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Respiratory > Lung Tumors > Flashcards

Lung Tumors Flashcards

1
Q

What are different types of lung tumors?

A
  • Brochogenic Carcinoma – 90 – 95%
    • Originate in the bronchial (or bronchiolar ) epithelium
  • Carcinoids – 5%
  • Other tumors – 2- 5%
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2
Q

Describe the incidence of bronchogenic carcinomas:

A
  • Public enemy # 1 in industrialized countries
  • Incidence is decreasing in men and increasing in women
    • Most frequent fatal malignancy in men and women
  • Most common visceral malignancy in males
    • 1/3 of cancer deaths in males/ 7% of cancer deaths in both sexes
    • Males > Females
  • Dramatic increase in incidence in women (cigarette smoking)
    • Lung Ca has surpassed breast Ca as a cause of cancer death in women
  • A disease of middle and late adult life, with a peak incidence in 50s or 60s
    • < 2% below age 40
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3
Q

What are the etiologies of bronchogenic carcinomas?

A
  • Tobacco smoking
  • Industrial hazards
  • Air pollution
  • Molecular genetics
  • Scarring
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4
Q

What is the statistical evidence for tobacco smoking as a cause of bronchogenic carcinoma?

A
  • Association between frequency of lung ca. & amount of daily smoking
    • Smokers 10-fold greater risk
    • Heavy smokers 20-fold greater risk
    • X smoking for 10 yrs, reduces risk to control level
  • Tendency to inhale
  • Duration of smoking habit
    • Pack year - calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked
  • Other associations – lip, tongue, mouth, pharynx, larynx, esophagus, UB, pancreas, kidney
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5
Q

What is the clinical evidence for tobacco smoking as a cause of bronchogenic carcinoma?

A
  • Histologic changes in the respiratory tract of smokers
    • 96.7% smokers - atypical changes in bronchial epithelium
    • 0.9% control subjects - similar changes
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6
Q

What is the experimental evidence for tobacco smoking as a cause of bronchogenic carcinoma?

A
  • Cancer induction in experimental animals by exposure to tobacco smoke
  • Potential carcinogens –
    • Initiators (benzopyrene)
    • Promoters (phenol derivatives)
  • Radioactive elements (carbon-14, potassium-40)
  • Contaminants (arsenic, nickel, molds, additives)
  • Experimental mice – Skin tumors, few lung cancers (bronchioloalveolar carcinoma)
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7
Q

What industrial hazards potentially lead to bronchogenic carcinoma?

A
  • Radiation – Increased incidence in Hiroshima/Nagasaki survivors
  • Uranium miners – lung cancer rates higher than general population
  • Asbestos – Much higher risk than general population of developing lung cancer
  • Other hazards – Nickel, chromates, coal, mustard gas, arsenic, beryllium, iron
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8
Q

Why are people exposed to asbestos at a higher risk of developin bronchogenic carcinoma?

A
  • Asbestos w/o smoking ⇒ 5 times greater risk than gen. pop.
  • Asbestos + smoking ⇒ 50 – 90 times greater risk than gen. pop.
  • Latent period ⇒ 10 – 30 years
  • 1/5 deaths – Lung Ca.
  • 1/10 deaths – Mesothelioma
  • 1/10 deaths – GI Ca
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9
Q
  • How can air pollution increase the risk of bronchogenic carcinoma?
  • Who is partciularly at risk?
A
  • Indoor air pollution – Radon exposure
    • ubiquitous radioactive gas
    • lung cancer in non-smokers may be attributed to radon exposure
  • Miners exposed to higher concentrations
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10
Q

What are the genes/proteins potentially involved in bronchogenic carcinoma?

