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Pulmonary Boards > Neoplasm > Flashcards

Neoplasm Flashcards

1
Q

What are the features of a thymoma?

A

Most common anterior mediastinal mass, can also be bilateral pleural based masses, peak incidence 40-60yo. Metastasizes locally or seeds the pleura. Classified as encapsulate, invasive, or metastatic. Can cause airway or SVC obstruction. Has MG as a paraneoplastic presentation (will present earlier, won’t completely resolve with resection). Tx with resection, chemo and radiation

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2
Q

What are the Lung-RADS categories?

A

Based off the most concerning nodule
1- no nodule, yearly screening
2- very low risk (solid nodules <6mm) yearly surveillance
3- low risk (solid 6-8mm) 6 month scan
4- moderate risk (8+mm), scan in 3months, PETCT, or biopsy/resection

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3
Q

How does HIV affect lung cancer risk?

A

Increased risk of developing and in younger population with worse prognosis, but equal distribution of histologic types

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4
Q

Which are the malignant and benign tracheobronchial tumors?

A

90% malignant
Benign- Hamartoma (most common, SC papillomas (may undergo malignant transformation), papillomatosis (HPV 6/11), lipomas, leiomyomas, chondromas, neurogenic tumors, granular cell tumor
Malignant- Squamous CC (most common), adenoid cystic carcinoma, carcinoid tumor, small CC, mucoepidermoid carcinoma, sarcoma, mets (breast/colon/kidney/melanoma), direct invasion (thyroid/larynx/esophagus)

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5
Q

When evaluating nodules, what must you do first?

A

Look at it from all 3 planes to determine characteristics

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6
Q

What are the features of bronchogenic cysts?

A

Usually along medial mediastinum along trachea, can compromise airway (particularly in infants), can become infected. Tx with resection.

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7
Q

What are the features of esophageal duplication cysts?

A

More common on right side toward lower esophagus, can cause airway obstruction when higher in the chest, more commonly experience dysphagia, retrosternal pain, epigastric discomfort due to local growth. Tx with resection

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8
Q

What are the features of thymic cysts?

A

Anterior mediastinum or neck, can cause local compression symptoms, Tx with resection. Take care to ensure that it is not confused with a cystic thymoma

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9
Q

Rattle off the tumor staging category definitions

A
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10
Q

Rattle off the tumor TNM staging

A
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11
Q

What are the features of Castleman disease?

A

Giant lymph node hyperplasia, associated with HHV8. 3 types (hyaline vascular, plasma call, and mixed). Unicentric CD usually in mediastinum and hilum, rounded solitary mass, mild to moderate FDG uptake.

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12
Q

What is the malignant potential of pure ground glass nodules?

A

Usually adenocarcinoma in situ, non-invasive and slow to progress, rarely traveling to hilar LN during a year of surveillance. Duration of surveillance is longer than for solid (5 years). If the nodule grows or develops a solid component, risk of invasive malignancy increases. Low metabolic activity means low PETCT sensitivity. Low yield on CT biopsy.

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13
Q

How do you stage cancers with multiple nodules?

A

Comprehensive histologic and molecular characterization of each tumor is needed as patients can have separate primary tumors. Different primary tumors is favored by different imaging appearance, different behavior/rate of growth, absence of regional spread, different molecular biomarker patterns

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14
Q

What are the features of mesothelioma?

A

Histo: epithelioid (best prognosis), biphasic, sarcomatoid (worst prognosis), +vimentin/calretinin and -PAS/CEA (opposite adeno Ca)
Features: persistent chest wall pain, hx asbestos exposure
Imaging: pleural thickening, pleural calcifications
Dx: pleural biopsy/VATS, stage with EBUS, low yield for pleural fluid analysis (can also be difficult to distinguish adenocarcinoma from mesothelioma), associated with BAP1 gene mutation. Tumor markers soluble mesothelin-related peptides, fibulin-3, osteopontin, calretinin, Wilms tumor antigen-1, CK5/6
Tx: resection, chemo (platinum + pemetrexed), radiation, nivolumab + ipilimumab in non-resectable non-epithelioid

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15
Q

How are IPCs utilized in the treatment of malignant pleural effusions?

