Lung Neoplasms Flashcards
What 2 things are risk factors for squamous papillomas in the large airways?
Smoking
HPV
What HPV serotypes are associated with recurrent respiratory papillomatosis/juvenile laryngotracheal papillomatosis?
11 and 6
Treatment for recurrent respiratory papillomatosis/juvenile laryngotracheal papillomatosis?
Surgical excision and laser ablation
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
Micronodular pneumocyte hyperplasia
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
Hamartomas
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?
Recurrent respiratory papillomatosis with lung involvement, most likely squamous cell cancer
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
Solitary fibrous tumor
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
Squamous cell carcinoma
What markers stain positive on squamous cell carcinoma?
p63
Cytokeratin 5/6
What markers stains positive on adenocarcinoma??
Thyroid transcription factor-1
Napsin A
Cytokeratin 7
This subtype of adenocarcinoma arise from cuboidal/columnar cells that form acini and tubules
Acinar
This subtype of adenocarcinoma has malignant cells arranged on the surface of fibrobascular cores
Papillary
This subtype of adenocarcinoma is also known as adenocarcinoma in situ, and is characterized by slow lepidic growth
Bronchioalveolar carcinoma
Name 2 other adenocarcinoma subtypes
Solid with mucin production
Mixed subtype
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.
TRUE
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
Large cell carcinoma
What differentiates typical from atypical carcinoid tumors based on # of mitoses and necrosis?
Typical: <2 mitoses per 10 HPF and ABSENCE of necrosis
Atypical: >2 mitoses per 10 HPF OR PRESENCE of necrosis
What is the classic clinical features of carcinoid tumors?
Usually in never smokers
70% in proximal airways and associated with cough, hemoptysis, and obstruction
<2% have carcinoid syndrome
Low moderate acitivity on PET
Treatment for typical carcinoid tumors?
Limited resection with segmentectomy and regional lymph node dissection
Treatment for atypical carcinoid tumors?
Lobectomy and mediastinal lymph node dissection
Treatment for carcinoid tumors that metastasize?
No benefit for chemo or radiation
Local treatment of mets may lead to prolonged remission
Give me the 5 year survival rates based on the following stages:
IA IB IIA IIB IIIA IIIB IV
IA 73% IB 58% IIA 46% IIB 36% IIIA 24% IIIB 9% IV 13%
Any metastasis in lung cancer (M1a or b) automatically gets you in what stage, regardless of tumor size?
Stage IV
Stage IA is made up of T1a or T1b, with always N0. What differentiates T1a and T1b?
T1a ≤ 2 cm
T1b >2cm but < 3cm
What tumor staging is stage IB lung cancer?
T2a (3-5cm), N0, M0
Stage IIA consists of T1a, T1b, or T2a + what other tumor staging feature?
N1
What is N1 mean?
Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodules involved by direct extension of the primary tumor
So stage IIA consists of T1a, T1b, and T2a + N1, as well as what other tumor stage with N0?
T2b
Tumor size in T2b?
5-7cm
What 2 stages are in stage IIB lung cancer?
T2b, N1, M0
T3, N0, M0
Tumor characteristics in T3 disease?
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
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
Any T between T1a and T2b + N2
T3, N1 or N2
T4, N0 or N1
What is N2 disease?
Metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes
What tumor characteristics are associated with T4 disease?
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
What are the 2 stagings that get you into stage IIIB?
T4, N2, M0
Any T with N3
What is N3 disease?
Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral scalene, or supraclavicular lymph node
Differentiate M1a and M1b diesease
M1a - contralateral long nodules, pleural or pericardial nodules, or malignant pleural or pericardial effusion
M1b - distant metastasis
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.
Stage IIA
T1b (2-3cm)
N1 (ipsilateral bronchial nodes)
M0
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.
Stage IIB
T2b (5-7cm)
N1
M0
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.
Stage IA
T1b (2-3cm)
N0
M0
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.
IIIa
T3 (mass causing atelectasis of lobe)
N2 (subcarinal lymph node involvement)
M0
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.
Stage IIIB
T of any size
N3 (mets to supraclavicular lymph node)
M0
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.
IB
T2a (3-5cm)
N0
M0
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.
Stage IIV
Any T
Any N
M1a (malignant effusion)
First line therapies for stage I and II disease?
Surgery
No role for chemo or radiation in stage IA disease, but consider adjuvant chemo in stage IB disease especially if tumor is > 4cm
Surgery (lobectomy preferred) is followed by what treatment in stage II disease?
Chemotherapy
Treatment options for stage III disease?
