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2. HDS Pulmonary > Pulmonary Tumors > Flashcards

Pulmonary Tumors Flashcards

1
Q

Lung Tumors

Overview

A
  • Bonchogenic carcinoma ⇒ 90-95% of primary lung tumors
  • 5% are carcinoids
  • Rest are misc. neoplasms including hamartoma
  • Benign lung tumors rare
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2
Q

Lung Tumor

Epidemiology

A
  • Bronchogenic carcinoma
    • Most common visceral malignancy
    • Most common cause of cancer death worldwide
  • US in 2012
    • 226k new cases of lung CA
      • 14% of new cancer dx
    • 160k deaths d/t lung CA
      • 8% of all cancer deaths
  • Since 1987, more women die of lung CA than breast CA
  • Peak incidence in 6th and 7th decades
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3
Q

Lung Carcinoma

Etiology

A
  • Cigarette smoking ⇒ #1
    • 40 pk-yr hx ⇒ 60x lung CA risk
    • 80% of lung CA occurs in smokers or those who recently quit
    • Only 11% of heavy smokers get lung CA
    • Cessation of smoking for 10 years ↓ risk but never to control levels
  • 10-15% of US lung CA occurs in never smokers
    • Usu. adenocarcinomas in ♀
  • Ionizing radiation
  • Asbestos
    • Just asbestos ⇒ 5x risk
    • Asbestos + smoking ⇒ 55x risk
  • Air pollution ⇒ 2nd hand smoke, Radon
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4
Q

Precursor Lesions

A

4 types of precursor lesions for lung carcinoma:

  • Atypical adenomatous hyperplasia
  • Adenocarcinoma in situ
  • Squamous dysplasia and carcinoma in situ
  • Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia

Not all precursor lesions will progress to invasive cancer.

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5
Q

Atypical Adenomatous Hyperplasia

A

Subtle focal thickening of lung parenchyma and hyperplasia of glandular epithelium

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6
Q

Adenocarcinoma In-situ

A

Proliferation and tufting of glandular epithelium with cellular atypia.

Does not invade into alveolar wall.

Can become invasive adenocarcinoma if process continues.

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7
Q

Squamous Dysplasia and Carcinoma In-situ

A

1st step ⇒ metaplasia of normal respiratory epithelium into squamous epithelium

2nd step ⇒ dysplasia of metaplastic sqamous epithelium, can be full thickness but does not invade down through BM

Cells can invade through BM and become Invasive Squamous Cell Carcinoma.

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8
Q

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia

A

Can become small cell carcinoma

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9
Q

Squamous Cell Carcinoma

Epidemiology

A
  • 20% of lung CA
  • Mostly in men
  • Strong association with smoking
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10
Q

Squamous Cell Carcinoma

Pathogenesis

A
  • Usu. centrally located near hilus
    • Increasingly becoming more peripheral
  • Metaplasia ⇒ dysplasia ⇒ growth & thickening by local spread ⇒ erosion of epithelial airway lining ⇒ invasion
    • Metastasizes later than most other patterns
  • Once invasive it can:
    • Form an intraluminal mass
      • Can lead to post-obstructive PNA
    • Penetrate bronchial wall and infiltrate into carina or mediastinum
    • Grow into lung parenchyma
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11
Q

Squamous Cell Carcinoma

Histology

A
  • Low grade tumors
    • Keratinization ⇒ squamous pearls or individual cells w/ eosinophilic, dense cytoplasm
    • Intercellular bridges
  • ± Central cavitation
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12
Q

Adenocarcinoma

Epidemiology

A
  • 38% of lung CA
    • ↑ incidence last 20 years
      • May be due to cigarettes making smokers inhaler more deeply
      • Expose peripheral airways where adenocarcinoma tends to form
  • Most common form in women
    • ↑ women smokers
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13
Q

Adenocarcinoma

Pathogenesis

A
  • Most located peripherally
  • Starts in mucus-producing glandular cells
  • Grows in various patterns
    • Acinar
    • Lepidic
    • Papillary / micropapillary
    • Mucinous
    • Microinvasive
  • Tumors grow more slowly
  • Usually smaller than squamous carcinomas
  • Variable glandular differentiation
    • May see mucin
  • Tends to metastasize more widely & earlier than squamous carcinomas
    • Spread to pleura, regional LN, vessels
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14
Q

Adenocarcinoma

Acinar Pattern

A

Gland structure clearly visible.

