundaries of:
- Anterior Mediastinum-
- Middle Mediastinum-
- Posterior
- Sternum to anterior to great vessels
- Heart, pericardium, asc aorta, brachiocephalic veins, trachea, bronchi, LNs
- Posterior aspect of heart and trachea to posterior vertebral bodies, include: desc aorta, esophagus, azygous, autonomic ganglia, thoracic LN, fat
Paraneoplastic syndromes associated with thymoma:
1, Hypogammaglobulinemia
- MG
- Pure red cell aplasia
Paraneoplastic syndromes mostly associated with ___ type of cancer?
-Except Hypercalcemia
and hypertrophic pulmonary osteoarthropathy
- Small cell lung cancer
- SCC
- adenoCA
Neurogenic Paraneoplastic Syndromes:
- Limbic encephalitis, brainstem encephalitis, cerebellar degen, myelopathy
- Cerebellar degen
- Lambert-Eaton
(exclusively in small cell)
- Anti-Hu
- Anti-Yo
- Ab to voltage-gated calcium channel type P/Q
Differentiate small cell from carcinoid on markers
Both have synaptophysin, chromogranin, CD 56
-Carcinoid lacks TTF-1
First line therapy for ALK + NSCLC?
Alceitinb, Crizotinib, ceritinib
Therapy for EGFR mutation in stage IV NSCLC?
osimertinib, erlotinib
Markers carcinoid vs Small Cell
- Carcinoid: synaptophysin, chromogranin, CD 56
- SCC synaptophysin, chromogranin, TTF-1, negative Napsin A