Chemotherapy and radiation
Surgery often not indicated as they are often unresectable
Therapies for stage IV lung cancer?
Chemotherapy
Radiation for palliation only
What is the interval for follow-up CT scans for post-therapy surveillance in lung cancer?
Every 4-6 months for the first 2 years and then every 2 years thereafter
These are somatic genomic alterations that occur in cancer cells that encode for proteins critical to cell growth and survival.
Driver mutations
What are the 2 main driver mutations in lung cancer?
EGFR
ALK
What medications are indicated for EGFR mutations in lung cancer?
Single agent EGFR TKI (erlotinib, getinib, afatinib) for initial management
Medication indicated first line for ALK mutation?
Crizotinib
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
Small cell cancer (SCC)
What stains are usually positive in SCC?
Thyroid transcription factor- 1
CD 56
Synaptophysin
Chromogranin
98% of patients with SCC have a history of what?
Smoking
Fill in the blank:
SCC has an excellent response to ___ but almost always recurs.
Chemotherapy
Median survival for SCC confined to the chest without treatment?
Survival for metastatic disease without treatment?
Chest: 4-6 months
Metastatic: 4-9 weeks
Define the 2 stages for SCC
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
When is prophylactic whole brain radiation recommended for patients with SCC?
Recommended for ALL patients with a good performance status and attain remission after induction chemotherapy and radiation therapy
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
MALT lymphoma
Typical patient that MALT lymphoma occurs in?
> 45 y.o
Slight male preponderance
Those with immunosupression
Prognosis of MALT lymphomas?
Indolent and excellent prognosis, 5 year survival >80%
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
Lymphomatoid granulomatosis
What are the main cell types involved with Lymphomatoid granulomatosis?
CD4 T lymphocytes with scattered atypical B cells infected with EBV
Prognosis of Lymphomatoid granulomatosis?
Grim
5 year survival 30-40%
Treatment for Lymphomatoid granulomatosis?
Chemotherapy with high dose steroids and cyclophosphamide
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?
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.
Sensitivity and specificity of PET scan for mediastinal metastases in lung cancer?
Sensitivity 74%
Specificity 85%
When do you use MRI in lung cancer workup/staging?
When evaluation superior sulcus tumors to check for invasion of brachial plexus or vertebra
Sensitivity of bronchoscopy for diagnosis in lung cancer?
88%
Sensitivity and specificity of transthoracic needle aspiration in lesions not accessible by bronchoscopy?
Sensitivity 90%
Specificity 97%
Main risk for transthoracic needle aspiration?
Pneumothorax (22-45%)
Sensitivity and specificity of EBUS?
Sensitivity 84%
Specificity 99.5%
Gold standard for staging the mediastinum in patients with known or suspected lung cancer?
Mediastinoscopy
Tell me the imaging and clinical features for thymomas
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
Tell me the imaging and clinical features for lymphomas
Imaging - mediastinal lymphadenopathy, homogenous lobulated soft tissue mass
Clinical - young adults, involves mediastinum and widespread disease, Hodgkin > non-Hodgkin
Tell me the imaging and clinical features for teratomas
Imaging - well-circumscribed unilocular or multilocular cystic lesion containing fluid, soft tissue, and fat
Clinical - usually asymptomatic
Tell me the imaging and clinical features for seminomas
Imaging - large lobulated homogenous well-defined mass
Clinical - asymptomatic, AFP normal
Tell me the imaging and clinical features for nonseminomas
Imaging - large, irregular, hetergenous mass with areas of central necrosis, hemorrhage, or cyst formation
Clinical - usually symptomatic, AFP increaased
Tell me the imaging and clinical features for thyroid goiters
Imaging - Encapsulated, lobulated, heterogenous mass
Clinical - often discovered incidentally
What neoplastic syndromes are associated with thymoma?
Pure red cell aplasia, myasthenia gravis, and hypogammaglobulinemia
This middle mediastinal mass is well-circumscribed with a homogenous density with water attenuation, and located paratracheally or in the subcarinal area
Bronchogenic cyst
This middle mediastinal mass is commonly located at the right cardiophrenic angle, unilocular, nonenhancing mass with water attenuation
Pericardial cyst
TRUE/FALSE: both bronchogenic and pericardial cysts are usually symptomatic with chest pain and dyspnea
FALSE
They are usually asymptomatic
What is the most common type of neurogenic tumor in the posterior mediastinum?
Schwannoma
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)?
Indistinct fuzzy borders with occasional halo of GGO
Size criteria of a nodule to be defines a solitary pulmonary nodule?
