Lung cancer Flashcards
Small cell lung cancer (SCLC) (oat cell cancer)
Kulchitsky cells
- ∼ 15%
- CENTRAL
- Strong correlation with cigarette smoking ! (molto raro nei non fumatori)
- Pulmonary neuroendocrine tumor; associated with several paraneoplastic syndromes (SIADH, Lambert Eaton, ACTH)
- Very aggressive ; early metastases
- Associated mutations: l-myc
Non-small cell lung cancer
(NSCLC) approx. 85%
Adenocarcinoma
∼ 40%👓
- Peripheral🧨
- Most common type of lung cancer overall and in women
- Most common lung cancer in non-smokers
- Associated mutations: EGFR , ALK , and KRAS
- Distant metastases are common
- Noninvasive subtype: bronchioloalveolar carcinoma!
- SCAR cancer: tipicamente è il tumore che insorge su cicatrici pregresse, soprattuto TBC
- la variante che maggiormente si associa a versamento pleurico
- Hypercoagulability and thrombophlebitis migrans (adenocarcinoma)
- Nonbacterial verrucous endocarditis (adenocarcinoma)
- Hypertrophic osteoarthropathy (also known as Pierre-Marie-Bamberger disease) :
- Clubbing of the fingers and toes (Hippocratic fingers)
- Swelling and pain in joints and long bones
Squamous cell carcinoma (SCC) 20-25%
- Central airways
- Strong association with smoking!
- Cavitary lesions are common👓
- Direct spread to hilar lymph nodes
- ↑ Parathyroid hormone-related protein (PTHrP) leads to hypercalcemia
- Related to Pancoast syndrome
Large cell carcinoma 5–10%
- Peripheral
- Late metastases
- Poor prognosis
- ginecomastia
- Can secrete β-hCG
General paraneoplastic manifestations
- cachexia, increased risk of thrombosis (and lung embolism!)
- Dermatomyositis
- Acanthosis nigricans
Approach to suspected lung cancer and workup of a solitary pulmonary nodule
1.Chest x-ray and comparison to previous images if available
2.CT imaging for further evaluation indicated if
-New lesion detected on chest x-ray
-Changes (e.g., enlargement) compared to previous
chest x-ray are inconclusive
-No previous CXR/CT is available
Assessment of lesion size and probability of malignancy (based on CT findings and patient characteristics)
- Increased probability of malignancy
- History of smoking
- Patient age > 40 years
- Other known risk factors (e.g., positive family history, asbestos exposure)
Chest x-ray
- Solitary nodule
- Indirect signs: atelectasis, postobstructive pneumonia, pleural effusion (particularly unilateral), mediastinal widening, cavitary lesions
CT imaging
Signs of malignancy
- Solid lesion ≥ 8 mm
- Irregular margins
- Spicules
- No or irregular calcifications
If the following signs are visible on CT imaging, biopsy needs to be performed to rule out lung cancer. In the absence of these findings, a follow-up CT is recommended at 3–6 months
Positron emission tomography (PET)
- More accurate than CT at differentiating between benign and malignant nodules
- Performed prior to biopsy if the CT imaging is inconclusive, particularly for patients with a high probability of malignancy
Bronchoscopy and biopsy
Confirmatory test
- Bronchoscopy with transbronchial biopsy: central nodules
- CT-guided transthoracic biopsy: peripheral nodules
- Thoracoscopy: if bronchoschopy or CT-guided biopsy are inconclusive, or in small peripheral nodules
- Mediastinoscopy: to biopsy mediastinal nodes or masses
Staging of diagnosed lung cancer
!CT scan (chest, liver, adrenal glands) to evaluate
Nodules: localization, size, margins, calcifications
Regional spread (hilar lymph nodes, mediastinal invasion, pleural effusions)
Distant metastasis (hepatic lesions, adrenal gland mass)
Carcinoid bronchial carcinoma
Indolent neuroendocrine tumor that rarely metastasizes. Carcinoid syndrome may occur.
