Neoplasms

Question 1

Adenocarcinoma

Question 2

Squamous Cell Carcinoma

Answer 2

Pathology:

• Etiology: squamous metaplasia –> dysplasia –> caricnoma insitu –> invasive carcinoma
• Association: smoking
• Irregular endobronchial lesion + bronchial wall invasion + grow along bronchial mucosa
• Micro: irregular and large nuclei, keratin pearls (laminated whorls of eosinophil cells), high mitotic rates

Epidemiology: old men who smoke

Imaging:

• Central (endobronchial) mass/nodule +/- post-obsructive effects
• Peripheral mass/nodule:
  
  • ​+/- central necrosis
  • +/- cavitation
  • +/- calcification
  • pancoast tumour: typically adenocarcinoma/SCC
• Local invasion: lymph nodes, mediastinum, pleua, diaphgram, chest wall

DDx:

• Adenocaricnoma
• Small cell carcionma
• Bronchial carcinoid
• Mediastinal mets

https://app.statdx.com/document/squamous-cell-carcinoma/825c331a-7a95-4b15-be5c-f7de40254206?searchTerm=sqamous%20cell%20carcinoma

Question 3

Small Cell Carcinoma

Answer 3

Pathology:

• Association: smoking
• 90-95% arise from lobar/mainstem bronchi
• Micro: small blue, round/oval cells, high mitotic rate
• Immuno: TTF-1 80%
• Aggresive malignancy with high rate of metastatic rate: 65% metastatic at diagnosis

Imaging:

• Central pulmonary nodule/mass +/- post obstructive effects
• Hilar/mediastinal lymphadneopathy (80-90%)
• Encasement of medastinal structures: heart, great vessels, SVCO
• Metastasis: Bone/liver > adrenals > brain

PET/CT: avid FDG uptake. Good for staging and restaging.

DDx:

• Mediasinal B-cell Lymphoma
• Squamous cell carcioma
• Carcinoid tumour

Question 4

Multifocal lesions

Answer 4

Defintion:

• >2 intrapulmonary lesions
  
  • Solid
  • Sub solid:
    
    • Semi-solid (mixed solid + GGO)
    • Non-solid (pure GGO)
• Variable location:
  
  • single lung lobe
  • Multiple ipsilateral lobes
  • Bilateral lungs
• Features to describe:
  
  • Shape : lobulated/spiculated = more suspicious
  • Attenuation
  • Location
  • Size
  • Other: local invasion, lymphadneopahty, pleural effusion, osseous mets

DDx:

• Infection
• Neoplasm: primary vs metastatic
• Inflammatory: sarcoid, vasculities
• Other: Drug toxicity, PAVM, infarction, amyloid

Question 5

Pulmonary Harmatoma

Answer 5

Pathology:

• Unknown etiology
• Genetics: recombination of chromosomal bands 6p21, 14q24
• Association:
  
  • Carney triad: mutliple pulmonary chondromas, gastric epithelioid leiomyosarcoma, functional extra-adrenal paraganglioma
  • Cowden sydnrome
• Gross: well-circumscribed firm mass, easily resected from surrounding lung, may be densly calcified
• Micro: myxomatous connective tissue containig cartilage:
  
  • Variable: fat, smooth muscle, bone, lymphovascular structures
  • Cartilage may calcify
  • Double layered epithelial cell-lined clefts

Epidemiology:

• 60s
• M > F (2-3:1)
• Most common benign lung tumour
• 6% of all solitary pulmonary nodules

Clinical

• Incidental finding
• usually doesn’t require treatment
• Consider resection if rapidly growing/endobronchial

Imaging:

• Solitary pulmonary nodule
• Smooth/lobular margins
• Calcifications (75%) - popcorn calcification of cartilage in only 15%
• Fat attenuation (60%)
• Heterogenosu enhancement
• PET/CT: 20% show uptake

DDx:

• lung malignancy
• Carcinoid
• Solitary met
• Lipoid pneumonia
• Liposarca

Question 6

Bronchial Carcinoid

Answer 6

Pathology :

• Eitiology: no association with smoking or inhaled carinogens
• Gross: smooth, red, polypoid endobronchial nodule/mass mostly from central bronchi
• Micro:
  
  • Neuroendocrine neoplasm: spectrum of more aggresive large cell NET/small cell carcinomas
  • Typical carcinoid (85%):
    
    • uniform cells in sheets, trabeculae, gland-like stuctures seperated by fibrovacular stroma.
    • Moderate cytoplasm with numerous neurosecretory granules.
    • Rare mitotic figures.
    • Dystrophic calcification.
  • Atypical (15%): necrosis, loss of architecture, nuclear pleomorphism, higher mitotic activity
• Associations: pulmonary tumorlets (benign neuroendocrine hyperplastic growths)

