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Pulmonary Review > Lung Neoplasms > Flashcards

Lung Neoplasms Flashcards

1
Q

What 2 things are risk factors for squamous papillomas in the large airways?

A

Smoking

HPV

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2
Q

What HPV serotypes are associated with recurrent respiratory papillomatosis/juvenile laryngotracheal papillomatosis?

A

11 and 6

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3
Q

Treatment for recurrent respiratory papillomatosis/juvenile laryngotracheal papillomatosis?

A

Surgical excision and laser ablation

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4
Q

This condition is characterized by numerous small, well-demarcated parenchymal nodules, associated with tuberous sclerosis and/or LAM, path show hyperplastic type II pneumocytes, and treatment is not indicated as it doesnt progress

A

Micronodular pneumocyte hyperplasia

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5
Q

This is the most common benign lung neoplasm, common in men in 6th and 7th decade of life, have popcorn calcification, and are made of hyaline cartilage with fat, fibromyxoid tissue, and/or smooth muscle cells

A

Hamartomas

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6
Q

A 23-year-old man presents with cavitary lung nodules and a vocal polyp. He has a history of hoarseness as a child. What is the diagnosis?

A

Recurrent respiratory papillomatosis with lung involvement, most likely squamous cell cancer

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7
Q

These are rare spindle cell tumors also referred to as localized fibrous mesotheliomas, arise from visceral or parietal pleura, diagnosed in 6th decade of life in men and women equally

A

Solitary fibrous tumor

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8
Q

This form of NSCLC is a malignant epithelial tumor with keratinization and/or intercellular bridges on pathology, associated with smokers, centrally located, and associated with cavitation, Pancoast syndrome, and hypercalcemia

A

Squamous cell carcinoma

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9
Q

What markers stain positive on squamous cell carcinoma?

A

p63

Cytokeratin 5/6

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10
Q

What markers stains positive on adenocarcinoma??

A

Thyroid transcription factor-1
Napsin A
Cytokeratin 7

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11
Q

This subtype of adenocarcinoma arise from cuboidal/columnar cells that form acini and tubules

A

Acinar

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12
Q

This subtype of adenocarcinoma has malignant cells arranged on the surface of fibrobascular cores

A

Papillary

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13
Q

This subtype of adenocarcinoma is also known as adenocarcinoma in situ, and is characterized by slow lepidic growth

A

Bronchioalveolar carcinoma

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14
Q

Name 2 other adenocarcinoma subtypes

A

Solid with mucin production

Mixed subtype

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15
Q

True/False: because bronchiolalveolar carcinoma does not invade nearby structures, they have a 100% 5 year survival rate if the lesion is <2cm at the time of resection.

A

TRUE

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16
Q

These lung cancers are undifferentiated malignant epithelial tumors that lack features of small cell carcinoma and glandular or squamous differentiation, and are characterized by large nuclei, prominent nucleoli, and a moderate amount of cytoplasm

A

Large cell carcinoma

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17
Q

What differentiates typical from atypical carcinoid tumors based on # of mitoses and necrosis?

A

Typical: <2 mitoses per 10 HPF and ABSENCE of necrosis

Atypical: >2 mitoses per 10 HPF OR PRESENCE of necrosis

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18
Q

What is the classic clinical features of carcinoid tumors?

A

Usually in never smokers
70% in proximal airways and associated with cough, hemoptysis, and obstruction
<2% have carcinoid syndrome
Low moderate acitivity on PET

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19
Q

Treatment for typical carcinoid tumors?

A

Limited resection with segmentectomy and regional lymph node dissection

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20
Q

Treatment for atypical carcinoid tumors?

A

Lobectomy and mediastinal lymph node dissection

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21
Q

Treatment for carcinoid tumors that metastasize?

A

No benefit for chemo or radiation

Local treatment of mets may lead to prolonged remission

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22
Q

Give me the 5 year survival rates based on the following stages:

IA
IB
IIA
IIB
IIIA
IIIB
IV
A 
IA 73%
IB 58%
IIA 46%
IIB 36%
IIIA 24%
IIIB 9%
IV 13%
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23
Q

Any metastasis in lung cancer (M1a or b) automatically gets you in what stage, regardless of tumor size?

A

Stage IV

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24
Q

Stage IA is made up of T1a or T1b, with always N0. What differentiates T1a and T1b?

A

T1a ≤ 2 cm

T1b >2cm but < 3cm

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25
Q

What tumor staging is stage IB lung cancer?