- Round or oval opacities
- Size typically 2–5 cm
- Hilar or perihilar mass
Hamartomas
- “Popcorn” calcifications
- Round, well-circumscribed nodules, lobulated by respiratory epithelium
Histology findings
-Disorganized connective and epithelial tissue: predominantly cartilage that may undergo calcification or osseous changes
Fat, fibromyxoid tissue, sometimes smooth muscle
Size typically 1–3 cm
90% are peripheral, 10% are endobronchial 💥
Treatment NSCLC
- EGFR inhibitors (e.g., gefitinib) in advanced-stage NSCLC that is EGFR-positive
- ALK tyrosine kinase inhibitors (e.g., crizotinib) in advanced-stage NSCLC that is ALK-positive
Stage I and II: l’approccio è CURATIVE
Surgical resection ± adjuvant chemotherapy (radiation therapy is only required if the resection margins are not tumor free)
If surgery is not possible: radiation therapy + polychemotherapy
Stage IIIA: CURATIVE
Polychemotherapy + radiation therapy (per N2 è neoadiuvante)
Consider surgery if tumor size decreases significantly after initial treatment
Prophylactic cranial irradiation does not improve survival
Stage IIIB and IV
Palliative !
Polychemotherapy ± targeted therapy
Alternative: symptom-oriented palliative support
Radiation therapy may be considered for management of metastases and complications (e.g., bone pain, brain metastasis, SVC syndrome)
Pancoast tumors up to stage IIIB Curative
Neoadjuvant radiation therapy + polychemotherapy
Surgery
Managment SCLC
Limited disease (20%), Curative🧨
Polychemotherapy + radiation therapy
Usually unresectable; consider surgery in patients with very small, resectable lesions (solo T0N0M0)
-Prophylactic cranial irradiation in patients who respond to initial chemotherapy treatment
Extensive disease (75%), Palliative
Polychemotherapy
Radiation therapy if the patient responds well to initial chemotherapy
Prophylactic cranial irradiation if the patient responds to the initial chemotherapy treatment
Quale tumore polmonare può presentarsi come una lesione diffusa multinodulare?
Carcinoma squamoso. Carcinoma a piccole cellule. Carcinoma a grandi cellule. Adenocarcinoma. Carcinoma bronchio-alveolare.✔
I carcinomi polmonari bronchio-alveolari interessano le zone periferiche del polmone come un nodulo semplice o più frequentemente come noduli diffusi multipli che possono confluire per produrre consolidazioni di tipo polmonitico (risposta 5 corretta). Il nome deriva dalla modalità di accrescimento che si osserva al microscopio, dal momento che le cellule tumorali crescono lungo le strutture preesistenti, come bronchioli e alveoli. Le cellule tumorali sono alte e colonnari, a volte con muco intracellulare, essendo la maggior parte di queste ben differenziate.
SCENARIO Paziente di 72 anni, ex fumatore, senza antecedenti anamnestici. Giunge alla vostra osservazione per comparsa di parestesie e deficit di forza all’emilato di destra. Esegue una TC cerebrale che mostra una lesione di natura secondaria nell’emisfero di sinistra. Come approfondimento diagnostico esegue un TC toraco-addominale che mostra un processo eteroformato a margini spiculati del diametro di 4 cm al lobo superiore del polmone di destra. Alla TC PET captazione a livello della massa riscontrata. All’esame istologico viene diagnosticato un adenocarcinoma EGFR+. DOMANDA Qual è il chemioterapico di scelta?
CHT a base di Cisplatino Nivolumab Crizotinib Gefitinib Pembrolizumab
in presenza di espressività genica è indicato il trattamento specifico. In presenza di EGFR sono indicati gefitinib, erlotinib e afatinib; in presenza di ALK il crizotinib; in presenza di PDL-1 il pembrolizumab di prima linea ed il nivolumab in seconda linea.