A

IPCs have a shorter hospital LOS, fewer repeat pleural procedures. TO be used when associated with symptoms and lung re-expansion. No difference in survival, increased cellulitis (7%) and pleural infections (4%). Talc may be administered to increase pleurodesis and ability to remove catheter, also daily drainage. IPC stays in place for initial treatment of pleural infection.

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16
Q

Which tumor is associated with t(11;19)(q21;p13)?

A

Pulmonary mucoepidermoid carcinoma, MECT1 gene onto MAML2

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17
Q

Which tumor is associated with t(6;9)(q22-23;p23-24)?

A

Pleomorphic ademonas, v-myb oncogene to nuclear factor 1B

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18
Q

Memorize the algorithm for lung resection evaluation

A
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19
Q

With stage 1V adenocarcinoma with single metastasis to brain or adrenal gland, how should this be treated?

A

Curative intent resection with adjuvant chemo only if there is no evidence of regional mets to mediastinal LADs, EBUS must be performed.

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20
Q

What are the common anterior mediastinal masses?

A

5Ts- thymoma, teratoma/germ cell tumor, thyroid (goiter/neoplasm), terrible lymphoma, thoracic aorta (aneurysm). Ectopic thyroid is seen 2% of the time, more commonly continuous with thyroid

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21
Q

What are the features of a carcinoid tumor?

A

Histo: typical: polygonal-shaped cells with round nuclei in distinct growth patterns and few mitotic figures
Features: 80% of typical carcinoids express somatostatin receptors, symptoms of bronchial obstruction or vascularity, can have liver mets
Dx: somatostatin receptor scintography, low uptake on PET
Tx: resection

22
Q

What are the features of hamartomas?

A

Histo: heterogenous, with fat and cartilage
Features: most common benign lung neoplasm, slow growing
Imaging: popcorn calcification and fat on CT
Dx: biopsy

23
Q

How can neurfibromatosis type 1 evolve?

A

Malignant transformation to malignant peripheral nerve sheath tumors (seen in posterior mediastinum). Happens when patients are in their 20-30s, cause pain, neuro deficit, enlargement (same as benign tumors). Difficult to diagnose with PET or MRI, resection comes with high morbidity so diagnosis must be confirmed histologically.

24
Q

What are the features of hypertrophic osetoarthropathy?

A

Triad of periostitis, digital clubbing and painful arthropathy of the large joints. AD, is rare, secondary is associated with lung/pleural conditions (NSCLC, malignant mesothelioma, benign fibrous tumors, also fibrosis, bronchiectasis, cyanotic congenital heart disease, GI tumors, cirrhosis, IBD). Clubbing associated with malignant disease. Dx with 99mTc bone scan.

25
Q

What are the features of a solitary fibrous tumor of the pleura?

A

<5% of pleural masses. Adults in 50-60s, incidental asymptomatic masses. Dense collagenous acellular background on histology. IHC analysis can differentiate from spindle cell tumors. Can be assosciated with HOA

26
Q

Describe the immune-related adverse events with ICIs

A

Tend to occur in the first few weeks to months. Pulmonary toxicity in 2.7-3.5%, but seen higher in patients with lung cancer. Increased risk associated with radiation, driver mutation targeted therapy, a second ICI along with underlying inflammatory/fibrotic lung disease. Nonspecific imaging findings and histology. Sarcoid-like granulomatous mediastinal/hilar LAD

27
Q

What are the features of Kaposi’s sarcoma?

A

Histo: staining for CD31, CD34 and HHV8
Features: CD4 <100, cutaneous pink-purple-brown lesions in 2/3 patients, oral/laryngeal/pharyngeal mucosal lesions can be patches to nodular. GI involvement in 1/2 patients with low density hepatic lesions commonly.
Imaging: Pulmonary KS has interlobular septal thickening with irregular nodules, can get effusions and LAD. Endobronchial lesions have cherry red appearance at bifurcations, delayed thallium uptake on scintography and not gallium (unlike lymphoma)

28
Q

Does LDCT screening lead to overdiagnosis?

A

Yes, 1.38 cancers overdiagnosed for every lung cancer death averted

29
Q

What are the common middle mediastinal masses?

A

the 3 A’s
Adenopathy (neoplasm/infection/sarcoid)
Aneurysm
Abnormal development (bronchogenic cysts, esophageal duplication cysts, pericardial cysts)

30
Q

What mediastinal masses are commonly hypervascular on contrast CTs?