A
  • Genetic alterations which accumulate and ultimately lead to neoplasia
  • Oncogenes
    • C-myc ⇒ small cell carcinoma
    • K-ras, EGFR, EML4-ALK ⇒ adenocarcinoma
  • Tumor suppressor genes
    • p53
    • Retinoblastoma
    • ? Genes on short arm of Chromosome 3
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11
Q

__________ causes DNA damage at the same codons of the p53 gene

A

Benzopyrene causes DNA damage at the same codons of the p53 gene

  • Familial clustering and variable risk among heavy smokers suggest genetic predisposition
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12
Q
  • What is the role of scarring in brochogenic carcinoma?
  • Which type is scarring usually seen?
A
  • “Scar cancers” – Cancers occurring in the vicinity of pulmonary scars
    • Usually adenocarcinomas
  • In most cases, the scar is a response to the tumor
    • Sometimes, scar precedes cancer (old infarcts, wounds, granulomatous infections)
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13
Q

**Bronchogenic Carcinoma: **

Clinical Features and Course

A
  • Usually present in their 50s
  • Average duration of symptoms ⇒ 7 months
  • Major presenting complaints:
    • cough (75%)
    • wt loss (40%)
    • chest pain (40%)
    • dyspnea (20%)
  • Increased sputum production – Cytology
  • May be diagnosed upon secondary spread
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14
Q

What is a Pancoast tumor? What can it lead to?

A
  • Tumor at the extreme apex of the lung
  • Involvement of superior cervical sympathetic ganglion
    • Horner’s syndrome:
      • Ipsilateral lid lag
      • Miosis
      • Ipsilateral anhydrosis
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15
Q

What are the two major classifications of bronchogenic carcinomas?

A
  1. Small cell carcinoma
  2. Non-small cell carcinoma
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16
Q

What are the different types of small cell carcinoma?

A
  • Oat cell (lymphocyte-like)
  • Intermediate cell (polygonal)
  • Combined (usually with squamous)
17
Q

What are the different types of non-small cell carcinoma?

A
  • Squamous cell (epidermoid) carcinoma
  • Adenocarcinoma
    • Glandular (acinar) with mucin
    • Papillary
    • Solid
    • (Lepidic) Bronchioloalveolar
  • Large cell carcinoma
    • Neuroendocrine
    • Undifferentiated
    • Giant cell
    • Clear cell
  • Adenosquamous carcinoma
18
Q

Small cell vs. non-small cell carcinomas based on reponse to treatment:

A
  • Small cell carcinoma
    • responds well to chemotherapy
    • does not respond to surgery
  • ​Non-small cell carcinoma
    • responds well to surgery depending on stage of the tumor
    • chemotherapy is less effective
19
Q

What are the pharmacologic options for treating adenocarcinoma and ** squamous cell carcinoma**?

A
  1. Epidermal growth factor receptor (EGFR), KRAS and EML4-ALK mutations
    • Confined to adenocarcinoma
    • Predictive of response (EGFR) and resistance (KRAS) to:
      • EGFR TKIs – Erlotinib (Tarseeva) and Gefitinib (Iressa)
    • ALK inhibitor - Crizotinib
  2. Bevacuzimab – Antibody to vascular endothelial growth factor (VEGF)
    • Toxicity in SqCC (hemorrhage)
  3. Pemetrexed
    • Activity in non-SqCC
20
Q

Squamous cell carcinoma:

  • Incidence:
  • Clinical presentation:
  • Histology:
A
  • The most common type in Males
  • Cigarette smoker
  • Central cavitary necrosis
    • Usually arise centrally (main or lobar bronchi)
    • Usually endobronchial, polypoid growth
  • Histology:
    • keratin formation, intercellular bridges, atypia and invasion
    • Well/moderately/poorly differentiated subtypes depending on degree of squamous differentiation
21
Q

Adenocarcinoma:

  • Incidence:
  • Clinical presentation:
A
  • Most common type in women and non-smokers (most patients with adenocarcinoma are smokers)
  • Most common form of lung carcinoma in USA
  • Usually peripheral with pleural retraction or puckering
    • Associated with scarring
  • Grow more slowly, metastasize more frequently than squamous cell carcinoma
  • Asymptomatic (peripheral tumor) – Late diagnosis
22
Q

Bronchioloalveolar carcinoma:

  • Incidence:
  • Clinical presentation:
    • What has a worse prognosis?
  • Histology:
A
  • A subset of adenocarcinoma
  • 1% – 9% of all lung carcinomas
  • Gross
    • Single peripheral nodule
    • Multiple nodules (several lobes/bilateral) –
      • multifocal/aerogenous spread
    • Diffuse pneumonia-like infiltrate
  • Histology — Lepidic spread (tumor cells spread along alveolar septa)
    • Nonmucinous (Clara cells, type 2 pneumocytes) – 2/3 cases
    • Mucinous (tall columnar mucinous cells) – Worse prognosis
23
Q