<3cm
True/False: volumetric doubling of malignant solitary pulmonary nodules in >400 days are typically benign
TRUE
True/False: volumetric doubling of a solitary pulmonary nodule in <20 days is often from an acute inflammatory process
TRUE
Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:
<4mm
Low risk pt
No surveillence
Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:
<4mm
High risk patient
CT in 12 months
No further if no change
Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:
4-6mm
Low risk pt
CT in 12 months
No further if no change
Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:
4-6mm
High risk pt
CT chest in 6-12 months
CT in 18-24 mo if no change
Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:
6-8mm
Low risk pt
CT chest in 6-12 months
CT in 18-24 mo if no change
Choose the appropriate follow-up for a solitary pulmonary nodule <8mm:
6-8mm
High risk pt
CT chest in 3-6 months
CT chest at 9-12 mo if no change
CT chest at 24 mo if no change
This benign nodule can grow slowly, fat visible on CT in 60% of them, often in men >50, and popcorn calcification in about 25%
Hamartomas
What is appropriate management when a solitary, pure ground-glass nodule > 5 mm is found on chest CT scan?
Initial follow-up at 3 months
and then annual
surveillance for at least 3
years.
What is appropriate management when a solitary, pure ground-glass nodule < 5 mm is found on chest CT scan?
No follow-up
Follow-up for partly solid GGN if solid component >8mm?
CT chest in 3 months
Follow-up for solid pulmonary nodule 8-10mm with intermediate pretest probability for malignancy?
PET-CT
Which type of lung cancer is most frequently associated with paraneoplastic syndromes?
Small cell lung cancer
What types of paraneoplastic syndromes are associated with small cell lung cancer?
SIADH
Cushing
Carcinoid syndrome
Neurogenic syndrome
What type of paraneoplastic syndrome are associated with adenocarcinoma?
Hypertrophic pulmonary osteoarthropathy
What type of paraneoplastic syndrome are associated with squamous cell carcinoma?
Hypercalcemia
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
Limbic encephalitis—Anti-
Hu antibodies
What are the symptoms of limbic encephalitis/anti-Hu syndrome?
Brain stem encephalitis Opsoclonus-myoclonus Cerebellar degeneration Myelopathy Peripheral nerve palsy
What are the symptoms of anti-Yo syndrome?
Cerebellar degeneration
Treatment of anti-Yo syndrome?
IVIG early
Treatment of cancer doesnt cure disease
What 2 immunohistochemical markers are positive in mesothelioma?
Vimentin
Calretinin
What 2 immunohistochemical markers are positive in adenocarcinoma?
PAS
CEA
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.
The correct answer is A. There is no synergy between asbestos exposure and smoking in MPM.
Treatment options for mesothelioma?
Surgery (pleurectomy, decortications)
Radiation
Chemotherapy with pemetrxed and cisplatin
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
Solitary fibrous tumor
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
D. VO2 max < 35% of
predicted places the
patient at very high risk for
surgery.
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
Creatinine > 2 = 1 pt
Pneumonectomy = 1.5 pts
Previous CVA or TIA = 1.5 pts
Previous ischemic cardiac disease = 1.5 pts
Choose the next step in the evaluation for lung resection:
Patient with predicted post-operative (PPO) FEV1 and DLCO > 60% predicted
No further tests needed
Choose the next step in the evaluation for lung resection:
PPO FEV1 and DLCO <60% but >30%
AND
6MWT > 22m or SCT > 400m
Low risk –> go to surgery
Choose the next step in the evaluation for lung resection:
PPO FEV1 and DLCO <60% but >30%
AND
6MWT < 22m or SCT < 400m
CPET
Choose the risk level in the evaluation for lung resection:
PPO FEV1 and DLCO <30%
VO2 max > 20ml/kg/min or >75% predicted
Low risk
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
Moderate risk
Choose the risk level in the evaluation for lung resection:
PPO FEV1 and DLCO <30%
VO2 max <10-20ml/kg/min or <35% predicted
High risk
How to calculate the PPO FEV1 in a pneumoectomy?
Pre-operative FEV1 x (1-fraction of total perfusion of resected lung using VQ)
How to calculate the PPO DLCO in a pneumoectomy?
Pre-operative DLCO x (1-fraction of total perfusion of resected lung using VQ)
How to calculate the PPO FEV1 in a lobectomy?
Pre-operative FEV1 x (1-y/z)
y = # of functional or unobstructed lung segments to be removed z = total # of functional segments
How to calculate the PPO DLCO in a lobectomy?
Pre-operative DLCO x (1-y/z)
y = # of functional or unobstructed lung segments to be removed z = total # of functional segments