A

T2a (3-5cm), N0, M0

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26
Q

Stage IIA consists of T1a, T1b, or T2a + what other tumor staging feature?

A

N1

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27
Q

What is N1 mean?

A

Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodules involved by direct extension of the primary tumor

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28
Q

So stage IIA consists of T1a, T1b, and T2a + N1, as well as what other tumor stage with N0?

A

T2b

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29
Q

Tumor size in T2b?

A

5-7cm

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30
Q

What 2 stages are in stage IIB lung cancer?

A

T2b, N1, M0

T3, N0, M0

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31
Q

Tumor characteristics in T3 disease?

A

Tumor of any size that invades chest wall, diaphragm, mediastinal pleural, pericardium, or tumor in main bronchus <2cm distal to the carina without involvement of carina, associated atelectasis or obstructive pneumonitis of the entire lung, or separate tumor nodules in the same lobe

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32
Q

Fill in the blank for the staging system for stage IIIA lung cancer:

Any T between T1a and T2b + N__
T3, N_ or N_
T_, N0 or N1

A

Any T between T1a and T2b + N2

T3, N1 or N2

T4, N0 or N1

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33
Q

What is N2 disease?

A

Metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes

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34
Q

What tumor characteristics are associated with T4 disease?

A

Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina; or with separate tumor nodules in a different ipsilateral lobe of the lung

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35
Q

What are the 2 stagings that get you into stage IIIB?

A

T4, N2, M0

Any T with N3

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36
Q

What is N3 disease?

A

Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral scalene, or supraclavicular lymph node

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37
Q

Differentiate M1a and M1b diesease

A

M1a - contralateral long nodules, pleural or pericardial nodules, or malignant pleural or pericardial effusion

M1b - distant metastasis

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38
Q

Tell me the stage of cancer based on the following scenario:

Patient presents with CT findings for a 2.5cm LLL mass. He is taken for EBUS with reveals biopsy of mass positive for adenocarcinoma. Station 10L node positive, otherwise nodes are negative. PET negative for any other active lesions.

A

Stage IIA

T1b (2-3cm)
N1 (ipsilateral bronchial nodes)
M0

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39
Q

Tell me the stage of cancer based on the following scenario:

Patient presents with 6cm RUL mass on CT. EBUS shows positive 10R lymph nodes. PET negative.

A

Stage IIB

T2b (5-7cm)
N1
M0

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40
Q

Tell me the stage of cancer based on the following scenario:

Patient presents with 2.5cm peripheal mass on CT. A Ct-guided biopsy shows adenocarcinoma in situ. PET negative for nodal involvement.

A

Stage IA

T1b (2-3cm)
N0
M0

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41
Q

Tell me the stage of cancer based on the following scenario:

Patient presents with 4cm endobronchial mass on CT of the RML with associated atelectasis of the RML. EBUS performed and reveals squamous cell carcinoma. Station 7 positive for NSCLC. PET otherwise negative.

A

IIIa

T3 (mass causing atelectasis of lobe)
N2 (subcarinal lymph node involvement)
M0

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42
Q

Tell me the stage of cancer based on the following scenario:

Patient presents to the hospital for pneumonia symptoms and found to have LUL mass. Biopsy of left supraclavicular lymph node shows positive squamous cell carcinoma. PET negative otherwise.

A

Stage IIIB

T of any size
N3 (mets to supraclavicular lymph node)
M0

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43
Q

Tell me the stage of cancer based on the following scenario:

Patient presents with 4cm LLL mass. EBUS performed and biopsy of mass reveals adenocarcinoma. Lymph node biopsy otherwise negative. PET negative otherwise.

A

IB

T2a (3-5cm)
N0
M0

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44
Q

Tell me the stage of cancer based on the following scenario:

Patient presents to the hospital for generalized fatigue. CT chest reveals 3cm lingular nodule with pleural effusion. Thoracentesis reveals adenocarcinoma.

A

Stage IIV

Any T
Any N
M1a (malignant effusion)

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45
Q

First line therapies for stage I and II disease?

A

Surgery

No role for chemo or radiation in stage IA disease, but consider adjuvant chemo in stage IB disease especially if tumor is > 4cm

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46
Q

Surgery (lobectomy preferred) is followed by what treatment in stage II disease?

A

Chemotherapy

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47
Q

Treatment options for stage III disease?

A

Chemotherapy and radiation

Surgery often not indicated as they are often unresectable

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48
Q

Therapies for stage IV lung cancer?

