Lung Neoplasms Flashcards by Daniel Guck

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

Smoking

HPV

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

11 and 6

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Treatment for recurrent respiratory papillomatosis/juvenile laryngotracheal papillomatosis?

Surgical excision and laser ablation

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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

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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

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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

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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

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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

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What markers stain positive on squamous cell carcinoma?

p63

Cytokeratin 5/6

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What markers stains positive on adenocarcinoma??

Thyroid transcription factor-1
Napsin A
Cytokeratin 7

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

Acinar

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

Papillary

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

Bronchioalveolar carcinoma

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Name 2 other adenocarcinoma subtypes

Solid with mucin production

Mixed subtype

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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

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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

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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

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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

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Treatment for typical carcinoid tumors?

Limited resection with segmentectomy and regional lymph node dissection

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Treatment for atypical carcinoid tumors?

Lobectomy and mediastinal lymph node dissection

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Treatment for carcinoid tumors that metastasize?

No benefit for chemo or radiation

Local treatment of mets may lead to prolonged remission

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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%

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

Stage IV

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

T1a ≤ 2 cm

T1b >2cm but < 3cm

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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?

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 ```