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15
Q

Adenocarcinoma

Lepidic Pattern

A

Malignant cells grow along alveolar walls.

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16
Q

Adenocarcinoma

Mucinous Pattern

A

Satellite lesions.

Can resemble PNA.

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17
Q

Microinvasive

Adenocarcinoma

A

Tumor less than 3 cm.

Invasive component less than 5 mm.

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18
Q

Adenocarcinoma

Molecular Testing

A

Helps to determine treatment and prognosis for non-small cell lung cancers, esp. adenocarcinoma.

  • Test each case of adenocarcinoma
    • EGFR mutations or other tyrosine kinases
      • Targeted treatment w/ specific inhibitors
      • Prolonged survival
    • Activating KRAS mutations ⇒ ~ 30%
      • Associated w/ worse prognosis
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19
Q

Small Cell Carcinoma

Epidemiology

A
  • 14% of lung CA
  • Very strong association w/ smoking
  • Most aggressive lung tumor
20
Q

Small Cell Carcinoma

Pathogenesis

A
  • Thought to arise from Kulchisky cells in bronchial epithelium
  • Starts as diffuse idiopathic pulmonary neuroendocrine cell hyperplasia
  • Highly malignant ⇒ very poor prognosis
  • May secrete polypeptide hormones ⇒ paraneoplastic syndrome
21
Q

Small Cell Carcinoma

Histology

A
22
Q

Small Cell Carcinoma

Treatment and Prognosis

A
  • Surgical resection ineffective
  • Sometimes sensitive to radiation and chemotherapy
  • Mean survivial rate after dx ~ 1 year
23
Q

Large Cell Carcinoma

Epidemiology

A
  • 10-15% of total lung CA
  • 18% of lung CA in males
  • 10% of lung CA in female
24
Q

Large Cell Carcinoma

Characteristics

A

Undifferentiated malignant epithelial tumor without characteristics of squamous cell or adenocarcinoma.

  • Large Cell Neuroendocrine carcinoma is a variant
  • Probably represents undifferentiated adeno- and squamous cell carcinomas
  • EM show adeno and squamous differentiation
25
Q

Mixed Carcinomas

A

Combined types occur in ~ 10% of patients:

Squamous cell carcinoma + adenocarcinoma

or

Squamous cell + small cell carcinoma

26
Q

Lung Carcinoma

Clinical Effects

A
  • Focal emphysema
  • Atelectasis
  • Abscesses
  • SVC syndrome ⇒ venous congestion and edema of head and arm
  • Pericarditis
  • Pleuritis
27
Q

Lung Carcinoma

Clinical Presentation

A
  • Cough ⇒ 75%
  • Weight loss ⇒ 40%
  • Chest pain ⇒ 40%
  • Dyspnea ⇒ 20%
28
Q

Lung Cancer

Clinical Classification

A

Divided into two groups based on likelihood of metastasis and response to available therapies.

  1. Small cell carcinomas
    • Most often metastatic at time of dx
    • Not amenable to surgery
    • Have good initial response to chemotherapy
  2. Non-small cell carcinoma
    • Less likely to be metastatic at time of dx
    • First perform staging
    • Try surgery first if possible
29
Q

Lung Cancer

Staging

A

‘N’ and ‘M’ factors

  • Overall, > 50% of lung CA show nodal involvement @ dx
  • Can spread through lymph and blood
  • Sometimes metastasis is first manifestation of a problem ⇒ occult carcinoma
30
Q

Lung Cancer

Metastatic Sites

A
  • Adrenals ⇒ > 50% of cases
  • Liver ⇒ 30-50%
  • Brain ⇒ 20%
  • Bone ⇒ 20%
31
Q

Lung Cancer

Survival Rates

A
  • One year survival rate
    • 34% in 1975
    • 41% in 2007
  • 5 yr survival rate for all stages combined ⇒ 16%
    • 52% if cancer localized to lung @ dx
    • 22% w/ regional metastasis to LN
    • 4% w/ distant metastasis
32
Q

Paraneoplastic Syndromes

Definition

A

Symptom complex in cancer pts not explained by local or distant spread of tumor or by excess of hormones indigenous to tissues.