Epi:

• 30-60
• Most frequent primary pulmonary neoplasm
• 1-2% of all lung neoplasms

Clinical:

• Cough
• Hemoptysis (50%)
• Recurrent infections
• Paraneoplastic syndrome:
  
  • Cushings syndrome (ACTH production)
  • Carcinoid syndrome (almost always have hepatic mets)

Imaging:

Typical (85%):

• Central endobronchial mass: lobular borders
  
  • ​85% in main/lobar/segmental bronchi >> 15% solitary peripheral nodules >>>>>> trachea
  • Ice berg lesion: small endoluminal tumor with dominant extraluminal component
  • Dystropic calcification/ossification (30%)
  • Marked homogenous enhancement
• Hilar/mediastinal lymphadneopathy: metastasis or reactive LN from recurrent infection
• Obstructive effect: ball-valve effect
  
  • Atelectasis
  • Post obstructive pneumonia: abscess, bronchiectasis
  • Mucoid impaction with air trapping
• Mets: liver, bone (sclerotic), adrenal glands, brain

Atypical (15%)

• Lung nodules/mass: peripheral > central
• LN metastasis common
• Multiple carinoid tumors and tumorlets (DIPNECH)

PET CT:

• FDG falsly negative due to relative low metabolism.
• Octreotide: diagnosis and localisaiton of occult carcinoid tumors

DDx:

• Adenoid cystic carcinoma
• Pulmonary harmatoma
• Lung cancer
• Mucoepidermoid carcinoma
• Broncholithiasis
• Pulmonary mets

Question 7

Lymphangitis Carcinomatosis

Answer 7

Pathology:

• Permeation of lymphatic system by neoplastic cells
• Eitiology
  
  • Hematogenous mets
    
    • typically adenocarcinoma
    • Breast, stomach, pancreas, prostate cancers
    • Tumour emboli –> small pulmonary artery branches –> spread along lymphatics
  • Lung cancer: spreading via lymphatics to adjacent lung/hilum/mediastinum
  • Lymphoma: retrograde spread from hilar to pulmonary lymphatics
• ~45% of all solid tumours
• Macro: interlobular septal thickening, desmoplastic reaciton, dilated lymphatics, obstructed lymphatic drainage from hilar/mediastinal LN
• Micro: nests of tumor within lymphatics. Tumor emboli in adjacent arterioles common. Occluded lymphatics.

Epidemiology: 6-8% of metastatic cancer to lung

Clinical: poor prognosis, 15% 6 month survival.

Radiograph:

• Normal in 30-50%
• Reticulonodular opacities
• Coarse bronchovascular markings
• Septal lines/fissural thickening
• Unilateral > bilateral
• Hilar/mediastinal lympnadneopathy
• Pleural effusion

CT:

• Location: basilar predominance, asymmetric
• Interlobular septal thickening: irregular > beaded
• Peribronchovascular and fissural thickening
• +/- Centrilobular nodules/GGO
• Lung architecture preserved
• Ancillary:
  
  • Pleural effusion
  • Hilar/mediastinal lymphadenopathy
  • Primary lung cancer/Metastatic disease

DDx:

• Pulmonary oedema
• IPF
• Lymphoma
• Sarcoidosis
• Scleroderma
• Asbestosis
• Drugs
• HP

Question 8

Endobronchial Mass (DDx)

Answer 8

• Non-small cell carcinoma:
  
  • 95% of all malignant endobronchial tumours.
  • SCC most common.
• Small cell lung cancer:
  
  • 20% of all lung cancers
  • Usually peribronchial with bronchial submucosal invasion
• Carcinoid : 1-2% of all lung neoplasms
• Lung mets: breast, colorectal, renal, melanoma
• Aspiration
• Other endobronchial tumours:
  
  • ​Malignant: adenoid cystic carcinoma, mucoepidermoid carcinoma
  • Benign: Pulmonary harmatoma
• Bronchial atresia
• Laryngeal papilomatosis: related to HPV
• Broncholith

Question 9

Middle lobe syndrome (DDx)

Answer 9

Definition: recurrent or chronic atelectasis of right middle lobe/lingula

• Obstruction: extrincic compression (LN/mass), Endobronchial mass, bronchostenosis
• Pneumonia
• Atelectasis
• Pectus excavatum

Question 10

Hemoptysis

Answer 10

Lung malignancy: primary vs metastatic disease

Infection: TB, aspergillosis, abscess

Bronchiectasis

Bronchitis

PE

Diffuse alveroalr hemorrhage

Congestive heart failure

Mitral stenosis

Pulmonary artery aneruysm/pseudoanerusym

Arteriovenous malformation

Broncholithiasis

Pseudosequestration

Kaposi sarcoma