Module 7 Pulmonary Flashcards
What is the most common lung cancer?
Secondary lung tumors from metastasis
–if female the primary is usually breast cancer
–if male the primary is usually colon cancer
(remember adenocarcinoma is the most common primary tumor of the lung)
What are the pulmonary causes of finger clubbing?
All causes of bronchiectasis, empyema, lung abscess, lung cancer, mesothelioma (pleural cancer) and idiopathic pulmonary fibrosis
What conditions do not give you finger clubbing?
Bronchial asthma
COPD
Chronic bronchitis
Emphysema
What are the cardiovascular cause of finger clubbing?
Sub acute infective endocarditis
atrial Myxoma
R to left shunt
The last type of lung cancer that will be discussed with be carcinoid tumor of the lung aka Bronchial carcinoid, what is a bronchial carcinoid and what cells does it arise from?
Cell of Origin: Kulchitsky (neuroendocrine cells
-identical to small cell lung carcinoma on histology
Slow growing neuroendocrine tumor of the lung
Why is bronchial carcinoid more resectable and curable than small (oat) cell carcinoma?
because bronchial tumors rarely metastasis
- -centrally located, well differentiated and nested
- -can lead to resorption atelectasis
Is bronchial carcinoid associated with smoking?
nope
On gross specimen what is the appearance of bronchial carcinoid?
- -Spherical pale mass protruding into lumen of bronchus
- -intact nodular surface
- -can lead to ball valve type effects leading to atelectasis
On histology what is the appearance of bronchial carcinoid?
- -Cells show characteristic organoid nesting pattern of uniform cells
- -uniform round cells
- -neuroendocrine nuclear chromatin
- -no pleomorphism
- rare mitoses/mitotic figures
- -nesting is key!
- -salt and pepper chromatin
- -fine granular cytoplasm
- -no necrosis
- –rare mitoses
What clinical symptoms would you see from a bronchial carcinoid?
Intraluminal growth = obstruction === cough hemoptysis and infection
Bronchial carcinoid can also cause carcinoid syndrome, what is carcinoid syndrome?
Tumor secretes hormones = array of secondary symptoms
- 1% of all carcinoid tumor patients show neuropeptides secreted into systemic circulation = symptoms
- -increased levels of 5HIAA in the urine due to increased serotonin and therefore increased PSNS symptoms
- -episodic flushing, wheezing and diarrhea
What is a bronchogenic carcinoma?
Malignant neoplasm arising from epithelium of bronchus or bronchiole
–can be squamous, small, large, and some bronchioalveolar cancer
What is seen on CXR in these patients?
Tracheal deviation and diaphragmatic paralysis
elevation of diaphragm due to paralysis of the left phrenic nerve
obstruction of a large airway
also mass effect as discussed before
A lesion that may be seen on chest xray is a solitary coin lesion, what is this lesion?
No metastasis
What are the possible etiologies of a solitary pulmonary nodule, called a coin lesion?
- Granulomatous diseases (TB/histoplasmosis)
- Pulmonary hamartoma (tumor of normal tissue in a normal location, but in disorganized amounts and arrangement)
- Lung Cancer: adenocarcinoma (peripheral and invasive and rapid growth)
What do you find on gross specimen of a coin lesion?
Firm discrete lesion often have calcifications in them that appear on CXR
What do you ask the patient for with a coin lesion that will help with diagnosis?
Ask patient for previous xrays to compare rate of growth or do serial x-rays
What is a pulmonary hamartoma?
Asymptomatic and Begin
- -only coin lesion with popcorn calcifications
- -capillary hemangioma also has a hamartoma
- -incidental findings
- disorganized normal tissue
What do a pulmonary hamartoma look like on histo?
Composed mostly of benign cartilage on the right jumbled with fibrovascular stroma and scattered bronchial glands
–haphazard mass of normal tissue/cells - not a neoplasm
Mets to the lung has what type of appearance on CXR?
Cannonball lesions on CXR
Review Quiz: what are the symptoms of Horners syndrome and what structure is compressed
Cervical sympathetic plexus damaged
—ipsilateral enophthalmos, ptosis, meiosis and anhidrosis
Review Quiz: Pancoast syndrome (pancoast tumor, pulmonary sulcus tumor or superior sulcus tumor), what symptoms are produced?
Apical neoplasm T1T2 destruction
- -wasting of hand muscles, pain in arms (ulnar nerve) - if tumor compresses brachial plexus
- -Horner syndrome if compression of sympathetic ganglion
- –compression of blood vessels — edema
- –recurrent laryngeal nerve paralysis –hoarse voice
- –esophagus involvement: dysphagia
- –thoracic duct obstruction: chylothorax
Review Quiz: what are general features of lung cancer?
- -peripheral tumors may be silent
- –central tumors (hilar): obstruction, infection, and atelectasis
- -cough, weight loss, hemoptysis and SOB
- –pulmonary osteoarthropathy: clubbing
- –hoarseness and CP
- -pericardial and pleural effusion
- –persistent atelectasis, pneumonitis
- –superior vena cava syndrome due to obstruction
Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with that?
Tyrosine kinase inhibitors (gefitinib and erlotinib) than are patients without mutation
Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to what/
Pemetrexed than are patients with squamous cell carcinoma
What drug is contraindicated in patients with squamous cell carcinoma because it can lead to life threatening haemorrhage?
Bevacizumab
What is a protein kinase inhibitor drug which inhibits the active EMBL4/ALK fusion protein found in up to 45% of NSCLC patients?
Crizotinib
The rationale is that KRAS mutations are associated with what?
poor response to EGFR inhibitor treatment and should be therefore avoided as patients do not respond
Review Quiz: Bronchial Carcinoid tumor of the lung, typically involves what kind of patients?
Females with fresh hemoptysis and no other symptoms previously
how is atypical carcinoid tumor different than typical bronchial carcinoid tumor
Single cell necrosis: apoptosis
mitoic active that is more frequent then in typical carcinoid tumor
What is malignant mesothelioma?
- –Primary malignancy of pleura, peritoneum or pericardium, strongly associated with asbestos
- –patients present with CP and or SOB; occ w/ cough and fatigue
What does imaging studies how of mesothelioma?
Moderate to large unilateral pleural effusion, nodular pleural thickening and enhancement with PET
What are the histological findings of malignant mesothelioma?
—epithelial, sarcomatoid and mixed (biphasic)
What is the prognosis and tx of mesothelioma?
typically progressive and fatal, with usual survival of 1-2 years after dx
–most effective tx approach is multi-modality including surgery, radiation and chemotherapy.
What is the most common location of a carcinoid tumor?
GI (appendix and small bowel) but NOT LUNG
Review: if you found a coin lesion on xray for a patient what is the best case and worse case scenerio in regards to origin of that lesion?
Best: Harmatoma (no growth and popcorn calcification)
Worst: Adenocarcinoma (only peripheral tumor)
What are the contents of a harmatoma?
hyaline contents (well differentiated chondrocytes, fat cells, connective tissue and smooth muscle cells)
Review: What two conditions do divergent differentiation?
parotid gland
Wilms tumor
In Mets to the lung the cancer always starts in the lower lobes due to more perfusion, what other syndromes start in the lower lobes?
pan acinar emphysema (genetic defect) IPF (geographic heterogenity) Mets to the lung Lung abscess (aspiration pneumonia from patient sitting up) Asbestosis