Small cell carcinoma

  • Incidence:
  • Clinical presentation:
  • Prognosis:
A
  • 20 – 25% of lung cancers
  • Predominantly in males, smokers, central location
  • Highly malignant, median survival – 4 months
  • Submucosal/circumferential infiltration
  • Rare endobronchial polypoid growth
  • Subclassification:
    • Oat cell
    • Intermediate cell
    • Mixed (small cell/large cell)
    • Combined (small cell/adeno or squamous)
24
Q

What is the clinical course of small cell carcinoma?

A
  • Extensive necrosis, crush artifact
  • Secretory granules of neuroendocrine type
  • Metastasis by the time of diagnosis
    • 70% patients seen at advanced stage
  • Ectopic hormone production (paraneoplastic syndrome)
  • Excellent response to chemotherapy
25
Q

Large cell carcinoma

  • Incidence:
  • Clinical presentation:
  • Prognosis:
A
  • 10 – 15% of lung cancers
  • Pleomorphic, large cells without differentiation
  • Ultrastructural evidence of glandular or squamous differentiation
  • 5-year survival 6%
  • Giant cell carcinoma
    • Highly malignant
    • Mostly peripheral
    • < 10 month survival
26
Q

Adenosquamous carcinoma

  • Incidence:
  • Clinical presentation:
A
  • 1 – 3% of lung carcinomas
  • Definite evidence of squamous cell carcinoma and adenocarcinoma in the same neoplasm
  • Peripheral tumor, associated with scar
  • Clinical presentation and behavior similar to adenocarcinoma
  • The majority of patients are smokers
27
Q

Where do bronchogenic carcinomas metastasize?

A
  • Metastases
    1. Hilar lymph nodes
    2. Adrenal gland (50%)
    3. Liver (30%)
    4. Brain (20%)
    5. Bone
28
Q

What the two most important factors in determining survival and choice of therapy for bronchogenic carcinomas?

A

Histologic type and tumor staging are the two most important factors in determining survival and choice of therapy

29
Q

Bronchogenic carcinoma

TNM classification

A
  • Single most important prognostic parameter in non-small cell carcinoma
  • Small cell carcinoma
    • Limited disease:
      • hemithorax with/without LN involvement
    • Extensive disease:
      • Contralateral lung, distant metastasis
30
Q

Define paraneoplastic syndrome:

A

Symptom complexes that occur in patients with cancer that cannot be readily explained by local or distant spread; or by elaboration of hormones by tumor cells

31
Q

What are some examples of paraneoplastic syndromes caused by:

  1. Small cell carcinoma
  2. Squamous cell carcinoma
A
  1. Small cell carcinoma
    • Cushing’s syndrome (ACTH)
    • Hyponatremia (inappropriate ADH secretion)
    • Carcinoid syndrome (serotonin)
    • Myasthenic syndrome (Eaton-Lambert syndrome)
  2. Squamous cell carcinoma​
    • ​​​​​​​​Hypercalcemia (parathormone)
32
Q

What is the incidence of carcinoid tumors?

A
  • 1-5% of all lung tumors
  • Most patients are <40 years of age
  • M=F
  • 20-40% are non-smokers
  • Low-grade malignant neoplasms
33
Q

What can be seen microscopically in carcinoid tumors?

A
  • Nests/ cords/ masses
  • Uniform cells with round nuclei
  • “Salt & Pepper” chromatin
  • IHC: NSE, chromogranin, synaptophysin +
34
Q

Carcinoid Tumors

  • Clinical Course:
  • Prognosis:
A
  • Hemoptysis, cough, obstructive symptoms (due to intraluminal growth) –
    • infections, bronchiectasis, atelactasis or emphysema
  • Carcinoid syndrome – intermittent diarrhea, flushing and cyanosis.
  • Metastases occur rarely (1-5%)
  • Usually follow a benign course for long periods and are amenable to resection
  • 5 and 10 year survival (87%)

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