  • Occurs in 1-10% of pts w/ advanced malignancies
  • May represent initial manifestation
  • May represent significant clinical problems
33
Q

Paraneoplastic Syndromes

Manifestations

A
  • ADH ⇒ hyponatremia
  • ACTH ⇒ Cushings syndrome
  • Parathyroid hormone, parathyroid hormone-related peptide, prostaglandin E, and some cytokines ⇒ hypercalcemia
    • Often seen w/ lung CA
  • Calcitonin ⇒ hypocalemia
  • Gonadotropins ⇒ gynecomastia
  • Serotonin and bradykinin ⇒ carcinoid syndrome
34
Q

Lung CA Associated

Paraneoplastic Syndromes

A

Most tumors that produce ACTH and ADH ⇒ small cell carcinoma

Most tumors that produce hypercalcemia ⇒ squamous cell carcinoma

35
Q

Lambert-Eaton Myastenic Syndrome

A

Muscle weakness caused by auto-Ab directed to the neuronal calcium channels.

Possibly elicited by tumor ionic channels.

36
Q

Horner Syndrome

A
  • Classic sx ⇒ enophthalmos, ptosis, miosis, anhidrosis
  • Other manifestations ⇒ peripheral neuropathy, acanthosis nigricans, leukemoid reactions
  • Seen in Pancoast tumors
    • Located at apex of the lung
37
Q

Apical Lung Cancers

A
  • Tend to invade neural structures around trachea
    • Including the cervical sympathetic plexus
  • Can see Horner syndrome on ipsilateral side
    • Tumors that cause this care called ‘Pancoast tumors’
38
Q

Metastatic Tumors

to Lung

A
  • The lung is the most common site for mestastic tumors
  • See multiple nodules
  • May see spread via lymphatics
    • Manifests as Lymphangitic Carcinomatosis
39
Q

Carcinoid Tumors

Epidemiology

A
  • 1-5% of lung tumors
  • Pts usu. < 40 y/o
  • Male = female
  • No known relationship to smoking
40
Q

Carcinoid Tumors

Pathogenesis

A
  • Thought to arise from Kulchitsky’s cells of bronchial mucosa
  • May secrete hormonally active polypeptides ⇒ carcinoid syndrome
    • See diarrhea and flushing
  • Often grow endobronchially ⇒ central lesion
  • Covered by intact mucosa
  • May present w/ airway obstruction
  • More pleomorphic tumors ⇒ atypical carcinoids
    • More agressive
    • Can spread to LN
    • Usually cured by resection
41
Q

Carcinoid Tumors

Histology

A
  • Sheets of uniform cells divided into “islands by CT septa
  • Cells have round nuclei w/ ‘salt and pepper’ chromatin
  • Neuroendocrine granules on EM
42
Q

Hamartoma

A
  • Usually composed of mature hyaline cartilage
  • May contain fibrous tissue, fat, blood, vessels
  • Usually incidental finging on CXR ⇒ coin lesion
43
Q

Metastatic

Pleural Tumors

A
  • Far more common than primary tumors
  • Most arise from lung and breast CA
  • Often see a malignant effusion
44
Q

Solitary (Localized) Fibrous

Pleural Tumors

A
  • Usually benign, local growth
  • Does not usu. cause an effusion
  • Not related to asbestos
45
Q

Malignant Mesothelioma

Characteristics

A

“Primary Malignant Tumor of Pleura”

  • Most are asbestos-related
    • Long latency ⇒ 10% heavily exposed develop tumor w/in 25-45 years
  • Smoking does not increase risk
  • 50% of pts die within 1 year of dx
  • Few survive longer than 2 years
46
Q

Malignant Mesothelioma

Gross Appearance

A
  • Diffuse tumor spreads in pleural space
  • Eventually encases the lung in a rind of tumor
  • Often causes an effusion
  • Can also be seen in pericardium and peritoneum
47
Q

Malignant Mesothelioma

Histology

A
  • Usually composed of 2 cell types
    • Epithelioid cells
    • Mesenchymal cells
  • Can see microvilli on EM
  • May see ferruginous bodies

2. HDS Pulmonary (28 decks)

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