A

Chemotherapy

Radiation for palliation only

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49
Q

What is the interval for follow-up CT scans for post-therapy surveillance in lung cancer?

A

Every 4-6 months for the first 2 years and then every 2 years thereafter

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50
Q

These are somatic genomic alterations that occur in cancer cells that encode for proteins critical to cell growth and survival.

A

Driver mutations

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51
Q

What are the 2 main driver mutations in lung cancer?

A

EGFR

ALK

52
Q

What medications are indicated for EGFR mutations in lung cancer?

A

Single agent EGFR TKI (erlotinib, getinib, afatinib) for initial management

53
Q

Medication indicated first line for ALK mutation?

A

Crizotinib

54
Q

This type of lung cancer is characterized by the proliferation of cells with scant cytoplasm, ill-defined borders, salt and pepper chromatin, frequent nuclear molding, and a high mitotic count

A

Small cell cancer (SCC)

55
Q

What stains are usually positive in SCC?

A

Thyroid transcription factor- 1
CD 56
Synaptophysin
Chromogranin

56
Q

98% of patients with SCC have a history of what?

A

Smoking

57
Q

Fill in the blank:

SCC has an excellent response to ___ but almost always recurs.

A

Chemotherapy

58
Q

Median survival for SCC confined to the chest without treatment?

Survival for metastatic disease without treatment?

A

Chest: 4-6 months

Metastatic: 4-9 weeks

59
Q

Define the 2 stages for SCC

A

Limited stage (20-30% of patients) - confined to single radiation portal or localized to one hemithorax

Extensive stage (70-75% of patients) - any disease outside the hemithorax

60
Q

When is prophylactic whole brain radiation recommended for patients with SCC?

A

Recommended for ALL patients with a good performance status and attain remission after induction chemotherapy and radiation therapy

61
Q

This type of lung cancer acconts for 70-90% of pulmonary lymphomas, has diffuse infiltration of small monomorphic lymphoid cells with typical lymphangitis growth pattern that spread along bronchovascular bundles and interlobular septa and form solid nodules that fill the alveolar spaces

A

MALT lymphoma

62
Q

Typical patient that MALT lymphoma occurs in?

A

> 45 y.o
Slight male preponderance
Those with immunosupression

63
Q

Prognosis of MALT lymphomas?

A

Indolent and excellent prognosis, 5 year survival >80%

64
Q

This is malignant B cell angiocentric and angiodestructive lymphoproloferative disorder mainly in 40-50 y/o men, where multiple confluent nodules of atypical angiocentric and polymorphous lymphoid infiltration involving the vascular walls from the subendothelium to the adventitial zones with focal lumen obliteration

A

Lymphomatoid granulomatosis

65
Q

What are the main cell types involved with Lymphomatoid granulomatosis?

A

CD4 T lymphocytes with scattered atypical B cells infected with EBV

66
Q

Prognosis of Lymphomatoid granulomatosis?

A

Grim

5 year survival 30-40%

67
Q

Treatment for Lymphomatoid granulomatosis?

A

Chemotherapy with high dose steroids and cyclophosphamide

68
Q

A 36-year-old patient with unresolving right middle lobe pneumonia of 2 months’ duration presents for evaluation. Chest CT scan shows a right middle lobe alveolar infiltrate with air bronchograms. What is the next step?

A

CT-guided lung biopsy. The biopsy showed complete replacement of lung architecture by monomorphic small lymphoid cells with positive immunohistochemistry for mucosa-associated lymphoid tissue–type lymphoma.

69
Q

Sensitivity and specificity of PET scan for mediastinal metastases in lung cancer?

A

Sensitivity 74%

Specificity 85%

70
Q

When do you use MRI in lung cancer workup/staging?

A

When evaluation superior sulcus tumors to check for invasion of brachial plexus or vertebra

71
Q

Sensitivity of bronchoscopy for diagnosis in lung cancer?

A

88%

72
Q

Sensitivity and specificity of transthoracic needle aspiration in lesions not accessible by bronchoscopy?

A

Sensitivity 90%

Specificity 97%

73
Q

Main risk for transthoracic needle aspiration?

A

Pneumothorax (22-45%)

74
Q

Sensitivity and specificity of EBUS?

A

Sensitivity 84%

Specificity 99.5%

75
Q

Gold standard for staging the mediastinum in patients with known or suspected lung cancer?