A

Angiofollicular LN hyperplasia (Castleman disease), AVMs, metastatic disease from hypervascular tumors (RCC/melanoma/thyroid/NE), paraglangliomas, parathyroid adenomas, thymic carcinoids (anterior), and neurogenic tumors (posterior)

31
Q

Are lung nodule risk calculators consistent with each other?

A

No, there is significant variation depending on the population prevalence they were developed in

32
Q

What factors increase risk of PTX for transthoracic need biopsy?

A

Current/former smoking, COPD, and it being a planned procedure (ie not performed during a hospital stay)

33
Q

What is the recommended surveillance for NSCLC treated with curative intent?

A

CT scan every 6 months after completion of therapy for 2 years, then yearly through 5 years. No evidence for surveillance PETCT monitoring. Consider surveillance bronchs for airway lesions or small resection margins. As patient’s are more likely to develop another lung cancer, consider surveillance as screening for a new primary

34
Q

Rattle off the lung nodule screening guidelines

A
35
Q

What stains are consistent with mesothelioma?

A

calretinin, Wilms tumor-1 gene product, and CK5/6

36
Q

What are the different airway complications that relapsing polychondritis, amyloidosis, tracheobronchopathia osteochondroplastica, and GPA have?

A
37
Q

When is it appropriate to biopsy a pure ground glass lung nodule?

A

When it develops a solid component, otherwise serial imaging (likely to be an adenocarcinoma spectrum lesion)

38
Q

How do you calculate the predicted postoperative FEV1/DLCO values?

A

Segmentally: (19-segments resected)/19 x preoperative value

Quantitative perfusion imaging: preoperative value x (1-%resected/100)

Quantitative outperforms other measures and all measure overestimate lung removed

39
Q

Review the histopathology of lung cancers visually

A
40
Q

Review the tumor markers of adeno, SCC, and SCLC

A
41
Q

What percentage PD-L1 would you then start nivolumab for surgically resectable tumors with neoadjuvent chemo?

A

1% or greater

42
Q

How is BAC/adenocarcinoma in situ treated?

A

Staged and treated as adeno
If pure BAC, may consider lesser resection
50% responsive to EGFR inhibitors

43
Q

What is the rate of PTX from CT guided lung biopsy?

A

15%, 6% require chest tube

44
Q

What thresholds are fairly safe for lung resection surgeries?

A

Pre-op FEV1 2L for pneumonectomy and 1.5L for lobectomy

45
Q

What are the treatments for each stage of NSCLC?

A

Stage 1: Curative surgery, can do SBRT instead
Stage 2: Surgery and adjuvant chemo (osimertinib for EGFR+) except for Pancoast (them induction chemoradiation then surgery), f/u CT q6m x2 years then q12m x 5 years before standard LDCT screening
Stage 3: chemorad + adjuvent immunotherapy, or neoadjuvant chemorad + surgery, adjuvant osimertinib for EGFR+

46
Q

Describe the grading of ICI pneumonitis and its management?

A

Grade 1: asymptomatic with radiographic changes, continue therapy with close observation
Grade 2: symptomatic with no limitation of activity, hold therapy, consider bronch, and oral pred 1mg/kg/day if no improvement
Grade 3: Discontinue therapy, bronch, 1mg/kg/day oral prednisone or IV at equivalent dose. Consider infliximab +/- cyclophosphamide or MMF

47
Q

How is limited and extensive SCLC treated?

A

Limited: chemo and XRT, can consider prophylactic cranial XRT
Extensive: chemo, XRT only palliative

48
Q

What considerations must be made if doing bronchoscopy on a pregnant patient?

A

Wait until 28 weeks if able, position in left lateral, avoid fluoro, prepare for OB complications and perform in institution with OB resources

49
Q

Which is the preferred method of topical anesthesia for bronchoscopy?

A

Lidocaine, benzocaine and tetracaine have higher risks of methemoglobinemia
Lido 1%= each cc has 10mg. Total topical dose should not exceed 7mg/kg
No difference in 1% versus 2 in efficacy so use lower concentration to avoid toxicity

50
Q

What are the common primary neoplasms that metastatsize to the lungs?

A

Breast, colon, kidney, uterus, head/neck

Pulmonary Boards (14 decks)

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