A

Mediastinoscopy

76
Q

Tell me the imaging and clinical features for thymomas

A

Imaging- soft tissue attenuation, mild to moderate contrast enhancement, round well circumscribed lesion

Clinical - usually >40 y/o, associated with myasthenia gravis, hypogammaglobulinemia, and pure red cell aplasia

77
Q

Tell me the imaging and clinical features for lymphomas

A

Imaging - mediastinal lymphadenopathy, homogenous lobulated soft tissue mass

Clinical - young adults, involves mediastinum and widespread disease, Hodgkin > non-Hodgkin

78
Q

Tell me the imaging and clinical features for teratomas

A

Imaging - well-circumscribed unilocular or multilocular cystic lesion containing fluid, soft tissue, and fat

Clinical - usually asymptomatic

79
Q

Tell me the imaging and clinical features for seminomas

A

Imaging - large lobulated homogenous well-defined mass

Clinical - asymptomatic, AFP normal

80
Q

Tell me the imaging and clinical features for nonseminomas

A

Imaging - large, irregular, hetergenous mass with areas of central necrosis, hemorrhage, or cyst formation

Clinical - usually symptomatic, AFP increaased

81
Q

Tell me the imaging and clinical features for thyroid goiters

A

Imaging - Encapsulated, lobulated, heterogenous mass

Clinical - often discovered incidentally

82
Q

What neoplastic syndromes are associated with thymoma?

A

Pure red cell aplasia, myasthenia gravis, and hypogammaglobulinemia

83
Q

This middle mediastinal mass is well-circumscribed with a homogenous density with water attenuation, and located paratracheally or in the subcarinal area

A

Bronchogenic cyst

84
Q

This middle mediastinal mass is commonly located at the right cardiophrenic angle, unilocular, nonenhancing mass with water attenuation

A

Pericardial cyst

85
Q

TRUE/FALSE: both bronchogenic and pericardial cysts are usually symptomatic with chest pain and dyspnea

A

FALSE

They are usually asymptomatic

86
Q

What is the most common type of neurogenic tumor in the posterior mediastinum?

A

Schwannoma

87
Q

Though most mets to the lung have round and sharply demarcated borders, what are the imaging findings for mets that tend to hemorrhage (choriocarcinoma, RCC, melanoma, thyroid carcinoma, Kaposi sarcoma)?

A

Indistinct fuzzy borders with occasional halo of GGO

88
Q

Size criteria of a nodule to be defines a solitary pulmonary nodule?

A

<3cm

89
Q

True/False: volumetric doubling of malignant solitary pulmonary nodules in >400 days are typically benign

A

TRUE

90
Q

True/False: volumetric doubling of a solitary pulmonary nodule in <20 days is often from an acute inflammatory process

A

TRUE

91
Q

Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:

<4mm

Low risk pt

A

No surveillence

92
Q

Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:

<4mm

High risk patient

A

CT in 12 months

No further if no change

93
Q

Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:

4-6mm

Low risk pt

A

CT in 12 months

No further if no change

94
Q

Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:

4-6mm

High risk pt

A

CT chest in 6-12 months

CT in 18-24 mo if no change

95
Q

Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:

6-8mm

Low risk pt

A

CT chest in 6-12 months

CT in 18-24 mo if no change

96
Q

Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:

6-8mm

High risk pt

A

CT chest in 3-6 months
CT chest at 9-12 mo if no change
CT chest at 24 mo if no change

97
Q

This benign nodule can grow slowly, fat visible on CT in 60% of them, often in men >50, and popcorn calcification in about 25%

A

Hamartomas

98
Q 
What is appropriate
management when a
solitary, pure ground-glass
nodule > 5 mm is found on
chest CT scan?
A

Initial follow-up at 3 months
and then annual
surveillance for at least 3
years.

99
Q 
What is appropriate
management when a
solitary, pure ground-glass
nodule < 5 mm is found on
chest CT scan?
A

No follow-up

100
Q

Follow-up for partly solid GGN if solid component >8mm?

A

CT chest in 3 months

101
Q

Follow-up for solid pulmonary nodule 8-10mm with intermediate pretest probability for malignancy?

A

PET-CT

102
Q 
Which type of lung cancer
is most frequently
associated with
paraneoplastic
syndromes?
A

Small cell lung cancer

103
Q

What types of paraneoplastic syndromes are associated with small cell lung cancer?

A

SIADH
Cushing
Carcinoid syndrome
Neurogenic syndrome

104
Q

What type of paraneoplastic syndrome are associated with adenocarcinoma?

A

Hypertrophic pulmonary osteoarthropathy

105
Q

What type of paraneoplastic syndrome are associated with squamous cell carcinoma?

A

Hypercalcemia

106
Q 
Which of the following
paraneoplastic syndromes
is appropriately matched
with the corresponding
antibodies?

Lambert–Eaton
myasthenia syndrome—
Anti-Yo antibodies

Cerebellar
degeneration—Voltagegated
channel antibodies

Limbic encephalitis—Anti-
Hu antibodies

A

Limbic encephalitis—Anti-

Hu antibodies

107
Q

What are the symptoms of limbic encephalitis/anti-Hu syndrome?

A 
Brain stem encephalitis
Opsoclonus-myoclonus
Cerebellar degeneration
Myelopathy
Peripheral nerve palsy
108
Q

What are the symptoms of anti-Yo syndrome?

A

Cerebellar degeneration

109
Q

Treatment of anti-Yo syndrome?

A

IVIG early

Treatment of cancer doesnt cure disease

110
Q

What 2 immunohistochemical markers are positive in mesothelioma?

A

Vimentin

Calretinin

111
Q

What 2 immunohistochemical markers are positive in adenocarcinoma?

A

PAS

CEA

112
Q 
Which of the following
statements about mesothelioma is
false?
A. There is a synergistic
effect between asbestos
exposure and smoking.
B. Serum biomarkers are
not useful as a
screening tool.
C. There is a long latency
period between
exposure to asbestos
and development of
symptoms.
D. Treatment is rarely
curative.
A 
The correct answer is A.
There is no synergy
between asbestos
exposure and smoking in
MPM.
113
Q

Treatment options for mesothelioma?

A

Surgery (pleurectomy, decortications)
Radiation
Chemotherapy with pemetrxed and cisplatin

114
Q

These are rare spindle cell mesenchymal tumors originating from the pleura (80% visceral and 20% parietal), account for 5% of all pleural tumors, and most are benign

A

Solitary fibrous tumor

115
Q 
Which of the following
parameters places the
patient at high risk for
surgical complications?
A. 77 years old
B. Chronic obstructive
pulmonary disease
with hypercapnia
C. Able to climb three
flight of stairs
D. VO2 max 30% of
predicted
A

D. VO2 max < 35% of
predicted places the
patient at very high risk for
surgery.

116
Q

Fill in the blanks for the Thoracic RCRI:

___ > 2 = 1 pt

__ectomy = 1.5 pts

Previous __ or __ = 1.5 pts

Previous ischemic __ disease = 1.5 pts

A

Creatinine > 2 = 1 pt

Pneumonectomy = 1.5 pts

Previous CVA or TIA = 1.5 pts

Previous ischemic cardiac disease = 1.5 pts

117
Q

Choose the next step in the evaluation for lung resection:

Patient with predicted post-operative (PPO) FEV1 and DLCO > 60% predicted

A

No further tests needed

118
Q

Choose the next step in the evaluation for lung resection:

PPO FEV1 and DLCO <60% but >30%

AND

6MWT > 22m or SCT > 400m

A

Low risk –> go to surgery

119
Q

Choose the next step in the evaluation for lung resection:

PPO FEV1 and DLCO <60% but >30%

AND

6MWT < 22m or SCT < 400m

A

CPET

120
Q

Choose the risk level in the evaluation for lung resection:

PPO FEV1 and DLCO <30%

VO2 max > 20ml/kg/min or >75% predicted

A

Low risk

121
Q

Choose the risk level in the evaluation for lung resection:

PPO FEV1 and DLCO <30%

VO2 max 10-20ml/kg/min or 35-75% predicted

A

Moderate risk

122
Q

Choose the risk level in the evaluation for lung resection:

PPO FEV1 and DLCO <30%

VO2 max <10-20ml/kg/min or <35% predicted

A

High risk

123
Q

How to calculate the PPO FEV1 in a pneumoectomy?

A

Pre-operative FEV1 x (1-fraction of total perfusion of resected lung using VQ)

124
Q

How to calculate the PPO DLCO in a pneumoectomy?

A

Pre-operative DLCO x (1-fraction of total perfusion of resected lung using VQ)

125
Q

How to calculate the PPO FEV1 in a lobectomy?

A

Pre-operative FEV1 x (1-y/z)

y = # of functional or unobstructed lung segments to be removed
z = total # of functional segments
126
Q

How to calculate the PPO DLCO in a lobectomy?

A

Pre-operative DLCO x (1-y/z)

y = # of functional or unobstructed lung segments to be removed
z = total # of functional segments

Pulmonary Review (14 decks)

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